Abstract
Exposure of the skin to ultraviolet (UV) radiation is the main risk factor for skin cancer, and a major source of vitamin D, in many regions of the world. Sun protection messages to minimize skin cancer risks but avoid vitamin D deficiency are challenging, partly because levels of UV radiation vary by location, season, time of day, and atmospheric conditions. The UV Index provides information on levels of UV radiation and is a cornerstone of sun protection guidelines. Current guidelines from the World Health Organization are that sun protection is required only when the UV Index is 3 or greater. This advice is pragmatic rather than evidence based. The UV Index is a continuous scale; more comprehensive sun protection is required as the UV Index increases. In addition, a wide range of UVA doses is possible with a UVI of 3, from which there may be health consequences, while full sun protection when the UVI is “moderate” (between 3 and 5) may limit vitamin D production. Finally, the duration of time spent in the sun is an essential component of a public health message, in addition to the intensity of ambient UV radiation as measured by the UV Index. Together these provide the dose of UV radiation that is relevant to both skin cancer genesis and vitamin D production. Further education is required to increase the understanding of the UV Index; messages framed using the UV Index need to incorporate the importance of duration of exposure and increasing sun protection with increasing dose of UV radiation.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Change history
27 October 2020
A Correction to this paper has been published: https://doi.org/10.1039/c8pp90034e
References
WHO, INTERSUN: The global UV project: a guide and compendium, World Health Organization, 2003.
F. Zaratti, R. D. Piacentini, H. A. Guillen, S. H. Cabrera, J. B. Liley and R. L. McKenzie, Proposal for a modification of the UVI risk scale, Photochem. Photobiol. Sci., 2014, 13, 980–985.
R. L. McKenzie and S. Madronich, in Encyclopedia of Atmospheric Sciences, ed. J. Holton, J. Pyle and J. Curry, Academic Press, London, 2002, pp. 2474–2480.
R. McKenzie, R. Scragg, B. Liley, P. Johnston, J. Wishart, A. Stewart and R. Prematunga, Serum 25-hydroxyvitamin-D responses to multiple UV exposures from solaria: inferences for exposure to sunlight, Photochem. Photobiol. Sci., 2012, 11, 1174–1185.
F. R. de Gruijl, Action spectrum for photocarcinogenesis, Recent Results Cancer Res., 1995, 139, 21–30.
World Health Organization, Global Solar UV Index, World Health Organization, World Meteorological Organization, United Nations Environment Programme, International Commission on Non-ionizing Radiaton Protection, Geneva, 2002.
O. B. Carter and R. J. Donovan, Public (Mis)understanding of the UV Index, J. Health Commun., 2007, 12, 41–52.
Cancer Institute NSW, UV Index. The Facts, http://www.darksideoftanning.com.au/pdf/facts-sheet_uv-index.html.
B. Rajiv and R. Gray, Sun Protection Alert - a simple tool for a complex issue. UV radiation and its ejfects: an update. Auckland, NZ, 2014.
EPA, UV Alert, http://www2.epa.gov/sunwise/uv-alert, (accessed 11 May 2014).
European Commission Scientific Committee on Health, Opinion on biological ejfects of ultraviolet radiation relevant to health with particular reference to sunbeds for cosmetic purposes, European Commission, 2016.
R. M. Lucas, M. Norval, R. E. Neale, A. R. Young, F. R. de Gruijl, Y. Takizawa and J. C. van der Leun, The consequences for human health of stratospheric ozone depletion in association with other environmental factors, Photochem. Photobiol. Sci., 2015, 14, 53–87.
D. Liu, B. O. Fernandez, A. Hamilton, N. N. Lang, J. M. Gallagher, D. E. Newby, M. Feelisch and R. B. Weller, UVA irradiation of human skin vasodilates arterial vasculature and lowers blood pressure independently of nitric oxide synthase, J. Invest. Dermatol., 2014, 134, 1839–1846.
N. M. Scott, R. L. Ng, S. Gorman, M. Norval, J. Waithman and P. H. Hart, Prostaglandin E2 imprints a long-lasting effect on dendritic cell progenitors in the bone marrow, J. Leukocyte Biol., 2014, 95, 225–232.
F. P. Noonan, M. R. Zaidi, A. Wolnicka-Glubisz, M. R. Anver, J. Bahn, A. Wielgus, J. Cadet, T. Douki, S. Mouret, M. A. Tucker, A. Popratiloff, G. Merlino and E. C. De Fabo, Melanoma induction by ultraviolet A but not ultraviolet B radiation requires melanin pigment, Nat. Commun., 2012, 3, 884.
