Do you practice safe sun?
This may seem like an antiquated question, yet…
Despite the proliferation of sun care products—an estimated $16.84 billion global market size by 2027—skin cancer is still the most commonly diagnosed cancer in the US (1, 2).
Melanoma of the skin is projected to be the fifth most commonly diagnosed cancer for both men (58,120) and women (39,490) in 2023 (3, 4).
How Our Sun Habits Have Shifted
Over the last 50 years, our beliefs and behaviors around sun exposure have swung like a pendulum from one extreme to another.
Back in the 1970s and 80s, bronzed was beautiful. Most people pursued a “perfect” Coppertone (no SPF!) tan without apology. Getting sunburned, especially if you were fair, meant that you were one step closer to achieving that golden tan. Fast forward to the 2000s when SPF 100 sunscreen became available; SPF was added to everything from makeup to body lotions; and the media proselytized about the dangers of sun exposure; the importance of “covering up”; and the necessity of using sunscreen every day as well as other sun-protective products.
The pendulum began to swing back again when, in recent years, Vitamin D, an important pro-hormone and fat-soluble vitamin, made health headlines because Vitamin D deficiency (< 20 ng/mL) and Vitamin D insufficiency (21-29 ng/ml) is so highly prevalent in the US. Low Vitamin D is associated with low immunity, greater susceptibility to COVID-19, bone loss, depression, Type 2 diabetes, and heart disease (5).
Unsure of your Vitamin D level? Request the 25-hydroxy Vitamin D test, also known as the 25-OH(D) test; it is the best way to monitor your blood level of Vitamin D3 (not D2)! You can also order it here (go to “Vitamin D” under “Nutrient Panel”).
Greater public awareness that sun exposure can make Vitamin D in the skin, as well as the role of Vitamin D in immune health, has contributed to a shift towards more unprotected sun exposure.
In fact, a recent (2023) survey of 2,000 respondents that included Millennials (ages 26 to 41) and Gen Xers (ages 42 to 57) found that the majority of respondents do not engage in safe sun practices and, generally, have low skin cancer awareness (6). For example, 78% of all respondents have gone outside on a sunny day without sunscreen (7).
So…should we be afraid of the sun or embrace sun exposure, no holds barred?
As always, the truth lies somewhere in the middle.
The Important Benefits of Sun Exposure
Sunlight is essential for human health. Studies link optimal sunlight exposure with the following benefits (8, 9):
–Enables natural production of Vitamin D in humans; synthesized from the exposure of skin to sunlight between 10AM and 3PM (10).
–Regulates the body’s circadian rhythm (11).
–Optimizes production of melatonin, which promotes sleep (12).
–Energizes infection-fighting T cells that improve immune function (13).
–Reduces risk of heart disease (14, 15).
–Lowers blood pressure (16, 17).
–Lowers risk of Type 2 diabetes (18).
–Lowers risk of some cancers, including breast, prostate, pancreatic and, ironically, melanoma (19).
–Lowers risk of osteoporosis (20).
–Reduces risk of autoimmune dise.ases, like multiple sclerosis (MS) and Type 1 diabetes (21).
–Improves mood (22).
–Enhances DNA repair (23).
–Can result in less lesions in psoriasis, eczema and vitiligo (24).
Getting too little sun—or completely avoiding sun exposure—can actually hurt your health (25).
A 2016 study of 29,518 Swedish women found that, across the board, those women who avoided the sun were more likely to die earlier—and from all causes of death—than women who maintained active sun exposure (26).
The study also found that non-smokers who avoided the sun had a life expectancy similar to smokers in the highest sun exposure group, indicating that avoiding the sun altogether has a risk factor for death—similar to smoking (27).
One of the biggest benefits of sun exposure is that it enables your body to make Vitamin D, also known as “the sunshine vitamin”. Exposing large areas of bare skin to sunlight, specifically, ultraviolet B (UVB) rays, is one of the most natural—and efficient—ways that your body can get (and make) vitamin D (28).
That being said…when it comes to optimal sun exposure, more is not better.
The 3 Most Common Skin Cancers
Today, the three main types of skin cancers—basal cell carcinoma, squamous cell carcinoma and melanoma—are largely attributed to excessive ultraviolet radiation (UVR) exposure (29).
Cancer cells develop because of multiple changes in their genes. Why? The causes of these changes can include: inflammatory food choices and lifestyle habits, genetic propensity and exposure to environmental toxins and/or cancer-causing agents (30).
