(See updated information on Suntan Products, Sunscreens and Tanning)
Americans' rising health consciousness may finally be overriding their obsession to obtain an enviable tan. At the height of poolside-lounging sessions and a host of other sun-drenching activities, we're beginning to realize that soaking up the rays isn't as cheap as it once was. The cost of a bronzed body is growing steeper, as a sometimes-fatal skin cancer becomes alarmingly prevalent. Diagnosed in 1 of every 128 Americans, melanoma killed nearly 6,000 victims last year--a 93 percent increase in the number of cases since 1980. Particularly troubling is the deadly cancer's newest victims: while doctors once rarely saw melanoma patients under age 40, today people in their 20s are commonly treated for the disease. At the current rate, researchers estimate melanoma will strike 1 in every 90 Americans by the year 2000.
This year more than half a million Americans will develop melanoma and other less serious skin cancers, according to the New York- based Skin Cancer Foundation, a nonprofit organization that conducts skin cancer public awareness campaigns. The current skin cancer figure could double to more than 1 million annual cases during the next 25 years. Contributing culprits are unprecedented leisure time for outdoor activities, ozone depletion, skimpier summertime attire, population growth in the sunbelt states, and sunbathing binges.
But we're modifying our sun-worshipping ways-perhaps in response to the grim cancer projections. According to a survey by the Skin Cancer Foundation and Health Magazine, 95 percent of 1,000 Americans interviewed believe repeated sun exposure leads to skin cancer, and 84 percent report using some kind of sun protection. Seventy-three percent say they have limited their sun exposure in the past two years, while only 12 percent report taking no precautions in the sun. A testament to these findings is sales figures on sunscreens, which have replaced tanning lotions as the hottest sellers in the sun-care market. Sunscreen sales hit the $390 million mark last year, and the market is expected to continue to grow over the next five years--reaching $560 million by 1992, according to Packaged Facts, Inc., a New York market research firm. Analysts say sun-care products now represent about 10 percent to 15 percent of the sales for major cosmetic companies today--at least twice the level of several years ago. Over the years, sun can irreversibly damage the elastin fibers in the skin, causing the sagging, wrinkling, and weather-beaten look associated with years of excessive tanning. But the major threat of excessive sun exposure is skin cancer.
In the early stages of the disease, skin cancer may not look like a growth; it can appear as just a discoloration of the skin. Particular attention should be paid to any changes in the size, color, shape or thickness of moles, birthmarks, or other irregularities. A spot or growth that begins to itch, hurt, crust, scab, erode, or bleed could signal a problem. The American Cancer Society recommends a monthly self-examination to detect early skin cancer warning signs. The best time for this is after a bath or shower, using a full-length mirror and a hand mirror to check moles, blemishes or birthmarks from the top of your head to your toes.
If a self-examination uncovers anything unusual, it is best to consult a physician. If the doctor is suspicious of the lesion, he or she will usually do a biopsy. This involves taking a specimen of the questionable lesion for laboratory analysis to determine whether the growth is benign, precancerous or cancerous. Major treatments for precancerous and cancerous lesions include:
There are three types of skin cancer--basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. All have been linked to sun exposure. The most common is basal cell carcinoma, comprising about 80 percent of the skin cancers, or some 400,000 cases each year. Characterized by raised translucent nodules that may crust, ulcerate and sometimes bleed, basal cell carcinomas occur most often on the face and other exposed areas of the body, but can crop up anywhere.
The next most common skin cancer is squamous cell carcinoma, with about 100,000 cases reported each year. The growths look like raised, pink, opaque nodules or patches, which often ulcerate in the center. They may grow anywhere on the body, but, like basal cell carcinomas, most often show up on exposed areas.
The most deadly skin cancer, malignant melanoma, usually appears as a small brown-black or larger nulticolored patch, plaque or nodule with an irregular outline. Melanomas may crust on the surface or bleed. Detected early, the Skin Cancer Foundation says, all three skin cancers have at least a 90 percent cure rate. (For more on skin cancer, see "Out of the Bronzed Age," in the June 1987 FDA Consumer.)
With increasing awareness of the dangers of excessive exposure to the sun's damaging rays, more people are turning to sunscreens for protection. Sunscreens work by absorbing, reflecting or scattering ultraviolet light, thereby reducing the amount that reaches the skin. While sunscreens traditionally have been aimed at filtering ultraviolet B (UVB) radiation, future products are expected to offer greater protection against ultraviolet A (UVA) rays. UVB rays cause burning tanning, and increased cancer risks, while UVA radiation penetrates more slowly and deeply into the skin, causing changes in blood vessels, creating sags and bags associated with premature aging, and adding to the cancer risk of UVB rays. Research on mice has shown that animals exposed to both UVA and UVB have a much higher incidence of skin cancer than those exposed just to UVB light.
