108

REVIEW

Sun Exposure Behavior and Protection: Recommendations for

Travelers

James H. Diaz, MD, MPH&TM, DrPH∗ and Lee T. Nesbitt Jr, MD†
∗
Program in Environmental and Occupational Health Sciences, Schools of Public Health and Medicine; † Department of
Dermatology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA

DOI: 10.1111/j.1708-8305.2012.00667.x

See the Editorial by John B. Lowe, pp. 67–68 of this issue.

Background. Although there have been recent advances in the development of photoprotective clothing and broad-spectrum
sunscreens, few peer-reviewed publications have focused on photoprotection recommendations for travelers.
Methods. In order to describe the adverse health effects of excessive ultraviolet (UV) radiation exposures; review recent studies
of public perceptions regarding photoprotection and sun exposure behaviors; identify special populations at increased risks
of drug-induced photosensitivity reactions and UV-induced skin cancers; and recommend several effective photoprotection
strategies for travelers, Internet search engines were queried with the key words as search terms to examine the latest references
on photoprotection and the epidemiology of UV-associated skin cancers.
Results. Observational studies have demonstrated that the public knows little about proper sunscreen protection, selection, and
use, and often abuses sunscreens for intentional UV overexposures. Cohort studies have identified special populations at increased
risks of UV-associated skin cancers without the proper use of sunscreens and photoprotective clothing including children,
fair-skinned persons, patients taking photosensitizing drugs, and organ transplant recipients (OTRs). Clinical investigations
support the regular use of broad-spectrum sunscreens to prevent the development of premalignant actinic keratoses (AK) in all
sun-exposed subjects, especially OTRs; to prevent the development of squamous cell carcinomas from new AK in sun-exposed
subjects, especially OTRs; to possibly prevent the development of cutaneous malignant melanomas in children and adults; and to
possibly prevent the development of basal cell carcinomas in OTRs.
Conclusions. Recommended photoprotection strategies for travelers should include avoiding intense sunlight, wearing
photoprotective clothing, wearing sunglasses, and selecting the right sunscreen for their skin type. Travel medicine practitioners
should counsel travelers about photoprotection and encourage travelers to take advantage of recent advances in the development
of more effective broad-spectrum sunscreens and photoprotective clothing for themselves and their children.

S unbathing, swimming, skiing, and many other

outdoor pursuits remain popular activities among
travelers despite well-documented associations between
excessive ultraviolet (UV) radiation and skin cancer.
Although there have been recent advances in broad-
spectrum sunscreens and photoprotective clothing, few
peer-reviewed publications have focused on preventive
strategies for excessive solar radiation exposures during
Corresponding Author: Prof. James H. Diaz, MD,
MPH&TM, DrPH, Program in Environmental and
Occupational Health Sciences, School of Public Health,
Louisiana State University Health Sciences Center, 2020
Gravier Street, Third Floor, New Orleans, LA 70112, USA.
E-mail: jdiaz@lsuhsc.edu
travel to temperate, tropical, and high altitude regions
with high UV indices. In response, the objectives of
this review were (1) to describe the adverse health
effects of excessive UV radiation exposures, (2) to
review recent cohort studies of public perceptions
regarding sun exposure and protective behaviors, (3)
to identify special populations at increased risks of
UV photosensitivity, and (4) to recommend simple and
effective photoprotection strategies for travelers.
Methods
Internet search engines were queried with the key words
as search terms to examine the latest references on pho-
toprotection and the epidemiology of UV-associated

