Temporal and spatial melanoma trends in Austria: an ecological study

Exposure to Atmospheric Ozone Disruption and Altitude Over 3500 m.a.s.l. are Associated with a Higher Prevalence of Photodermatoses in Pediatric Population of High-Altitude in Peru

Objective

To determine if exposure to atmospheric ozone disruption and other factors are associated with photodermatoses in the high-altitude pediatric population in Peru.

Materials and Methods

A cross-sectional study based on data obtained from studies of dermatological diseases among the population exposed to mine tailings in Peru which included children under the age of 18 in 6 population centers located over 2500 meters above sea level (m.a.s.l). We evaluated the presence of photodermatoses and possible associated factors obtaining the adjusted odds ratio (aOR) and confidence intervals (CI).

Results

594 children below the age of 18 participated in this study, 53.0% girls, the average age was 10.4 ± 4.1 years. 51.3% were exposed to a mini hole in the ozone layer, 60.1% resided at an altitude over 3500 m.a.s.l and 51.9% presented cutaneous manifestations of atopy upon physical examination. The prevalence of photodermatoses was 64.8%, of which the most frequent were actinic prurigo (49.3%), pityriasis alba (18.5%) and actinic cheilitis (4.4%). The multivariate analysis found that residing in a region exposed to the mini hole in the ozone layer (aOR = 4.23; CI 95%: 2.32–7.72) and residing at an altitude over 3500 m.a.s.l (aOR = 2.76; CI 95%: 1.57–4.86) were both independent associated factors to photodermatoses.

Conclusion

A high prevalence of photodermatoses exists among the pediatric population living at high-altitude in Peru. Residing in a region exposed to a mini hole in the ozone layer and residing over 3500 m.a.s.l constituted associated factors.

Cutaneous Melanoma in Alpine Population: Incidence Trends and Clinicopathological Profile

Previous studies associated high-level exposure to ultraviolet radiation with a greater risk of cutaneous malignant melanoma (CMM). This study focuses on the changing incidence of CMM over time (from 1990 to 2017) in the Veneto region of Northeast Italy, and its Alpine area (the province of Belluno). The clinicopathological profile of CMM by residence is also considered. A joinpoint regression analysis was performed to identify significant changes in the yearly incidence of CMM by sex and age. For each trend, the average annual percent change (AAPC) was also calculated. In the 2017 CMM cohort, the study includes a descriptive analysis of the disease's categorical clinicopathological variables. In the population investigated, the incidence of CMM has increased significantly over the last 30 years. The AAPC in the incidence of CMM was significantly higher among Alpine residents aged 0-49 than for the rest of the region's population (males: 6.9 versus 2.4; females 7.7 versus 2.7, respectively). Among the Alpine residents, the AAPC was 3.35 times greater for females aged 0-49 than for people aged 50+. The clinicopathological profile of CMM was significantly associated with the place of residence. Over three decades, the Veneto population has observed a significant increase in the incidence of CMM, and its AAPC. Both trends have been markedly more pronounced among Alpine residents, particularly younger females. While epidemiology and clinicopathological profiles support the role of UV radiation in CMM, the young age of this CMM-affected female population points to other possible host-related etiological factors. These findings also confirm the importance of primary and secondary prevention strategies.

COVID-19: Regional Differences in Austria

In the turbulent year 2020, overshadowed by the global COVID-19 pandemic, Austria experienced multiple waves of increased case incidence. While governmental measures to curb the numbers were based on current knowledge of infection risk factors, a retrospective analysis of incidence and lethality at the district level revealed correlations of relative infection risk with socioeconomic, geographical, and behavioral population parameters. We identified unexpected correlations between political orientation and smoking behavior and COVID-19 infection risk and/or mortality. For example, a decrease in daily smokers by 2.3 percentage points would be associated with an increase in cumulative incidence by 10% in the adjusted model, and an increase in voters of the right-wing populist party by 1.6 percentage points with an increase in cumulative mortality by 10%. While these parameters are apparently only single elements of complex causal chains that finally lead to individual susceptibility and vulnerability levels, our findings might have identified ecological parameters that can be utilized to develop fine-tuned communications and measures in upcoming challenges of this and other pandemics.

