Low vitamin D in dark-skinned immigrants is mainly due to clothing habits and low UVR exposure: a Danish observational study

Low 25-hydroxyvitamin D₃ (25(OH)D) among dark-pigmented persons has been observed. To elucidate the reason for this we examined sun behaviour, sun-exposed body area, solar UVR exposure and 25(OH)D levels in immigrants with dark pigmented skin and Danes with light pigmented skin. Clothing, sun behaviour, and diet were recorded daily during a Danish summer season (93 analysed days). Erythema-weighted UVR doses were measured by personal electronic UVR dosimeters (with erythema response, measurement every 5th second) and 25(OH)D was measured in 72 participants (33 dark-skinned and 39 light-skinned). The immigrants exposed 28% less skin area, received 70% less UVR dose, and had 71% less 25(OH)D increase during the summer. The UVR reactivity (Δ25(OH)D per joule accumulated UVR dose) was similar (P = 0.62) among the immigrants (0.53 nmol l^-1 J^-1) and the Danes (0.63 nmol l^-1 J^-1). In the groups combined, 25(OH)D levels after summer were mainly influenced by UVR dose to exposed skin (28.8%) and 25(OH)D start level (27.9%). Height and measured constitutive skin pigmentation were of minor influence: 3.5% and 3.2%, respectively. Sun exposure and clothing habits were the main reasons for lower 25(OH)D level after summer in the darker immigrants, as both groups had similar UVR reactivity.

Difference in Sun Exposure Habits Between Individuals with High and Low Risk of Skin Cancer

Background

Skin cancer incidence is rapidly increasing. The main risk factor, sun exposure, can be modified. Informational campaigns can be effective in raising skin cancer awareness and target the high-risk population. Still, sun exposure habits in people at high risk of skin cancer are not well-known.

Objective

To investigate if and how sun exposure habits differ between low-risk and high-risk individuals.

Methods

During the Swedish Euromelanoma campaign of 2018, questionnaires were collected containing information regarding sun exposure habits and risk factors for skin cancer. Data on 4,141 participants was used to investigate the association between risk factors and sun exposure habits.

Results

A fair skin type and a previous history of skin cancer were significantly associated with enhanced sun protective behavior. Family history of skin cancer, childhood sunburns and the presence of large/atypical nevi had no effect on sun exposure habits. Going on sunny holidays were particularly unaffected by being at high risk of skin cancer.

Conclusion

Individuals at high risk of developing skin cancer showed suboptimal sun exposure habits and harmful traveling behaviors. We suggest that future skin cancer campaigns inform on accurate sun protection behavior during sunny holidays and associated risk factors. Risk factors such as childhood sunburns, numerous common and large/atypical nevi, as well as family history of skin cancer seem to be less recognized by the population.

Sun exposure reduction by melanoma survivors with wearable sensor providing real-time UV exposure and daily text messages with structured goal setting

Despite knowledge of subsequent melanoma risk and the benefit of sun protection in risk reduction, melanoma survivors often do not engage in adequate sun protection and continue to sunburn at rates similar to individuals without a history of skin cancer. This novel intensive intervention provided a wearable UV sensor delivering real-time UV exposure with a smartphone and daily text messages. On days 1-10 (period 1), behavioral facilitation and outcome expectancies messages were provided. On day 10, participants reviewed and reflected on their daily UV exposure on the previous 10 days and set goals for improving sun protection. Then on days 11-21 (period 2) self-efficacy and self-regulation messages were provided. Sixty melanoma survivors were randomized (1:1) to receive structured or unstructured goal setting queries on day 10. Controlling for cloudy/rain conditions with less UV due to weather, there was a time effect with a significant decrease in UV exposure from periods 1-2 [period 1-2, F (59) = 22.60, p < 0.0001]. In this short-term study, melanoma survivors managed their daily UV exposure to stay below their maximum tolerated UV dose. ClinicalTrials.gov Protocol Record NCT0334796, date of registration Nov 15, 2017.

Solar Ultraviolet Exposure in Individuals Who Perform Outdoor Sport Activities

BACKGROUND

Skin cancer is the most common cancer in the USA. Therefore, it is important to review the contribution of ultraviolet radiation (UVR) exposure to skin cancer in individuals with the highest risk. Documenting the relationship between outdoor sports solar ultraviolet exposure and their risk of skin cancer along with appropriate risk mitigation strategies can help inform clinicians of practical information for counseling sun protective behaviors in this population.