Choosing a sunscreen is highly subjective. "You just sort of have to use your own judgment," says Jeanne Rippere, a microbiologist with FDA's over-the-counter drug evaluation division. "Look at your skin and know your history. If you burn readily with minimum exposure, you would want to pick a sunscreen with a higher SPF (sun protection factor), especially in a hot climate."
To maximize protection, it's important to apply the right amount of sunscreen. While most labels advise applying sunscreens liberally and often, this can be confusing since lotions, creams, gels, liquids, and sprays all cover the skin differently. Recent studies indicate that most people use only about half as much sunscreen as necessary for full protection. "As a rule of thumb, you'll get the labeled SPF protection by using about an ounce to cover your entire body," according to a Consumer Reports article evaluating sunscreens. It is best to apply a sunscreen about 30 minutes before exposure so it can be absorbed and is less likely to be washed off by perspiration.
Many dermatologists recommend daily sunscreen use to protect against insidious sun damage. Ultraviolet rays don't feel hot, so it's easy to be lulled into a false sense of security if there is a cool breeze or overcast sky. But shade--or even thin clothing--offers little protection. Ultraviolet radiation can also reflect off sand and water, pass through gauzy robes and wet T-shirts, and penetrate several feet underwater.
Although a few cases of skin cancer are caused by overexposure to X-rays and by chronic exposure to chemicals such as arsenic, the chief villains are the sun's ultraviolet rays. Our bodies keep score on the amount of radiation we take in, and when the numbers get too high, the body reacts. Normally, if abnormalities occur during cell division, enzymes repair the damage. Radiation from too much sun, or another source, can put these enzymes out of commission.
Recent sunscreen developments include products that are greaseless, hypoallergenic, waterproof, or PABA-free. PABA, or para- aminobenzoic acid, is a once-popular sunscreen chemical that can irritate skin and stain clothing. The allergic reaction manifests itself as redness and itching about 24 hours after the sunscreen is applied. If you suspect you are sensitive to PABA, apply the sunscreen to a small patch of skin, preferably on the underside of the forearm, and cover the area with an adhesive bandage. After 24 hours, remove the bandage and expose the area to sunlight for 15 minutes. If you're sensitive to PABA, a reaction will appear the next day in the form of redness and swelling. Many sunscreens contain PABA derivatives, so if you're allergic to the chemical, look for PABA-free products with benzophenones and anthranilates. Allergies to these chemicals are less common. Moreover, these agents offer protection against both UVA and UVB rays, while PABA products protect only against UVB.
Marketers are also earmarking more waterproof sunscreens for children, who sweat more heavily than adults and dash in and out of water more frequently, thereby easily removing products that are not waterproof.
To help consumers select the product best suited for their skin types, FDA worked with several sun-care manufacturers from 1974 to 1976 to outline categories and procedures for determining sun protection factor numbers. In 1978, an FDA panel recommended SPFs from 2 to 15. The SPF number indicates the amount of protection the sunscreen provides against ultraviolet rays and sunburn. An SPF of 10, for example, enables a person who is likely to sunburn after half an hour's exposure to safely sunbathe for five hours, or 10 times longer than usual.
Until 1986, the highest sunscreen SPF available was 15, which is the highest number currently endorsed by FDA. Today, there are sunscreens with SPFs as high as 50. These products do not yet require FDA approval, since the agency is still evaluating whether to endorse higher SPFs.
"This is a gray area," admits Rippere. "Many SPFs are exempt from legal action unless there's a safety problem." Rippere estimates an SPF decision will be reached in two years. Under current FDA consideration are whether higher SPFs are really necessary and whether testing procedures accurately determine SPF values, says Rippere. "We're pretty sure that testing procedures can accurately determine an SPF of 8, but don't know if they can determine the effectiveness of a 30." Sunscreens with SPFs higher than FDA's allowable protection factor could ultimately be pulled off shelves, says Rippere.
Meanwhile, debate continues on the necessity and effectiveness of higher SPFs. "I think there's possibly some justification for SPFs up to 30. For someone with very fair skin, a 15 might not be enough," says Rippere. "But I think you get a diminishing return when you get to higher numbers. SPFs of 49 to 50 are absurd, in my view." Besides the still-unanswered question of higher SPF effectiveness, there is concern that higher strengths cause increased irritation among people sensitive to the active ingredients in sunscreens.
Despite an increase in sunscreen use, only time will tell if America will be able to reverse its spiraling skin cancer rate. Some speculate it will take another generation for noticeable cancer reductions. While experts agree the media have done a good job of publicizing the sun-cancer link and some progress is evident, confirmed sun-worshippers nevertheless remain reluctant to forego tanning sessions. Perpetuating the problem is the long-held perception equating a suntan with status and a "healthy" look--a belief that's unlikely to fade as quickly as a tan.
Cheryl A. Sweet is a free-lance writer in Phoenix, Arizona.
(See updated information on Suntan Products, Sunscreens and Tanning)