The Abcs of Sun Protection for Children

DERMATOLOGY NURSING

The ABCs of Sun Protection for Children

Maryellen Maguire-Eisen Karen Rothman Marie France Demierre

Excessive sun exposure in childhood is a critical variable Objectives This educational activity is designed for nurses and other health care influencing skin cancer risk. providers who care for and educate patients regarding sun protection for Nurses must teach parents how children. For those wishing to obtain CE credit, an evaluation follows. After studying the information presented in this article, the nurse will be able to: to properly protect their 1. Describe the risk of skin cancer in children. children from excessive sun 2. Discuss sun-protection policies recommended for children. exposures by demystifying UV 3. List characteristics of sun-protective clothing. 4. Describe the characteristics of sunblocks for protecting children from radiation and teaching proper the sun. sun-protection measures. Protecting children from excessive sun exposure, while kin cancer is the most prevalent can get skin cancer but inherent risk cancer in our society with over factors are very important (Mag- not curtailing recreation, 1 million new cases annually. uire-Eisen, 2003). Skin color, eye should be the goal of all nurses SSkin cancer is becoming more color, freckling tendency, nevi common in children and accounts for count, and family history increase caring for children. approximately 4% of pediatric malig- one’s risk of developing skin cancer. nancies. It is estimated that 90% of all However, the individual’s child- skin cancers are preventable (Schmid- hood sun-exposure history appears Wendtner et al., 2002). This is a stag- to significantly influence the risk of gering statistic when you consider that skin cancer (Kennedy, Bajdik, one American dies every hour from Maryellen Maguire-Eisen, MSN, RN, Willemze, & Gruijl, 2003; Rhodes, OCN, is an Oncology Certified Nurse, and skin cancer. Nurses can play a pivotal 1995; Silverberg, 2001; Tsao, Executive Director, Sun Protection role in prevention and early detection Atkins, & Sober, 2004). Skin can- Foundation, Hingham, MA. of this serious cancer by teaching cers are associated with both proper sun protection to children and intense, sporadic sun exposure (sun- Karen Rothman, MD, is an Assistant their parents. burn) and with chronic sun expo- Professor of Medicine and Pediatrics, Division sure (tanning) (Koh, Geller, Miller, of Dermatology, University of Massachusetts Background Medical School, Worcester, MA. Grossbart, & Lew, 1996). Skin cancers are malignancies Overexposure to ultraviolet Marie France Demierre, MD, that develop in the epidermis, der- radiation is a growing health con- FRCPC, is an Assistant Professor, and mis, or the adnexal structures of the cern for children in our society due Director, Skin Oncology Program, Boston skin most often due to overexpo- to environmental changes and cul- University School of Medicine, Boston, MA. sure to both natural and artificial tural trends. The ozone layer acts as sources of ultraviolet light. There a planetary “sunscreen” reflecting Acknowledgment: The authors thank are three major types of skin cancer: and absorbing ultraviolet radiation. Jane Shanney and Rachel Butler for their edi- torial review. basal cell carcinoma, squamous cell Ozone depletion has resulted in carcinoma, and melanoma. Anyone increasing levels of ultraviolet (UV)

