A comparison of patterns of sun protection during beach holidays and everyday outdoor activities in a population sample of young German children

Background Reducing exposure to ultraviolet (UV) radiation is the main effective measure for preventing skin cancer. Educational campaigns targeting sun protection have been focused either on behaviour on the beach during the summer holiday alone, or during everyday outdoor activities of the children. Little is known about the comparison between these different settings. Objectives To analyse whether parents apply similar protective measures to reduce UV exposure for their young children in different outdoor environments. Methods Families (n = 2619) with children aged 3–6 years (response: 64·7%) were enrolled in a population‐based survey in the German city of Erlangen and its surrounding rural county. Using a self‐administered standardized questionnaire parents gave information about demographic and photosensitivity data of their children, their knowledge about risk factors for skin cancer and their typical instructions given to their children when these played outside on a summer day in different outdoor environments. Results Significant discrepancies regarding the four UV protective measures (clothes, shade, sunhat, sunscreen) for children between an everyday outdoor setting and a holiday setting on the beach were observed. A high level of parental risk factor knowledge was significantly associated with a better protection for children in all four measures only on the beach. Photosensitivity and demographic characteristics had some impact on protective behaviour, too. Measures of sun protection were reduced with children’s increasing age. Conclusions Skin cancer prevention campaigns should target the encouragement of sun protection for children also in outdoor activities of daily living, not only during a summer holiday on the beach.     

Evaluation of tourists’ UV exposure in Paris

Background Ultraviolet (UV) exposure is one of the most important risk factor for skin cancers. If UV hazard has been evaluated in tropical countries or in some population – children, outdoor activities – little information is available about UV hazard in high latitude towns like Paris, considered as the most ‘charismatic city’ in the world. Objective To evaluate UV exposure in Paris in spring, in sun and shade, in real life conditions. Methods We evaluated erythemal UV exposure, during four sunny days in May‐June in eight Paris touristic sites during peak hours (2 days), and during two walks in touristic downtown of Paris. Measures were performed in sun and shade. UV radiation exposure was evaluated with UV index performed with a ‘Solarmeter ultraviolet index (UVI)’ and UV dose with ‘standard erythema dose’ (SED) and ‘minimal erythema dose’ (MED) calculations. Results Despite ‘average’ UVI in sunny conditions, a 4‐h sun exposure reaches 13–20 SED and 3–10 MED according to phototype. Clouds were inefficient to protect against UV. Shade of places reduces moderately UVI (50–60%) in forecourts. Exposure during 1‐h walk reach at least one MED in real life conditions for skin phototypes I–IV. Conclusions UV risk for tourist is quite high in spring in Paris. UVI remains high despite high cloud fraction. Shade reduces UVI, but UV protection factor is only 2–3 in large places such as Place Notre Dame and Place Charles de Gaulle. So sun protection campaigns should be proposed, and sun protective strategies could be integrated in urban planning.     

Parental perspective on sun protection for young children in Bavaria

Background: Exposure to ultraviolet (UV) radiation is the most important modifiable risk factor for skin cancer. Parents are responsible for sun protection of their young children and thus their knowledge and attitudes should be assessed. Methods: A survey that included 2619 children aged 3–6 years (response: 64.7%) was performed in Erlangen during 2001/2002. Parents' attitude, knowledge and behavior regarding sun protection were ascertained by using a self‐administered questionnaire. Demographic and photosensitivity data of the children were recorded, along with the UV radiation‐related outcomes. Results: Most parents correctly recognized the risk factors of skin cancer, except the intermittent and intensive sun exposure. Nevertheless, most parents also agreed with statements regarding sun‐ and tanning related beauty and well‐being. The overwhelming majority of parents stressed the necessity of sun protection for their children; however, 50% of the children experienced some form of solar radiation injury during the preceding summer. Children eagerly pursued outdoor activities, especially boys compared with girls (P<0.01). A gender difference was also apparent, with boys showing more willingness to wear hats than girls (P<0.01). Conclusion: The relatively high level of knowledge was in contrast to a prevalent attitude of regarding sunlight as enhancing health and well‐being. This may hamper UV radiation avoidance strategies. Thus, future campaigns should not only address preventive knowledge but also focus on associated attitudes to effectively modify the behavior.     