E. Emanuele, J. M. Spencer and M. Braun, From DNA repair to proteome protection: new molecular insights for preventing non-melanoma skin cancers and skin aging, J. Drugs Dermatol., 2014, 13, 274–281.
R. B. Weller, Sunlight Has Cardiovascular Benefits Independently of Vitamin D, Blood Purif., 2016, 41, 130–134.
D. L. Damian, Y. J. Matthews, T. A. Phan and G. M. Halliday, An action spectrum for ultraviolet radiation-induced immunosuppression in humans, Br.J. Dermatol., 2011, 164, 657–659.
G. M. Halliday, S. N. Byrne and D. L. Damian, Ultraviolet A radiation: its role in immunosuppression and carcinogenesis, Semin. Cutaneous Med. Surg., 2011, 30, 214–221.
R. M. Lucas, A. L. Ponsonby, K. Dear, P. C. Valery, M. P. Pender, B. V. Taylor, T. J. Kilpatrick, T. Dwyer, A. Coulthard, C. Chapman, I. van der Mei, D. Williams and A. J. McMichael, Sun exposure and vitamin D are independent risk factors for CNS demyelination, Neurology, 2011, 76, 540–548.
A. Swaminathan, Doctor of Philosophy, The Australian National University, 2013.
F. Xiang, R. Lucas, F. de Gruijl and M. Norval, A systematic review of the influence of skin pigmentation on changes in the concentrations of vitamin D and 25-hydroxyvitamin D in plasma/serum following experimental UV irradiation, Photochem. Photobiol. Sci., 2015, 14, 2138–2146.
T. B. Fitzpatrick, The validity and practicality of sun-reactive skin types I through VI, Arch. Dermatol., 1988, 124, 869–871.
P. Vecchia, M. Hietanen, B. Stuck, E. van Deventer and S. Niu, Protecting workers from ultraviolet radiation, International Commission on non-Ionizing Radiation Protection, 2007.
P. Hoeppe, A. Oppenrieder, C. Erianto, P. Koepke, J. Reuder, M. Seefeldner and D. Nowak, Visualization of UV exposure of the human body based on data from a scanning UV-measuring system, Int. J. Biometeorol., 2004, 49, 18–25.
S. Seite, A. Fourtanier, D. Moyal and A. R. Young, Photodamage to human skin by suberythemal exposure to solar ultraviolet radiation can be attenuated by sunscreens: a review, Br.J. Dermatol., 2010, 163, 903–914.
D. L. Mitchell, B. Volkmer, E. W. Breitbart, M. Byrom, M. G. Lowery and R. Greinert, Identification of a non-dividing subpopulation of mouse and human epidermal cells exhibiting high levels of persistent ultraviolet photodamage, J. Invest. Dermatol., 2001, 117, 590–595.
I. Martincorena, A. Roshan, M. Gerstung, P. Ellis, P. Van Loo, S. McLaren, D. C. Wedge, A. Fullam, L. B. Alexandrov, J. M. Tubio, L. Stebbings, A. Menzies, S. Widaa, M. R. Stratton, P. H. Jones and P. J. Campbell, Tumor evolution. High burden and pervasive positive selection of somatic mutations in normal human skin, Science, 2015, 348, 880–886.
S. Brown, C. M. Pineda, T. Xin, J. Boucher, K. C. Suozzi, S. Park, C. Matte-Martone, D. G. Gonzalez, J. Rytlewski, S. Beronja and V. Greco, Correction of aberrant growth preserves tissue homeostasis, Nature, 2017, 548, 334–337.
S. J. Felton, M. S. Cooke, R. Kift, J. L. Berry, A. R. Webb, P. M. Lam, F. R. de Gruijl, A. Vail and L. E. Rhodes, Concurrent beneficial (vitamin D production) and hazardous (cutaneous DNA damage) impact of repeated low-level summer sunlight exposures, Br. J. Dermatol., 2016, 175, 1320–1328.
E. F. Meanwell and B. L. Diffey, Reciprocity of ultraviolet erythema in human skin, Photodermatology, 1989, 6, 146–148.
J. Garssen, F. de Gruijl, D. Mol, A. de Klerk, P. Roholl and H. Van Loveren, UVA exposure affects UVB and cis-urocanic acid-induced systemic suppression of immune responses in Listeria monocytogenes-infected Balb/c mice, Photochem. Photobiol., 2001, 73, 432–438.