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radiation reaching the Earth’s sur- and cutaneous melanomas are the snow create reflective surfaces that face. Between 1983 and 1993, there most serious health risks. increase scatter by 10%, 15%, and was a 6% drop in total ozone. It is 80% respectively (Environmental estimated that for every 1% drop in Sun-Protection Actions Protection Agency [EPA], 2004) ozone there is a 1% to 5% increase Sun-protection policies recom- Educating parents and teachers in skin cancer (Grant-Kels, 1993). mend avoiding artificial and natural how to use the Global UV Index to Sunburn incidence among ultraviolet light sources, proper use gauge the potential for sun damage American children is extremely of sunscreens, and the appropriate from natural sources is an impor- high, ranging from 29% to 83% for use of shade or sun-protection gear tant way to protect children from the previous summer season and (see Table 1) (American Academy excessive exposures to the sun. The between 7% and 13% for the previ- of Pediatrics, 1999; Centers for UV Index, developed by the ous summer weekend (Geller et al., Disease Control [CDC], 2002). National Weather Service and the 2002; Robinson, Rigel, & However, studies indicate that sun- EPA, is a prediction or estimate of Amonette, 2000). Repeated and protection measures are infrequent- UV intensity and the associated severe sunburns affect 12% of ado- ly utilized to prevent sun damage. risk of overexposure to human lescents with reports of five or more Sunscreens, hats, sunglasses, and skin. There are sun precautions or sunburns during one summer sea- avoiding midday sun are routinely actions that correspond to UV son (Davis, Cokkinides, Weinstock, used by less than one-third of chil- intensity levels. These actions O’Connell, & Wingo, 2002). Sun- dren (Banks, Silverman, Schwartz, include sunglasses, sunscreens, burn incidence is associated with & Tunnessen, 1992; Hall, McDavid, physical protection, and sun avoid- increasing age, fair skin, time spent Jorgenson, & Kraft, 2001; Geller et ance (see Table 2). outdoors, sporadic sunscreen use, al., 2002; Olson et al., 1997). Most Dermatology nurses should be and inadequate protective clothing schools in the United States lack pragmatic regarding limiting mid- (Geller et al., 2002). These factors sun-protection policies. The CDC day exposures and outdoor play. are important because one sunburn (2002) and the National Association Instruct parents that when the UV may double a child’s risk for devel- of State Boards of Education (2005) intensity is high, early morning, oping melanoma. Parental attitudes have sample school policies on skin late afternoon, or early evening that a child looks “healthier with a cancer prevention. Recently, states outdoor activities should be tan” may be a contributing factor began introducing legislation that planned whenever possible. If mid- influencing sun damage and skin addresses skin cancer prevention day activities are unavoidable, rec- cancer risk (Robinson, Rigel, & for children at school. California ommend portable shade including Amonette, 1997). has led the way in this effort with parasols, beach umbrellas, and sun Overexposure to ultraviolet the ratification of the Billy Bill (CA- tents, as well as protective clothing radiation via indoor tanning is SB 310). This bill prevents schools and sunblock. They are all practical another growing concern. Artificial from prohibiting children from and easy to employ. tanning is a billion dollar industry wearing sunglasses or hats on cam- Advising parents about the real frequented by an increasing num- pus (Sun Safety for Kids, 2005; risks of indoor tanning is impera- ber of teenage girls (Lazovich & William S. Graham Foundation for tive. There is no such thing as a Forster, 2005). Tanning rates for Melanoma Research, 2005). “safe tan” despite advertisements to teenage girls double between ages the contrary. Indoor tanners are at 14 to 15 and 15 to 16 (Geller et al., Ultraviolet Protection increased risk of developing all 2002). Indoor tanning is driven by Ultraviolet radiation varies dra- forms of skin cancer (Lazovich & social pressures, appearance moti- matically both daily and seasonally. Forster, 2005). Legislation forbid- vation, physiologic effects on mood, Peak readings occur at midday dur- ding indoor tanning in young teens and having a parent who tans ing noon time and seasonally on has been ratified in Wisconsin and (Feldman et al., 2004; Lazovich, et the Summer solstice, June 21st. UV Illinois. Many other states are al., 2004; Stryker et al., 2004). intensity is higher in May than in working on bills to protect this pop- Health risks associated with indoor August, leading to a high incidence ulation (Lim et al., 2005). tanning include severe skin or of sunburn in the Spring. Altitude is corneal burns, cataract formation, another important variable to con- Sun-Protective Clothing skin infections, photoaging, exacer- sider, because UV intensity is Sun-protective clothing is an bation of photosensitive disorders, greater at higher altitudes, increas- excellent way to shield children and skin cancer. Basal cell carcino- ing by 2% for every 1,000 feet from ultraviolet radiation exposure. mas, squamous cell carcinomas, above sea level. Water, sand, and Sun-protective clothing can range

