Synergy under the Sun? Nanoplastics Enhance Estrogenicity of Common UV-Blocker.

Human cells and zebrafish coexposed to nanoplastics and the sunscreen ingredient homosalate showed more plastics in tissues, estrogenic activity, and relevant gene expression changes than they showed after either exposure alone.

Factors Influencing Patient Selection of Sunscreen.

Sunscreen is an essential component of sun protection. The most important characteristics for patient selection of sunscreens have not been evaluated. A cross-sectional survey study was performed at an academic dermatology office. The sunscreen characteristic chosen most frequently was SPF (75.2%). Fewer patients selected broad-spectrum (20.7%) and water-resistance (22.7%). There remains a gap in patient knowledge regarding AAD recommendations for sunscreen characteristics and educational initiatives may be required. J Drugs Dermatol. 2024;23(6):e154-e155.     doi:10.36849/JDD.8324e  .

Sunscreen Practices and Preferences of Skin of Color Patients.

Sunscreen is an essential way to protect against photodamage from ultraviolet (UV) radiation. Despite the recognized benefits of sunscreen in preventing skin damage from UV light, its use varies across different patient groups. This cross-sectional, questionnaire-based study aims to uncover the sunscreen usage patterns, preferences, and barriers among non-Hispanic White (NHW) and skin of color (SOC) individuals. Our findings demonstrate that NHW individuals are more likely to wear sunscreen daily (31% NHW vs 25% SOC) and reapply sunscreen at least once a day (76% NHW vs 45% SOC) compared with SOC individuals. SOC individuals demonstrate a willingness to use sunscreen, but they face barriers such as cost (2% NHW vs 16% SOC), lack of knowledge in finding suitable products (22% NHW vs 41% SOC), and concerns about white cast (7% NHW vs 25% SOC). SOC individuals are less likely to know the difference between mineral and chemical sunscreen (49% NHW vs 29% SOC), less likely to learn about sunscreen from dermatologists (36% NHW vs 22% SOC), and more likely to prefer sunscreen from brands owned by people of color (13% NHW vs 47% SOC).  In addition to analyzing the broader categories of NHW and SOC, subgroup analysis was conducted on specific subgroups, including Black, Asian, and Hispanic groups. Herein, we highlight differences in motivations, sunscreen preferences, sources of information, and knowledge levels about sun protection between NHW and SOC individuals. By uncovering the unique needs and challenges faced by SOC individuals, we aim to improve culturally competent patient education and promote effective sun protection practices across diverse populations. J Drugs Dermatol. 2024;23(6):456-462.     doi:10.36849/JDD.8268.

Prevalence of selected UV filter compounds in Biscayne National Park.

This research was carried out in order to assess a baseline occurrence in Biscayne National Park, Florida, of four organic contaminants: the UV filters oxybenzone, dioxybenzone, and benzophenone, as well as the topical pain reliever benzocaine. A total of 35 samples were taken from five locations within the park, four near barrier islands, and one at a coral reef. Analyses were carried out using liquid chromatography coupled to high-resolution mass spectrometry. Oxybenzone was detected in 26% of samples from the park at concentrations up to 31 ng/L. Benzophenone was detected in 49% of samples from the park at concentrations up to 131 ng/L. Benzocaine and dioxybenzone were not detected in any of the samples.

Sunproofing from within: A deep dive into oral photoprotection strategies in dermatology.

BACKGROUND: Photoprotection is the first measure in the prevention and treatment of the deleterious effects that sunlight can cause on the skin. It is well known that prolonged exposure to solar radiation leads to acute and chronic complications, such as erythema, accelerated skin aging, proinflammatory and procarcinogenic effects, and eye damage, among others. METHODS: A better understanding of the molecules that can protect against ultraviolet radiation and their effects will lead to improvements in skin health. RESULTS: Most of these effects of the sunlight are modulated by oxidative stress and proinflammatory mechanisms, therefore, the supplementation of substances that can regulate and neutralize reactive oxygen species would be beneficial for skin protection. Current evidence indicates that systemic photoprotection should be used as an adjunctive measure to topical photoprotection. CONCLUSION: Oral photoprotectors are a promising option in improving protection against damage induced by UVR, as they contain active ingredients that increase the antioxidant effects of the body, complementing other photoprotection measures. We present a review of oral photoprotectors and their effects.

