Sun, Sense & Sensibility

It is not clear when attitudes towards sunbathing changed.
Pale skin was considered fashionable in the 19th Century: a suntan then being associated with farmers, peasants and the working classes with outdoor jobs. In the 1920s, Coco Chanel, an icon of her time, returned to Paris with a tan after a holiday cruise. This, at once, influenced and popularised the "bronzed" look. A suntan quickly, became associated with health, wealth, leisure and fashion. Nowadays, the wisdom of acquiring a suntan needs to be rethought as our understanding of the dangers of sunbathing increases. No longer should the bronzed look be 'de rigeur'.
There is no doubt that sunlight and pleasant summer warmth have a beneficial effect psychologically, but the expert warnings about premature ageing and skin cancer are still largely ignored, despite much recent media coverage. A tan is NOT an indicator of good health.
The simple message to all sun worshippers is that you will have to pay later for your suntan. Dermatologists agree that it is not possible to tan without some degree of skin damage. However, we can take measures to effectively lessen the risk. What follows is not just relevant to Southern Europe or the Tropics. The sun can shine very strongly in the U.K. too.

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Sunlight consists of visible light and the invisible: ultraviolet and infrared. The latter we experience as heat. Ultraviolet light, or more correctly radiation, is of three types. These are ultraviolet A, B and C, known as UVA, UVB and UVC.

UVA has the longest wavelength. These rays mainly cause premature ageing and wrinkling as they penetrate deep into the skin, damaging collagen fibres.
UVB rays are of medium wavelength. They are responsible for sunburn and are the biggest contributors to the development of skin cancers.
UVC has the shortest wavshortelength and is filtered out by the ozone in the atmosphere. It should not reach the earth's surface. However, it could contribute to skin cancers in the future if the thinning of the ozone layer continues.

Sunlight may feel pleasant enough, but in reality, the skin reacts as though it is being attacked. Therefore, it attempts to protect itself against both short and long term damage.

This occurs most commonly in fair skinned people, or when there has been insufficient time for the skin to react. Redness develops and mav be followed by sorenesst blistering and peeling. Severe over-esposure can make you very unwell, but normally recovery occurs after a day or two of discomfort and inconvenience. It may leave 'sunburn freckles' in its wake.

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This is due to an increase in the normal skin pigment (melanin). It causes the brown sun-tanned appearance. Melanin is produced by specialised skin cells in order to protect against sunlight. Fair people who cannot tan uniformly get freckles.

The body also tries to protect itself by causing skin cells to divide more rapidly than normal. The top layer (epidermis) may be two to four times its normal thickness following light esposure. The melanin will have been taken up in this layer in the process. This response is important in fair-skinned individuals who produce less melanin in response to sunlight.

This is the first of the long-term effects. It occurs on the face. neck and other esposed parts and is caused by damage to collagen and elastic fibres resulting in wrinkling and a yellowish appearance especially in those with a fair complexion. Flat bronwn blotches inappropriately called "liver spots" are commonly associated on the backs of the hands and forearms. These changes may take years to become apparent.

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Again, a long term effect.

Solar keratoses are scaly patches that appear on the skin surface. They are rough to the touch and often reddish-brown in colour. They are common and usually appear on the face, ears and backs of the hands occurring with greatest frequency in fair skinned people, especially outdoor workers They are particularly common on bald scalps particularly in the elderly. Most are harmless but they can occasionally give rise to cancers.

Basal cell carcinomas (rodent ulcers) occur in many forms: but most often present as domed pearly lumps on light esposed skin such as the temples and forehead. Unlike other cancers, they do not spread to other parts of the body but enlarge locally, producing damage to adjacent skin and underlying tissue.

Squamous cell carcinoma usually shows itself as a hard lump with a warty surface or as a crust covered crater. It too occurs most often on esposed skin and may spread elsewhere if left untreated. It can develop from a solar keratosis. Solar keratoses, rodent ulcers and squamous cell carcinomas are all easily curable if treated early enough.

Malignant melanoma is the most dangerous tumour and accounts for nearly all deaths from skin cancer. It may grow and change appearance slowly or quickly. Early treatment is essential. During recent decades, cases of malignant melanoma have risen substantially in the U.K.. and this correlates well with the increase in holidays taken abroad. Many are linked to short periods of excessive esposure to intense sunlight rather than the long term, cumulative doses acquired over the years, which result in solar keratoses and squamous cell carcinomas. Spending 2 weeks a year sunbathing on the beach in the Mediterranean without any protection is a recipe for later disaster. Melanomas are most common on the trunk in men and the lower leg in women. but can occur anywhere. They can develop on normal skin or in an existing mole.
Malignant change in a mole is related to the total amount of skin esposed to the sun and not to the sun shining directly on the mole. Covering moles with plasters is therefore nonsense. If you have fair freckly skin, red hair and many moles you are at greater risk. The same applies if there is a family history of melanoma. There are several types of malignant melanoma but this seven-point checklist should enable you to identify any signs that require attention:

1. Size: A mole with a diameter of less than 7mm is unlikely to be malignant. (This does not mean, of course, that a mole greater than 7mm is malignant).
2. Increasing size, in either diameter or thickness.
3. Itching.
4. Colour variation: development of different shades of brown: pink, orange or black within the mole.
5. Inflammation or redness.
6. The development of an irregular outline or dark halo.
7. Bleeding or crusting.

