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ORIGINAL ARTICLE, p.803

The reduction of ultraviolet (UV) radiation exposure is the main strategy in order to prevent skin cancer, and early childhood before the age of 6 years is regarded as a particularly vulnerable period of life. The article of Li and colleagues1 is based upon a population-based questionnaire survey of 2619 parents with young children aged 3–6 years. The authors emphasize that patterns of sun protection differ between sunny holidays with a higher degree of sun-protective activities and everyday outdoor activities with less sun-protective attention. Interestingly, better knowledge about sun exposure and skin cancer affected the sun-protective behaviour only in the beach environment, but not in everyday life. Furthermore, with increasing age the attention for sun protection decreased.

The data of this study allow additional insight into the sun-protective behaviour of parents with young children: they rely mainly on the protective effect of sunscreens. In the beach setting 98·6% regularly used sunscreens and 79·2% even several times a day. However, only 29·7% used T-shirts and only 2·5% long-sleeved shirts. T-shirts were used much more often in the garden setting, by 84·6%, but sunscreens (88·6%) were the most frequently used measure of sun protection also in this setting.

It would have been interesting to test in such a study the guiding messages for the sun-protection behaviour. The broad majority of parents would probably have agreed with the following two sentences: (i) the avoidance of sunburns protects against skin cancer; and (ii) the application of sunscreens prevents skin cancer.

Both messages, however, are wrong or misleading. First, the avoidance of sunburns is not enough, because DNA damage can occur long before sunburn appears. It has been shown in animal studies that DNA damage was induced already by 0·1 of the minimal erythema dose.2 On the contrary, sunburns may even elicit a protective effect regarding epithelial skin cancer by elimination of heavily DNA damaged cells by apoptosis.3

The use of sunscreens provides only small protective effects, and clothing is a much more efficacious prevention. In studies in young children use of sunscreens had either only a marginal effect on the development of melanocytic naevi or no effect at all.4,5 Furthermore, the use of sunscreens prolongs UV exposure times particularly in the beach setting.6

Our sun-protection messages for the public remain to be redefined. The current steady increase in the incidence of skin cancer will continue in future, and past messages have not affected the rapidly increasing incidences of melanoma and nonmelanoma skin cancer.7,8 In order to reach a turning point in skin cancer development, the public has to be aware that avoidance of sunburns and application of sunscreens is not enough to prevent skin cancer. Positive messages remain to be elaborated, and studies like that from Li and colleagues are necessary in order to give precise sun-protection messages.

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