Outdoor sports and skin cancer

Ultraviolet radiation is estimated to be one of the most important risk factors for nonmelanoma and melanoma skin cancers. Athletes practicing outdoor sports receive considerable UV doses because of training and competition schedules with high sun exposure, and in alpine sports, by altitude-related increase of UV radiation and reflection from snow- and ice-covered surfaces. Extreme UV exposure in outdoor sports such as skiing, mountaineering, cycling, or triathlon has been documented in a series of dosimetric studies. Sweating because of physical exercise may contribute to UV-related skin damage as it increases the individual photosensitivity of the skin, facilitating the risk of sunburns. Large epidemiological studies showed that recreational activities such as sun exposure on the beach or during water sports were associated with an increased risk of basal cell carcinoma, whereas skiing has been shown to be at increased risk for squamous cell carcinoma. Risk factors of cutaneous melanoma such as the number of melanocytic nevi and solar lentigines have been found to be more frequent in subjects practicing endurance outdoor sports. An increased risk for cutaneous melanoma may be assumed for these athletes. In addition to the important sun exposure, exercise-induced immunosuppression may increase the risk for nonmelanoma skin cancer and cutaneous melanoma in athletes. Frequently, athletes seem to know little about the risk of sun exposure. Protective means such as avoiding training and competition with considerable sun exposure, choosing adequate clothing, and applying water-resistant sunscreen still need to be propagated in the community of outdoor sportsmen.     

Physicians involved in the care of patients with high risk of skin cancer should be trained regarding sun protection measures: evidence from a cross sectional study

Background Knowledge, regarding sun protection, is essential to change behaviour and to reduce sun exposure of patients at risk for skin cancer. Patient education regarding appropriate or sun protection measures, is a priority to reduce skin cancer incidence. Objective The aim of this study was to evaluate the knowledge about sun protection and the recommendations given in a population of non‐dermatologists physicians involved in the care of patients at high risk of skin cancer. Materials and methods This study is a cross‐sectional study. Physicians were e‐mailed an anonymous questionnaire evaluating the knowledge about risk factors for skin cancer, sun protection and about the role of the physician in providing sun protection recommendations. Results Of the responders, 71.4% considered that the risk of skin cancer of their patients was increased when compared with the general population. All the responders knew that UV‐radiations can contribute to induce skin cancers and 71.4% of them declared having adequate knowledge about sun protection measures. A proportion of 64.2% of them declared that they were able to give sun protection advices: using sunscreens (97.8%), wearing covering clothes (95.5%), performing regular medical skin examination (91.1%), to avoid direct sunlight exposure (77.8%), avoiding outdoor activities in the hottest midday hours (73.3%) and practising progressive exposure (44.4%). Conclusion Non‐dermatologist physicians reported a correct knowledge of UV‐induced skin cancer risk factors. The majority of responders displayed adequate knowledge of sun protection measures and declared providing patients with sun protection recommendation on a regular basis. Several errors persisted.     

Ultraviolette Strahlung – Quellen,Spektren, Umwelteinflüsse

The UV‐radiation in our environment is part of the electromagnetic radiation, which emanates from the sun. It is designated as optical radiation and reaches from 290 – 4,000 nm on the earth's surface. According to international definitions UV irradiation is divided into short‐wave UVC (200 – 280 nm), medium‐wave UVB (280 – 320 nm), and long‐wave UVA (320 – 400 nm). Solar radiation which reaches the surface of the globe at a defined geographical site and a defined time point is called global radiation. It is modified quantitatively and qualitatively while penetrating the atmosphere. Besides atmospheric conditions, like ozone layer and air pollution, geographic latitude, elevation, time of the season, time of the day, cloudiness and the influence of indirect radiation resulting from stray effects in the atmosphere and reflection from the underground play a role in modifying global radiation, which finally represents the biologically effective radiation. The radiation's distribution on the body surface varies according to sun angle and body posture. The cumulative UV exposure is mainly influenced by outdoor profession and recreational activities. The use of sun beds and phototherapeutic measures additionally may contribute to the cumulative UV dose.     