You should consult your doctor if two or more of the above changes occur in the same mole at the same time.

There are several other disorders where sunlight affects the skin, some are due to an allergy to the sun's rays or to hereditary diseases, while others can come about through contact with the sap of certain plants. Some medication, either by mouth or applied to the skin can make you light sensitive. If you have any queries about your medication then ask. It would be unfair to expect your doctor to remember every potential reaction to every drug: it is simply not possible, but the current MIMS Compendium and National formulary should be available in every surgery for reference. However, most of these problems are rare.

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These widely available creams and lotions are applied directly to the skin. They work by absorbing the UVB and reflecting the UVA. All UVB sunscreens should state a "sun protection factor" (SPF). The higher the SPF the greater the protection. It tells you how long you may stay in the sun without burning. For example, if it normally takes 10 minutes for your skin to burn then an SPF of 6 will take 6 times as long, i.e. 60 minutes.
UVA protection is indicated by a star rating of 1 to 4. The stars are a guide to the amount of UVA protection relative to the UVB. Four stars indicate most effective protection with UVB and UVA "balanced". i.e. both equally and effectively blocked. Decide on your choice of sunscreen according to your 'skin type', but remember this guide can, occasionally, be misleading and it is wiser to overprotec,. at least to start with.

These should be used throughout for types 1 and 2 but may be regarded as for initial use for types 3 and 4 reducing to a lower factor after 4-5 days.

There are no sunscreens with a SPF of 50 for exceptionally sensitive skin. Only sunscreens with an SPF of 15 or over can be prescribed by your doctor and then only if there is known medical reason for their use such as excessive photosensitivity or photoallergy.

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Wear loose fitting cotton clothing to cover body, arms and legs, as well as your sunscreen and a hat. These measures will protect you from burning but remember up to 50% of the sun's rays can penetrate such clothing, even in the shade. Large amounts of light are reflected by snow: sand (especially white sand), white washed buildings and to a lesser estent, by water.

1. If you must sunbathe, don't do so between Il am and 3 pm. UVB rays are at their strongest between these times and they peak at midday. The nearer you get to the tropics, the greater the intensity and the more you are at risk..
2. Put the higher factor sunscreens on sensitive areas. e.g. nose, cheeks, skin around the eyes and shoulders. Wearing sunglasses will also help protect the eyes and lids. Fair skinned races have no pigment in their lips so these may need protection too. Light blocking lip salve screens are available.
3. Always remember to apply your sunscreen at least half an hour before going out into the sun. Water and wet clothing do not protect you from burning. Keep on reapplying at intervals if you are going out in the sun for a long time.
4. Young children are particularly at risk, so use the highest factors available combined with sensible clothing and a hat. Babies should never be esposed to strong sunlight. A bad attack of sunburn in childhood appears to carry a greater risk of melanoma in later life.
5. Don't be deceived by a breeze, even if it is cool. It can't blow awav the sun's rays! The skin will feel cooler but you can still burn easily. This applies to winter sun as well, especially if skiing, where altitude and reflection from snow increase irradiation.
6. Do not apply perfume, aftershave or fragrance products in the sun. These can occasionally interact with the sun and cause allergic reactions. It is said that they attract mosquitoes.
7. Never fall asleep in the sun. If you feel sleepy, move into the shade or indoors before it is too late.
8. Some drugs such as the contraceptive pill can cause pigmentary changes, especially on the face. Although harmless, this may be made darker by light exposure. A sunscreen can lessen the effect.
9. Never confuse sunlight with heat. Some people seem to think of them as synonymous. They are as different as the problems they cause.
10. If it is overcast in the morning, the sun can suddenly burn through at any time, so don't forget your sunscreen. Remember too, that substantial amounts of UV light can pass through cloud cover.

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If you are concerned about a change in a mole or freckle, seek professional advice as soon as you can. It will probably turn out to be nothing but please get it checked anyway for your own peace of mind. If you have many moles, make a point of checking them now and again using the 7-point checklist. Remember that protecting your skin from sun damage is the simplest defence against skin cancer and premature ageing. We are not killjoys. We want you to enjoy your time abroad. After all, many of us spend our holidays in sunny climates too. Please don't run any unnecessary risks. Do yourself and your family a favour, just be sensible and have a great time. May see you there!

This factsheet written by Dr D Porter, retired Dermatologist, Hospital of St Cross, Rugby, based on a booklet by Staff Nurse Jane Spencer of Walsgrave Hospital, Coventry.

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