METHODS

We conducted a review of the current evidence using PubMed to answer the following research questions: (1) How is ultraviolet radiation measured? (2) What is the modern utility of the ultraviolet index in modifying recreational sun protection behaviors? (3) What is the risk of developing skin cancer for outdoor sport participants? (4) What is the prevalence of skin cancer in sport participants? and (5) Is the number of nevi and solar lentigines elevated in outdoor sport participants?

RESULTS

Based on the literature, individuals who practice outdoor sport-related activities receive high ultraviolet radiation exposure, have a high risk for skin cancer, have a high prevalence for pigmented lesions, and may benefit from electronic sun protection educational interventions.

CONCLUSIONS

Individuals who practice outdoor sports experience substantially higher ultraviolet radiation exposure, routinely exceed the recommended exposure limits, and are at a higher risk of developing skin cancer. Therefore, those who are frequently engaged in outdoor leisure activities should be coached about efficient sun protective practices and relevant mobile technologies that may facilitate adherence.

Protection-adjusted UV dose estimated for body areas: Daily self-reported sun protection modification of wearable UV sensor dose

BACKGROUND

During the last 20 years, 50% of adults with sun-sensitive skin have sunburned annually. Reducing the proportion of people who sunburn requires understanding the circumstances and outdoor activities during which at-risk people sunburn.

METHODS

A 7-day observational study of melanoma survivors (n = 20) and young adult first-degree relatives of melanoma survivors (FDRs) (n = 20) captured daily UV exposure, sun protection, and sunburns during spring and summer in the Midwest of the United States (latitude 41.8°N). Participants wore UV and physical activity sensors and completed a daily self-reported survey of sun protection, sunburn, and physical activities. The estimated protection-adjusted UV dose was calculated for each body area by integrating self-reported sun protection with UV sensor dose.

RESULTS

In 254 days, at least one body area in 9 of 20 (45%) melanoma survivors and 11 of 20 (55%) FDRs was sunburned (erythema at 24 hours). Sunburns were associated with spring and walking for transportation or leisure, especially walking the dog. Melanoma survivors used sunscreen daily on the face; however, forearms and lower legs were not protected during walking. Young adults did not use sun protection on the face, forearms or lower legs during walking for transportation and use was ineffective during sports.

CONCLUSION

The sun protection patterns of daily living identified in this study may promote recognition of erythema as sunburn and inform the development of tailored sun protection mobile applications promoting self-monitoring with wearable UV sensors.

Adult UVR exposure changes with life stage - a 14-year follow-up study using personal electronic UVR dosimeters

Over a period spanning 14 years (1999-2001, 2006 and 2012), 31 volunteers participated in sun behaviour studies with the same protocol wearing a personal, electronic wrist-borne UVR dosimeter and completed sun exposure diaries resulting in a total of 15 946 measurements days (126 days per person per year). The participants individually maintained their UVR dose level and behaviour over the years. No statistically significant differences were seen from year to year in the "estimated annual UVR dose", the "mean UVR dose per day", the "mean percentage of ambient UVR", "days sunbathing to get a tan", "days with intermittent exposure" or in "sunburn episodes". The 20 participants still active in the labour market used sunscreen on more days in 2012 than in 1999 (p = 0.019) and with a significantly higher SPF (sun protecting factor (p < 0.001)) resulting in significantly fewer days with risk behaviour without sunscreen applied in 2012 than in 2006 (p < 0.001) and 1999 (p < 0.003). This was in contrast to the 11 participants who retired during the study period. The retired group received a non-significant 45% higher UV dose in 2012 than in 1999 (p = 0.054). In an additional study, nine 30-year-old indoor workers (high school students in the 1999 study) had changed their sun exposure pattern and had fewer days sunbathing (p = 0.008) and fewer risk behaviour days without sunscreen applied in 2012 than in 1999 (p = 0.002). Conclusion: The participants still active in the labour market maintained their sun exposure behaviour over a 14-year period. The retirees had a higher UVR dose and riskier exposure behaviour after retirement, while the high school students had changed to less risky sun behaviour on becoming indoor workers.