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Table 1. Sun Protection Glossary Sun Term Definition Application UV Intensity Ultraviolet light intensity is influenced by rotation and revolution of the Meters are available to planet (daily and seasonal variations), proximity to the equator, ozone measure UVB intensity and concentration, altitude, and weather (cloud cover and wind velocity). the scales may range from 0-15. Ultraviolet Index A measure of the risk for sunburn on a given day. Collected via satellite Global UV Index ranges and adjusted for environmental conditions including humidity, wind, and from 1-11+ with color clouds. coding for risk estimates. Sun Protection The ratio of time to develop a sunburn wearing a specific sunscreen as SPF >15 is recommended Factor (SPF) compared to the time to develop a sunburn without a sunscreen. For as the minimal strength of example, a SPF 15 will provide a person who burns in 10 minutes, 150 sunscreen. One ounce per minutes of sun protection. application is the required dose to achieve the SPF. Physical Blockers Inorganic compounds that may include titanium dioxide or zinc oxide. New Work on application and (non-chemical) techniques that micronize the inorganic compounds have resulted in are great for children with improved consumer acceptability. sensitive skin. Chemical Blockers Chemical ingredients that may include PABA, PABA derivatives, Higher SPFs may include cinnamates, salicylates, and anthralins. These agents vary in their ability to multiple ingredients to protect against longer ultraviolet wavelengths. achieve the higher SPF rating. Broad Spectrum Denotes protection against both UVA and UVB radiation. Degree of protection into UVA spectrum can vary by ingredients. Substantivity The ability for a sunscreen to maintain its SPF rating given exposure to Immediate reapplication of water and adverse conditions. It is classified as either water resistant or sunscreen after any water very water resistant. exposure or heavy perspiration may further Water Resistant Claims that a sunscreen maintains its SPF after two 20-minute water safeguard sun-sensitive immersions or moderate physical activity. individuals against sunburn.

Waterproof Claims that a sunscreen maintains its SPF after 80 minutes of water immersion or extreme physical activity. Ultraviolet An industry standard for sun-protective garments. It provides a guideline Good = 15-24 Protection Factor for consumers to evaluate the degree of protection available in a product. Very good = 25-39 (UPF) Excellent = 40-50+

from hats, t-shirts, and sunglasses to protection in studies despite color SPF in garments. Rit® Sun Guard™ specialized garments. Hats can pro- or moisture content. Sun-protective is one commercially available addi- vide shade to the face and neck. clothing is now widely available tive available at local drugstore Hats with wide brims provide the and can be found at local stores or retailers or via the Internet. most protection. Summer clothing via the Internet. Coolibar, Sun Sunglasses are recommended usually provides limited protection Precautions, Nozone, and Solartex for children of all ages. Appropriate because of the looseness of weave, are some of the retailers that offer sunglasses should provide broad- ranging from 2 to 6.5 SPF (sun-pro- these garments for children and spectrum protection with 99% of tection factor). Synthetic materials adults. The styles are practical and the ultraviolet rays blocked. Broad used in sun-protective garments stylish and have become popular spectrum denotes protection against provide better protection because with children and adults world- both UVB (shorter wavelengths of the tightness of the weave wide. Laundry additives can ranging from 280 to 320 nm) and (Adams, 1999). These specialized enhance the sun protection afford- UVA (longer wavelengths ranging garments demonstrate high solar ed by garments by boosting the from 320 to 400 nm). Look for sun-