Skin cancer typically starts in the top layer of the skin, also known as the epidermis. Excess sun exposure is often the culprit (31)
Two out of the three most common skin cancers are non-melanoma: basal cell carcinoma and squamous cell carcinoma. The other type is melanoma, which can be an invasive and aggressive skin cancer.
The good news? Most skin cancers, including melanoma, can be cured—IF detected and treated early. Skin cancer can be harder to treat once it spreads to other parts of the body.
1. Basal Cell Carcinoma.
Basal cells are located in the lower part of the epidermis. Eight (8) out of 10 skin cancers are basal cell cancers. Basal cell cancer usually develops on sun-exposed areas, such as the face, head, neck. Basal cell cancers grow slowly, but, if left untreated, can invade the bone or other tissues beneath the skin (32).
2. Squamous Cell Carcinoma.
Squamous cells are flat cells located in the upper (outer) part of the epidermis. Two (2) out of 10 skin cancers are squamous cell carcinoma. Squamous cell cancers usually appear on sun-exposed areas of the body, including the face, ears, neck, lips, and backs of hands (33).
Squamous cell carcinoma can also develop in scars; in chronic skin sores elsewhere; or it can start in actinic keratoses (AK), a pre-cancerous skin condition caused by overexposure to the sun. AK are small, rough, or scaly spots that are pink-red or flesh-colored. Among fair-skinned, middle-aged, or older people, actinic keratoses can form on the face, ears, backs of hands and arms. Most AK are benign, but a small percentage can turn into squamous cell skin cancers (34).
Bowen Disease is squamous cell carcinoma in situ, meaning that the cells of the cancer are still in the upper layer of the skin and have not yet penetrated deeper into the skin. Bowen Disease appears as large, reddish, scaly patches and can sometimes be crusty. They appear in sun-exposed areas of the skin. When Bowen Disease appears in the genital and anal areas, however, it is often related to a sexually transmitted infection, like HPV, or human papillomavirus (35).
Melanoma can develop when melanocytes—the cells that make a brown pigment called melanin that gives skin its “tan” or brown color—grow out of control. Melanin has a protective effect against some of the harmful effects of the sun.
Melanoma tumors are usually black or brown and can develop anywhere on the skin. However, common sites where melanoma potentially start are the chest and back (for men) and on the legs (for women). The neck and face are other common areas (36).
Invasive melanoma accounts for 1% of all skin cancer cases, but it is the most aggressive form of skin cancer, and it can spread to other parts of the body if not detected and treated early. (37, 38).
Incidence rates of melanoma are higher for women than men under age 50. After age 50, however, incidence of melanoma is higher in men (39).
Rare But Aggressive
Merkel cell carcinoma (MCC) is a rare but aggressive form of skin cancer. It begins in the Merkel cells, located beneath the top layer of skin near the nerve endings. It’s more likely to occur in Caucasians over the age of 70 and those who have a weaker immune system. Men are nearly twice as likely to have it than women. MCC is more likely to metastasize than non-melanoma cancers and it can be hard to treat—and fatal—once it has spread to the brain, liver, lungs or bones. MCC can start on sun-exposed sites, like the face, neck and arms. MCC presents as pink, red or purple lumps or bumps on the skin. They usually don’t hurt but they are fast-growing (40).
What Affects Our Skin Cancer Risk?
The following factors affect skin cancer risk (41):
1. Skin color.
Fair-skinned Caucasians, in particular, those with blonde or red hair, blue or green eyes, and/or freckles, are most susceptible to skin cancer because they have less epidermal melanin, a natural skin pigment that can provide protection against the sun’s ultraviolet rays. Darker-skinned groups—e.g., Hispanics, Asians and Blacks—have more epidermal melanin, which filters out twice as much UV radiation than does the epidermis of Caucasians (42).
That said…anyone—no matter what their skin color—can get skin cancer. Yes, there is a lower incidence of skin cancers in darker-skinned groups. However, when skin cancer does occur, non-whites are more likely to be diagnosed at an advanced stage because of delays in detection or presentation, making treatment more difficult (43, 44). As a result of delayed diagnosis or treatment, darker-skinned groups are at higher risk of death from skin cancer than whites (45).
2. Excess exposure to UV radiation from sunlight.
Ultraviolet radiation (UVR), especially cumulative sun exposure, is a key factor in the development of skin cancer, (46).