A Practical Algorithm for Integrating Skincare to Improve Patient Outcomes and Satisfaction With Energy-Based Dermatologic Procedures.

BACKGROUND: Medical aesthetic procedures for facial antiaging with laser and energy-based devices (EBDs) are rapidly increasing, but standards integrating skincare before, during, and after these treatments are lacking. The algorithm for integrated skin care for facial antiaging treatment with EBDs aims to stimulate healing, reduce downtime, and improve comfort and treatment outcomes. METHODS: A panel of 8 global physicians employed a modified Delphi method and reached a consensus on the algorithm integrating skincare based on the best available evidence, the panel's clinical experience, and opinions. RESULTS: The algorithm has a pretreatment (starts 2 - 4 weeks before the procedure) and treatment (day of treatment) section, followed by care after the procedure (0 - 7 days) and follow-up care (1 - 4 weeks after the procedure or ongoing). Applying a broad-spectrum sunscreen with an SPF 50 or higher, combined with protective measures such as wearing a wide-brimmed hat and sunglasses, is recommended to protect the face from sun exposure. Dyschromia is a significant concern for those with skin of color (SOC). Clinicians may recommend skincare using a gentle cleanser and moisturizer containing vitamins C and E, retinoid, or other ingredients such as niacinamide, kojic acid, licorice root extract, azelaic acid, and tranexamic acid, depending on the patient's facial skin condition. CONCLUSION: Medical aesthetic procedures for facial antiaging with EBDs integrating skincare or topical treatments may improve outcomes and patient satisfaction. Topical antioxidants and free radical quenchers can combat photodamage and may offer a safe alternative to topical hydroquinone.  J Drugs Dermatol. 2024;23(5):353-359.     doi:10.36849/JDD.8092.

Ultraviolet Protection From a Patented Amino Acid Complex Technology.

OBJECTIVE:   This study aimed to investigate the ultraviolet (UV) protection/repair benefits of a patented Amino Acid Complex (AAComplex). METHODS: I) AAComplex was incubated with dermal fibroblasts, with/without UVA, and collagen I was measured with a GlasBoxPlus device. II) A lotion, with/without AAComplex (1%) was applied topically to skin explants, following UVA irradiation, and quantified for health-related biomarkers (TNFalpha, histamine, and MMP-1). III) A broad spectrum sunscreen with SPF 46 and a skincare serum containing AAComplex (2%) were assessed using epidermal equivalents, in the presence of UV irradiation, for effects on IL-1alpha, thymine dimers, Ki-67, filaggrin and Nrf2. RESULTS: I) Collagen I synthesis in dermal fibroblasts was significantly decreased after UVA compared to without UV. The presence of AAComplex prevented this decrease. II) UVA irradiation of skin explants increased histamine, TNFα, and MMP-1. Hydrocortisone aceponate cream significantly decreases all 3 biomarkers. AAComplex contained lotion also significantly decreased all 3 biomarkers, the no AAComplex control lotion only reduced histamine. III) With the regimen of sunscreen + AAComplex contained skincare serum, the significant reduction in IL-1alpha was observed along with a complete recovery of Ki-67 and stimulation of filaggrin and Nrf2T. No thymine dimer positive cell was observed indicating the most positive skin impact from the regiment.  Conclusion: This research using different human skin models demonstrated that AAComplex can provide protection and damage repair caused by UV, at the ingredient level also when formulated in a serum or lotion formula. Skin may be best protected from UV damage when the regimen is used.   J Drugs Dermatol. 2024;23(5):366-375. doi:10.36849/JDD.7916.

PRESOLRE: study protocol for a primary school-based, cluster randomised controlled trial of three sun exposure risk prevention strategies on Reunion Island.