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Table 2. tion, vehicle, and substantivity The UV Index and Corresponding Sun Precautions (water resistance) should be consid- ered when recommending a sun- Global Rating Recommended Precautions block. Sun-protection factor is a UV Index concept that parents must under- stand because it is a measure of pro- 1-2 Low tection afforded by sunblocks against ultraviolet B (burning rays) only. The SPF rating is calculated based on the time it takes for the 3-5 Moderate skin to develop minimal erythema (sunburn) with the application of 2 cc/cm2 of sunscreen. Minimal ery- 6-7 High thema or sunburn is the result of overexposure to UVB rays. SPF is not a measure of the potential damage from UVA rays and does not 8-10 Very High denote protection from the tanning rays. There is no official rating sys- tem for UVA protection at this time. 11+ Extreme A label that specifies broad-spectrum protection is the best indica- tion of UVA protection. Proper sunscreen application is Table 3. the only way to achieve the SPF rat- Appropriate Sunblock Application ing indicated by the manufacturer. A consumer must apply one ounce Know when to protect yourself: Apply sunblock when the UV Intensity is of sunblock per total body applica- >2. tion (a handful) for an adult and half Use an adequate SPF: Use a SPF >15 for limited exposures and SPF ounce for the average child. A SPF >30 for prolonged or intense exposures. 15 sunscreen rating indicates that Wear the right sunblock: Wear broad-spectrum sunblocks that protect the protected skin is shielded from against UVA and UVB exposures. Ingredients that include titanium dioxide, UVB radiation for 15 times longer zinc oxide, or Parsol 1689 provide excellent broad spectrum protection. than unprotected skin. On a day Wear the proper dose of sunblock: Sunblock is to be applied thickly; with high UV intensity (>6) a per- adults require one ounce (a handful) per application and children require son with pale skin would burn in an half ounce. average of 10 minutes. Therefore, a Don’t forget difficult sites: Write BEENS on your sunblock bottle to SPF 15 sunscreen applied in the remind you to apply to Back of knees, Ears, Eye area, Neck, Scalp. Apply appropriate dose would protect the sunblock before going outside to insure protection and to cover border individual for approximately 150 areas (under straps/waistbands). minutes, provided there isn’t any Don’t forget to reapply: Reapplication is recommended every 2 hours heavy perspiration or prolonged during prolonged exposures or after swimming or heavy perspiration. water submersion. However, SUNBLOCK SHOULD NOT BE USED TO INCREASE UV EXPOSURE because most consumers apply a TIMES. sub-therapeutic does of sunblock there is a resulting relative lowering of the sun-protection factor. For glasses that indicate the glass vent against cataracts, macular example, when a parent applies absorbs ultraviolet light up to 400 degeneration, and ocular mela- 25% of the recommended does of a nm. Sunglasses are an essential noma (American Academy of SPF 15 sunblock instead of the cor- component of sun-protection attire Ophthalmology, 2005). rect dose, the sunblock protection and should not be overlooked. approximates a SPF 4. They may protect the eyes from Sunblock ultraviolet damage and help pre- The SPF, spectrum of protec- continued on page 431

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Table 4. Sun-Protection Curriculums

Curriculum Organization Grade level Web Address Content Evaluations Block the American K – grade 3, www.aad.org/btsntf/btfntsl.html Downloadable material Crane, Sun not Academy of 3-8 www.aad.org/kids/index.html for kindergarten Schneider, the Fun Dermatology through adolescence. Yohn et al. (1999)

Learn Not 2 Sun Protection Pre-school to www.sunprotectionfoundation.org Lesson plan includes In process Burn™ Foundation grade 12 learning objectives, strategies, and resources for providing an interactive classroom lessons. National Centers for Middle and high www.cdc.gov/excute/skincancer/ Skin cancer module Science Disease school index.htm designed to prepare Olympiad Control students for Olympiad. Other applications for health education included. Project M.D. Anderson Middle through www.mdanderson.org/departments CD-Rom with three Kamin, Safety Cancer Center high school /projectsafety science based lessons O’Neill, & accompanied by an 80 Ahearn (1993) page teacher guide. Skin Check Melanoma High school www.skincheck.com/mef_page_4. Sunspots, a 16 minute Education htm videotape, training Foundation session on site for health educators. Quiz questions, supple- mentary info for teachers Sun Safe The Norris NA www.dartmouth.edu/dms/sunsafe Downloadable Grant- Project Cotton Cancer educational materials Petersson, Center at for teachers, nurses, Dietrich, Sox Dartmouth- and parents. et al. (1999) Hitchcock Medical Center Sunny Days AMC Cancer Kindergarten www.sdhw.info CD-Rom provides a Buller, Hall, Health Ways Research through grade 5 comprehensive Powers et al. Center curriculum with lesson (1999) plans, student activities, and assessments.