When your skin is exposed to excessive UVR, pigment distribution is disturbed and can result in solar lentigines, dark, irregular, edge-freckled spots, considered a sign of photodamage. In a 2019 Danish study, researchers found that lifetime UVR exposure was associated with the development of solar lentigines. And skin cancer (BBC, squamous and melanoma) was positively linked with facial solar lentigines (47).
3. Use of indoor tanning beds.
No, indoor tanning beds are NOT safer than sunlight!! Nor will they help you make Vitamin D. In fact, the International Agency for Research on Cancer has deemed tanning devices, like tanning beds, that emit UV radiation as “carcinogenic to humans”. Tanning beds are in the highest cancer risk category. Using tanning beds before age 35 increases your risk of melanoma by 75% (48). Avoid!
4. History of actinic keratoses (AK).
AK, the result of chronic sun damage to the skin, is closely linked with non-melanoma skin cancer. A pre-cancerous lesion that often appears on sun-exposed areas, like the head, face, lips, ears, scalp, neck, shoulders, forearms, back of hands and upper back, AK can potentially morph into non-melanoma skin cancer, in particular, squamous cell carcinoma (49, 50).
AKs appear as small dry, scaly or crusty patches of skin and can be red, light or dark tan, white, pink, flesh-toned or a combination of colors. However, AKs are more easily felt than seen. Your skin may feel dry and rough to the touch; or raw, sensitive and painful or itchy with a pricking or burning sensation; or, you may have multiple red bumps (51).
5. Weakened immune system.
Our immune function has a system of checks and balances. It helps our bodies tell the difference between healthy cells, abnormal or foreign cells and other potentially threatening organisms. A healthy immune system constantly engages in immunosurveillance. This process involves scanning our cells for potential threats, like foreign proteins (e.g., bacteria, fungi, viruses and cancer cells); and, once detected, they are destroyed (52).
However, our immune system can be weakened or suppressed by the following:
–Previous radiation treatment.
Therapeutic radiation may increase risk of skin cancers, especially basal cell and squamous cell carcinomas, at the radiation treatment site (53, 54)
Tobacco contains multiple carcinogenic compounds. A study published in the Journal of Investigative Dermatology found that smokers were at significantly higher risk of squamous cell carcinoma than those who never smoked (55).
–HIV (human immunodeficiency virus).
Those with HIV are at increased risk of non-melanoma skin cancers, such as basal cell or squamous cell (56).
–Medications or medical conditions that result in photosensitivity.
Photosensitivity is characterized by a high degree of skin reactivity to even minimal sun exposure. Photosensitivity often manifests as rashes and/or itchiness in areas exposed to the sun.
A rash may not sound like a big deal. But photosensitivity matters because it reduces your skin’s natural defenses and increase your risk of damage from the sun’s rays. Photosensitivity reactions from medication(s) you take or a medical condition, like lupus, can potentially increase your risk of developing skin cancer (57).
Photosensitivity can be triggered by prescription or OTC medications, including (but not limited to): antibiotics; non-steroidal anti-inflammatory drugs (NSAIDS); antifungals; Accutane (prescribed for acne); antihistamines; birth control pills and estrogens; retinoids; certain Type 2 diabetes medications; cholesterol-lowering statins, some heart medications; diuretics “water pills”; and tricyclic anti-depressants (58, 59)
Certain diseases or medical conditions, like lupus, rosacea or psoriasis, also contribute to sunlight hypersensitivity.
6. History of severe sunburn (60).
Growing up, I remember how people would shrug off a lobster-red sunburn as being sometimes painful, but no big deal. The reality? A sunburn is an inflammatory reaction after acuteintermittent exposure of the skin to intense solar radiation. A sunburn has been identified as a strong predictor of melanoma risk. In particular, a sunburn on the trunk serves as strong predictor of risk of developing melanoma—in both men and women—than a sunburn on other parts of the body (61).
Keep in mind: even one blistering sunburn in childhood or adolescence more than doubles your risk of developing melanoma later in life.
Having 5 or more sunburns more than doubles your risk of developing malignant melanoma (62). One study found that women, who had at least 5 blistering sunburns between ages 15 and 20, were 80% more likely to develop melanoma later on (63).
Photoaging—those wrinkles, fine lines and pigmentation that are the direct result of cumulative sun damage—and skin cancer risk rise with age. Malignant melanoma risk increases with age: half of all melanomas occur in people over age 50; the median age is 59 (64).
8. Personal and/or family history of skin cancer.
If you have already had skin cancer—basal cell, squamous cell or melanoma—you are at increased risk of developing melanoma (first- time or repeat incident).
