Sun protection

Limit sun exposure and use an effective suncream to protect skin - remember 'slip, slap and slop' Sun protection

 

Key Messages

Over exposure to sunlight is a major cause of skin cancer. A tan is not a sign of health - it is a visible sign of sun damage. 
Use effective, high factor sun protection - sun creams with sun protection factor (SPF) of 30 or above and 4 or 5 star UVA protection
The greatest risk is when the sun is high in the sky (around noon). Limit sun exposure between 11am and 3pm. The sun’s rays are strongest in countries near the equator and at high altitude. Snow can also increase sun exposure by reflecting UV rays
Children should be protected with high factor sun cream, clothes, hats, and sun shelters. Babies under six months should NEVER be left in direct sunlight:
  • Slip on a t-shirt
  • Slop on some sun cream
  • Slap on a hat
Urgent medical advice should be sought for any changes to moles: such as bleeding, itching, increases in size and changes in shape.

Overview

A tan is a goal for many travellers. However, prolonged, unprotected sun exposure harms skin. While many people associate a tan with looking healthy, a tan is actually a sign that skin has been injured by ultraviolet (UV) radiation and is trying to protect itself. This damage increases risk of skin cancer developing. Sunburn (skin redness) and heavy tans are harmful and can never be justified (1).

All travellers are at risk of the harmful effects of the sun, including those with darker skin. Those at greater risk include babies, young children and immunosuppressed individuals (those with a weakened immune system). Certain medicines, including some cancer treatments, increase vulnerability to sun damage.

The sun damages skin by exposing it to UVA rays and UVB rays, two different forms of UV radiation - both can cause cancer [2]. Sand, snow and water reflect UV light and can amplify this exposure. Approximately 90-99 percent of UV radiation reaching the earth is UVA and up to 10 percent is UVB [3].

It is often thought that only fair skinned people are at risk from sun damage. However, this is not the case. Whilst dark skin has more protective melanin pigment and skin cancer is less common in people with darker skin, it is reported.  Unfortunately, as skin cancer is often detected at a later stage in people with darker skin, it can be more dangerous [4].

UV radiation is affected by:

Altitude

At higher altitudes, a thinner atmosphere filters less UV radiation. 

Cloud cover and wind

Burning is possible on cool, cloudy days, as the water content in clouds does not absorb UV radiation in the way it absorbs heat. A cool wind is falsely reassuring as UVB levels remain unchanged on windy days.

Time of day

Ideally sun exposure should be limited between 11am and 3pm (local time) when the sun is usually at its strongest.

Reflection

Sand and snow reflect UV radiation, increasing risk of sunburn. Rippling water and rough seas reflect more UVB radiation than calm water.

Season

UVA and UVB levels can vary greatly between winter and summer in areas such as northern Europe [5]. However, they are consistently high all year round in tropical and sub-tropical countries near the equator. 

Effects of UV radiation

Some UV radiation is reflected by the skin’s surface, but the majority will penetrate the skin. It then passes into tissues and can be absorbed by certain molecules, including deoxyribonucleic acid (DNA).

Tanning

UVA radiation stimulates melanin pigment production in the upper skin cell layers, making it tan. UVB radiation leads to a dark and longer-lasting tan. It also stimulates skin cells to produce a thicker epidermis (the outer layer of skin) to protect against further damage [5].

Sunburn 

When UVB penetrates deep skin layers, it is absorbed by DNA and cell damage occurs. As a result, cells try to repair themselves by releasing chemicals [1]. Sunburn is a visible reaction, causing redness, heat and pain. Sometimes the damage is so severe that cells die, causing blistering, swelling and weeping. Fluids and pain relief can help relieve symptoms.

Sun cream absorbs UV light, but is not 100% protective.

Photo-ageing 

Photo-ageing is long-term skin damage from both UVA and B radiation. The skin’s structure deteriorates; resulting in dryness, roughness and thickening. Sometimes skin also becomes thin and fragile. 

Skin cancers 

One in every three cancers diagnosed worldwide is a skin cancer [6].

Those at higher risk of skin cancer are:

  • People with fair skin that burns easily
  • Anyone with a personal or family history of skin cancer
  • People with lots of moles (more than 50)
  • Anyone being treated with immunosuppressive drugs [1].

Skin cancers are divided into non-melanoma skin cancers (NMSC) and melanomas. NMSC include basal cell and squamous cell carcinomas. UV radiation is the major reason that people develop skin cancer [7].

Skin cancers occur when cells undergo malignant transformation due to UV radiation damage to their DNA. These cells reproduce independently and can spread to neighbouring tissues or spread via the bloodstream to the body’s major organs.