INTRODUCTION: Reunion Island, a French overseas department, is located in the southern hemisphere, close to the Capricorn tropic. This island has a multicultural and multiethnic population of 860 000 inhabitants, a quarter of whom are at high risk of developing skin cancer due to intense ultraviolet radiation. Melanoma is responsible for the majority of skin cancer deaths. The early prevention of melanoma is based on sun protection in childhood, but French regulations are not adapted to the environmental conditions of this tropical region.The main objective of our study is to evaluate the effectiveness of three sun protection programs conducted in Reunionese primary schools through a pupil knowledge questionnaire. METHODS AND ANALYSIS: PRESOLRE is an interventional, open-label, cluster-randomised controlled trial, in four parallel arms, that is being conducted throughout 2022-2023 on Reunion Island. The trial design assumes an escalation interventional effect using: first, a control arm without proposed intervention (arm 1); second, an arm whose classes are encouraged to use the validated educational programme 'Living With the Sun' (LWS) (arm 2); third, an arm whose classes are encouraged to use both 'LWS' combined with 'Mission Soleil Réunion's sun protection awareness programme (arm 3); fourth, an arm benefiting from an intervention similar to arm 3, combined with the distribution of hats, sunglasses and sun creams (arm 4). In all, 1780 pupils from 18 classes of 20 pupils, on average, will be included. Randomisation applies to the classes of pupils (so defined as clusters). The primary outcome is based on the proportion of correct answers to the knowledge questions after the awareness programme, compared between the four arms using a linear mixed model with random intercept. ETHICS AND DISSEMINATION: The study obtained ethics approval in 2022 (ID: 2022-A00350-43). Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05367180.

Toxicity of the sunscreen UV filter benzophenone-3 (OBZ) to the microalga Selenastrum capricornutum: An insight into OBZ's damage to photosynthesis and respiration.

Oxybenzone (OBZ; benzophenone-3, CAS# 131-57-7), as a new pollutant and ultraviolet absorbent, shows a significant threat to the survival of phytoplankton. This study aims to explore the acute toxic effects of OBZ on the growth of the microalga Selenastrum capricornutum, as well as the mechanisms for its damage to the primary metabolic pathways of photosynthesis and respiration. The results demonstrated that the concentrations for 50 % of maximal effect (EC50) of OBZ for S. capricornutum were 9.07 mg L-1 and 8.54 mg L-1 at 72 h and 96 h, respectively. A dosage of 4.56 mg L-1 OBZ significantly lowered the photosynthetic oxygen evolution rate of S. capricornutum in both light and dark conditions for a duration of 2 h, while it had no effect on the respiratory oxygen consumption rate under darkness. OBZ caused a significant decline in the efficiency of photosynthetic electron transport due to its damage to photosystem II (PSII), thereby decreasing the photosynthetic oxygen evolution rate. Over-accumulated H2O2 was produced under light due to the damage caused by OBZ to the donor and acceptor sides of PSII, resulting in increased peroxidation of cytomembranes and inhibition of algal respiration. OBZ's damage to photosynthesis and respiration will hinder the conversion and reuse of energy in algal cells, which is an important reason that OBZ has toxic effects on S. capricornutum. The present study indicated that OBZ has an acute toxic effect on the microalga S. capricornutum. In the two most important primary metabolic pathways in algae, photosynthesis is more sensitive to the toxicity of OBZ than respiration, especially in the dark.

Knowledge, Attitudes, and Practices of Sun Exposure and Sun Protection among the Population of Kazakhstan: A Cross Sectional Study.

OBJECTIVE: The aims of this study were to assess knowledge, attitudes, and practices regarding sun exposure and sun protection among the population of Kazakhstan. METHOD: A cross sectional study was conducted by administering an online questionnaire via social networking sites to residents of Kazakhstan. The questionnaire was designed to determine demographic information as well as knowledge, attitudes and practices regarding sun exposure and sun protection. RESULT: The responses of 249 participants were analysed.  Descriptive tests, bivariate analyses, and multiple linear regression were used to statistically analyse the data. The mean age of the participants was 31.7 ± 11.5 (SD) years. Most participants were of Kazakh nationality (88.7%), female (71.0 %), urban residents (93.9 %), and possessed higher education degrees (88.0 %). The level of knowledge and attitudes were found to be moderate amongst the population whilst practices were determined to be low.  Knowledge (p=0.002), attitudes (p=0.002), female gender (p=0.002), and having children educated in school about sun safety (p=0.018) were significantly associated with improved sun-protective practices. CONCLUSION: This study has demonstrated low adoption of sun protective practices in the Kazakhstan population, despite the identification of certain characteristics associated with higher rates of practice.

Sunscreen compound benzophenone-3 and its relationship with white blood cell counts.

