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A 36-year-old male presented with a two-year history of discoloration of the right ear. The patient brought the area of interest to his primary care physician’s attention after noting a change in the color and size of the area. The patient described a sensation of itch and was concerned when the lesion bled after being scratched.

An exam of the posterior right helix revealed a 1.0 x 1.2cm brown patch with a central pink macule.

Given the size of the lesion, a partial shave biopsy was performed revealing a melanoma, Breslow depth 0.45mm, no ulceration or mitoses with a moderate lymphocytic infiltrate.  

Figures 1a (left) and 1b (right): Patient’s right ear before and after complete re-excision of melanoma in situ performed by plastic surgery with 1cm margins.

Complete re-excision (see Figures 1a and 1b) was performed by plastic surgery with 1cm margins and pathology revealed persistent melanoma in situ present centrally, margins clear. The patient has been followed on a quarterly basis for two years with no recurrence to date.  


Melanoma is one of the most common malignancies diagnosed in adults younger than 40 in the US and worldwide. Mortality from melanoma is greater in men than women amongst all races within the US and abroad.1 The incidence of melanoma of the external ear has increased in the <40 age group by 111.9 percent in the past 40 years. Men are affected significantly more than women at a ratio of 6.4:1.2

Exposure to ultraviolet radiation and acute and intermittent sunburns are known risk factors for melanoma. It follows that protecting the skin from the sun should decrease the incidence of melanoma over time. However, national surveys of sunburn and sun protection habits suggest that one-third of Americans get sunburned yearly.

Safe in the Sun

After seeing countless patients, particularly male patients, present with preventable skin cancers on the head, neck, and back, Rebecca Shpall, MD created her own sun protection clothing company, Waterhoody (, to help encourage sun-safe behavior.

“It is essential for dermatologists to educate our patients. During a clinic visit, we have our patients’ attention, which gives us the opportunity to both inform them about the risks of unprotected sun exposure and encourage use of sunscreen, clothing and avoidance when possible,” Dr. Shpall explains.

Patients have many excuses for not protecting themselves from the sun’s harmful effects while living an active lifestyle. From hearing excuses like disliking having sunscreen drip in their eyes, forgetting to wear a hat, or wanting to look good at the beach, Dr. Shpall says she realized there was a need in the market for flattering, effective sun-protective clothing.

“I started Waterhoody because I couldn’t find a swim shirt on the market to provide scalp, neck, and ear protection particularly for men at higher risk,” Dr. Shpall says. “I also wanted to develop a flattering shirt that would make people feel both confident and protected.”

She worked with a swim and sportswear expert based in Los Angeles, because design, particularly the fit of the hood, was of the utmost importance. The swim shirts are UPF 50+ (in and out of water) and are made of ultra-premium Italian fabric.

To date, the feedback from patients is great, Dr. Shpall says—the company maintains a five-star rating on Amazon. She’s in the process of launching a children’s line this month, and a product for babies is in the works.

Sunburn incidence is higher among men, and less than one-third of men routinely use an appropriate form of sun protection.3 Sun protective clothing has been shown to be more effective at preventing sunburn than sunscreen.4

To address the issue of the rising incidence of skin cancer including melanoma and the ongoing high-risk behavior of excessive UV exposure and sunburn, the US Surgeon General issued a Call to Action to Prevent Skin Cancer in July of 2014.5 Goals one and two of the call-to-action—increasing opportunities for sun protection and empowering individuals to make safe choices about UV exposure—specifically require the attention and action of dermatologists and related healthcare providers. By leveraging our influence both among our patients and in our social circles, we can work to change perceptions of what is fashionable when out in the sun.

Dr. Shpall is a clinical dermatologist at the Palo Alto Medical Foundation and founder of Waterhoody, an ultra premium sun protective swimwear company.

Disclosures: Dr. Shpall is CEO of Waterhoody.

1. Matthews NH, Li WQ, Qureshi AA, et al. Epidemiology of Melanoma. In: Ward WH, Farma JM, editors. Cutaneous Melanoma: Etiology and Therapy [Internet]. Brisbane (AU): Codon Publications; 2017 Dec 21. Chapter 1. Available from: 10.15586/codon.cutaneousmelanoma.2017.ch1

2. Patel TD, Chin OY, Baredes S, Eloy JA, Ying Y-LM. A Population Based Analysis of Melanoma of the External Ear. Otology & Neurotology. 2018;39(2). doi:10.1097/mao.0000000000001645.

3. Buller DB, Cokkinides V, Hall HI, et al. Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: Review from national surveys and case studies of 3 states. Journal of the American Academy of Dermatology. 2011;65(5). doi:10.1016/j.jaad.2011.05.033.

4. Linos E, Keiser E, Fu T, Colditz G, Chen S, Tang JY. Hat, shade, long sleeves, or sunscreen? Rethinking US sun protection messages based on their relative effectiveness. Cancer Causes & Control. 2011;22(7):1067-1071. doi:10.1007/s10552-011-9780-1.

5. The Surgeon General’s Call to Action to Prevent Skin Cancer. Accessed April 12, 2018.

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