Melanoma survivors, in particular, have a 9-fold increased risk of developing subsequent melanoma compared to the general population. This risk for developing a subsequent melanoma remains elevated for 20 years after an initial melanoma diagnosis (65).
A family history of melanoma means that one or more first-degree relatives (e.g., parents, siblings, children) or second-degree relatives (e.g., aunts, uncles, nephews, nieces, grandparents) have had melanoma. Roughly 10% of people with melanoma have a family history of melanoma (66).
9. Having atypical, large or numerous (50-plus) moles or a large number of moles (10+) on the legs (67).
Moles can appear anywhere on the body, and everyone has at least one mole. Most moles are harmless, but others can grow or change shape or color (68).
Congenital moles and/or atypical moles are associated with increased risk of melanoma.
Congenital moles are present at birth, while acquired moles appear during childhood or adulthood. Those with congenital moles are at increased risk of melanoma. Atypical moles are larger than a pencil eraser, shaped irregularly and uneven in color with a dark brown center.
People with 5 or more atypical moles are at increased risk for developing melanoma; even having one very large or atypically shaped mole can increase your risk of melanoma (69).
If you have many moles body-wide, the best preventative strategy is to see a dermatologist for routine skin checks.
10. Alcohol consumption
Sipping cocktails, poolside, sounds fun and relaxing, but your skin may pay the price. In a recent study (2023), researchers analyzed 14,037 skin cancer cases among 450,112 study participants (men and women aged 25 to 70) that developed over a median follow-up of 15 years. Researchers found that alcohol intake (from baseline) was linearly associated with an increased rise in skin cancer, especially basal cell and squamous cell carcinoma. ”Baseline” refers to the total number of alcoholic beverages (e.g., beer, cider, wine, sweet liquors or distilled spirts/wines) consumed per day.
In other words, the more you drink, the greater your skin cancer risk.
Average alcohol intake during adulthood was also associated with non-melanoma skin cancer risk; notably, with SCC and BCC in men and with BCC in women.
For men, drinking liquor/spirits was positively associated with melanoma and basal cell carcinoma, whereas wine intake was associated with basal cell carcinoma and squamous cell carcinoma. For women, wine intake was associated with a higher risk of basal cell carcinoma. Beer intake was not associated with skin cancer risk in men or women (70).
Because women metabolize alcohol differently than men, women are more vulnerable to the harmful effects of sun exposure and alcohol consumption.
A study published in the journal Cancer Causes Control found that, among nearly 60,000 post-menopausal Caucasian women, a high current consumption of alcohol; a high lifetime consumption of alcohol; and a preference for white wine or liquor was associated with increased risk of malignant melanoma and non-melanoma skin cancer. For “heavy” drinkers (defined as 7+ drinks per week), there was a 65% increased risk of melanoma compared to non-drinkers and a 23% increased risk for non-melanoma skin cancers compared to non-drinkers (71).
What makes alcohol a risk factor for skin cancer? Alcohol, in and of itself, is not carcinogenic. However, alcohol metabolism (the biological process by which your body eliminates alcohol) creates acetaldehyde, a toxic byproduct and known carcinogen. Alcohol metabolism creates oxidative stress, which can lead to DNA damage and carcinogenesis (the formation of a malignant tumor in otherwise healthy tissue). Alcohol metabolites can have photosensitizing effects, which contribute to cellular damage and suppression of the immune system (72).
In other words, drinking alcohol can alter your body’s ability to produce a normal immune response in the presence of UV (sun) exposure, resulting in greater cellular damage and a higher probability that skin cancer(s) will form.
In previous studies, those who reported a higher alcohol intake were also more likely to engage in riskier behaviors; for example, not using sunscreen, frequent use of tanning beds, etc., increasing skin cancer risk (73).
How to Practice Safe Sun
What you can do to reap the benefits of sun exposure—without increasing your skin cancer risk:
1. Build up sun exposure gradually. After a long winter, it’s tempting to throw caution to the wind and catch as much sunshine as possible.
2. Always wear sunscreen on your face, neck and chest. Your skin is more delicate and vulnerable in these areas to sun overexposure and sun damage.
3. Monitor time spent in the sun, especially between 10AM and 3PM.
4. Be mindful that a little bit of sun exposure—without sunscreen—at the right time goes a long way towards helping your body produce Vitamin D. Your body requires UVB rays to produce Vitamin D. The best time to expose bare skin to UVB rays is between noon and 1PM. Unlike UVA rays that are present throughout the day, UVB rays are most abundant between 10AM to 2PM (74, 75), and, in the Northeast, UV rays are strongest in July and August.
