**7. Sun protection education**

Social perceptions and miscommunications about the dangers of UVR exposure contribute to the continued incidence of sunburns and skin cancer. The message that sun safety should be practiced daily is not widely followed, as evident by the fact that people are more likely to follow skin protection methods while on vacation or at the beach than when participating in other outdoor recreational activities [19]. Intentional unprotected sun exposure for cosmetic purposes is prominent in young adults because of the perception that tanned skin is more attractive [48]. About 50% of people in the U.S. between the ages of 18 and 24 years old report having a sunburn in the last year, compared to about 35% of people over the age of 25 who reported having a sunburn in the last year [25]. This is coincides with the tendency for young people to expose themselves to solar and artificial UVR for tanning. Over one million people go to tanning salons on an average day in the United States [34], and most are under the age of 25 [25]. This risky behavior may contribute to melanoma being the second most common cancer in young adults between the ages of 15 and 29 years old [4]. In 2004, it was found that 69% of youths between the ages of 11 and 18 reported in a cross-sectional study survey that they had been sunburned that summer [19]. Summertime sunburns should not be taken lightly or treated as a normal occurrence. The risk of developing melanoma more than doubles for individuals who report having five or more severe sunburns during adolescence [19]. A study by the University of Miami on sun protection behavior in high school students found that white-Hispanics were not likely to use sunscreens, more than twice as likely to go tanning, and generally did not believe that they had a risk of getting skin cancer compared to white non-Hispanics [23]. This is an example of the need to educate young adults and teenagers who are unaware of the health risks associated with sun exposure.

enzymes required to make calcitriol. It is suggested that when vitamin D levels are high local production of calcitriol keeps cell proliferation in check and reduces risk of carcinogenesis [46]. Thus, it is speculated that vitamin D production in the skin is protective and sunscreen use

There is almost no evidence supporting the idea that the vitamin D deficiency epidemic is correlated to the overuse of sunscreen [48]. Sunscreen use may diminish photosynthesis of vitamin D, but it is not necessary or recommended to obtain vitamin D from intentional sun exposure. To maximize cutaneous synthesis of vitamin D, individuals would have to expose themselves to sunlight for the amount of time required to achieve one third of their MED, meaning the skin would incur damage to make vitamin D. Incidental sun exposure for 10-20 minutes on skin protected with SPF 15 or greater sunscreen could maximize cutaneous vitamin D synthesis while protecting the skin because sunscreen does not block all UV [48]. While some people find the idea of synthesizing their own vitamin D through intentional sun exposure holistic and appealing, the better option is to continue protecting skin from solar UVR with sunscreen and protective clothing, and to obtain vitamin D from dietary sources and incidental protected sun exposure. A variety of foods including milk, bread, cereal, yogurt, and multi‐ vitamins are fortified with vitamin D in the United States and are good alternatives to intentional exposure to sunlight. The use of indoor tanning beds to increase vitamin D levels

Populations susceptible to vitamin D deficiency are the eldery, people with darkly pigmented skin, breastfed infants, and obese people. The suggestion that elderly and darkly pigmented populations intentionally expose themselves to UVR is not a good solution because these susceptible populations generally have poor cutaneous vitamin D synthesis. The ability to photosynthesize vitamin D in the skin decreases with age because there is less 7-dehydrocho‐ lesterol in the skin. People with darkly pigmented skin have increased melanin in the epider‐ mis that inhibits cutaneous vitamin D synthesis [2, 46, 48]. It does not make sense for the elderly or people with darkly pigmented skin to intentionally expose themselves to sunlight to make vitamin D since the process is inefficient in their skin. Rather, they should take dietary supplements and incorporate foods fortified with vitamin D. Obesity is also a risk factor for deficiency of vitamin D. Vitamin D3 is stored deep in the body fat of obese individuals and is not readily bioavailable to them during winter months, so they can only mobilize about half the amount of vitamin D3 as persons with healthy weights [46]. Human breast milk contains less than 78 IU vitamin D per liter so it is recommended that infants also receive vitamin D supplementation [47]. Infants should not be exposed to solar UV to increase vitamin D synthesis [2]. Dietary supplementation with vitamin D is the best option for all people, especially those with reduced ability to synthesize and maintain vitamin D levels in their body.

Social perceptions and miscommunications about the dangers of UVR exposure contribute to the continued incidence of sunburns and skin cancer. The message that sun safety should be

diminishes protection by inhibiting vitamin D synthesis.

is not advised [4, 48, 50].

224 Highlights in Skin Cancer

**7. Sun protection education**

Physicians play in important role in educating patients about sun protection. Primary care physicians should actively promote broad spectrum sunscreen use, and review proper application techniques with patients to reduce sunburn. They should educate patients about the use of sunscreen as an adjunct to the other sun protection methods, and warn patients not to use sunscreen as a tool for prolonging sun exposure because that behavior increases the risk of sunburn [19, 26]. They could point patients towards many informative public education websites about sun protection and skin cancer prevention that are available from government and non-profit organizations.

Skin cancer prevention awareness is spreading with the help of government organizations, such as the National Institutes of Health and National Council on Skin Cancer. Increasing numbers of advertisements for skin cancer prevention are seen on television, heard on the radio, and posted in public places. Major awareness advocates, programs, and campaigns include the SunSmart campaign in Australia and the United Kingdom, the European Skin Cancer Foundation, the SunAWARE non-profit educational organization in the U.S., the USEPA SunWise program, American Academy of Dermatology, the Skin Cancer Foundation in the U.S., and the American Cancer Society. These groups and programs aim to educate the public about skin cancer and encourage multi-step behavioral modifications to reduce the risk of developing skin cancer. The SunAWARE organization uses AWARE as an easy acronym to help people remember the steps of sun protection (figure 3). Skin cancer incidence rates have been stabilizing when compared to the rapid increases seen before the rise in establishment of government-sponsored sun protection programs [19]. The message is starting to be heard, as evident by an overall increase in adult sunscreen use between 2005 and 2010 [25]. Sun safety

awareness is encouraged by campaigns such as national "Don't Fry Day" that takes place on the Friday before Memorial Day in the U.S. and is supported by the National Council on Skin Cancer and SunWise program [5, 51].

