**1. Introduction**

The prevalence of skin cancer varies greatly according to the geographic location and is developing rapidly in Western countries. This type of cancer is most frequent in fair-skinned people. In Australia, the rate of melanomas increased annually by 6.3% in men and 2.9% in women between 1959 and 1985. This type of cancer is the most frequent one in fair-skinned people. Since 1985, the rate has levelled off, which is reassuring even though the incidence of skin cancer in Australia is the highest in the world [1] (table 1) [2], followed by New Zealand and Norway [3]. As a comparison, we can look at the rate of non-melanoma skin cancer (NMSC) in Japan, which is between 1.2 and 5.4 per 100,000, that is to say a factor of 50 compared to Australia [4]. Skin cancer in children is rare. In teenagers (from 15 to 19 years old) the prevalence in England is 10 cases per million per year for melanomas and 24 cases per million per year for NMSC. The risk factors are: a family history of melanomas, *Xeroderma pigmento‐ sum* [5] and pathologies responsible for states of immunosuppression. Cases of congenital melanomas are extremely rare [6]. Excessive sun exposure has long been recognised as the most important environmental factor to be taken into account; indeed, ultra-violet radiation (UV) is the cause of 90% of NMSC and 67% of melanomas [7]. The high incidence of skin cancer in certain countries of the world is therefore not just down to chance but has a direct link to the population's skin type (fair-skinned, blue-eyed people who burn easily, who never tan and who often have freckles) [8] and to the level of sunshine [9]. Although UV rays only represent 3% of the total radiation which reaches Earth, from a point of view of energy, it is thought that they account for 10% of light energy [10]. Mountainous regions bring a greater risk of devel‐ oping sunburn, as the quantity of UVB increases by 4% every 300 metres [11], and in a similar way, the position with relation to the equator is of utmost importance, (the risk is greatest around the Tropics). UV radiation (UVA and B) causes alterations in DNA by either direct or indirect actions (by means of an oxidizing stress). The types which react to oxygen can cause either an increase in cell proliferation or their apoptosis, accordingly [12]. The notion of

© 2013 Couteau and Coiffard; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

phototypes, put forward by Fitzpatrick as early as 1975 within the framework of the care of patients treated with PUVA therapy, is linked to the concept of sun-reactive skin. This scale enables Caucasian subjects to be classed according to their sensitivity to UV rays. At first, 4 phototypes were established, called I, II, III and IV (Table 2), then this scale was later extended to include phototypes V (brown skin or Asian skin) and VI (black) [13]. A classification concerning Japanese people was also drawn up by Kawada [14]. The three corresponding groups are JI (always burn and rarely tan), JII (burn and tan moderately), JIII (never burn and always tan). These three groups should be linked to the Caucasian phototypes II, III and IV [15]. In the 1990s, JP Césarini introduced the notion of melano-compromised subjects (Photo‐ types I and II), melanocompetent subjects (Phototypes III and IV) and melanoprotected subjects according to their varying capabilities to protect themselves against skin cancer [16]. The best level of photoprotection is reached by black subjects, who are shown to have a low incidence of skin cancer (1 to 2% of cancers affecting black people are skin cancers compared to 20 to 30% for Caucasians). The phototypes are linked to melanin, which is a biopolymer functioning as a filter and which enables black people to produce an SPF (Sun Protection Factor) of around 13. The dispersion of melanosomes and their lack of degradation throughout the keratinization process forms an effective barrier. A black person's melanin filters twice as much UVB radiation as a Caucasian's melanin. The black epidermis is much more protected than a Caucasian one, as it transmits 7.4% of UVB radiation and 17.5% of UVA radiation compared to 24 and 55% for a Caucasian epidermis. In terms of Minimal Erythemal Dose (MED), it can be observed that this dose is between 6 and 33 times higher in black subjects [17]. It is important to create new classifications on a regular basis because of the interbreeding of races in the population. For example, in 1990, the US Census Bureau registered 6 races and 23 sub-types in the United States; 10 years later, the Census Bureau still counted 6 categories, but the number of sub-types had increased to 67, creating a multiplicity of sensitivities to the sun [18]. It seems that precautions taken by people who work outside to protect themselves from the sun are related to their phototype, as an American study shows that fair-skinned people are more aware in this respect [19]. The current way of life in industrialized countries goes hand in hand with an increase in the frequency of the length of exposure to the sun during leisure time. Contrary to previous centuries where pale skin tones were all the rage, the fashion of having a sun-tan, which began in the Thirties, is still current. The SUVIMAX study which was conducted in France in 1994 showed that in the cohort of 7,822 subjects questioned, 196 (110 women and 86 men) had travelled to a country with high levels of sunshine (high UV index) within the previous year and for a period of at least one month. Women, in particular, appear to be most concerned with daily exposure to sunshine (more than 2 hours per day) and admit that "getting a tan" is very important for them [20]. Sunbathing is still popular. Professor Dubertret is pessimistic and considers that if nothing is done in the way of prevention campaigns, the rate of skin cancer will double every ten years and a child born in 2000, if he behaves in the same way as his parents regarding his exposure to the sun, will have a 1 in 75 risk of developing a melanoma and a 1 in 7 risk of developing basocellular cancer [21]. The behavior of young Europeans tends towards improvement. Indeed, an increase in the use of sun products throughout exposure can be observed. In 10 years (between 1990 and 2000), the use of sun products increased from 52 to 63% in boys and from 80 to 87% in girls. It is a pity

