SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 410 RESEARCH LETTERS Adolescent Sun Protection Behaviors and Beliefs Roya S. Nazarian, BA,1 Michael Pan, MD,1 Sarah Utz, MD,2 Lauren Geller, MD1 1Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY 2Department of Dermatology, Wayne State School of Medicine, Detroit, MI Skin cancer is the most common malignancy in the United States, with a rising incidence, including in children and adolescents at a rate of 2% per year.1 Exposure to ultraviolet (UV) radiation, either from natural sunlight or indoor tanning, is a known risk factor for the development of skin cancer. Research has found that only 30% of adolescents report regular use of sunscreen and that 70-80% of them had sunburns the previous summer.2 Previous studies on photo protection have utilized data from nationwide surveys of high school students; it is unclear whether these ABSTRACT Importance: The incidence of melanoma and non-melanoma skin cancer has increased among children and adolescents. Studies in the pediatric population have shown low rates of sun protection with modest improvement over the past several decades. Objective: This descriptive study characterizes photo protection behaviors and knowledge, specifically among pediatric dermatology patients in order to identify gaps in knowledge and guide discussion for health providers. Methods: Adolescents ages 12 to 20 completed surveys, which evaluated use of sun protection, beliefs about tanning and skin cancer, and sources of information. Results: Results demonstrated that only nine percent of participants reported daily, year-round use of sunscreen. The majority (71%) reported use only during the summer months or when spending prolonged periods of time outdoors. Rates of indoor tanning were lower than reported in the literature, with only one percent reporting indoor tanning use. The majority of patients reported family members were the primary source of sun protection education. Conclusions and Relevance: The authors conclude that while adolescents receiving care in the pediatric dermatology setting demonstrate sufficient knowledge about skin cancer prevention, adherence remains low. This study identified family members as the primary source of sun protection knowledge. Dermatologists should consider increased parental education to improve adolescent patient behavior. INTRODUCTION SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 411 trends accurately reflect the beliefs of adolescents who seek dermatologic care, who may be hypothesized to practice better sun protection. Our study aims to characterize the behaviors and beliefs specifically of adolescents frequenting a pediatric dermatology clinic in order to better guide educational efforts by physicians. 105 subjects age 12-20 were recruited from an outpatient pediatric dermatology practice at the Icahn School of Medicine at Mount Sinai in New York, where the study received Institutional Review Board approval. Participants completed a 26-question survey, which solicited information about demographics, knowledge of proper photo protection behavior, and implementation of sun protective practices, including use of sunscreen, frequency of application, use of indoor tanning, and use of sun protective clothing. The mean age of the participants was 14.46 years, with 61% identifying as female and 65% as Caucasian. Twenty-eight participants (27%) reported a family history of skin cancer. Of those, 50% reported a family history of melanoma, and 40% reported basal cell carcinoma. Eighty-seven participants (87%) self-reported a lifetime history of at least one sunburn, and 54 participants (51%) reported a history of sunburn one or more times in the past year alone (Table 1). Most participants did report some use of sunscreen, however, only 9% wore sunscreen daily and year-round, with the majority (71%) only doing so during the summer months or when spending prolonged periods of time outdoors. Of those who reported any use of sunscreen, half reapplied sunscreen multiple times throughout the day. Use of other photo protection measures was low, with 39% reporting use of sunglasses and 25% reporting use of hats. Eighteen percent wore sun protective clothing. Only one adolescent in our study (1%) reported use of indoor tanning, however, they had done so 17 times (Table 2). Analysis of sun protection attitudes and beliefs revealed that the majority had accurate knowledge about sunscreen, tanning, and skin cancer (Table 2). Many participants reported that family members, especially parents, had discussed sun protection (90%) and skin cancer (57%) with them. Much fewer reported that teachers had done so (32% and 37%). Table 1. Basic Demographics of the Study Population (N=105) Characteristic N % Age in years (N=105) 12-15 72 69 16-20 33 27 Sex (N=104) Male 41 39 Female 63 61 Race (N=105) Caucasian 70 67 African American 9 9 Latino 14 13 Asian 5 5 Other 7 7 Skin's reaction to sun (N=105) Always burns, never tans 10 10 Usually burns, sometimes tans 23 22 METHODS RESULTS SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 412 Sometimes burns, tans evenly everywhere 15 14 Burns occasionally, always tans 24 23 Very rarely burns, always tans 30 29 Never burns, never tans 3 3 Hair Color (N=105) Brown/black 83 79 Blonde 21 20 Red 1 1 Eye Color (N=104) Brown 59 57 Blue 19 18 Green 9 9 Hazel 17 16 Family History of Skin Cancer (N=104) Yes 28 27 No 66 63 Unsure 10 10 Table 2. Sun Protective Behavior and Knowledge Behavioral Characteristic N % Frequency of sunscreen Use (N=105) Daily year-round 9 9 Daily during summer months only 9 9 Only when outdoors for prolonged time 58 55 Only when at the beach 13 12 Rarely 12 11 Never 4 4 SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 413 Frequency of reapplication of sunscreen (N=105) Once a day 47 45 Multiple times a day 47 45 I don’t wear sunscreen 11 10 Strength of SPF (n=90) SPF lower than 15 1 1 SPF 15 to 25 11 10 SPF 30 to 45 32 30 SPF 50+ 46 44 Use of hat when outdoors (N=105) Always 4 4 Usually 22 21 Rarely 53 50 Never 26 25 Use of sunglasses when outdoors (N=105) Yes, always 13 12 Usually 28 27 Rarely 37 35 Never 27 26 Use of sun protective clothing (N=104) Yes 19 18 No 85 82 Lifetime history of sunburn (N=105) Yes, once 28 26 Yes, more than once 59 55 No 18 19 History of sunburn in last year (N=105) Yes, once 34 32 SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 414 Yes, more than once 20 19 No 51 49 History of Indoor Tanning (N=105) Never 104 99 Once 0 0 2-5 times 0 0 5-10 times 0 0 > 10 times 1 1 Knowledge and Attitudes N % I feel healthier with a tan (N=99) Agree 13 13 Disagree 86 87 I feel more attractive when I am tan (N=98) Agree 39 40 Disagree 59 60 I can stay out in the sun as long as I want if I wear sunscreen (N=103) Agree 21 20 Disagree 82 80 Sunscreen is waterproof (N=100) Agree 27 27 Disagree 73 73 Getting a “base tan” from indoor tanning can prevent sunburn later in the summer (N=97) Agree 5 5 Disagree 92 95 If you have darker skin you cannot get skin cancer (n=100) Agree 6 6 Disagree 94 94 SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 415 Sources of Sun Protective Knowledge N % Have your teachers in school talked to you about sun protection (N=104) Yes 33 32 No 71 68 Have your teachers in school talked to you about skin cancer (N=104) Yes 38 37 No 66 63 Has anyone in your family talked to you about sun protection (N=104) Yes 93 90 No 11 10 Has anyone in your family talked to you about skin cancer (N=104) Yes 59 57 No 45 43 Results demonstrate that photo protection amongst pediatric dermatology patients remains low, and rates of sunburns are high. Overall prevalence of daily sunscreen use throughout the year was low (9%), similar to data from national surveys on adolescent health, which found that 7-14% of high school adolescents regularly apply sunscreen.3 This rate is much lower when compared to adults in the general US population, in which 14.3% of men and 29.9% of women report daily sunscreen use.4 More specifically, proper use of photoprotection, such as sunscreen, remains a challenge. Healthcare providers should encourage reapplication of sunscreen and year-round use, which is the current recommendation by the American Academy of Dermatology.5 Additionally, our study found that adolescents are infrequent users of sun-protective clothing, with many citing unfamiliarity with this concept in the free text response. This highlights a specific area for improved patient education. The prevalence of indoor tanning has decreased nationwide studies in the past decade, and our results suggest that adolescents frequenting a pediatric dermatology clinic are less likely to use indoor tanning, as only 1% of participants reported use of indoor tanning, compared to 7% of U.S. high school in the general population.6 This suggests indoor tanning should not be the focus of in-office discussions by health providers.6 However, our data may be biased, given that the study population was recruited from an urban center in the Northeast, where tanning bed DISCUSSION SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 416 CONCLUSION usage has historically been less popular compared to Southern and rural areas. With regards to skin cancer prevention knowledge, the vast majority of study participants had accurate information about proper photo protection