UVR: sun, lamps, pigmentation and vitamin D

Exposure to ultraviolet radiation (UVR) has important and significant consequences on human health. Recently, there has been renewed interest in the beneficial effects of UVR. This perspective gives an introduction to the solar spectrum, UV lamps, UV dosimetry, skin pigment and vitamin D. The health benefits of UVR exposure through vitamin D production or non-vitamin D pathways will be discussed in this themed issue in the following articles.

Skin autofluorescence reflects individual seasonal UV exposure, skin photodamage and skin cancer development in organ transplant recipients

IMPORTANCE

Ultraviolet radiation (UVR)-induced skin cancers varies among organ transplant recipients (OTRs). To improve individual risk assessment of skin cancer, objectively quantified skin photodamage is needed.

OBJECTIVES

We measured personal UVR-exposure dose in OTRs and assessed the relation between individual UVR exposure, skin cancer and objectively measured photodamage in terms of skin autofluorescence, pigmentation, and black light-evaluated solar lentigines.

MATERIALS AND METHODS

Danish OTRs with (n=15) and without a history of skin cancer (n=15) kept sun diaries from May to September and wore personal dosimeters recording time-stamped UVR doses in standard erythema doses (SED). Photodamage was quantified as skin autofluorescence with excitation at 370nm (F370) and 430nm (F430), skin pigmentation (pigment protection factor, PPF), and black light-evaluated solar lentigines.

RESULTS

OTRs with skin cancer received a higher UVR dose than OTRs without skin cancer (median 116 SED vs. 67 SED, p=0.07) and UVR exposure doses were correlated with increased PPF (p=0.052) and F370 on the shoulder (F370_shoulder) (p=0.04). We found that skin cancer was associated with F370_shoulder (OR 10.53, CI 3.3-31,938; p=0.018) and time since transplantation (OR 1.34, CI 0.95-1.91, p=0.097). A cut-off at 7.2 arbitrary units, 89% of OTRs with skin cancer had F370_shoulder values above 7.2 arbitrary units and F370_shoulder was additionally related to patient age (p=0.09) and black light-evaluated solar lentigines (p=0.04).

CONCLUSION

F370 autofluorescence indicates objectively measured photodamage and may be used for individual risk assessment of skin cancer development in OTRs.

An Inexpensive High-Temporal Resolution Electronic Sun Journal for Monitoring Personal Day to Day Sun Exposure Patterns

Exposure to natural sunlight, specifically solar ultraviolet (UV) radiation contributes to lifetime risks of skin cancer, eye disease, and diseases associated with vitamin D insufficiency. Improved knowledge of personal sun exposure patterns can inform public health policy; and help target high-risk population groups. Subsequently, an extensive number of studies have been conducted to measure personal solar UV exposure in a variety of settings. Many of these studies, however, use digital or paper-based journals (self-reported volunteer recall), or employ cost prohibitive electronic UV dosimeters (that limit the size of sample populations), to estimate periods of exposure. A cost effective personal electronic sun journal (ESJ) built from readily available infrared photodiodes is presented in this research. The ESJ can be used to complement traditional UV dosimeters that measure total biologically effective exposure by providing a time-stamped sun exposure record. The ESJ can be easily attached to clothing and data logged to personal devices (including fitness monitors or smartphones). The ESJ improves upon self-reported exposure recording and is a cost effective high-temporal resolution option for monitoring personal sun exposure behavior in large population studies.

Clustering of prevention behaviours in patients with high-risk primary melanoma

OBJECTIVE

Because melanoma patients are at high risk of further disease, we aimed to study their melanoma prevention behaviours.

METHODS

In a large cohort of patients newly diagnosed with high-risk melanoma in Queensland, Australia, we assessed clustering of preventive behaviours using latent class analysis. We assessed associated factors with prevalence proportion ratios (PPRs) and 95% confidence intervals (CIs) estimated by Poisson regression and also if preventive behaviour was associated with better tumour prognosis at diagnosis.

RESULTS

Among 789 primary melanoma patients (57% male; 21% with previous melanoma), we identified 4 different behaviour clusters: "no/ low prevention" (34% of cohort), "sun protection only" (25%), "skin checks only" (25%), and "sun protection and skin checks" (17%). Prevalence of clusters differed between males and females and also the component behaviours. Preventive behaviours were associated with having skin that burned and past cutaneous cancer, and for males, combined sun protective and skin checking behaviour was associated with higher education and non-smoking. In patients with no past history of cutaneous cancer, males in the "skin checks only" cluster had significantly reduced chances of a thick (poor prognosis) melanoma (PPR = 0.79, 95% CI 0.68, 0.91) and females in the "sun protection and skin checks" cluster were significantly less likely to have an ulcerated melanoma (PPR = 0.85, 95% CI 0.74, 0.98) compared with the "no/ low prevention" cluster.