Recent Malignant Melanoma Epidemiology in Upper Silesia, Poland. A Decade-Long Study Focusing on the Agricultural Sector

The aim of the present study was to create spatial and spatio-temporal patterns of cutaneous malignant melanoma (MM) incidence in Upper Silesia, Poland, using the largest MM database (<4K cases) in Central Europe, focusing on the agricultural sector. The data comprised all the registered cancer cases (C43, according to the International Classification of Diseases after the 10th Revision) between the years 2004-2013 by the Regional Cancer Registries (RCRs) in Opole and Gliwice. The standardized incidence ratios (SIRs), spatio-temporal growth rates (GRs), and disease cluster relative risks (RRs) were estimated. Based on the regression coefficients, we have indicated irregularities of spatial variance in cutaneous malignant melanoma, especially in older women (≥60), and a possible age-migrating effect of agricultural population density on the risk of malignant melanoma in Upper Silesia. All the estimates were illustrated in choropleth thematic maps.

The global burden of skin cancer: A longitudinal analysis from the Global Burden of Disease Study, 1990-2017

Background

Despite efforts toward the earlier detection and prevention of skin cancer, the prevalence of skin cancers continues to increase. Identifying trends in skin cancer burdens among populations can lead to impactful and sustainable interventions.

Methods

We assessed the global trends in skin cancer from 1990 to 2017 in 195 countries worldwide through the Global Burden of Disease Study (GBD) 2017 database.

Results

The rate of change in skin cancers between 1990 to 2017 varied among countries. Squamous cell carcinomas increased by 310% during this time, the highest among any neoplasm tracked by the GBD. Men experienced greater age-specific prevalence rates of keratinocyte carcinoma across all ages (P < .05). Women had a greater prevalence of melanoma until approximately age 50 years, after which the trend reversed until age 85 years. Men experienced greater age-specific death rates across all ages. The disability-adjusted life years (DALYs) of melanoma and keratinocyte carcinoma increased exponentially with age (P < .05).

Conclusion

The incidence, prevalence, and DALYs of skin cancers are increasing disproportionately among different demographic groups. As a worldwide epidemiological assessment, the GBD 2017 provides frequently updated measures of the skin cancer burden, which may help to direct resources and allocate funding to close the gap in global skin cancer disparities.

The influence of climate change on skin cancer incidence - A review of the evidence

BACKGROUND

Climate change is broadly affecting human health, with grave concern that continued warming of the earth's atmosphere will result is serious harm. Since the mid-20th century, skin cancer incidence rates have risen at an alarming rate worldwide.

OBJECTIVE

This review examines the relationship between climate change and cutaneous carcinogenesis.

METHODS

A literature review used the National Institutes of Health databases (PubMed and Medline), the Surveillance, Epidemiology, and End Results and International Agency for Research on Cancer registries, and published reports by federal and international agencies and consortia, including the Australian Institute of Health and Welfare, Climate and Clean Air Coalition, U.S. Environmental Protection Agency, Intergovernmental Panel on Climate Change, National Aeronautics and Space Administration, National Oceanic and Atmospheric Administration, United Nations Environment Programme, World Health Organization, and World Meteorological Organization.

RESULTS

Skin cancer risk is determined by multiple factors, with exposure to ultraviolet radiation being the most important. Strong circumstantial evidence supports the hypothesis that factors related to climate change, including stratospheric ozone depletion, global warming, and ambient air pollution, have likely contributed to the increasing incidence of cutaneous malignancy globally and will continue to impose a negative on influence skin cancer incidence for many decades to come.

CONCLUSION

Because much of the data are based on animal studies and computer simulations, establishing a direct and definitive link remains challenging. More epidemiologic studies are needed to prove causality in skin cancer, but the evidence for overall harm to human health as a direct result of climate change is clear. Global action to mitigate these negative impacts to humans and the environment is imperative.

The Association of Residential Altitude on the Molecular Profile and Survival of Melanoma: Results of an Interreg Study

