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Smart children don't burn in the sun

Carol Coley
RN BSc(Hons)
Skin Cancer Nurse Specialist
Portsmouth Hospital NHS Trust

Many people believe that a suntan is a sign of being healthy and attractive, but there is no such thing as a healthy tan. A tan is the skin's response to the sun's damaging rays. Too much sunlight is harmful and can damage the skin, and repeated exposure to too much sun over a number of years can lead to sun-damaged skin, for example premature aging, wrinkling, brown spots, actinic keratoses (benign warty lesions) and skin cancer.(1) The incidence of skin cancer is increasing worldwide. There are over 70,000 new cases of skin cancer diagnosed each year in the UK, a figure that has doubled since the 1980s.

The "ABCDE" rule
As nurses we need to teach our patients the "ABCDE" rule for mole watching. If any of the following changes are noticed, seek advice from a doctor:

  • Asymmetry - the two halves of the mole do not look the same.
  • Border -  the edges of the mole are irregular, blurred or jagged.
  • Colour - the colour of the mole is uneven, with more than one shade.
  • Diameter - the mole is more than 6 mm in diameter (the size of a pencil eraser).
  • Enlargement - any mole that enlarges over a six-week period should be discussed with a doctor.

Some experts believe that the chances of developing a malignant melanoma (the most serious form of skin cancer) are doubled by just one episode of blistering sunburn before the age of 20.(2)

UV radiation
As nurses we need to educate our patients to protect themselves and their families from the harmful ultraviolet (UV) sunrays and raise their awareness on detecting skin cancers, as early detection can have a more favourable outcome.(3) If we do not protect our skin, the UV rays penetrate deep into the skin's layers and damage the cells.
There are three types of UV rays that damage our skin: UVA, UVB and UVC.
UVA radiation is the predominant type of radiation from the sun. It causes more pigment (melanin) to be produced in the skin giving a temporary tan. UVA rays penetrate deeper into the dermis affecting elastin (which gives the stretchiness to the skin) and ageing the skin. Long-term exposure can lead to skin cancer.
UVB radiation makes up a small proportion of the sun's UV radiation. It can cause redness and burning as it penetrates the upper layer of the skin - the epidermis - and can cause sunburn and skin cancer.
UVC radiation gets filtered out by the ozone layer and does not reach the earth, but can be artificially produced by arc welding lights and is extremely dangerous to the skin.(4) The depletion of the ozone layer has resulted in increased levels of UV radiation reaching the earth's surface. Between 1983 and 1993 there was a 6% drop in the total ozone. It is estimated that for every 1% drop in the ozone there is a 1-5% increase in skin cancer.(5)
Our skin burns when we stay too long in the sun and sunburn is our body's chemical response to over-exposure to UV rays. Sunburn doesn't just happen in the summer; UV radiation is present when the sun shines and it can penetrate through cloud. Sun damage and sunburn can also occur when sunlight is reflected from water, sand and snow.(6) When you are sunburnt the outermost layers of skin release chemicals that cause blood vessels to swell and leak fluids. This causes inflammation, pain and redness. The skin becomes hot and painful and severe sunburn can cause swelling and blisters. Skin peeling can occur; this is the body's way of getting rid of skin cells that have been damaged by the sun, and is necessary because cells damaged by the sun are at risk of becoming cancerous. However, although the skin peels and new skin layers form, some of the damage may remain and this can cause problems in later life.(7)

Protecting the children
Children are far more likely to burn than adults, as their skin is thinner and more delicate. Children with fair or red hair, pale eyes or freckles are most at risk of burning. Children with brown or black skin have a lower risk of developing skin cancer, but can still burn in strong sunlight. There are a number of simple things that parents can do to protect their children and help towards ensuring that their children do not become one of the skin cancer statistics in the future (see Box 1).

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It is advisable that babies under the age of six months are kept in the shade under a sun umbrella to provide maximum shade at all times. Sunscreen needs to be applied 30 minutes before going out in the sun and it should be reapplied liberally and regularly. A high-factor sunscreen should be used, at least sun protection factor (SPF) 15 or above. When advising patients about what type of sunscreen they should buy for their children there are a number of things to remember:

  • The higher the SPF number the more protection you get (always use an SPF of 30 or above - the higher the better).
  • Buy a "broad-spectrum" sunscreen. Check the label to ensure it protects against UVB and UVA. Check the star rating on the bottle too. The star rating denotes the UVA protection - the more stars the greater the protection.
  • Water-resistant sunscreen is good, as it is less likely to wash off or be sweated off.
  • A valid "use by" date (sunscreens can "go off" and not work after a time).

Application
When applying sunscreen advise your patients to:

  • Apply it 30 minutes before going out. Sunscreen needs to be applied even on a cloudy day as up to 80% of the sun's rays can still penetrate light clouds and applying sunscreen before going out will help to prevent getting caught out if the sun comes out later in the day. Going out applies to going anywhere outside; the garden, park or shopping, not just to the seaside. Advise parents to apply sunscreen on children before they go to school and give their children some to take to school to reapply at break times.
  • Apply to clean, dry skin and rub in lightly before getting dressed. This will help to prevent "missing" any areas that could lead to sunburn, for example straps on shoulders or swimsuit lines. There are a number of sunscreens available that children might find fun and easier to apply themselves, such as, ones that change colour when rubbed in, mousse or spray sunscreens.
  • Use a generous amount (golf ball-size quantities for small children). Remember to apply to all exposed areas: shoulders, nose, ears, cheeks and tops of feet.
  • Reapply every two hours or more frequently if washed, rubbed or sweated off, especially after swimming or playing with water in the garden.
  • Put on before any moisturisers or insect repellent. Some sunscreens contain insect repellent, which can be useful especially if parents are taking their children abroad.
  • A lip balm should be used too (with an SPF of at least 15).