BACKGROUND: Evidence from animal models suggests a role for the organic ultraviolet filter benzophenone-3's (BP-3) on white blood cells (WBCs). However, BP-3's effect on WBCs in humans is unknown. MATERIALS AND METHODS: We used National Health and Nutrition Examination Survey data from 2003 to 2016. We included participants >6 years with data on urinary BP-3, urinary creatinine, and WBC count. Quintiles of urinary creatinine-normalized BP-3 (CnBP-3) levels were used in linear regression models adjusting for age, gender, race, body mass index (BMI), smoking status, education level, family income to poverty threshold ratio, survey cycle, and season. RESULTS: Of the 16 959 participants, 8564 (50.5%) were females, 6602 (38.9%) were White, and 3870 (22.8%) were Black. The mean (standard deviation) age was 37.6 (22.7) years, BMI was 26.8 (7.40) kg/m2, WBC count was 7.22 (2.53) × 109/L, neutrophil count was 4.15 (1.86) × 109/L, and lymphocyte count was 2.25 (1.33) × 109/L and median (interquartile range) of CnBP-3 was 12.1 (44.9) µg/gm. The highest quintile of CnBP-3 was associated with significantly lower WBC and neutrophil counts compared to the lowest quintile of CnBP-3 (Δ quintiles = -137 × 106/L, 95% CI: -249 to -24, p = 0.02 and = -177 × 106/L, 95% CI: -323 to -30, p = 0.02, respectively). In contrast, we did not observe a difference in lymphocyte count between the lowest and highest quintiles of CnBP-3 in unadjusted or adjusted analyses. CONCLUSION: We found an inverse relationship between BP-3 levels and WBC and neutrophil counts, and not with lymphocyte count. Further research is needed to confirm our findings.

Combined effects of organic and mineral UV-filters on the lugworm Arenicola marina.

Pollution from personal care products, such as UV-filters like avobenzone and nano-zinc oxide (nZnO), poses a growing threat to marine ecosystems. To better understand this hazard, especially for lesser-studied sediment-dwelling marine organisms, we investigated the physiological impacts of simultaneous exposure to nZnO and avobenzone on the lugworm Arenicola marina. Lugworms were exposed to nZnO, avobenzone, or their combination for three weeks. We assessed pollutant-induced metabolic changes by measuring key metabolic intermediates in the body wall and coelomic fluid, and oxidative stress by analyzing antioxidant levels and oxidative lesions in proteins and lipids of the body wall. Exposure to UV filters resulted in shifts in the concentrations of Krebs' cycle and urea cycle intermediates, as well as alterations in certain amino acids in the body wall and coelomic fluid of the lugworms. Pathway enrichment analyses revealed that nZnO induced more pronounced metabolic shifts compared to avobenzone or their combination. Exposure to avobenzone or nZnO alone prompted an increase in tissue antioxidant capacity, indicating a compensatory response to restore redox balance, which effectively prevented oxidative damage to proteins or lipids. However, co-exposure to nZnO and avobenzone suppressed superoxide dismutase and lead to accumulation of lipid peroxides and methionine sulfoxide, indicating oxidative stress and damage to lipids and proteins. Our findings highlight oxidative stress as a significant mechanism of toxicity for both nZnO and avobenzone, especially when combined, and underscores the importance of further investigating the fitness implications of oxidative stress induced by these common UV filters in benthic marine organisms.

Changes in life history parameters and expression of key genes of Brachionus plicatilis exposed to a combination of organic and inorganic ultraviolet filters.

The increasing use of ultraviolet filters has become an emerging contaminant on the coast, posing potential ecological risks. Rotifers are essential components of marine ecosystems, serving as an association between primary producers and higher-level consumers. These organisms frequently encounter ultraviolet filters in coastal waters. This study aimed to assess the comprehensive effects of organic ultraviolet filters, specifically 2-ethylhexyl-4-methoxycinnamate (EHMC), and inorganic ultraviolet filters, namely, titanium dioxide nanoparticles (TiO2 NPs), on the rotifer Brachionus plicatilis. We exposed B. plicatilis to multiple combinations of different concentrations of EHMC and TiO2 NPs to observe changes in life history parameters and the expression of genes related to reproduction and antioxidant responses. Our findings indicated that increased EHMC concentrations significantly delayed the age at first reproduction, reduced the total offspring, and led to considerable alterations in the expression of genes associated with reproduction and stress. Exposure to TiO2 NPs resulted in earlier reproduction and decreased total offspring, although these changes were not synchronised in gene expression. The two ultraviolet filters had a significant interaction on the age at first reproduction and the total offspring of rotifer, with these interactions extending to the first generation. This research offers new insights into the comprehensive effects of different types of ultraviolet filters on rotifers by examining life history parameters and gene expression related to reproduction and stress, highlighting the importance of understanding the impacts of sunscreen products on zooplankton health.