Cutaneous melanoma (CM) incidence is rising worldwide and is the primary cause of death from skin disease in the Western world. Personal risk factors linked to environmental ultraviolet radiation (UVR) are well-known etiological factors contributing to its development. Nevertheless, UVR can contribute to the development of CM in different patterns and to varying degrees. The present study aimed at investigating whether altitude of residence can contribute to the development of specific types of CM and/or influence its progression. To this aim, 306 formalin-fixed and paraffin-embedded (FFPE) tissues from primary CM diagnosed in different geographical areas were submitted to B-RAF proto-oncogene serine/threonine kinase (BRAF) and N-RAS proto-oncogene GTPase (NRAS) mutational status detection and mRNA and miRNA profiling by qPCR. Genes were chosen for their functions in specific processes, such as immune response (CD2, PDL1, or CD274) and pigmentation (MITF, TYRP1, and TRPM1). Furthermore, four microRNAs, namely miR-150-5p, miR-155-5p, miR-204-5p, and miR-211-5p, were included in the profiling. Our results highlight differences in the gene expression profile of primary CM with respect to the geographical area and the altitude of residence. Melanoma-specific survival was influenced by the gene expression of mRNA and miRNAs and varied with the altitude of patients' residence. In detail, TYRP1 and miR-204-5p were highly expressed in patients living at higher altitudes, unlike miR-150-5p, miR-155-5p, and miR-211-5p. Since miRNAs are highly regulated by reactive oxygen species, it is possible that different regulatory mechanisms characterize CMs at different altitudes due to the different environment and UVR intensity.

Macroenvironment-gene-microenvironment interactions in ultraviolet radiation-induced melanomagenesis

Cutaneous malignant melanoma is one of the few major cancers that continue to exhibit a positive rate of increase in the developed world. A wealth of epidemiological data has undisputedly implicated ultraviolet radiation (UVR) from sunlight and artificial sources as the major risk factor for melanomagenesis. However, the molecular mechanisms of this cause-and-effect relationship remain murky and understudied. Recent efforts on multiple fronts have brought unprecedented expansion of our knowledge base on this subject and it is now clear that melanoma is caused by a complex interaction between genetic predisposition and environmental exposure, primarily to UVR. Here we provide an overview of the effects of the macroenvironment (UVR) on the skin microenvironment and melanocyte-specific intrinsic (mostly genetic) landscape, which conspire to produce one of the deadliest malignancies.

UV-Radiation: From Physics to Impacts

Ultraviolet (UV) radiation has affected life at least since the first life forms moved out of the seas and crawled onto the land. Therefore, one might assume that evolution has adapted to natural UV radiation. However, evolution is mostly concerned with the propagation of the genetic code, not with a long, happy, and fulfilling life. Because rickets is bad for a woman giving birth, the beneficial effects of UV-radiation outweigh the adverse effects like aged skin and skin tumors of various grades of malignancy that usually only afflict us at older age. Anthropogenic damage to the stratospheric ozone layer and frighteningly high rates of melanoma skin cancer in the light-skinned descendants of British settlers in Australia piqued interest in the health impacts of UV radiation. A changing cultural perception of the beauty of tanned versus light skin and commercial interests in selling UV-emitting devices such as tanning booths caught public health experts off-guard. Counseling and health communication are extremely difficult when dealing with a “natural” risk factor, especially when this risk factor cannot (and should not) be completely avoided. How much is too much for whom or for which skin type? How even measure “much”? Is it the (cumulative) dose or the dose rate that matters most? Or should we even construct a more complex metric such as the cumulative dose above a certain dose rate threshold? We find there are still many open questions, and we are glad that this special issue offered us the opportunity to present many interesting aspects of this important topic.

Is UV an etiological factor of acral melanoma?

Ultraviolet (UV) radiation is a major environmental risk factor for melanoma, particularly among Caucasians. However, studies have generated conflicting results on the role of UV exposure in the development of acral melanoma, the most prevalent subtype of melanoma in non-Caucasians. In this review, we analyzed studies that have examined the relationship between acral melanoma and UV and show that acral melanoma has specific epidemiological and genetic characteristics, with a lower frequency or absence of UV-induced features. Therefore, we postulate that UV is probably not involved in the etiology of acral melanoma. However, further epidemiological and laboratory studies are required to fully address this controversial issue, which may lead to a better understanding of the pathogenesis and prevention of acral melanoma.

UV "Indices"-What Do They Indicate?

