As the weather turns warm, children and adults of all ages naturally gravitate toward outdoor activities. Many dream of the start of beach season and lazy days basking in the sun. But protecting skin from the sun’s radiation is an important aspect of preventing cancer, and the sun-protective habits developed during childhood could have lifelong impacts.
To get the scoop on sun protection and the latest research on how to help families change behavior to maximize sun safety, Cornerstone recently chatted with Leslie Castelo-Soccio, MD, PhD, a pediatric dermatologist at The Children’s Hospital of Philadelphia and assistant professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. She and Albert Yan, MD, section chief of Dermatology, co-authored an editorial in the journal JAMA Pediatrics, commenting on a study in the journal that used a combination of methods, including text messaging, to engage young children and their parents in developing sun-protective habits. The edited conversation follows below.
Tell us about the editorial you and Dr. Yan recently co-authored in JAMA Pediatrics about a sun-protection education study. What were the strengths of that program you especially valued?
We know that in-person education is helpful, but compliance will be low if we don’t give reinforcement. A lot of the patients who dermatologists try to educate might only be seen in the clinic once per year. For the purpose of that reinforcement, the study’s follow-up with text messaging was appropriate and seemed to be effective for families.
Text messaging is already in the fabric of how a lot of families approach their lives, as a tool for appointment reminders and other in-the-moment notifications, such as when packages arrive. It is a good method to approach education for sun protection and other skin disease. In our editorial, we recommended continuing to tailor these strategies based on the emerging evidence for these methods, as well as potentially adding other strategies that are woven into people’s lives, such as social media.
The other thing the group did which was nice was to remove a barrier for patients who might not be able to order sun-protective clothing — by just giving it to the families. Most companies that provide sun protective clothing do it online. Giving the clothing away especially helps families that may not have access to the internet or may not have a credit card, and it removes that secondary step of placing an order, for all families.
Is skin cancer a serious concern for children and teenagers, or is the need to educate about sun protection more of a long-term concern focused on later lifetime risk?
Sun-protection behaviors are important to begin when you are a child and will decrease the numbers of skin cancers and amount of sun damage when you’re an adult.
We are seeing earlier skin cancers in kids and teenagers. There has been an increase in melanoma and non-melanoma skin cancers in patients who practice tanning in tanning beds and outdoor tanning, and these sun-induced skin cancers occur even in the teens and early 20s.
I have taken care of adults as well as kids. The predominant diagnosis in many adults is premalignant keratosis or skin cancers. With good sun protection, we’ll see less of that in kids we’re treating now.
What kind of education about sun protection do you offer to children and families you see at CHOP?
Every patient who comes in for a full skin exam to look at their moles receives education about types of sunscreen, about appropriate use of sunscreen, about sun protective clothing, and about why these things help protect the skin and prevent skin cancer. They also learn about the concerning changes in moles.
I personally like sun protective clothing in addition to sunblock. With the protective clothing, you have long lasting protection. My own kids wear full sleeves and full pants or one-piece, wetsuit-like bathing suits when they’re at the beach, then I only have to put sunscreen on their face or tops of their hands and feet. That’s a lot easier when you have squirmy kids who are in and out of water.
In your editorial, you discussed the idea that typical educational messaging is “less is more.” But the study you commented on used a “more is more” approach, and that seemed to work well. How do you balance these ideas?
Simplicity is the best way to achieve compliance. If you provide a simplified message to the patient in your appointment, “Wear a sunscreen with an certain SPF and apply every 2 hours”— that’s going to be more effective. With a very complicated regimen, people will throw their hands up and think, “I can’t do any of it.”
The “more is more” idea plays into the fact that different people learn best using different methods, some audio and some visual. Multimodal methods for education and reinforcement may be better for heterogeneous audiences. For many, adding that text message every four weeks is helpful especially in sunny months. During summertime, families may have been armed with information at the start of the season, then may fall out of the habit over time. A reminder may get them back on the right track to put the sunblock in their bag, or buy more before they leave for their vacation. Families can be proactive by adding a reminder in their online or phone calendars about the importance of sun protection.
Simplicity but repetitiveness is probably the best message for sun protection.
Are there any common myths or misperceptions about sun protection that people should know about?
Education about sun protection is just as important for families who may never have used sun protection because they have darker colored skin. They still are at risk for skin cancer including melanoma and should be concerned about changes in their skin with time. I give the same information to patients whether they have skin that burns easily or if they never burn. Burning risk may be different based on skin color, but all patients need the same information and protection against cancer.
Another myth is that sunblock is waterproof. Even sun blocks that claim to be water resistant only last a certain amount of time. The amount of time is now mandated to be listed on the product label. Some families think if you put it on once, you’re done for the day, and that is not the case.