"**Sun Protection Measures**. Spending time in the sun increases your risk of skin cancer and early skin aging. To decrease this risk, regularly use a sunscreen with a Broad Spectrum SPF of 15 or higher and other sun protection measures including: • limit time in the sun, especially

Skin Cancer Prevention Strategies http://dx.doi.org/10.5772/55241 227

Previous labeling requirements were confusing and misleading about water resistance. Sunscreens resistant to water must be called "water resistant" and not "waterproof" because there is a limit to the amount of time that they are effective on wet skin. Likewise, the term "sweatproof" is also not permitted. Previous labeling indicating that a sunscreen was "water resistant" or "very water resistant" did not clearly differentiate between the two. It is now required that the label state how much time can be spent in the water, for example "water resistant (40 minutes)" or "water resistant (80 minutes)" is very clear about the duration of protection. Emphasis on the duration of water resistance encourages re-application of the

Screening for skin cancer is an effective means of secondary prevention. There is a good chance that skin cancer is curable when detected early enough. Simple excision of the lesion that can be performed as an outpatient procedure by a dermatologist is an effective means of removing the cancer and increasing survival [17]. Designated skin cancer screening days help to identify malignant lesions before they progress to more dangerous stages. Organ‐ ized skin cancer screenings in Germany have resulted in a 50% reduction in melanoma mortality in the screened population, indicating the usefulness and success of mass skin

It is predicted that 40-50% of Americans will have non-melanoma skin cancer at least once before the age of 65 [25]. The lifetime accumulation of skin damage contributes to the devel‐ opment of skin cancer. Skin damage incurred by natural and artificial UVR affects cellular proteins, cell signaling, damages DNA, suppresses the ability of the immune system to detect cancer cells, causes tissue damage, and cell death. Fortunately, melanoma and non-melanoma skin cancers can be prevented by reducing exposure to UVR through a number of behavioral practices. These practices include avoiding excess UV exposure, applying adequate amounts of broad spectrum sunscreen with SPF of 15 or greater and remembering to reapply when necessary, wearing protective clothing including hats and sunglasses, seeking shade, avoiding cosmetic tanning, acquisition of vitamin D from dietary sources rather than intentional UV exposure, and routinely checking the body for suspicious growths on the skin. Dietary intake of phytochemicals and antioxidants has been shown to provide systemic protection from erythema and is a good addition to the recommended sun protection program. Many of these photoprotective compounds are currently included in sunscreen formulations for added protection. It is strongly encouraged that all individuals regardless of ethnicity or skin type follow these sun protection measures to reduce skin cancer risk. Public education through awareness programs is critical for correcting social perceptions and teaching sun protective

from 10 a.m. - 2 p.m. • wear long-sleeved shirts, pants, hats, and sunglasses" [1]

sunscreen at appropriate time intervals [1].

cancer screenings [6].

**8. Conclusion**

behaviors.

**Figure 3.** Sun protection advice displayed on SunAWARE website using the acronym AWARE. http://www.suna‐ ware.org/be-sunaware/

Product labeling is another means for providing specific information on how to protect the skin. Sunscreen labels are strictly regulated by the USFDA. In the most recent law passed on sunscreen labeling in 2011, known as the "final rule", the USFDA required a new indication statement, simpler labeling, and clearer instructions for the usage of water resistant sunscreen [1]. Instead of indicating protection against UVA and/or UVB, labels are required to state "broad spectrum" to simplify the choice for consumers. The effectiveness rating of the sunscreen must be listed next to the broad spectrum phrase in the same size and style font to encourage consumers to look for broad spectrum sunscreens with a high SPF rating. To teach consumers that broad spectrum sunscreens with SPF 15 and greater are more protective when combined with other sun protection measures than sunscreens with low SPF that are not broad spectrum, the following indication statement is required on all broad spectrum SPF 15 and greater sunscreens:

"**Sun Protection Measures**. Spending time in the sun increases your risk of skin cancer and early skin aging. To decrease this risk, regularly use a sunscreen with a Broad Spectrum SPF of 15 or higher and other sun protection measures including: • limit time in the sun, especially from 10 a.m. - 2 p.m. • wear long-sleeved shirts, pants, hats, and sunglasses" [1]

Previous labeling requirements were confusing and misleading about water resistance. Sunscreens resistant to water must be called "water resistant" and not "waterproof" because there is a limit to the amount of time that they are effective on wet skin. Likewise, the term "sweatproof" is also not permitted. Previous labeling indicating that a sunscreen was "water resistant" or "very water resistant" did not clearly differentiate between the two. It is now required that the label state how much time can be spent in the water, for example "water resistant (40 minutes)" or "water resistant (80 minutes)" is very clear about the duration of protection. Emphasis on the duration of water resistance encourages re-application of the sunscreen at appropriate time intervals [1].

Screening for skin cancer is an effective means of secondary prevention. There is a good chance that skin cancer is curable when detected early enough. Simple excision of the lesion that can be performed as an outpatient procedure by a dermatologist is an effective means of removing the cancer and increasing survival [17]. Designated skin cancer screening days help to identify malignant lesions before they progress to more dangerous stages. Organ‐ ized skin cancer screenings in Germany have resulted in a 50% reduction in melanoma mortality in the screened population, indicating the usefulness and success of mass skin cancer screenings [6].