Ultra-Violet (UV) radiation covers the spectrum of wavelengths from 100 to 400 nm. The potency and biological activity for a variety of endpoints differ by wavelength. For monitoring and communication purposes, different UV action spectra have been developed. These spectra use different weighting functions. The action spectrum for erythemal dose is the most widely used one. This erythemal dose per time or dose-rate has been further simplified into a “UV index”. Following this example, in our review we use the term “index” or (plural) “indices” in a more general description for all simplified single-value measures for any biologically effective UV dose, e.g., for human non-melanoma skin cancer and for previtamin D production rate. Ongoing discussion about the existence of an increased melanoma risk due to UV-A exposure underscores the uncertainties inherent in current weighting functions. Thus, we performed an online literature search to review the data basis for these indices, to understand their relevance for an individual, and to assess the applicability of the indices for a range of exposure scenarios. Even for natural (solar) UV, the spectral composition varies spatially and temporally. Artificial UV sources and personal protection introduce further variation to the spectral composition. Many biological effects are proposed for UV radiation. Only few endpoints have been studied sufficiently to estimate a reliable index. Weighting functions for chronic effects and most importantly for cancer endpoints have been developed in animal models, and often for proxy endpoints only. Epidemiological studies on biological effects of UV radiation should not only depend on single-value weighted UV dose estimates (indexes) but should strive for a more detailed description of the individual exposure. A better understanding of the adverse and beneficial effects of UV radiation by wavelength would also improve medical counseling and health communication regarding individual health-supportive behavior.

Protection from Ultraviolet Radiation during Childhood: The Parental Perspective in Bavaria

During childhood, parents play a vital role in sun protection of their children. Their guidance is essential for avoiding excessive exposure to ultraviolet (UV) radiation, a risk factor for developing skin cancer in later life. In a population-based cross-sectional study conducted between October 2011 and February 2012, we assessed how 3281 parents implemented sun protection for their three- to six-year-old children in practice. In particular, clothing, shade-seeking behavior, wearing of sunhats and sunglasses, use of sunscreens and the amount of time spent outdoors were ascertained in two settings (beach, garden/playground). The results showed that the overall level of parental sun protection for their children in the beach setting, and to a lesser extent also in the everyday outdoor setting, is relatively high. Using sunscreens with a high sun protection factor and instructing children to wear a sunhat were very common. Lesser attention was paid to sun-protective clothing, seeking the shade and wearing sunglasses. The amount of time spent outdoors during summer days was high. Therefore, the recommendation to completely avoid sun exposure during peak UV times around noon during summertime needs to be reinforced. In addition, the observed difference in the protective behavior between the beach and an everyday outdoor setting points to the necessity to encourage better sun protection for children also in outdoor activities of daily living.

Is Multidirectional UV Exposure Responsible for Increasing Melanoma Prevalence with Altitude? A Hypothesis Based on Calculations with a 3D-Human Exposure Model

In a recent study, melanoma incidence rates for Austrian inhabitants living at higher altitudes were found to increase by as much as 30% per 100 m altitude. This strong increase cannot simply be explained by the known increase of erythemally-weighted irradiance with altitude, which ranges between 0.5% and 4% per 100 m. We assume that the discrepancy is partially explainable by upwelling UV radiation; e.g., reflected by snow-covered surfaces. Therefore, we present an approach where the human UV exposure is derived by integrating incident radiation over the 3D geometry of a human body, which enables us to take upwelling radiation into account. Calculating upwelling and downwelling radiance with a radiative transfer model for a snow-free valley and for snow-covered mountain terrain (with albedo of 0.6) yields an increase in UV exposure by 10% per 100 m altitude. The results imply that upwelling radiation plays a significant role in the increase of melanoma incidence with altitude.

Herbal extracts, lichens and biomolecules as natural photo-protection alternatives to synthetic UV filters. A systematic review

Besides the unquestionable positive effects of solar exposure for human health, UV rays have been widely investigated for toxicology aspects related to excessive UVB and UVA doses, which involve sunburns, skin aging, DNA skin damage and tumorigenesis. At present, synthetic and mineral sunscreens are used to protect against these damages but several natural molecules can provide UV protection, including also synergic effect or enhanced photo stability. Although a large number of herbal extracts and plant origin molecules can deserve potential applications, most of the study reported utilizes different method and different strategies of investigation, making thus difficult to understand the real versus claimed potential. This is possibly one of the reasons why, beside the large body of literature there are no officially approved natural commercial sun-filter but a consistent number of commercially available solar products (sunscreen) on the market that contain herbal derivatives. In this review we have evaluated the papers appeared in the last 15years and we have critically collected the most significant data. Several databases, namely Scifinder, Pubmed, Google Scholar, ISI-Web of Science and Scopus, were used as literature sources; excluding patents and symposium or congress papers. Only articles in the English language have been selected. New formulation, new skin delivery systems, skin penetration enhancers and boosters are most likely the next frontier of investigation in order to better understand the role of whole herbal extracts in exerting their photo protective activity.

