To Attenuate the Skin Cancer Epidemic, Start Early

As a dermatologist and Mohs surgeon who spends a significant amount of my clinic time removing skin cancers and treating photodamage, I recognize the importance of educating the public about UV exposure risks. As a father of young children (Their grandparents have a broad history of melanoma in situ, SCC, and BCC.) who is married to a pediatrician, I recognize that it is especially important to protect children from UV exposure. The benefit of early education/intervention is two-fold:

1. Reduction of UV exposure in youngsters has an exponential benefit in minimizing lifetime cumulative UV-induced damage.

2. Habits—good and bad—can be formed at a young age, so starting children on the path to good UV habits is essential. The best weapon we have against skin cancer is prevention, and prevention has to start at a young age.

In my mind, to effectively reach young people requires a clear-cut, (at-least) three-pronged program: counseling, school engagement, and community outreach.

Counseling

Just as we dermatologists talk to adult patients about UV safety and the need for sunscreen, so should we be counseling our youngest patients. The US Preventive Services Task Force (USPSTF), as an independent body, has provided a clear-cut, sun safety recommendation. Specifically, they have affirmed the need for and benefit of UV education for children and adolescents.¹ In addition, the American Academy of Pediatrics has also endorsed the need for UV counseling focused on adolescent patients, in particular.

The harsh realities of skin cancer among younger people are unavoidable: One study found an eight-fold increase in the incidence of melanoma among young women (ages 18-39) and a four-fold increase among young men from 1970 to 2009—quite possibly attributed to tanning among youths.²

And yet, data show that young people may be actively engaging in risky UV-related behaviors. Although indoor tanning among high school students appears to be on a recent decline, the practice is still somewhat common. CDC researchers report that 15 percent of non-Hispanic white female high school students tan indoors. Indoor tanning was associated with an increased likelihood of sunburn according to this study.³ Clearly, patients of all ages need to hear from us about the risks of tanning, the risk of unprotected UVR, that each sunburn significantly increases the risk of future skin cancer, that one in five Americans will get a skin cancer during their lifetime, and one American dies every hour from melanoma skin cancer.

People need to know that UVR is considered a Class I carcinogen by the WHO and tanning beds are classified as carcinogenic by the International Agency for Research on Cancer.

Furthermore, patients should be informed that research clearly shows that regular sunscreen use reduces the risk for melanoma,^4,5 and SCC.⁵ Research supports a role for sunscreens in preventing UV-induced DNA damage.⁶

School Engagement

Research has highlighted a lack of sun safety promotion in America’s schools. Fewer than half of schools (47.6 percent) allotted time for students to apply sunscreen during the day.⁷ And only 13.3 percent of schools actually made sunscreen available for student use. Elementary and middle schools were more likely than high schools to implement favorable sun safety behaviors.⁷

Teen Athletes Require Sunscreens. Encourage teen athletes/coaches to apply sunscreen when practicing or exercising outdoors so they can avoid sunburns.

In an editorial accompanying the studies, Henry W. Lim, MD, President of the American Academy of Dermatology, notes that, “Clearly, both the dermatology and medical communities need to continue public awareness campaigns regarding photoprotection, including sun-safety practices such as seeking shade when outdoors and wearing photoprotective clothing, wide-brimmed hats, and sunglasses. Broad-spectrum sunscreens with SPF (sun protection factor) of at least 30 should be generously applied (and reapplied) to sun-exposed areas when outdoors.”⁸ I think all dermatologists and scientists in this field whole-heartedly endorse that sentiment.

Among the best tools for skin cancer prevention—after physical avoidance of UV radiation—is proper use of sunscreen. Here’s the rub: sunscreens are proven, tested, regulated products…and are therefore classified as OTC drugs by the FDA. That means that in some of our nation’s schools, students are not permitted to carry or apply sunscreen without parent/guardian permission.

Engagement with educators can make an impact on childhood health and safety.

I have worked with some Colorado schools to encourage early recess, so that students are not out in the midday sun. Schools should also ask students to bring sunscreen to school and allow time for application or re-application before going outdoors. In most cases, filing a simple permission slip signed by the parent is all that is necessary to allow the child to bring sunscreen to school and apply it. Because teachers of young children will have to help apply sunscreens, the permission slips for these students should include allowing the teacher to help the child put on sunscreen. The data show that sunscreen is most effective for two hours, and less if people are sweating, swimming or toweling off. A single morning application, like so many of our patients use, is totally insufficient.

I devised a permission slip for use by schools that you can download at PracticalDermatology.com.

Community Outreach

To truly make a difference, physicians and other health care providers must educate beyond our clinic walls. Dermatologists and pediatricians may offer to visit schools to educate students about UV avoidance and the importance of sun safety, as well as overall skin health. Other hot topics for the school age set include hand hygiene, face and hair care, and even acne facts and myths. Programs for teachers may also be valuable, addressing additional issues like the very small incidence of allergy to sunscreen ingredients. Requiring parents to supply their own sunscreen for their kids (clearly marked with the student’s name with permanent marker) is recommended to reduce the likelihood of allergic reactions.

Teachers should encourage boys and girls to wear hats, and schools should install shade structures on playgrounds.

Consider also reaching out to local religious or civic groups and sports leagues. Coaches and group leaders may welcome the offer for you to address the children in their programs. Perhaps even a local sales rep would help you acquire samples of sunscreens to donate to the group for a specific event.

Sponsoring uniforms for a team—including UV-protective hats or visors—is a way to help protect kids.

It Starts Now

The sun safety message cannot be provided too early or too often. Melanoma is a healthcare epidemic, and the problem is growing. We’re making strides in treating skin cancer, but there’s no “cure” on the horizon. Building good habits now may be the best way to reverse the alarming trend of increasing skin cancer rates across the US and around the world. Encouraging patients, kids, and families to use sunscreen, reapply sunscreen, wear hats and other photoprotective clothing, and do skin checks (self checks for new or changing lesions, and doctor checks at the office especially for families that have a skin cancer history) are keys to decreasing the skin cancer epidemic and treating potentially deadly skin cancers early.

Watch Dr. Cohen, Chief Editor for DermTube.com, discuss his approach to educating patients of all ages about skin cancer.

1. Final Update Summary: Skin Cancer: Counseling. U.S. Preventive Services Task Force. September 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-counseling

2. Reed KB, Brewer JD, Lohse CM, Bringe KE, Pruitt CN, Gibson LE. Increasing incidence of melanoma among young adults: an epidemiological study in Olmsted County, Minnesota. Mayo Clin Proc. 2012 Apr;87(4):328-34.

3. Guy GP, Berkowitz Z, Everett Jones S, Watson M, Richardson LC. Prevalence of Indoor Tanning and Association With Sunburn Among Youth in the United States. JAMA Dermatol. Published online March 03, 2017. 

4. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011 Jan 20;29(3):257-63.

5. Olsen CM, Wilson LF, Green AC, Bain CJ, Fritschi L, Neale RE, Whiteman DC. Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use. Aust N Z J Public Health. 2015 Oct;39(5):471-6.

6. Olsen CM, Wilson LF, Green AC, Biswas N, Loyalka J, Whiteman DC. Prevention of DNA damage in human skin by topical sunscreens. Photodermatol Photoimmunol Photomed. 2017 Feb 6.

7. Everett Jones S, Guy GP. Sun Safety Practices Among Schools in the United States. JAMA Dermatol. Published online March 03, 2017. 

8. Lim HW, Schneider SL. Sun Safety Practices—Progress Made, More to Go. JAMA Dermatol. Published online March 03, 2017.