CONCLUSION

These findings allow tailoring of preventive advice to melanoma patients to reduce their risk of future primary and recurrent disease.

Sun Exposure and Protection Behaviors among Long-term Melanoma Survivors and Population Controls

Introduction: Melanoma is considered a generally preventable cancer, with excessive ultraviolet radiation (UVR) exposure being a strong causal factor. UVR exposure following a melanoma diagnosis can be modified to reduce risk of second primary melanomas. The goal of this study was to compare measures of UVR exposure and protection behaviors between long-term melanoma survivors and controls.Methods: Participants from a previously conducted case-control study were recruited for a cross-sectional survey. Melanoma cases were 25 to 59 years old at diagnosis; controls were age and sex matched. Participants were asked about UVR exposure and protection measures used in the past year, and comparisons between melanoma survivors and controls were conducted using logistic regression models, adjusting for potential confounders.Results: A total of 724 (62.0%) long-term melanoma survivors and 660 (59.9%) controls completed the follow-up survey. Melanoma survivors were significantly less likely to report high sun exposure on a typical weekday [OR, 0.72 (0.55-0.94)], sunburns [OR, 0.40 (0.30-0.53)], or indoor tanning [OR, 0.20 (0.09-0.44)] than controls; however, high sun exposure on a typical weekend day was similar. Report of optimal sun protection behaviors was higher in melanoma survivors compared with controls. However, a few melanoma survivors reported indoor tanning, 10% reported intentionally seeking sun to tan, and 20% reported sunburns.Conclusions: Although long-term melanoma survivors reported healthier UVR exposure and protection behaviors compared with controls, a sizeable proportion still reported elevated sun exposure, sunburns, and suboptimal UVR protection behaviors.Impact: Opportunities remain for improving sun protection to reduce future melanoma risk among melanoma survivors. Cancer Epidemiol Biomarkers Prev; 26(4); 607-13. ©2017 AACR.

Estimation of individual cumulative ultraviolet exposure using a geographically-adjusted, openly-accessible tool

Background

Estimates of an individual’s cumulative ultraviolet (UV) radiation exposure can be useful since ultraviolet radiation exposure increases skin cancer risk, but a comprehensive tool that is practical for use in the clinic does not currently exist.

The objective of this study is to develop a geographically-adjusted tool to systematically estimate an individual’s self-reported cumulative UV radiation exposure, investigate the association of these estimates with skin cancer diagnosis, and assess test reliability.

Methods

A 12-item online questionnaire from validated survey items for UV exposure and skin cancer was administered to online volunteers across the United States and results cross-referenced with UV radiation indices. Cumulative UV exposure scores (CUES) were calculated and correlated with personal history of skin cancer in a case–control design. Reliability was assessed in a separate convenience sample.

Results

1,118 responses were included in the overall sample; the mean age of respondents was 46 (standard deviation 15, range 18 – 81) and 150 (13 %) reported a history of skin cancer. In bivariate analysis of 1:2 age-matched cases (n = 149) and controls (n = 298), skin cancer cases were associated with (1) greater CUES prior to first skin cancer diagnosis than controls without skin cancer history (242,074 vs. 205,379, p = 0.003) and (2) less engagement in UV protective behaviors (p < 0.01). In a multivariate analysis of age-matched data, individuals with CUES in the lowest quartile were less likely to develop skin cancer compared to those in the highest quartile. In reliability testing among 19 volunteers, the 2-week intra-class correlation coefficient for CUES was 0.94. We have provided the programming code for this tool as well as the tool itself via open access.

Conclusions

CUES is a useable and comprehensive tool to better estimate lifetime ultraviolet exposure, so that individuals with higher levels of exposure may be identified for counseling on photo-protective measures.

Electronic supplementary material

The online version of this article (doi:10.1186/s12895-016-0038-1) contains supplementary material, which is available to authorized users.