ABCs proof. Waterproof claims indicate PABA derivative, provide excellent continued from page 422 that a sunscreen maintains its SPF broad-spectrum protection. Sunblocks after two 20-minute water immer- should be applied 30 minutes before Nurses should recommend sun- sions or moderate physical activity. sun exposure and reapplied every 2 blocks with a broad spectrum of Water resistant claims indicate that hours or after swimming or heavy protection (UVB/UVA), in a cos- a sunscreen maintains its SPF after perspiration. Although spray sun- metically appealing vehicle, with a 80 minutes of water immersion or blocks are appealing due to the ease waterproof or water-resistant rating. extreme physical activity. of application, their coverage is Water resistant denotes a longer Titanium dioxide, zinc oxide, often inadequate due to difficultly in period of protection than water- or Avobenzone (Parsol 1789), a judging dosing and thickness of

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Table 4. (continued) Sun-Protection Curriculums

Curriculum Organization Grade level Web Address Content Evaluations SunWise The U.S. Kindergarten www.epa.gov/sunwise A tool kit with lessons, Geller, Program Environmental through grade 8 a poster, homework Rutsch, Protection activity sheets, a UV Kenausis et Agency reflective Frisbee, as al. (2003) well as policy guidelines, sample letters, and resources. SunSmart The Richard Elementary www.melanomafoundation.com CD-ROM available in America David Kann through high several languages Melanoma school provides lessons Foundation adapted from the Australian curriculum Sun Safety The National www.nsc.org/ehc/sunsafe.htm Activity Safety Guide Council’s Environmental Health Center

SS Kidz William F. Pre-school – www.bfmelanoma.com/sskidz.htm Grassroots educational Graham high school program that provides Melanoma classroom teachers to Foundation discuss age appropriate sun safety mlessons. Sunny Skin Cancer Elementary www.skincancer.org Minimal charge for kit States Foundation grades and instructions to Program create map of the Unites States depicting sun safety for each state. Sun Guard Maryland Skin Middle school www.sunguardman.org/core/shtml Educational materials Program Cancer and downloadable Prevention curriculum application and are not recom- ty educational curriculums that knowledge and sun-protective prac- mended. Because sunblocks work have been developed for pre- tices, it is important to remember by reflecting or absorbing ultravio- school through high school. They that repeated health messages are let radiation, they are broken down can be easily implemented to teach necessary to promote behavior or depleted more quickly on a high sun safety (see Table 4). Experts in change. UV intensity day. A higher SPF or the field of education and health more frequent application is advis- care have collaborated to create fun Conclusion able on a very high or extreme UV and informative programs that Sun protection is the responsi- day (see Table 3). teach sun protection to children and bility of both parents and nurses. early detection of skin cancer to We can no longer think of sunburn Sun-Safety Education adolescents. Many of these pro- or sun damage as a minor health School nurses must take grams are available free of cost, and problem for children but rather as responsibility for protecting chil- can be adapted or modified for permanent genetic damage. Many dren from excessive amounts of application in the community. parents do not know how to ade- ultraviolet radiation at school. Although the best curriculum is the quately protect their children from There are many wonderful sun-safe- one that results in both improved excessive ultraviolet radiation. Well-

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informed nurses are invaluable in www.epa.gov/sunwise/ Medicine, 158(9), 918-924. teaching parents effective sun pro- doc/uviguide.pdf Maguire-Eisen, M. (2003). Risk assess- Feldman, S.R., Liguori, A., Kucenic, M., ment and early detection of skin can- tection. Sun-safety education must Rapp, S.R., Fleischer, A.B., Jr., Lang, cers. Seminars in Oncology Nursing, be taught with a common sense W., et al. (2004). Ultraviolet exposure 19(1), 43-51. approach. With proper guidance is a reinforcing stimulus in frequent National Association of State Boards of and support from nurses, parents indoor tanners. Journal of the American Education. (2005). Sample policies to should be able to protect their chil- Academy of Dermatology, 51(1), 45-51. promote sun safety and prevent skin can- Geller, A., Rutsch, L., Kenausis, K., & cer. Retrieved on September 3, 2005, dren from overexposure to the sun’s Zhang, Z. (2003). 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