that a minority is still so resistant to using sun products [22]. On the other hand, young Australians (from 12 – 17 years old) largely ignore prevention campaigns and the use of sun products decreased between 1993 and 2000 (going from 54 to 36% for teenagers in general and from 73 to 50% for girls in particular) [23]. A second more optimistic study praises the SunSmart television advertising campaign, which seems to be bearing fruit [24]. Indeed, the slogans are well-chosen and are likely to bring about a change of attitude; as proof: « Leave your hat on » (1991 – 1992), « How to remove a skin cancer » (1996 – 1998) and « No tan is worth dying for: Clare Oliver » (2008). In short, depending on the panels and on the authors, opinions differ [25]. The fact remains that young people in general, and more particularly young Americans (from the south of the USA) are stubborn and are still fond of exposing themselves to the sun. Sunburn at the end of the weekend is not uncommon [26]. A lot of efforts still have to be made, as only 1/3 of parents questioned say that they prefer activities for their children which avoid exposure to the sun and confirm that they apply sun products whilst doing beach-based activities [27]. Public awareness campaigns are necessary, as childhood is a key stage and it is important to understand that people who do not want to use sun products whilst continuing to expose themselves to the sun, do so for aesthetic reasons, in order to have a tan [28]. We set out, therefore, to present a method for topical skin protection: the use of sun products.

About Suncare Products http://dx.doi.org/10.5772/55411 129

**Countries Prevalence**

France 7/100000

Sweden 11/100000

Australia 50/100 000

**Table 1.** Prevalence of skin cancers - 1995 [2]

**Table 2.** Phototypes according to the Fitzpatrick classification

US 14/100000

**Phototypes Sensitivity to sunlight**

I Always burns, never tans

II Burns easily, tans minimally

III Burns moderately, tans gradually to light brown

V Rarely burns, tans profusely to dark

VI Never burns, deeply pigmented

IV Burns minimally, always tans well to moderately brown

that a minority is still so resistant to using sun products [22]. On the other hand, young Australians (from 12 – 17 years old) largely ignore prevention campaigns and the use of sun products decreased between 1993 and 2000 (going from 54 to 36% for teenagers in general and from 73 to 50% for girls in particular) [23]. A second more optimistic study praises the SunSmart television advertising campaign, which seems to be bearing fruit [24]. Indeed, the slogans are well-chosen and are likely to bring about a change of attitude; as proof: « Leave your hat on » (1991 – 1992), « How to remove a skin cancer » (1996 – 1998) and « No tan is worth dying for: Clare Oliver » (2008). In short, depending on the panels and on the authors, opinions differ [25]. The fact remains that young people in general, and more particularly young Americans (from the south of the USA) are stubborn and are still fond of exposing themselves to the sun. Sunburn at the end of the weekend is not uncommon [26]. A lot of efforts still have to be made, as only 1/3 of parents questioned say that they prefer activities for their children which avoid exposure to the sun and confirm that they apply sun products whilst doing beach-based activities [27]. Public awareness campaigns are necessary, as childhood is a key stage and it is important to understand that people who do not want to use sun products whilst continuing to expose themselves to the sun, do so for aesthetic reasons, in order to have a tan [28]. We set out, therefore, to present a method for topical skin protection: the use of sun products.