Understanding the perception of sunscreen utility in African Americans.

Dyschromia is a top diagnosis among African Americans (AA). Sunscreen is an essential part of its management, but AA have low sunscreen use. We sought to examine the perception of sunscreen utility in dyschromia and photoaging among patients who identify as AA or Black. This cross-sectional study recruited participants from the Case Western Reserve University Academic Dental Clinic. Participants completed an electronic survey that contained questions related to sunscreen use, knowledge of the sun's role in hyperpigmentation and photoaging, and whether sunscreen could be used for hyperpigmentation and photoaging. Of the 151 participants recruited, 63.6% (n = 96) were women and 36.4% (n = 57) were men. Consistent with previous reports, participants had lower sunscreen use (20.5%) than whites (43.5%). The majority of participants (80.1% and 58.3%, respectively) didn't attribute the sun to hyperpigmentation or photoaging. Participants with dark/brown spots were significantly more likely to not attribute the sun to hyperpigmentation than those without spots. (p = 0.003) Limitations for this study include its small sample size, recall and reporter bias, question misinterpretation, and lack of question neutrality. This study highlights the knowledge gap of a major contributing factor to dyschromia which in turn could be leading to their view of the decreased utility of sunscreen.

Sunscreen use and affordability attitudes based on ethnicity, socioeconomic status, and Fitzpatrick skin type.

IMPORTANCE: One in five Americans will develop skin cancer during their lifetime. While use of sunscreen can help prevent the development cutaneous cancer, regular use remains low nationwide. OBJECTIVE: To assess and better understand health care consumer preferences for sun protection products and perceived product accessibility and availability based on socioeconomic factors, race, and ethnicity. DESIGN: This quantitative survey study was conducted March through June of 2023. SETTING: Participants were recruited from two university family medicine clinical sites in the Buffalo, New York area, one located in a low and one located in a middle-to-upper socioeconomic neighborhood. PARTICIPANTS: Eligible participants were 18 years or older, fluent in English, and residents of the Buffalo, New York area. Surveys and consent forms were distributed by scripted verbal invitation, inviting all clinic patients who met eligibility criteria to participate. Participants were asked to self-report their racial/ethnic group as well as other demographic information including age, gender identification, household income, and household size. Information regarding sun exposure behaviors, and affordability/access was obtained using a combination of multiple choice and yes/no questions. A total of 405 participants were recruited. After excluding 235 incomplete responses, 170 surveys were available for analysis. INTERVENTIONS: None. MAIN OUTCOMES AND MEASURES: Our study aim was to expose health care consumer preferences as well as barriers to access based on socioeconomic factors, race, and ethnicity. RESULTS: Using a 25-question anonymous survey, 405 participants from two university family medicine clinical sites representing low- and middle-to-high-income neighborhoods, participated in the survey. 170 participants completed the survey questions and were included for analysis. Of those, 61.8% identified as female, 37.6% as male, and 0.6% as other. 51.2% of participants identified as lower income, 38.2% as middle-income, and 10.6% as upper income. The results of the survey revealed disparities in sunscreen use and affordability perceptions across demographic groups. Compared with Hispanics, Caucasians exhibited higher rates of sunscreen use (85 Caucasians, 7 Hispanics; p = 0.0073), prioritized SPF (95 Caucasians, 10 Hispanics; p = 0.0178), and were more likely to perceive sunscreen as unaffordable (6 Caucasians, 4 Hispanics; p = 0.0269). Analysis by Fitzpatrick Skin Type demonstrated differences in sunscreen utilization, with Types I-III using more compared to Types IV-VI (70 Types I-III, 51 Types IV-VI; p = 0.0173); additionally, Type I-III individuals were significantly more likely to cite cost as barrier to sunscreen purchase (40 Type I-III, 65 Types IV-VI; p < 0.0001). Moreover, lower-income individuals were significantly more likely to perceive sunscreen as unaffordable (12 lower-income, 1 middle & upper income; p = 0.0025) and cited cost as a barrier to purchase (46 lower-income, 59 middle & upper income; p = 0.0146) compared to middle-to-upper income counterparts. Though statistical significance was not established, respondents from middle & upper income groups reported higher sunscreen usage rates compared with their lower-income peers. CONCLUSIONS AND RELEVANCE: These findings highlight the importance of socioeconomic factors and ethnicity on accessibility to sunscreen and the impact of disparities in utilization among different ethnic and socioeconomic groups.