Awareness, knowledge and attitudes towards sun protection among skin cancer-treated patients in France

BACKGROUND: The incidence of skin cancer has risen over the past years, owing to increased exposure to ultraviolet radiation. Sun protection measures include avoiding exposure to the sun, using covering clothing and applying sunscreen. We evaluated the knowledge and compliance with advices about sun protection in a population of patients who had presented skin tumour(s). SUBJECTS AND METHODS: A 30 question self-reporting questionnaire evaluating sun protective behaviour was distributed to 217 consecutive skin cancer-treated patients and completed by 198 of them. RESULTS: 72% of the responders had presented a melanoma, and 26% of them had presented only non-melanoma skin cancer. The present survey shows that patients who have had a skin cancer were aware of the cancer related risk of sunlight since 98% of the responders knew that ultraviolet radiations can include skin cancer. These patients did also take sun-protective measures because 73% of them had worn covering clothes when in the sun and 59% of them avoided outdoor activities during the midday hours. CONCLUSION: These results suggest that, after diagnosis of a skin cancer, patients limited their sun exposure; and wear protective clothing. However, sun-protection measures did not seem to be completely adequate. An evaluation of the various barriers to sun safety might be a key to understanding the sub-optimal sun protection.     

Sun awareness and sun protection practices in Malta

BACKGROUND: Concern regarding the rising incidence of melanoma and non-melanoma skin cancers in Malta has led to the organization of annual campaigns since the early 1990s. These aim to inform the public of the dangers of sun exposure and to promote sun protection. OBJECTIVE: To help guide future campaigns, a survey was carried out to evaluate current sun protection measures among the Maltese people and to assess their level of knowledge regarding harmful effects of the sun on the skin. STUDY DESIGN: A total of 559 pedestrians were interviewed in the main street of the capital city of Malta in the summer of 1999. RESULTS: Self-reported rates of regular sunscreen and hat use in adults exposed to the spring/summer sun between 10.00 h and 15.00 h were 51% and 32%, respectively, for leisure activities, and 25% and 37%, respectively, for outdoor work. Men reported using sunscreen less often than women during both leisure and work. The fairer-skinned outdoor workers actually reported making less use of a sunscreen and/or hat than their darker counterparts, and rates of sunscreen and/or hat use during leisure and work were not found to increase with the amount of time spent in the sun. Almost 75% of sunscreen users were using a sun protection factor of at least 15. Parents reported much higher rates of regular sunscreen and hat use by their young children than by themselves, with 87% of children under 12 years of age reported to be using sunscreen and 78% reported to be wearing a hat. The great majority knew that injudicious sun exposure is associated with skin cancer and skin ageing, but 48% were still regarding a suntan achieved without skin burning as 'healthy' The mass media was by far considered to be the main source of information for the general public regarding effects of the sun on the skin. CONCLUSIONS: The positive impact of past campaigns can be seen in the high reported rates of sun protection in children. However, much remains to be done with adults in order to change their attitude about a 'healthy suntan' and to convince them that it is worthwhile to protect themselves from the sun.     

The ABCs of sun protection for children

Excessive sun exposure in childhood is a critical variable influencing skin cancer risk. Nurses must teach parents how to properly protect their children from excessive sun exposures by demystifying UV radiation and teaching proper sun-protection measures. Protecting children from excessive sun exposure, while not curtailing recreation, should be the goal of all nurses caring for children.     

Evaluation of sun awareness with an emphasis on ultraviolet protection by clothing: A survey of adults in Western Germany

Background Little is known about the sun habits of the population in Germany. Objective We aimed to assess the sun awareness and notion on ultraviolet (UV) radiation protection by fabrics in adult subjects from North Rhine‐Westphalia in Germany. Methods During regular skin cancer screening campaigns, 1206 subjects completed and returned a structured questionnaire on constitutional parameters and the respondents’ sun habits. Results Staying in the shade and the use of high‐factor sunscreens are the most commonly performed sun‐protective measures reported by the respondents. Males and lower‐educated people use clothing in conjunction with sunscreens more infrequently. Most respondents, particularly females, know that sun protection provided by clothing is variable. However, the elderly more frequently consider sun protection by clothing as excellent. Notably, more than two‐thirds of the respondents would prefer clothing with a labelled ultraviolet protection factor. The respondents of this survey mainly considered baby wear, children wear, and leisure wear for sun‐protective clothing, whereby light‐weighted, breathable, natural fabrics preferably made of cotton and linen were the most frequently reported protective textiles. Conclusions Given the lack of epidemiological observations on people's sun habits and protection in Germany, the present relatively large survey provides useful information and implications for counselling in sun protection and marketing of UV‐protective clothing.     