**Table 1.** Prevalence of skin cancers - 1995 [2]

phototypes, put forward by Fitzpatrick as early as 1975 within the framework of the care of patients treated with PUVA therapy, is linked to the concept of sun-reactive skin. This scale enables Caucasian subjects to be classed according to their sensitivity to UV rays. At first, 4 phototypes were established, called I, II, III and IV (Table 2), then this scale was later extended to include phototypes V (brown skin or Asian skin) and VI (black) [13]. A classification concerning Japanese people was also drawn up by Kawada [14]. The three corresponding groups are JI (always burn and rarely tan), JII (burn and tan moderately), JIII (never burn and always tan). These three groups should be linked to the Caucasian phototypes II, III and IV [15]. In the 1990s, JP Césarini introduced the notion of melano-compromised subjects (Photo‐ types I and II), melanocompetent subjects (Phototypes III and IV) and melanoprotected subjects according to their varying capabilities to protect themselves against skin cancer [16]. The best level of photoprotection is reached by black subjects, who are shown to have a low incidence of skin cancer (1 to 2% of cancers affecting black people are skin cancers compared to 20 to 30% for Caucasians). The phototypes are linked to melanin, which is a biopolymer functioning as a filter and which enables black people to produce an SPF (Sun Protection Factor) of around 13. The dispersion of melanosomes and their lack of degradation throughout the keratinization process forms an effective barrier. A black person's melanin filters twice as much UVB radiation as a Caucasian's melanin. The black epidermis is much more protected than a Caucasian one, as it transmits 7.4% of UVB radiation and 17.5% of UVA radiation compared to 24 and 55% for a Caucasian epidermis. In terms of Minimal Erythemal Dose (MED), it can be observed that this dose is between 6 and 33 times higher in black subjects [17]. It is important to create new classifications on a regular basis because of the interbreeding of races in the population. For example, in 1990, the US Census Bureau registered 6 races and 23 sub-types in the United States; 10 years later, the Census Bureau still counted 6 categories, but the number of sub-types had increased to 67, creating a multiplicity of sensitivities to the sun [18]. It seems that precautions taken by people who work outside to protect themselves from the sun are related to their phototype, as an American study shows that fair-skinned people are more aware in this respect [19]. The current way of life in industrialized countries goes hand in hand with an increase in the frequency of the length of exposure to the sun during leisure time. Contrary to previous centuries where pale skin tones were all the rage, the fashion of having a sun-tan, which began in the Thirties, is still current. The SUVIMAX study which was conducted in France in 1994 showed that in the cohort of 7,822 subjects questioned, 196 (110 women and 86 men) had travelled to a country with high levels of sunshine (high UV index) within the previous year and for a period of at least one month. Women, in particular, appear to be most concerned with daily exposure to sunshine (more than 2 hours per day) and admit that "getting a tan" is very important for them [20]. Sunbathing is still popular. Professor Dubertret is pessimistic and considers that if nothing is done in the way of prevention campaigns, the rate of skin cancer will double every ten years and a child born in 2000, if he behaves in the same way as his parents regarding his exposure to the sun, will have a 1 in 75 risk of developing a melanoma and a 1 in 7 risk of developing basocellular cancer [21]. The behavior of young Europeans tends towards improvement. Indeed, an increase in the use of sun products throughout exposure can be observed. In 10 years (between 1990 and 2000), the use of sun products increased from 52 to 63% in boys and from 80 to 87% in girls. It is a pity

128 Highlights in Skin Cancer


**Table 2.** Phototypes according to the Fitzpatrick classification