The Knowledge, Attitudes, and Practices of Parents Regarding Sun Protection for Their Children.

OBJECTIVE: To evaluate the knowledge, attitudes, and practices of parents toward protecting their children against skin cancer and the sun. METHODS: This cross-sectional study was performed in Turkey from March through October 2022. The authors used a questionnaire investigating the parents' and children's characteristics, attitudes, and practices toward sun protection and the Skin Cancer and Sun Knowledge (SCSK) scale to collect data. RESULTS: Of 465 parents, 60.2% were women, 83.2% were light-skinned, 20.2% perceived their children as risk-free, 43.8% perceived their children as low risk in terms of skin cancer, 14.6% examined their children from head to foot, 62.3% applied sunscreen to their children, 9.7% made them wear long-sleeved clothing, 60.0% made them wear headgear, 61.1% made them remain in the shade or under a sunshade, and 32.3% made them wear sunglasses. The mean parental SCSK scale score was 14.3 ± 4.1. Scale scores were higher among those who perceived their children as being at high risk for skin cancer (P = .000), whose children had not experienced red or painful sunburn in the previous year (P = .000), and who informed their children about sun protection (P = .000). CONCLUSIONS: Although knowledge of skin cancer and solar protection was high, parental perception of the risk of skin cancer was very low, and attitudes toward skin examination were also very relaxed.

Inorganic UV filter-based sunscreens labelled as eco-friendly threaten sea urchin populations.

Although the negative effects of inorganic UV filters have been documented on several marine organisms, sunscreen products containing such filters are available in the market and proposed as eco-friendly substitutes for harmful, and already banned, organic UV filters (e.g. octinoxate and oxybenzone). In the present study, we investigated the effects of four sunscreen products, labelled by cosmetic companies as "eco-friendly", on the early developmental stages of the sea urchin Paracentrotus lividus, a keystone species occurring in vulnerable coastal habitats. Among sunscreens tested, those containing ZnO and TiO2 or their mix caused severe impacts on sea urchin embryos. We show that inorganic UV filters were incorporated by larvae during their development and, despite the activation of defence strategies (e.g. phagocytosis by coelomocytes), generated anomalies such as skeletal malformations and tissue necrosis. Conversely, the sunscreen product containing only new-generation organic UV filters (e.g. methylene bis-benzotriazolyl tetramethyl, ethylhexyl triazone, butylphenol diethylamino hydroxybenzoyl hexyl benzoate) did not affect sea urchins, thus resulting actually eco-compatible. Our findings expand information on the impact of inorganic UV filters on marine life, corroborate the need to improve the eco-friendliness assessment of sunscreen products and warn of the risk of bioaccumulation and potential biomagnification of inorganic UV filters along the marine food chain.

Skin cancers are the most frequent cancers in fair-skinned populations, but we can prevent them.

Cancers of the skin are the most commonly occurring cancers in humans. In fair-skinned populations, up to 95% of keratinocyte skin cancers and 70-95% of cutaneous melanomas are caused by ultraviolet radiation and are thus theoretically preventable. Currently, however, there is no comprehensive global advice on practical steps to be taken to reduce the toll of skin cancer. To address this gap, an expert working group comprising clinicians and researchers from Africa, America, Asia, Australia, and Europe, together with learned societies (European Association of Dermato-Oncology, Euromelanoma, Euroskin, European Union of Medical Specialists, and the Melanoma World Society) reviewed the extant evidence and issued the following evidence-based recommendations for photoprotection as a strategy to prevent skin cancer. Fair skinned people, especially children, should minimise their exposure to ultraviolet radiation, and are advised to use protective measures when the UV index is forecast to reach 3 or higher. Protective measures include a combination of seeking shade, physical protection (e.g. clothing, hat, sunglasses), and applying broad-spectrum, SPF 30 + sunscreens to uncovered skin. Intentional exposure to solar ultraviolet radiation for the purpose of sunbathing and tanning is considered an unhealthy behaviour and should be avoided. Similarly, use of solaria and other artificial sources of ultraviolet radiation to encourage tanning should be strongly discouraged, through regulation if necessary. Primary prevention of skin cancer has a positive return on investment. We encourage policymakers to communicate these messages to the general public and promote their wider implementation.