Shelter from the Sun

Sun protection — from sunscreen products and sun protective clothing, to beach tents and umbrellas — is essential to all. However, it is especially crucial to those with special considerations such as people who work, exercise or spend a significant amount of time in the outdoors; previous skin cancer or organ transplant recipient patients; those with skin other conditions and people with fair or ethnic skins.
A comprehensive sun protection regimen to reduce the risk of skin cancer and premature aging includes applying a water-resistant, broad-spectrum sunscreen — that protects against both types of ultraviolet radiation (UVA and UVB) — with an SPF 30 or higher, limiting sun exposure, seeking shade and wearing sun protective clothing (such as garments, hats and sunglasses), according to the American Academy of Dermatology (AAD).

Research points to the benefits of sun protective clothing in the spectrum of sun protection. A recent study by Reinau et al1 looked at the sun protective behavior and the sunburn experience of vacationers spending holidays in the tropics or subtropics. They found that the sunburn rate among returning vacationers was “alarmingly high.”

For the study, the researchers used standardized face-to-face interviews for cross-sectional surveys among air passengers waiting in the departure or the baggage claim area at the Airport Basel-Mulhouse (Switzerland/France), and among vacationers waiting for pre-travel health advice at a travel clinic in Basel, Switzerland. They completed 533, 324 and 308 interviews with departing air passengers, returning air passengers and vacationers at the travel clinic, respectively. The interviews revealed widespread misconceptions about how to prepare the skin for the sun before holidays. One common misconception was the benefit of indoor “pre-tanning.”

At the holiday destination, almost all respondents used sunscreen, whereas wearing protective clothing and seeking shade were less common behavior. Among the returning air passengers, 44% had got sunburned during their holiday stay. The researchers recommended skin cancer prevention campaigns and pre-travel health advice to dispel misconceptions regarding the preparation of the skin for the sun, and emphasized the significance of covering up and seeking shade.1

Another recent study from Coups et al2 looked at the prevalence and correlation of sun protection and exposure behaviors (sunscreen use, shade seeking, use of sun protective clothing and sunburns) among US Hispanics with sun sensitive skin, with a focus on potential differences according to acculturation and Hispanic origin.

The study included 1,676 Hispanic adults who reported having sun sensitive skin. Participants completed survey questions as part of the nationally representative 2010 National Health Interview Survey. Analyses were conducted in August 2012. The researchers conclude that greater acculturation was linked with risky (not wearing sun protective clothing) and protective (using sunscreen) sun-related practices and with an increased risk of sunburns. Sun protection and exposure behaviors also varied according to individuals’ Hispanic origin. For example, individuals of Mexican heritage had a higher rate of using sun protective clothing and experienced more sunburns than several other subgroups.

“Future research is needed to test culturally relevant, tailored interventions to promote sun protection behaviors among US Hispanics. Such initiatives should focus on public health education and increasing healthcare provider awareness of the importance of skin cancer prevention among Hispanics,” the researchers conclude.

Little is known about handheld umbrella use for sun protection in the United States. McMichael et al3 set out to determine whether women consider the handheld umbrella a socially acceptable form of sun protection. They also looked at whether viewing pictures of famous women carrying umbrellas would influence the study participants.

The cross-sectional survey study of 382 women included those who viewed a collage of famous women carrying umbrellas to assess the effect on social acceptability. Only 12% reported using a handheld umbrella for sun protection. Participants were more likely to use an umbrella after viewing the collage (P<.001). The majority indicated that they would consider umbrella use if recommended by a dermatologist.
Independent predictors of social acceptability were age, having not lived in another country, sun protective clothing use and no sunscreen use, while skin color, ethnicity and education were not. Mean rating of social acceptability was an intermediate score of 5.41 (1 = not acceptable, 10 = totally acceptable) and increased to 5.88 post-collage (P<.001).

The researchers conclude that the social acceptability of handheld umbrellas was moderate and that popular media might play a role in whether women view handheld umbrellas as a socially acceptable form of sun protection.

Dermatologists can consider recommending handheld umbrellas as an adjunct but not replacement for other methods of sun protection.

What to Recommend
In recent years, sun protective clothing has come a long way in terms of materials and style. At the recent Winter 2014 AAD meeting, each aisle seemed to hold at least one booth of fashionable sun protective clothing for all members of the family, from golf attire, to women’s beach wear, to children’s clothing and swim wear. With so many choices, it can be hard to know which is the best recommendation for patients and why?

The fabric material, color and Ultraviolet Protection Factor (UPF) level are some of the factors to be considered when it comes to helping patients determine which solutions are best for them. Flexibility of use, comfort, fashion and cost are additional factors (Figure 1).

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Figure 1. The Ultraviolet Protection Factor level is a factor when helping patients determine which solutions are best for them.

The American Society for Testing and Materials has developed standards for the manufacturing and labeling of sun protective products. The units for UV protection, or UPF, measure the ability of the fabric to block UV from passing through it and reaching the skin.4 The system includes:

• Good UV Protection (for UPF 15-24)
• Very Good UV Protection  (for UPF 25-39)
• Excellent UV Protection (for UPF 40-50)

Not all fabrics block UV light to the same extent. The UPF rating of clothing depends on numerous factors, such as the material’s weave and chemical additives when manufactured (such as UV absorbers or UV diffusers). Patients need to be informed that summer clothing usually does not have a high UPF.

