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Cutaneous melanoma (CM) has consistently been associated with intermittent sun exposure, while the association with chronic sun exposure is debated. The goal of this research was to examine the complex relationship between CM, sun sensitivity and sun exposure based on theoretical concepts of how these factors may be associated. Detailed sun exposure histories across life periods and various measures of sun sensitivity were collected in a population-based case–control study of melanoma in Iowa, USA. Participants were asked about their hours of sun exposure per day between March and October each year over periods or decades of life to estimate cumulative lifetime hours of sun exposure. Increased odds ratios (ORs) for CM were seen for most standard measures of sun sensitivity except for the tendency to sunburn. Minimal associations were seen with total hours of sun exposure early in life. However, an interaction was seen between fair skin color and lifetime hours of sun exposure, where the strongest associations with CM were seen among medium-skinned and dark-skinned participants. This suggests that cumulative sun exposure at high levels may increase CM among non-sun-sensitive individuals typically at lower risk of CM. Such a finding has implications for the prevention effort for melanoma regarding time in the sun among darker-skinned individuals.

Background Inadequate health and nutritional literacy is a common problem among adults, associated with poor health outcomes. Therefore, this study aimed to investigate the relationship between health literacy and nutritional literacy to sun exposure behaviour. Methods We conducted a cross-sectional study on 261 adults (18–65 years) in Iran. Data was collected on knowledge, motivation, health literacy, nutritional literacy, and sun exposure behaviour using an interview-assisted questionnaire. Using the information–motivation–behavioural skills model and structural equation modeling, we tested whether health and nutritional literacy were associated with the relationships between knowledge of vitamin D, attitudes toward sun exposure, and sun exposure behaviour. Different models using structural equation modeling were performed to analyze the data. Results The finding showed that health literacy ( β  = 0.29, p  < 0.001) and nutritional literacy ( β  = 0.14, p  = 0.02) was directly associated with sunlight exposure. Indirect relationships also existed between knowledge and sunlight exposure through health literacy ( β  = 0.33, p  < 0.001) and nutritional literacy ( β  = 0.22, p  = 0.01). The model had good fit (x 2 /df = 1.422; RMSEA = 0.040; CFI = 0.851; NFI = 0.657). There was no significant relationship between health literacy and motivation ( β  = 0.11, p  = 0.16), nutritional literacy and motivation ( β  = 0.06, p  = 0.42) and motivation and sun exposure (β = 0.01, p  = 0.91). Conclusions The findings showed that individuals with sufficient health literacy and nutritional literacy were more likely to have exposure to sunlight. Health and nutritional literacy should be considered when educating adults about vitamin D supplements and sunlight exposure.

Background Health questionnaires must present accredited measurement properties such as validity, reliability and sensitivity to change, the latter being essential for interventions to be planned and for evaluating their effectiveness. The aim of this study was to evaluate the sensitivity to change of a Beach Questionnaire. Methods Quasi-experimental before-after study carried out in 2011, for a study population of adolescents attending schools in the Costa del Sol. First, the questionnaire was administered to the adolescents, after which a multicomponent educational intervention was carried out; finally, three months later, the same questionnaire was re-administered to the same adolescents. Changes were assessed in the categories of each item, using the McNemar test, and the changes in the scores, standardised to a range of 0–100, using the Student t test for paired samples, and including the mean of the differences and the 95% confidence interval. The level of statistical significance was set at p < 0.05. Results 228 adolescents, aged 14–17 years, and 55.3% were girls. Statistically significant changes were observed in sunburn experiences, exposure to the sun at mid-day and attitudes to sun exposure and suncreams. For the seven items related to knowledge about sun exposure, a higher rate of correct answers was observed. The analysis of changes, within the standardised range, revealed a significant improvement in the scores for sun exposure habits (MD 4.33; CI 95% 2.2-6.5), attitudes to sun exposure (MD 2.22; CI 95% 1.2-3.2) and knowledge (MD 9.10; CI 95% 7.1-11.1), but not in those for sun-protection practices (MD 0.23; CI 95% -1.2-1.7). Conclusions The Beach Questionnaire on behaviour, attitudes and knowledge related to sun exposure is the first such instrument in Spanish language to provide sufficient sensitivity to change. It constitutes a useful tool for epidemiologic research into photoprotection and for skin cancer prevention programmes.

Low maternal vitamin D status during pregnancy may have negative consequences for both mother and child. There are few studies of vitamin D status and its determinants in pregnant women living at northern latitudes. Thus, the present study investigates vitamin D status and its determinants during the third trimester of women living in Sweden (latitudes 57–58°N). A total of ninety-five fair-skinned pregnant women had blood taken between gestational weeks 35 and 37. The study included a 4 d food diary and questionnaires on dietary intake, supplement use, sun exposure, skin type, travels to southern latitudes and measure of BMI. Serum 25-hydroxyvitamin D (25(OH)D) was analysed using the chemiluminescence immunoassay. In the third trimester of pregnancy, mean serum concentration of 25(OH)D was 47·4 (sd 18·1) nmol/l (range 10–93 nmol/l). In total, 65 % of women had serum 25(OH)D < 50 nmol/l and 17 % < 30 nmol/l. During the winter, 85 % of the pregnant women had serum 25(OH)D < 50 nmol/l and 28 % < 30 nmol/l. The main determinants of vitamin D status were as follows: season; use of vitamin D supplements; travels to southern latitudes. Together, these explained 51 % of the variation in 25(OH)D. In conclusion, during the winter, the majority of fair-skinned pregnant women had serum 25(OH)D < 50 nmol/l in their third trimester and more than every fourth woman < 30 nmol/l. Higher vitamin D intake may therefore be needed during the winter for fair-skinned pregnant women at northern latitudes to avoid vitamin D deficiency.