Occupational skin cancer induced by ultraviolet radiation and its prevention

Skin cancer is by far the most common kind of cancer diagnosed in many western countries and ultraviolet radiation is the most important risk factor for cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). Although employees at several workplaces are exposed to increased levels of UV radiation, skin cancer due to long-term intense occupational exposure to UV radiation is often not considered as occupational disease. The actually available evidence in the epidemiological literature clearly indicates that occupational UV radiation exposure is a substantial and robust risk factor for the development of cutaneous SCC and also clearly shows a significant risk for developing BCC. There is enough scientific evidence that outdoor workers have an increased risk of developing work-related occupational skin cancer due to natural UV radiation exposure and adequate prevention strategies must be implemented. The three measures which are successful and of particular importance in the prevention of nonmelanoma skin cancer in outdoor workers are changes in behaviour regarding awareness of health and disease resulting from exposure to natural UV radiation, protection from direct UV radiation by wearing suitable clothing, and regular and correct use of appropriate sunscreens.     

Sun protection policies in Miami-Dade County public schools: opportunities for skin cancer prevention

Childhood exposure to ultraviolet radiation from the sun and a history of sunburns are risk factors for skin cancer. Because children spend time outdoors when they are at school, school sun protection policies are an important health issue, particularly in areas of the country with year-round warm and sunny climates, such as Florida. To better understand the sun protection policies and practices in South Florida schools, a sample (n = 51) of elementary and middle schools in Miami-Dade County public schools were surveyed as part of a CDC-funded cancer control program at the University of Miami. Of the principals and teachers surveyed, most (78%) knew about the county school system's guidelines for avoiding excessive heat exposure, which include two sun protection measures. Two-thirds reported that they shared these guidelines with teachers; 21% shared them with parents. Few schools monitor implementation of the guidelines, although 70% schedule outdoor activities to avoid peak sun hours. No schools required sunscreen, hats, or protective clothing. Physical education teachers and students spend an average of 4.5 and 0.6 hours per day outdoors, respectively. Improved school sun protection policies and monitoring of such policies is needed to reduce sun exposure and skin cancer risk for both students and staff.     

Realidades y retos de la fotoprotección en la infancia

One of the main goals of all skin cancer prevention campaigns is to protect children from ultraviolet radiation. However, little is known about how sun exposure risks differ between adults and children or about how these risks are best managed. Children's skin is more susceptible to sun damage for a number of reasons, including certain anatomical and functional aspects in children under 2 years of age and habits that predispose to greater sun exposure during the first 2 decades of life. Oil-based emulsions containing inorganic filters appear to be safest sunscreens for children, although the addition of certain organic filters is necessary to achieve a sun protection factor of 50. Oxybenzone, and probably also octocrylene, should be avoided in sunscreens for children. Sunscreen use should be part of an overall sun protection strategy that includes avoidance of exposure to midday sun and the use of protective clothing and hats.The above considerations justify the implementation of primary prevention campaigns focused on sun protection education for children and the continuation of basic and epidemiological research into specific sun protection strategies and sunscreens for each age group.     

Good,but Not Perfect: Parental Knowledge About Risk Factors for Skin Cancer and the Necessity of Sun Protection in Southern Germany

The level of knowledge and awareness of skin cancer risks in parents of young children is largely unknown. The Erlangen Kindergarten study, which enrolled 3,129 parents of 3‐ to 6‐year‐old children in southern Germany, addressed this. The population‐based survey found an overall high level of knowledge about skin cancer risks and strong support for the necessity of sun protection but identified two areas (role of intermittent sun exposure, sun protection on cloudy summer days) offering a target for improvement in future public health campaigns.     