Skin cancer prevention practices among malignant melanoma survivors: a systematic review

PURPOSE

This systematic review was conducted to evaluate and summarize the existing literature on prevalence of ultraviolet radiation (UVR) exposure, sun protection, and screening behaviors among individuals diagnosed with malignant melanoma (MM).

METHODS

The search was performed in PubMed, CINAHL, PsycINFO, ScienceDirect, EMBASE, and ERIC from inception of each database through July 2014. Studies were included if (1) individuals diagnosed with MM were the primary sample, (2) measured UVR exposure, primary and secondary preventive behaviors, (3) original research communication that constitutes an entire set of empirical data, (4) observational design, and (5) English peer-reviewed. Studies were excluded if (1) all of the inclusion criteria were not met and (2) duplicates, conference abstracts, editorials, news, letters to the editor, comments, reviews, feature articles, white papers, and guidelines.

RESULTS

The search resulted in 255 articles that were screened for relevance; however, only 15 articles met all of the inclusion criteria. Most of the studies were cross-sectional (n = 10), used self-administered surveys (n = 8), and were conducted in North America (n = 10). The sample sizes ranged considerably, but were mostly Caucasian (n = 6) and included a higher proportion of women (n = 8). Evidence demonstrated that individuals with MM still engaged in sunbathing, indoor tanning, and reported sunburns. Moreover, survivors reported inadequate levels of both sun protection and skin self-examinations.

CONCLUSIONS

The findings highlight the need for intensifying intervention strategies to reduce the risk of new primary MMs in this group. Future research should increase in rigor and include more diverse populations and regions.

Black light visualized solar lentigines on the shoulders and upper back are associated with objectively measured UVR exposure and cutaneous malignant melanoma

Previous studies on the association of solar lentigines with ultraviolet radiation (UVR) exposure have been based on retrospective questionnaires about UVR exposure. We aimed to investigate the association between solar lentigines and UVR exposure in healthy individuals using objective measurements, and to investigate the association between solar lentigines and cutaneous malignant melanoma (CMM). Forty-eight patients with CMM and 48 controls that matched the patients individually by age, sex, constitutive skin type and occupation participated. Solar lentigines on the shoulders and upper back were counted and graded into 3 categories using black light photographs to show sun damage. Current UVR exposure in healthy controls was assessed by personal electronic UVR dosimeters that measured time-related UVR and by corresponding exposure diaries during a summer season. Sunburn history was assessed by interviews. Among controls, the number of solar lentigines was positively associated with daily hours spent outdoors between noon and 3 pm on holidays (P = 0.027), days at the beach (P = 0.048) and reported number of life sunburns (P < 0.001). Compared with matched controls CMM patients had a higher number of solar lentigines (P = 0.044). There was a positive association between CMM and higher solar lentigines grade; Category III versus Category I (P = 0.002) and Category II versus Category I (P = 0.014). Our findings indicate that solar lentigines in healthy individuals are associated with number of life sunburns, as well as time spent outdoors around noon on holidays and beach trips during a summer season, most likely reflecting past UVR exposure, and that solar lentigines are a risk factor for CMM.

Sunny holidays before and after melanoma diagnosis are respectively associated with lower Breslow thickness and lower relapse rates in Italy

Background

Previous studies have reported an association between sun exposure and improved cutaneous melanoma (CM) survival. We analysed the association of UV exposure with prognostic factors and outcome in a large melanoma cohort.

Methods

A questionnaire was given to 289 (42%) CM patients at diagnosis (Group 1) and to 402 CM patients (58%) during follow-up (Group 2). Analyses were carried out to investigate the associations between sun exposure and melanoma prognostic factors and survival.

Results

Holidays in the sun two years before CM diagnosis were significantly associated with lower Breslow thickness (p=0.003), after multiple adjustment. Number of weeks of sunny holidays was also significantly and inversely associated with thickness in a dose-dependent manner (p=0.007). However when stratifying by gender this association was found only among women (p=0.0004) the risk of CM recurrence in both sexes was significantly lower in patients (n=271) who had holidays in the sun after diagnosis, after multiple adjustment including education: HR=0.30 (95%CI:0.10-0.87; p=0.03) conclusions: Holidays in the sun were associated with thinner melanomas in women and reduced rates of relapse in both sexes. However, these results do not prove a direct causal effect of sun exposure on survival since other confounding factors, such as vitamin D serum levels and socio-economic status, may play a role. Other factors in sun seeking individuals may also possibly affect these results.