Adolescents are considered a risk group for the development of skin cancer in later life due to their high rates of sunburn. The aim of this study is to evaluate the association between attitudes to sun exposure and the sociodemographic characteristics of adolescents, their habits, practices and knowledge. As a secondary goal, we describe the magnitude and sign of the correlations between these attitudes. Cross-sectional study of adolescent students from 12 secondary schools in southern Spain, the subjects were asked to complete the ‘Beach Questionnaire’. This instrument examines four dimensions of attitudes, with standardised scores of 0–100, related to the sun, sun tanning, sun protection and sun cream. The higher the score, the more positive the attitude. The study population was composed of 270 adolescents. The highest scores were obtained for attitudes towards sun protection practices (mean 66.2; SD 18.6) and towards sun tanning (mean 64.2; SD 21.1). The lowest scores were obtained for attitudes towards using sun cream (mean 50.1; SD 24.6). Significant differences were found for all four attitudes, with a positive sign for the relationship between the number of days of sun exposure and a higher score for attitudes towards sunbathing (27.3 points difference between response extremes) and for attitudes towards suntanning (20 points difference). Favourable attitudes towards sunbathing and sun tanning have most influence on inadequate habits of sun exposure and deficient measures of sun protection. Adolescents should be considered a priority group for targeted interventions to improve sun protection behaviour.

Background: Epidemiologic studies have reported an inverse association between sun exposure and non-Hodgkin lymphoma (NHL), but these have been almost exclusively conducted in Western populations residing in temperate locations. We evaluated the association between personal outdoor sun exposure and risk of malignant lymphomas in Singapore. Methods: A hospital-based case-control study of 541 incident cases of lymphoid neoplasms and 830 controls were recruited during 2004-2008. Participants were interviewed regarding recreational or occupational outdoor activities during childhood and in adulthood. Basic demographics and potential confounders were also collected. Odds ratios (OR) and 95 % confidence intervals (CI) were calculated using unconditional logistic regression analysis. Results: Compared with individuals who did not have regular sun exposure, a lower risk of NHL was observed for those who reported regular exposure on non-school days during childhood [OR, 0.62; 95 % CI, 0.46-0.83] and non-working days in adulthood [OR, 0.70; 95 % CI, 0.51-0.97]. The protective effect was more evident among women. Conclusion: Our findings support an inverse relationship between intermittent sun exposure and the risk of NHL. These findings are consistent with the growing evidence from various countries, but further studies, especially prospective studies, are needed in Asian populations.

Key Points Melanomas on the non-glabrous skin (skin outside the palms and soles) can be broadly classified into those that arise on skin with chronic sun-induced damage (CSD melanomas) or those that arise on skin without such damage (non-CSD melanomas). These two melanoma subtypes differ with regard to their age of onset, associated patterns of exposure to UV radiation, association with precursor lesions, clinical and histopathological appearance and somatic mutations. Melanocytic neoplasms range from benign naevi, which are common and have a negligible risk of progressing, to invasive melanomas, which have the potential to metastasize. In between there are intermediate stages that include dysplastic naevi and non-invasive ( in situ ) melanoma. Different melanoma subtypes have different evolutionary trajectories. Non-CSD melanomas commonly arise from benign or dysplastic naevi, whereas CSD melanomas commonly arise from melanoma in situ . As melanomas evolve they do not always pass through discernable evolutionary phases but can seemingly skip individual phases and can even appear without any apparent precursor lesion. Several lines of evidence including TERT promoter mutations in benign or pre-malignant phases of evolution suggest that the cells of common and dysplastic naevi are more proliferative and not entirely senescent, as some models of naevi propose. The relatively stable size of the overall lesion can be explained by the fact that their slow rate of proliferation is offset by cell-attritional factors such as immunosurveillance. Transformation of melanocytes to melanoma is prevented by multiple barriers, which are successively disrupted by genetic alterations. Precursor lesions form when initial mutations induce cell proliferation that is subsequently constrained by cell-autonomous and non-autonomous factors. The expanding cell number increases the probability that descendent cells will acquire additional mutations that override these barriers, enabling evolution to the next phase of progression from a less-evolved precursor lesion. We propose that some melanomas without apparent precursor lesions arise from melanocytes in which the genetic alterations disrupting these barriers already pre-existed before the proliferation-inducing mutation occurred, thereby enabling the neoplasm to skip an evolutionary phase. Melanomas can disseminate in parallel to regional and distant sites to form metastases. Once several metastases have formed, cells from each metastasis continue to seed and reseed other tumours, adding considerable complexity to the diversity of metastatic clones. This Review proposes evolutionary models of tumour progression for melanomas on sun-exposed skin by integrating genetic, epidemiological, clinical and histopathological information. Melanomas on sun-exposed skin are heterogeneous tumours, which can be subtyped on the basis of their cumulative levels of exposure to ultraviolet (UV) radiation. A melanocytic neoplasm can also be staged by how far it has progressed, ranging from a benign neoplasm, such as a naevus, to a malignant neoplasm, such as a metastatic melanoma. Each subtype of melanoma can evolve through distinct evolutionary trajectories, passing through (or sometimes skipping over) various stages of transformation. This Review delineates several of the more common progression trajectories that occur in the patient setting and proposes models for tumour evolution that integrate genetic, histopathological, clinical and biological insights from the melanoma literature.