and skin cancer prevention, despite poor practices. This suggests that positive perceptions of tanned skin may have the greatest influence on adolescent sun behavior, even in a population frequenting a pediatric dermatology clinic.7 In fact 40% of participants reported they feel more attractive with a tan, which corroborates the current literature that self-image may impair safe practice, despite adequate knowledge (table II). This implies that healthcare providers should address whether tanned skin is valued by their patient as a standard of beauty prior to forming a preventative educational plan. Finally, this study identified parents rather than teachers as the primary source of skin cancer education in adolescents. Interestingly, sunscreen usage has been shown to decrease as adolescents get older, possibly a result of less parental supervision.8 We believe earlier educational efforts are needed. However, one study found that only 49% of parents reported ever discussing skin cancer prevention with their pediatrician and that sun protection ranked lowest among preventative topics discussed by pediatricians.9 We hope these findings will guide the educational efforts of dermatologists and pediatricians alike to prioritize sun protection when educating parents. Limitations of this study include the use of a non-validated survey. Additionally, there may be selection bias as subjects were largely Caucasian and from an urban center. It should be noted that while the majority of participants were Caucasian, almost 25% self-identified as African American or Latino. Studies have shown that African American subgroups may be less aware of preventative skin care and practice fewer sun protective behaviors, and these differing practices may have skewed the photoprotection behavior results for the overall cohort.10 Our study suggests that adolescent patients who seek dermatologic care are poor practitioners of photo protection, consistent with the general adolescent population. While many report some use of sunscreen, proper application and reapplication is lacking and the use of sun protective clothing is poor. Furthermore, many still maintain the belief that they are more attractive with a tan, highlighting self-image as an important target in sun safety education. Healthcare providers should continue to educate patients and their parents to modify these behaviors. Conflict of Interest Disclosures: None Funding: None Corresponding Author: Lauren Geller, MD 5 E 98th Street, 5th Floor New York NY 10029 Tel: (212) 241-9728 Fax: (212) 987-1197 Email: lgeller.md@gmail.com References: 1. Wong JR, Harris JK, Rodriguez-Galindo C, Johnson KJ. Incidence of childhood and adolescent melanoma in the United States: 1973- 2009. Pediatrics. 2013;131(5):846-854. 2. Cokkinides V, Weinstock M, Glanz K, Albano J, Ward E, Thun M. Trends in sunburns, sun protection practices, and attitudes toward sun exposure protection and tanning among US adolescents, 1998-2004. Pediatrics. 2006;118(3):853-864. mailto:lgeller.md@gmail.com SKIN November 2019 Volume 3 Issue 6 Copyright 2019 The National Society for Cutaneous Medicine 417 3. Jones SE, Saraiya M. Sunscreen use among US high school students, 1999-2003. The Journal of school health. 2006;76(4):150-153. 4. Buller DB, Cokkinides V, Hall HI, et al. Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: review from national surveys and case studies of 3 states. Journal of the American Academy of Dermatology. 2011;65(5 Suppl 1):S114-123. 5. https://www.aad.org/media/stats/prevention-and- care/vitamin-d-and-uv-exposure. 6. Guy GP, Jr., Berkowitz Z, Everett Jones S, Watson M, Richardson LC. Prevalence of Indoor Tanning and Association With Sunburn Among Youth in the United States. JAMA dermatology. 2017;153(5):387-390. 7. Wright C, Reeder AI, Gray A, Cox B. Child sun protection: sun-related attitudes mediate the association between children's knowledge and behaviours. Journal of paediatrics and child health. 2008;44(12):692-698. 8. Dusza SW, Halpern AC, Satagopan JM, et al. Prospective study of sunburn and sun behavior patterns during adolescence. Pediatrics. 2012;129(2):309-317. 9. McRee AL, Mays D, Kornides ML, Gilkey MB. Counseling About Skin Cancer Prevention Among Adolescents: What Do Parents Receive From Health Care Providers? The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2017;61(4):533-536. 10. Kelly S, Miller LE, Ahn HY, Haley JE. Perceptions and Portrayals of Skin Cancer among Cultural Subgroups. ISRN dermatology. 2014;2014:325281. https://www.aad.org/media/stats/prevention-and-care/vitamin-d-and-uv-exposure https://www.aad.org/media/stats/prevention-and-care/vitamin-d-and-uv-exposure