J. H. Rabe, A. J. Mamelak, P. J. McElgunn, W. L. Morison and D. N. Sauder, Photoaging: mechanisms and repair, J. Am. Acad. Dermatol., 2006, 55, 1–19.
C. Battie, S. Jitsukawa, F. Bernerd, S. Del Bino, C. Marionnet and M. Verschoore, New insights in photoaging, UVA induced damage and skin types, Exp. Dermatol., 2014, 23(Suppl 1), 7–12.
R. McKenzie, D. Smale and M. Kotkamp, Relationship between UVB and erythemally weighted radiation, Photochem. Photobiol. Sci., 2004, 3, 252–256.
D. L. Damian, R. S. Barnetson and G. M. Halliday, Low-dose UVA and UVB have different time courses for suppression of contact hypersensitivity to a recall antigen in humans, J. Invest. Dermatol., 1999, 112, 939–944.
P. H. Hart, S. Gorman and J. J. Finlay-Jones, Modulation of the immune system by UV radiation: more than just the effects of vitamin D?, Nat. Rev. Immunol., 2011, 11, 584–596.
M. Peterlik, Vitamin D insufficiency and chronic diseases: hype and reality, Food Funct., 2012, 3, 784–794.
M. J. Bolland, A. Grey, G. D. Gamble and I. R. Reid, The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes: a trial sequential meta-analysis, Lancet Diabetes Endocrinol., 2014, 2, 307–320.
P. Autier, P. Mullie, A. Macacu, M. Dragomir, M. Boniol, K. Coppens, C. Pizot and M. Boniol, The influence of vitamin D supplementation on non-skeletal conditions: a systematic review of randomised trials and of their metaanalyses, Lancet Diabetes Endocrinol., 2017, 5, 986–1004.
J. M. Lappe and R. P. Heaney, Why randomized controlled trials of calcium and vitamin D sometimes fail, Dermatoendocrinol., 2012, 4, 95–100.
L. E. Rhodes, A. R. Webb, H. I. Fraser, R. Kift, M. T. Durkin, D. Allan, S. J. O’Brien, A. Vail and J. L. Berry, Recommended summer sunlight exposure levels can produce sufficient (> or = 20 ng ml(-1)) but not the proposed optimal (> or = 32 ng ml(-1)) 25(OH)D levels at UK latitudes, J. Invest. Dermatol., 2010, 130, 1411–1418.
M. Schrempf, N. Thuns, K. Lange and G. Seckmeyer, Impact of Orientation on the Vitamin D Weighted Exposure of a Human in an Urban Environment, Int. J. Environ. Res. Public Health, 2017, 14, E920.
M. D. Farrar, A. R. Webb, R. Kift, M. T. Durkin, D. Allan, A. Herbert, J. L. Berry and L. E. Rhodes, Efficacy of a dose range of simulated sunlight exposures in raising vitamin D status in South Asian adults: implications for targeted guidance on sun exposure, Am. J. Clin. Nutr., 2013, 97, 1210–1216.
M. K. Bogh, A. V. Schmedes, P. A. Philipsen, E. Thieden and H. C. Wulf, Interdependence between body surface area and ultraviolet B dose in vitamin D production: a randomized controlled trial, Br.J. Dermatol., 2011, 164, 163–169.
J. Morris, T. Laing-Morton, P. Marno and A. Curnow, An investigation into the awareness and understanding of the ultraviolet index forecasts in the South West of England, Photochem. Photobiol. Sci., 2011, 10, 103–108.
C. Y. Wright, A. I. Reeder and P. N. Albers, School students’ knowledge and understanding of the Global Solar Ultraviolet Index, S. Afr. Med. J., 2015, 105, 1024–1029.
A. C. Green, G. M. Williams, V. Logan and G. M. Strutton, Reduced melanoma after regular sunscreen use: randomized trial follow-up, J. Clin. Oncol., 2011, 29, 257–263.
L. Finch, M. Janda, L. J. Loescher and E. Hacker, Can skin cancer prevention be improved through mobile technology interventions? A systematic review, Prev. Med., 2016, 90, 121–132.
Acknowledgements
Profs Lucas and Neale are funded by Senior Research Fellowships from the National Health and Medical Research Council of Australia.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 3.0 License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.
The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/3.0/.
About this article
Cite this article
Lucas, R.M., Neale, R.Ε., Madronich, S. et al. Are current guidelines for sun protection optimal for health? Exploring the evidence. Photochem Photobiol Sci 17, 1956–1963 (2018). https://doi.org/10.1039/c7pp00374a
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1039/c7pp00374a