Skin cancers are usually treated with surgery, although sometimes radiotherapy or chemotherapy is needed too.

Non- melanoma skin cancers (NMSC)

Between two to three million cases of NMSC occur worldwide each year [6]. There were around 780 NMSC skin cancer deaths in the UK in 2014, that’s around 2 deaths every day [7]. NMSC can be painful and disfiguring and are usually found on body parts more exposed to the sun: arms, ears, face and neck.

There are no UK statistics available for survival rates of people with NMSC skin cancer [9]. 

Basal cell skin cancer

Basal cell carcinoma is the most common NMSC accounting for 80 percent of all cases [10]. Doctors can almost always cure basal cell skin cancers and it is extremely rare for it to spread to another area of the body [9,10]. It can cause disfigurement and presents as slow growing pearly papules or nodules and often has a rolled edge [10].

Squamous cell skin cancer

Squamous cell carcinoma is less common, but potentially more serious than basal cell carcinoma. This tumour typically presents as a firm, slightly tender, persistent nodule on sun-damaged skin. Doctors can cure most people with squamous cell skin cancer. A small number of people might have squamous cell cancer that has spread to the lymph nodes or to other parts of the body. This may still be cured [9].

Melanomas

Malignant melanomas are the most serious form of skin cancer. 15, 459 people in the UK were diagnosed with malignant melanoma skin cancer in 2014, with 2,459 malignant melanoma deaths reported in the UK in 2014 [8]. Malignant melanoma is less common than NMSC [7].

The link between sun exposure and melanoma is not clearly understood. Melanomas can occur on areas of the body not usually exposed to sun, including palms of the hand and soles of the feet [11]. Intermittent exposure to strong sunlight causing sunburn is thought to be a risk factor [12]. Treatment is surgery to remove the lesion and chemotherapy or radiotherapy, if the cancer has spread to other parts of the body.

Sunbeds also increase the risk of both types of skin cancer [13, 14] with first exposure to sunbeds before the age of 35 years significantly increasing risk of melanoma [13].

Photosensitivity 

Some people have an abnormal skin reaction to UV radiation, called photosensitivity. Symptoms include: a red, itchy rash and blistering. This can also be caused by certain creams or gels applied to the skin, or tablets, injections or intravenous infusions. Photosensitivity may occur within minutes of sun exposure and typically appear, usually as a rash on the face, back of the neck and upper chest.

Drugs that may cause photosensitivity include acetazolamide (sometimes taken for altitude illness), non-steroidal anti-inflammatory painkillers and some antibiotics, including doxycycline, which can be taken to prevent malaria [2].

Eye problems (photokeratitis and photoconjunctivitis)

Photokeratitis is inflammation of the cornea, whilst photoconjunctivitis is inflammation of the conjunctiva. Both conditions are comparable to sunburn of the tissues of the eye. They are very painful, but reversible and are not associated with long-term damage.

An extreme form of photokeratitis, called snow blindness, can occur in skiers and climbers exposed to extreme UV radiation levels due to high altitude and strong sun reflection from snow. Blindness is a result of inflammation of the conjunctiva and cornea. These damaged tissues usually renew quickly and sight returns in a few days. However, very severe snow blindness can result in chronic irritation [7].

Before travel

Travellers should check the strength of the sun at their destination and ensure a good supply of  appropriate sun protection factor (SPF) sun cream, protective clothing and sun glasses. The World UV App has been developed by the British Association of Dermatologists and the Met office; it provides live UV ratings anywhere in the world and is free to download.  

The best way to avoid risk associated with UV radiation is by reducing sun exposure. It is still possible to enjoy the sun, but extra precautions should be taken.

Sun creams are one of the most common ways to protect skin against the damaging effects of the sun. They contain either physical filters to block UV or chemicals that absorb various wavelengths of UV radiation. Sunscreens are rated by their sun protection factor (SPF). This is the relative protection against sunburn received after applying the sunscreen, compared to not using it. The higher the SPF rating, the better the protection.

As an example: if it takes 10 minutes for a person to burn, applying an SPF 15 sun cream means that it will take 15 times as long (150 minutes) for them to burn.

Broad spectrum sun creams block UVA radiation as well as UVB. The ‘star’ system used in the UK determines the amount of UVA protection a sunscreen offers: 0 being the lowest and five the highest. Physical sunscreens containing titanium oxide or zinc oxide reflect both UVA and UVB rays. 

Studies have shown that DEET insect repellents (33 percent) can decrease protection of SPF 15 sunscreen [15]. There is no evidence that sunscreen reduces efficacy of DEET when used at concentrations above 33 percent [16, 17]. When both sunscreen and DEET repellents are needed, DEET should be applied after the sunscreen. 30 to 50 SPF sunscreen should be used to compensate for the DEET-induced reduction in SPF [18]. 