Sunbed Use Prevalence and Associated Skin Health Habits: Results of a Representative, Population-Based Survey among Austrian Residents

Recreational sunbed use accounts for the main non-solar source of exposure to ultraviolet radiation in fair-skinned Western populations. Indoor tanning is associated with increased risks for acute and chronic dermatological diseases. The current community-based study assessed the one-year prevalence of sunbed use and associated skin health habits among a representative, gender-balanced sample of 1500 Austrian citizens. Overall one-year prevalence of sunbed use was 8.9% (95% confidence interval (CI) 7.5%-10.4%), with slightly higher prevalence in females (9.2%, 95% CI 7.3%-11.2%) compared to males (8.6%, 95% CI 6.7%-10.6%). Factors predicting sunbed use were younger age (by trend decreasing with older age), place of living, smoking, skin type (by trend increasing with darker skin), sun exposure, motives to tan, and use of UV-free tanning products. Despite media campaigns on the harmful effects of excessive sunlight and sunbed exposure, we found a high prevalence of self-reported sunbed use among Austrian citizens. From a Public (Skin) Health perspective, the current research extends the understanding of prevailing leisure time skin health habits in adding data on prevalence of sunbed use in the general Austrian population.

Sun Exposure Prevalence and Associated Skin Health Habits: Results from the Austrian Population-Based UVSkinRisk Survey

Recreational sun exposure accounts for a large number of acute and chronic dermatological diseases, including skin cancer. This study aimed at estimating the one-year prevalence of sun exposure and skin health-associated knowledge and attitudes among Austrian citizens. The population-based UVSkinRisk survey investigated a representative sample of Austrian adults using a structured questionnaire. In total, 1500 study subjects (median age 33.0 years, 50.5% females) participated in this questionnaire survey. Among study participants, prevalence of sun exposure was 47%, with slightly higher rates in males (48%) compared to females (46%). Younger age, lower professional category, darker skin type, motives to tan, sunbed use, sunburn, and outdoor sport activity increased the odds for prevalent sun exposure. This is the first population-based study evaluating the prevailing sun exposure and recreational habits influencing skin health among Austrian citizens. Despite public media campaigns educating on the harmful effects of sunlight exposure, we found a high prevalence of self-reported sunlight exposure. The results suggest that multifaceted socio-cultural characteristics stimulate recreational sun exposure and tanning habits. Communicating individualized Public (Skin) Health messages might be the key to prevent photo-induced skin health hazards in light-skinned populations. The practical and theoretical implications of these findings are discussed.

Gender aspects of recreational sun-protective behavior: results of a representative, population-based survey among Austrian residents

PURPOSE

Lifetime risk for melanoma skin cancer is enlarged by sunlight exposure and reduced by sun protection. Austrian melanoma incidence and mortality rates are constantly rising with higher rates in males. Thus, we aimed at investigating gender-specific recreational sun exposure habits among the Austrian population.

METHODS

We conducted a telephone survey among 1500 adults (50.5% females) representing sociodemographic characteristics of the Austrian population. Using a structured questionnaire, we studied gender-specific sun exposure-related knowledge, motives to tan, and behavior.

RESULTS

Overall, using sunscreen, wearing sunglasses, and seeking shade were among the three most frequent sun safe measures. Basic skin health knowledge and tanning motives were similar among genders, although females protected themselves more. In general, sunburn occurrence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0-1.8), skin type IV (OR = 2.4, 95% CI = 1.3-4.5), ex-/non-smoking (OR = 1.4-1.6, 95% CI = 1.0-2.1), low motives to tan (both OR = 1.3, 95% CI = 1.0-1.7), no outdoor sport (OR = 1.3, 95% CI = 1.0-1.7), all P < 0.05, as well as the use of sunscreen with lower SPF values (OR = 1.0-3.0, 95% CI = 1.4-4.3) and male gender (OR = 1.6, 95% CI = 1.2-2.0), both P < 0.001, increased the odds of practicing low sun protection.

CONCLUSION

The results of this investigation suggest considering gender specificity when planning Public (Skin) Health-related educative campaigns and programs, for example, by highlighting the appearance-related benefits of sun light avoidance.