Ultraviolet radiation in alpine skiing: magnitude of exposure and importance of regular protection

BACKGROUND: Participation in outdoor alpine sports has been increasing over the last decade. Ultraviolet exposure levels for these activities can be extreme owing to the venue altitudes. The purpose of this study was to measure the levels of UV-A and UV-B radiation exposure incurred by performance skiers in a typical alpine venue and to determine the need for protection in that environment. OBSERVATIONS: Total UV-B exposure ranged from 12 to 185 mJ/cm(2) (0.5-7.6 times the minimum erythemal dose [MED] for individuals with type II skin). Ten percent of subjects received more than 1 MED/h at peak exposure times. Daily UV-A exposure ranged from 10.6 to 28 J/cm( 2) (daily average, 0.55 minimum melanogenic dose). CONCLUSIONS: Alpine skiers with skin types I and II are exposed to measurable erythemal and suberythemal levels of UV radiation repeatedly over the long term at levels that can cause photodamage to their skin and potentially increase their later risk for skin cancer. Programs should be developed to educate skiers regarding the need for UV protection. Given the high levels of exposure noted, skiers should use UV protective measures, including sun-protection factor 30 broad-spectrum sunscreen.     

Outdoor activities in childhood: a protective factor for cutaneous melanoma? Results of a case–control study in 271 matched pairs

BACKGROUND: A matched case-control study was performed in Munich, Germany, in 1996-97 to evaluate the risk of cutaneous melanoma due to ultraviolet (UV) exposure behaviour in Southern Bavaria, Germany. OBJECTIVES: Patients with cutaneous melanoma and controls were investigated by two physicians using a standardized questionnaire to identify risk factors for the development of melanoma, such as professional and leisure sun exposure behaviour. In each person, a total body examination was performed to detect benign skin alterations, phenotypic characteristics and precursor lesions for skin cancer. PATIENTS/METHODS: A total of 271 melanoma patients and 271 controls were individually matched for residence, age and gender. A multiple conditional logistic regression analysis was performed. RESULTS: Of 56 factors, those risk factors with a strong effect on the development of melanoma were: the existence of melanoma in first degree relatives, solar lentigo, actinic keratosis, actinic cheilitis, skin phototype, immediate skin reaction to UV light at the start of the outdoor season, sunburn in childhood and sun exposure during holidays in sunny areas 20 years before melanoma was diagnosed; outdoor activities in childhood were found to be protective. CONCLUSIONS: Sunburn in childhood and increased sun exposure during annual holidays in sunny areas should be avoided. In contrast, outdoor activities in childhood, including soccer and gardening, should be encouraged because they are associated with a lower risk of melanoma formation.     

Extreme UV exposure of professional cyclists

BACKGROUND: The most important risk factor for the development of melanoma and non-melanoma skin cancer is thought to be ultraviolet (UV) radiation. To date there is no quantification of the UV exposure of outdoor sports professionals training and competing at high solar UV levels. METHODS: During eight stages of the 'Tour de Suisse' cycling race, the UV exposure of 6 professional cyclists was monitored with Bacillus subtilis spore film dosimeters. RESULTS: The measurements showed a personal UV exposure between 0.2 minimal erythema dose (MED) during the prologue and 17.2 MED during a mountain stage. The mean daily personal exposure of all full stages (prologue excluded) was 8.1 MED. The personal exposure level determined during these races exceeded international exposure limits by more than 30 times. CONCLUSION: Therefore UV exposure of sports professionals should be limited by application of sun screens, protective clothing and training/competition at low insolation.     

Light protection: principles of UV protection

UV radiation is responsible for the induction of epithelial and melanocytic skin cancer, photoaging, and photodermatoses. UV protection is necessary to prevent damage caused by non-physiologic exposure. UV protection includes not only reduction of sun exposure but also use of sun protective filters, UV protective clothes, DNA repair enzymes, and antioxidant supplementation. Consumers are uncertain about the possibilities and limitations of commercial sun protection measures. Dermatologists must explain protective measures to the general public which continues to believe that UV-tanned skin is healthy. The sunscreen market is a highly competitive but lucrative market. The range of products with different designations and promises makes difficult for both consumers and dermatologists to determine what is sensible UV protection.     

Lichtschutz

UV radiation is responsible for the induction of epithelial and melanocytic skin cancer, photoaging, and photodermatoses. UV protection is necessary to prevent damage caused by non-physiologic exposure. UV protection includes not only reduction of sun exposure but also use of sun protective filters, UV protective clothes, DNA repair enzymes, and antioxidant supplementation. Consumers are uncertain about the possibilities and limitations of commercial sun protection measures. Dermatologists must explain protective measures to the general public which continues to believe that UV-tanned skin is healthy. The sunscreen market is a highly competitive but lucrative market. The range of products with different designations and promises makes difficult for both consumers and dermatologists to determine what is sensible UV protection.