During travel

Travellers should:
  • Limit exposure when the sun is at its highest point in the sky (11 am - 3pm).
  • Use abroad spectrum sunscreen with a high protection factor (30 SPF or higher with a UVA rating of 4 or 5 stars which blocks both UVA and UVB radiation) even on cloudy days. The British Association of Dermatologists (BAD) advises that when using lotions, a minimum of at least six full teaspoons for an average adult, should be applied [1]. 
  • Apply sunscreen liberally at least 30 minutes before exposure to the sun. It should be reapplied at least every two hours and also after swimming, exercise and towel drying.
  • Avoid the use of “once a day” sunscreens[1], reapplying sunscreen is important to get an even coverage and avoid missing patches of skin that may get burnt.
  • Protect lips with sun block.
  • Wear a wide-brimmed hat to protect the head and face.
  • Cover as much skin as possible with sun-protective clothing, especially if exposure during peak times is unavoidable.
  • Wear sunglasses, or goggles for skiing and climbing to help protect the eyes from sun damage and glare. Staring directly at the sun is dangerous and should be avoided.

Children are particularly vulnerable to the damaging effects of sunlight. Babies under six months of age should never be placed in direct sunlight and young children should always have a high SPF applied.

To treat mild sunburn

  • Have a cool bath/shower or sponge affected areas with cold water.
  • Drink plenty of fluids to prevent dehydration.
  • Take painkillers such as paracetamol or ibuprofen if needed. Aspirin should not be given to children under 16 years.
  • When comfortable to do so, apply a moisturising cream.
  • Cover up and stay out of the sun until the skin has fully healed.

Get prompt medical attention for swollen or blistered skin, chills, a high temperature, dizziness, headaches and feeling sick. 

After travel

Seek urgent medical advice for any changes to moles, such as increases in size, itchiness, bleeding or oozing, or if a new mole develops very quickly. These could be potential signs of cancer. 

First Published :   23 Dec 2016
Last Updated :   28 Dec 2016

  1. British Association of Dermatologists. Sunscreen and sun safety factsheet. 2013. [Accessed 22 December 2016]. 
  2. Ansell VE, Reisenauer AK. Sun Exposure. In: US Centers for Disease Control and Prevention. Health Information for International Travel 2016. Elsevier: Atlanta: 10 July 2015, 99-101. [Accessed 22 December 2015].
  3. Narayanan DL, Saladi RN, Fox JL. Ultraviolet radiation and skin cancer. Int J Derm. 49:978-86, 2010
  4. World Health Organization. Health effects of UV radiation. 2016 [Accessed 22 December 2016].
  5. Cancer Research UK. Am I at risk of sunburn? [Accessed 22 December 2016].
  6. World Health Organization. Skin cancers. [Accessed 22 December 2015].
  7. World Health Organization. The known health effects of UV. 2016. [Accessed 22 December 2016].
  8. Cancer Research UK. Skin cancer statistics. [Accessed 22 December 2016].
  9. Cancer Research UK. Non melanoma skin cancer – Survival. 1 September 2016. [Accessed 22 December 2016].
  10. Rubin AI, Chen EH, Ratner D. Basal-cell carcinoma. N Engl J Med. 353:2262-9, 2005
  11. Garibyan L, Fisher DE. How sunlight causes melanoma. Curr Oncol Rep. 12:319-26, 2010.
  12. Diepgen TL, Mahler V. The epidemiology of skin cancer. Br J Dermatol. 146 (Suppl 61):1-6, 2002.
  13. International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review. Int J Cancer. 120:1116-22, 2007.
  14. Karagas MR, Stannard VA, Mott LA, et al. The use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst. 94:224-6, 2002.
  15. Montemarano AD, Gupta RK, Burge JR, Klein K. Insect repellents and the efficacy of sunscreens. The Lancet. 1997;349(9066):1670-1.
  16. Murphy ME, Montemarano AD, Debboun M, Gupta R. The effect of sunscreen on the efficacy of insect repellent: a clinical trial. Journal of the American Academy of Dermatology. 2000;43(2):219-22.
  17. Webb CE, Russell RC. Insect repellents and sunscreen: implications for personal protection strategies against mosquito‐borne disease. Australian and New Zealand Journal of Public Health. 2009;33(5):485-90.
  18. Public Health England Advisory Committee on Malaria Prevention in UK travellers (ACMP) Guidelines for malaria prevention in travellers from the UK 2015, September 2015. [Accessed 22 December 2016].

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