Atopic skin
Children who suffer from eczema may find that sunscreens can aggravate their skin. Advise parents to do a skin test with any new products before applying all over the child's body. They can apply a little sunscreen to the inside of the child's arm and wait for 24 hours before applying it to the rest of the body. If during the 24 hours the child's skin becomes red and/or itchy do not use the sunscreen. Sunscreens contain preservatives, and one in particular - methyldibromoglutaronitrile - may cause allergic reactions, including swelling, itching and acute dermatitis. There are a number of sunscreens that are free from this product; they include Bergaderm Sunscreen Mousse, E45 Sun Lotions, Sun Sense and Vichy. The Eczema Society has a very comprehensive list of sunscreens and the ingredients they contain on their website (see Resources).

Sunburn
Sunscreen does not offer total protection from the sun's rays and using it is only one way to reduce your risk of skin cancer. People need to remember that whether they are at home in the UK or abroad they still need to take care in the sun as they can get sunburnt. Many cases of sunburn happen when people are not deliberately sunbathing. Walking, gardening or watching sport without having put on any sunscreen is equally dangerous. Everyone should avoid the sun between 11am and 3pm, as this is when it is at its most intense.
Providing shade for children is essential and there are a number of different ways of creating shade, eg, trees and foliage, umbrellas and parasols, canopies and awnings, tents, shelters and wide-brimmed hats.
Children should be dressed in cotton clothing that is baggy, close-weave and cool. If you hold the clothing up to the light and can see through the cloth it will not protect the child from the sun. Oversized t-shirts are good for covering most of their skin. Put them into dry clothing after they have been playing in water. Sun suits can also be used to protect children. These are widely available in most high street stores and via the internet, for example Sun Togs clothing (see Resources). Children should not wear vest tops or sundresses if they are going to spend a lot of time outdoors as their necks and shoulders can get burnt. They should wear hats with wide brims - the wider the brim the more skin will be shaded. Legionnaire-style hats with the piece of cloth at the back are excellent as they protect the child's neck too. Sunglasses (not toy ones) especially the wraparound type, protect children's eyes against the sun's rays. They do not have to be expensive sunglasses, but they should offer 100% UV protection, have the CE safety mark and British Standard (BS EN 1836:1997), and a UV 400 label to ensure that they will do the job they are meant for.9
  Should a child get sunburnt, SunSmart from Cancer Research suggests that parents:

  • Take the child indoors and carefully cool the area with cool water or compresses.
  • Apply aftersun lotion on the affected area.
  • Encourage the child to drink plenty of fluids.
  • Ensure that the sunburn is healed before exposing the skin to the sun again.

Parents should seek medical advice if the child is very young, a large part of the body is sunburnt, if the skin is blistered and swollen, or if they show signs of heatstroke such as:

  • Hot, dry and red skin.
  • Nausea or vomiting.
  • Raised temperature sustained over 38ºC or 100ºF.
  • Drowsiness or even confusion.
  • Dizziness or even unconsciousness.

Conclusion
Sun protection and education is the responsibility of parents and nurses. Sunburn and sun damage is not a minor health problem - it can lead to serious skin problems in later life. If we can teach children good safe sun practice it might help prevent the year-on-year increase in skin cancer. We all need a little sunshine, as we don't want everyone to become vampires and only come out at night; we just want everyone to be "smart"!

References:

  1. Prodigy. Sun and health - patient information. 2006. Available from: http://www.prodigy.nhs.uk
  2. Cancer Research UK. SunSmart skin cancer information. 2007. Available from: http://info.cancer researchuk.org/healthyliving/sunsmart/skincancer/
  3. Freak J. Promoting knowledge and awareness of skin cancer. Nurs Stand 2004;18:45-53.
  4. Cancer Research UK. Reducing your risk of sun and UV light. 2003. Available from: http://www.cancerresearchuk.org/aboutcancer/reducingyourrisk/sun_uv
  5. Maguire-Elsen M, Rothman K, Demierre MF. The ABCs of sun protection for children. Dermatol Nurs 2005;17:419-26.
  6. NHS Direct Health Encyclopaedia. Sunburn. 2007. Available from: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=355
  7. Cancer Research UK. SunSmart - stay safe - sunburn. 2007. Available from http://info.cancerresearchuk.org/healthyliving/sunsmart/staysafe/sunburn...
  8. Cancer Research UK. SunSmart. 2007. Available from: http://info.cancerresearchuk.org/healthyliving/sunsmart
  9. Cancer Research UK. SunSmart - stay safe - covering up. 2007. Available from: http://info.cancerresearchuk.org/healthyliving/sunsmart/staysafe/coverin...