Background: While ultraviolet (UV) radiation exposure is a recognized risk factor for skin cancer, associations are complex and few studies have allowed a direct comparison of exposure profiles associated with cutaneous melanoma, basal-cell carcinoma (BCC), and squamous-cell carcinoma (SCC) within a single population. Methods: We examined associations between UV exposures and skin cancer risk in a nested case-control study within E3N, a prospective cohort of 98,995 French women born in 1925–1950. In 2008, a lifetime UV exposure questionnaire was sent to all reported skin cancer cases and three controls per case, which were matched on age, county of birth, and education. Analyses were performed using conditional logistic regression and included 366 melanoma cases, 1,027 BCC cases, 165 SCC cases, and 3,647 controls. Results: A history of severe sunburns <25 years was associated with increased risks of all skin cancers (melanoma: OR 2.7; BCC: OR 1.7; SCC: OR 2.0 for ≥6 sunburns vs. none), while sunburns ≥25 years were associated with BCC and SCC only. While high-sun protection factor sunscreen use before age 25 was associated with lower BCC risk (Ptrend = 0.02), use since age 25 and reapplication of sunscreen were associated with higher risks of all three types of skin cancer. There were positive linear associations between total UV score and risks of BCC (Ptrend = 0.01) and SCC (Ptrend = 0.09), but not melanoma. While recreational UV score was strongly associated with BCC, total and residential UV scores were more strongly associated with SCC. Conclusions: Melanoma, BCC, and SCC are associated with different sun exposure profiles in women.

This article aims to alert the medical community and public health authorities to accumulating evidence on health benefits from sun exposure, which suggests that insufficient sun exposure is a significant public health problem. Studies in the past decade indicate that insufficient sun exposure may be responsible for 340,000 deaths in the United States and 480,000 deaths in Europe per year, and an increased incidence of breast cancer, colorectal cancer, hypertension, cardiovascular disease, metabolic syndrome, multiple sclerosis, Alzheimer’s disease, autism, asthma, type 1 diabetes and myopia. Vitamin D has long been considered the principal mediator of beneficial effects of sun exposure. However, oral vitamin D supplementation has not been convincingly shown to prevent the above conditions; thus, serum 25(OH)D as an indicator of vitamin D status may be a proxy for and not a mediator of beneficial effects of sun exposure. New candidate mechanisms include the release of nitric oxide from the skin and direct effects of ultraviolet radiation (UVR) on peripheral blood cells. Collectively, this evidence indicates it would be wise for people living outside the tropics to ensure they expose their skin sufficiently to the sun. To minimize the harms of excessive sun exposure, great care must be taken to avoid sunburn, and sun exposure during high ambient UVR seasons should be obtained incrementally at not more than 5–30 min a day (depending on skin type and UV index), in season-appropriate clothing and with eyes closed or protected by sunglasses that filter UVR.

Background The use of sunscreen significantly reduces the risk of skin cancer and helps maintain skin health; however, improper use can decrease its effectiveness. This study aimed to investigate the prevalence and factors associated with sunscreen use in Saudi Arabia as well as identifying areas of weakness in sunscreen practices. Methods A cross‐sectional survey‐based study was conducted with a diverse population sample in Saudi Arabia. Participants were asked about their sunscreen usage habits, motivations, and knowledge of proper application techniques. Demographic information, including age, gender, and skin type, were also collected. Results A total of 2321 individuals participated in the study. More than two‐thirds of the participants reported using sunscreen either always, regularly, or often, primarily to maintain a light skin color and prevent skin cancer. Factors associated with sunscreen use included younger age (18–40 years old), female gender, history of sunburn, and fair skin. Despite the majority reporting healthy sun exposure habits, several shortcomings were identified in sunscreen practices, including incorrect application and suboptimal reapplication frequency. Conclusion While sunscreen use is common among the study population, there is a need for improved education on proper application techniques. National awareness campaigns, especially those utilizing popular social media and digital platforms in Saudi Arabia, should focus on disseminating accurate sunscreen use guidelines to maximize sun protection and skin health.