Perceived Relevance of Educative Information on Public (Skin) Health: Results of a Representative, Population-Based Telephone Survey

Individual skin health attitudes are influenced by various factors, including public education campaigns, mass media, family, and friends. Evidence-based, educative information materials assist communication and decision-making in doctor-patient interactions. The present study aims at assessing the prevailing use of skin health information material and sources and their impact on skin health knowledge, motives to tan, and sun protection. We conducted a questionnaire survey among a representative sample of Austrian residents. Print media and television were perceived as the two most relevant sources for skin health information, whereas the source physician was ranked third. Picking the information source physician increased participants' skin health knowledge (p = 0.025) and sun-protective behavior (p < 0.001). The study results highlight the demand for targeted health messages to attain lifestyle changes towards photo-protective habits. Providing resources that encourage pro-active counseling in every-day doctor-patient communication could increase skin health knowledge and sun-protective behavior, and thus, curb the rise in skin cancer incidence rates.

Ultraviolet radiation, aging and the skin: prevention of damage by topical cAMP manipulation

Being the largest and most visible organ of the body and heavily influenced by environmental factors, skin is ideal to study the long-term effects of aging. Throughout our lifetime, we accumulate damage generated by UV radiation. UV causes inflammation, immune changes, physical changes, impaired wound healing and DNA damage that promotes cellular senescence and carcinogenesis. Melanoma is the deadliest form of skin cancer and among the malignancies of highest increasing incidence over the last several decades. Melanoma incidence is directly related to age, with highest rates in individuals over the age of 55 years, making it a clear age-related disease. In this review, we will focus on UV-induced carcinogenesis and photo aging along with natural protective mechanisms that reduce amount of “realized” solar radiation dose and UV-induced injury. We will focus on the theoretical use of forskolin, a plant-derived pharmacologically active compound to protect the skin against UV injury and prevent aging symptoms by up-regulating melanin production. We will discuss its use as a topically-applied root-derived formulation of the Plectranthus barbatus (Coleus forskolii) plant that grows naturally in Asia and that has long been used in various Aryuvedic teas and therapeutic preparations.

The impact of parental knowledge and tanning attitudes on sun protection practice for young children in Germany

Public health campaigns have improved knowledge on UVR-associated skin cancer risk and increased sun protection awareness. However, tanned skin is still a common beauty ideal. The relationship between knowledge, attitudes and protective behavior is not fully understood yet. A population-based survey was thus performed in the district of Erlangen involving 2,619 parents of 3- to 6-year old children. By means of a self-administered standardized questionnaire parental knowledge about risk factors for skin cancer, their attitudes towards tanning and details of protective measures taken for their children were assessed. The study analyzed specifically the impact of parental tanning attitudes on sun-protective measures for their children while controlling for parental knowledge about skin cancer risk factors. While parental knowledge was significantly (inversely) associated with agreement to the statement "Tanned skin is healthy skin", this was not the case for "Tanning makes me look better". Overall, tanning affirmative attitudes were inversely associated with protective measures taken for the children, whereas parental knowledge had a positive impact on sun protection at the beach only. Multivariable analyses provided evidence for an effect of parental attitude on protective behavior independent of parental knowledge. Tanning attitudes and tanned skin as the misguided ideal of beauty need to be addressed in future public health campaigns to enhance the effectiveness of preventive activities in changing sun protective behavior.

Connectedness to nature and public (skin) health perspectives: results of a representative, population-based survey among Austrian residents

Connectedness to nature (CN) influences motivation to have contact with outdoor natural environments. Spending leisure time in natural environments is beneficial for human health and well-being. Besides these positive effects, health risks of open-air activities are mainly related to unprotected sun light exposure-associated acute and chronic skin hazards. Thus, we conducted a cross-sectional, representative telephone survey among Austrian residents to study the association of perceived CN level with sun-exposure knowledge, tanning habits, and sun protective behaviour. In total, 1,500 study subjects (50.5% females) participated in this questionnaire survey. Although knowledge about tanning and motives to tan were similar among genders, females performed more photoprotective measures and were more connected to nature (all p < 0.001) compared to males. Older age and outdoor sport were significant gender-independent predictor variables influencing perceived CN level. Additionally, level of education was relevant in male CN, whereas non-smoking and higher knowledge were predictive of female CN. This survey provides so far unreported empirical data on the relationship between nature connectedness and skin health-relevant recreational habits of Austrian residents. The findings suggest to integrate hitherto neglected gender-specific Public (Skin) Health promotion when counselling on the manifold health advantages of outdoor activities.