“I am surprised to see that many patients mistakenly believed that their broad-brimmed, loosely woven sun hats were providing absolute sun protection. I recommend that patients use tightly woven, broad-brimmed hats, along with daily sunscreen application to the entire body with extra care to cover face, hands, neck and lips,” explains Indy Chabra, MD, PhD, in practice in Sioux City, IA.
“I also tell them if they plan to be in the sun between the hours of 10 am and 4 pm, wear loose fitting long sleeves/pants and bring a parasol to block the rays. Tinted car windows also decrease the risk of skin cancer and sun damage,” he says.

Purvisha Patel, MD, in practice in Memphis, TN, instructs patients to look for a high UPF rating. “A high UPF rating protects against UV radiation of both types (UVA and UVB), where sunscreen usually only protects against UVB.  Also, I suggest they look for darker, thicker fabrics that prevent sun damage better than thinner, lighter fabrics,” she says.

Additionally, Dr. Patel advises patients to care for clothing properly. “Washing your clothes can reduce its UPF, but there are products (like SunGuard) that you can add to your wash to help with that,” she says.
“Patients also need to remember that sun protective clothing is not a substitute for also using topical sunscreens, but that it also increases one’s sun protection by using both. Safe sun exposure is imperative in that sun avoidance is not possible at all times,” adds Lawrence Samuels, MD, in practice in St. Louis, MO.

Fashion Forward
Fashion and comfort are important elements, as well.

“There are more companies offering sun protective clothing than ever before, and the apparel has become much more stylish and versatile. Some pieces are now designed for specific activities like golf, biking and swimming. There is a new trend toward multi-use resort/fitness/swim styles,” says Donna Avery, chief executive officer at Coolibar, a sun protective clothing company.
“Coverage provided by clothing should be informed by its intended use. Usually, being out in the sun also means being in warm or hot weather. The weight, moisture wicking and/or cooling capabilities or fabric softness differ from brand to brand. People should look for the best product they can afford keeping in mind quality and reliability of protection. A well-constructed sun protective garment should stand up to normal wear, and be chlorine and salt water resistant, to last for many seasons,” says Avery.

Robbin Lacy, vice president of Sun Day Afternoons, a sun protective clothing company, says, “I have been in this business for nearly 25 years, and one thing I have learned is that people will not wear hats or apparel that they do not like. It’s hard to believe with skin health and sometimes our longevity on the table…but patients should indeed shop for what they like,” he says. “That said, there is no reason to opt for the lower UPF ratings, so always search out highest protection, which is 50 UPF, an excellent rating that blocks 98% of UVA and UVB rays.”

Comfort rules when it comes to headwear. Good sun hats have an adjustable sizing detail, brims in excess of 3 inches and should be breathable through porous fabric or mesh venting details (Figure 2).

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Figure 2. Hats are a popular protective sun wear option sold in dermatology offices. Photos courtesy - Coolibar

In recent years Lacy points out, the options for sun protective clothing have increased. “There are many new companies that have made sun protection part of their features in hats, clothing and swimwear. This includes nationally recognized sporting brands, big box stores and the like. Still many people are discovering the benefits of sun protection and are new to using such. Asian cultures are well-versed in this while in the European Union, its not wholly appreciated,” he says.

Outdoor Living
For the sports enthusiast, physicians can advise patients to look for performance fabric garments that are designed for wear while people are sweating and their body temperature is elevated.
“Performance fabric will be more comfortable because on a hot day it will feel cooling, it pulls sweat away from the skin, it is quick drying and it’s ultralight,” says Elise Champe, of Eclipse Sun Products.
Flexibility is also important. One Eclipse product, sun sleeves can be easily removed and can provide an alternative to long sleeve shirts. The sun sleeves design covers hand and arms while leaving fingers free and provides UPF 50 sun protection when wet or dry (Figure 3).

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Figure 3. Removable “sun sleeves” protect the active athlete.

“We have customers who have told us they had lesions removed from their arms, but they still wear T-shirts in the intense sun,” says Champe.
“The patented sun guard fabric is moisture wicking and quick dry. The spandex component assures a non-slip fit,” she adds.
The company’s sun protective line also includes children’s sun ponchos, sun gloves and sun sleeves for children and adults (Figure 4).

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Figure 4. Ponchos provide children with added sun protection.
Photos 3 and 4 courtesy - Eclipse Sun Products

1. Reinau D, Achermann C, Arnet N, Meier CR, Hatz C, Surber C. Sun protective behaviour of vacationers spending holidays in the tropics and subtropics. Br J Dermatol. Published online ahead of print March 26, 2014.
2. Coups EJ, Stapleton JL, Hudson SV, Medina-Forrester A, Natale-Pereira A, Goydos JS. Sun protection and exposure behaviors among Hispanic adults in the United States: differences according to acculturation and among Hispanic subgroups. BMC Public Health. 2012;12:985.
3. McMichael JR, Ezirike J,  Veledar E, Rice JE, Chen SC. The social acceptability of handheld umbrellas for sun protection. Photodermatol Photoimmunol Photomed. Published online ahead of print April 16, 2014.
4. Sun protective clothing. University of California, San Francisco website. Accessed May 21, 2014.