Keep in mind: when you expose skin with a larger surface area, like your back (versus a smaller area, like your face), you can make Vitamin D more efficiently. Start by exposing your skin for half the time it takes to turn pink; this can be 10 to 20 minutes (more or less) around midday (12noon to 1pm), depending on your sensitivity to the sun and skin type, whether fair or darker skinned (76). Use sunscreen on your face, where the skin is more delicate, especially if you are fair and/or wear a hat and sunglasses. Be sure to apply sunscreen afterwards.
Even though my skin tends toward olive, and I tan easily, I always wear sunscreen on my face, neck and chest.
5. Avoid getting burned. No, burns are not “cool”! Red, sore, blistered or peeling sun means that you’ve gotten too much sun and raises skin cancer risk (77).
6. Cover up! Wearing a bikini or swim trunks to spend hours in the sun is still a relatively new concept. Until the early 20th century, swim attire for both women and men covered much more of the body. The two-piece bikini debuted in 1946 and the infamous “Speedo” made its way to pools and beaches in the 1950s.
In addition to sunscreen, wear a hat, sunglasses and shirt to protect from UV rays, especially if you are going to be out in the sun all day. You can buy UPF-labeled (UPF = Ultraviolet Protection Factor) clothing OR when considering sun-protection clothing options, choose thicker fabrics; darker fabrics vs. light-colored ones; denser/tighter weaves vs lighter weaves; and polyester or nylon fabrics vs. natural fibers, all of which offer more UV protection (78).
7. Avoid relying only on sunscreen for sun protection. A common perception is that using sunscreen means that you can stay out in the sun longer (or as long as you want). Unfortunately, no.
A sunscreen’s SPF rating seldom matches its real-life performance.
Why? Because most SPF values are determined in a lab, using a very thick (and unrealistic) coating of sunscreen—2 mg/cm2 of skin surface. Most people apply 0.5 to 1.5 mg/cm2, an amount that achieves an SPF of roughly one-third of that stated on the label (79). For example, if you apply an SPF 30 sunscreen, you are likely applying an amount that achieves an SPF of 10. Because some types of sunscreens don’t form a thick and stable coating on the skin, and others may separate or clump over time, the actual amount of SPF achieved is much lower than stated on the label (80).
8. Choose a good sunscreen. A higher SPF is not better. While a higher SPF of 50+ may protect against sunburn, it leaves your skin susceptible to damaging UVA rays. Avoid spray sunscreens which pose an inhalation risk. And avoid sunscreens that contain endocrine-disrupting chemicals, like oxybenzone, avobenzone or homosalate (81).
9. Check your skin regularly. Note any new moles that are tender or growing or current moles that change shape, size, texture, color or that bleed.
10. Make anti-inflammatory food choices on a regular basis.
Like everything else…how your skin reacts to the sun—whether you burn easily (or not); whether your skin converts sunlight to Vitamin D (or not)—is affected by your food and lifestyle choices. An anti-inflammatory way of eating and living promotes clear skin, boosts immune health and reduces inflammation; it can even potentially protect your skin from sunburn.
Confused about how to get on an anti-inflammatory eating track? Jumpstart healthy eating and lifestyle habits with my, which focuses on clean eating and de-stressing the body.
11, Eat antioxidant-rich, skin-friendly foods. A review published in Journal of Cancershowed that dietary antioxidants, such as Vitamins C and E, beta-carotene and selenium, may prevent potential DNA damage and cancerous growths from UV radiation. Laboratory and animal studies show a strong association between certain antioxidants and skin cancer prevention.
In human studies, eating antioxidant-rich whole foods has shown promising skin-protective results compared to taking oral antioxidant supplements which were not effective (82).
Functional Health Coaching
Are you feeling overwhelmed, frustrated or anxious about your skin, your weight, your overall health or, perhaps, a seeming inability to make food or lifestyle changes that you know would be good for you?
This is where a functional health coach can help. We take a deeper dive into potential root cause issues that may be driving your symtoms.
If you would like to speak to me to ask questions about functional health coaching or how I can help you, please schedule a Free 15-Minute Consultation or email me at [email protected] with “Consultation Request” in Subject line.
My practice is 100% remote and I meet with clients via video (or phone if they prefer) in-state and out-of-state.
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