© 2012 International Society of Travel Medicine, 1195-1982

Journal of Travel Medicine 2013; Volume 20 (Issue 2): 108–118
Photoprotection for Travelers
skin cancers and other adverse effects of UV-radiation
exposures. This search yielded only three references
on photoprotection for travelers including a British
comparison of photoprotection recommendations from
five travel guides for travelers to Spain, a German
article on sun and insect bite protection while outdoors,
and a French article on sunglasses and sunscreens
during travel to tropical areas.1 – 3
The Dermal Effects of Excessive UV Radiation
Solar UV radiation is classified by wavelength
into UVA1 (340–400 nm), UVA2 (320–340 nm),
UVB (290–320 nm), and UVC (100–290 nm). The
stratospheric ozone layer effectively absorbs most UVB
radiation and all UVC radiation; but some UVB and all
UVA2 wavelengths still reach the earth’s surface. UVB
is mostly absorbed by the epidermis and is primarily
responsible for erythema and sunburn. UVB radiation
damages DNA at neighboring pyrimidine sites and can
cause local mutations in p53 tumor suppressor genes
with resulting squamous cell carcinomas (SCCs).4,5
The skin is continuously exposed to UV radiation
outdoors, receives the largest doses of radiation, and
suffers the most significant adverse effects, including
photoaging, sun allergy, premalignant skin lesions
[actinic keratoses (AK)], and skin cancers, of which
the most common types are non-melanoma skin
cancers [basal cell carcinoma (BCC) and SCC] and
cutaneous malignant melanoma (CMM).6 – 16 Skin
cancers exhibit different sun-exposure-related risk
factors with early, intermittent overexposures and
blistering sunburns associated with BCC and CMM, and
chronic and cumulative overexposures associated with
SCC.7,14,17 – 19
Non-Melanoma Skin Cancers
The non-melanoma skin cancers (NMSCs) comprise
95% of all skin cancers and are the most commonly
occurring malignancies among fair-skinned populations
worldwide.10 – 13 The annual world incidence of NMSCs
is estimated to be 2 to 3 million cases each year.10 – 13
An upward trend in NMSCs has now been observed in
Australia, Europe, and the United States (US) with an
average annual increase between 3% and 8%.10 – 13
The BCC, the most common malignancy in Cau-
casians, now accounts for 80% to 85% of all NMSCs
and 30% of all cancer diagnoses.10 – 13,17 The annual
worldwide incidence rate of BCC is anticipated to
increase in annual prevalence as the world population
ages.17 BCCs usually occur as nonhealing ulcers or
papulonodules on sun-exposed areas, especially on the
head and neck that rarely metastasize.
The SCCs begin in the uppermost layer of the skin,
account for approximately 15% of all skin cancers, and
have a 10-fold greater risk for metastasis and death than
BCCs.10 – 13 SCCs usually occur on sun-exposed areas
of the head, face, neck, and hands, and may be heralded
by AK.9 – 12,19
109
Cutaneous Malignant Melanoma
Cutaneous malignant melanoma (CMM) accounts for
approximately 5% of skin cancers worldwide and has
the highest case fatality rates. CMM is now the
most commonly increasing malignant disease with
an estimated annual incidence rate of 3% to 7%.11
The World Health Organization has estimated that
132,000 new cases of melanoma will occur each year
worldwide.11 Melanomas are more common in fair-
skinned people with light-colored eyes and blond or
red hair. Besides skin type and family history, the
greatest risk factors for melanomas include three or
more blistering sunburns before age 18 years, congenital
nevi (moles), large numbers of moles, and long-term
phototherapy for eczema or psoriasis with psoralens
and UVA (PUVA).6,7,10,11
Melanomas arise from melanocytes, are usually
darkly pigmented, and can occur anywhere, but occur
more commonly on the trunk in men and on the
legs in women.10,11 The characteristic physical features
of melanomas, often described as the ABCDs of
melanomas include: (1) asymmetric shape, (2) border
irregularity, (3) combination of colors, and (4) diameters
larger than a pencil eraser (6 mm). Although an
association between UVB overexposures and SCCs
has been well established, the exact UV wavelengths
associated with BCCs and CMMs are not clearly
defined.
Sun Exposure and Protection Behaviors in
Travelers, Nontravelers, and Expatriates
Ezzedine and colleagues have studied sun exposure
behaviors in large subcohorts of survey-responding
travelers, nontravelers, and expatriates nested in a larger
cohort of 12,741 French adult volunteers enrolled in
the SU.VI.MAX cohort and observed the following
results.20 (1) Women travelers reported more frequent
sun exposures over the past year, sunbathed in high UV-
index areas daily for more than 2 hours, and experienced
more intensive sun exposures than nontravelers. (2)
Although the usage of sun protection products was
similar in all travelers and nontravelers, women used
sunscreens with higher sun protection factors (SPFs)
more often and more regularly than men.
In a similarly designed study, the same investigators
sent sun exposure and sun protection behavior surveys
twice to all subjects in the SU.VI.MAX cohort, with
1,694 respondents reporting travel to a tropical or
high UV-index country during their lifetimes for
more than three consecutive months (expatriates).21
The investigators described the following results.21 (1)
Female expatriates reported more frequent deliberate
sun exposures, more sunbathing between 11 am and
4 pm, less gradual sun exposure, more intensive sun
exposures, more exposures during nautical sports, and
more nude exposures than female nonexpatriates. (2)
Male expatriates reported more frequent intensive sun
J Travel Med 2013; 20: 108–118
110
exposures and more skin exposures during nautical and
mountain sports than male nonexpatriates. Ezzedine
and colleagues have registered a large cohort of French
adults to observe for sun exposure and protection
behaviors in tropical and high UV-index countries
for short and prolonged stays, and their results have
repeatedly demonstrated that travelers would benefit
from more pre-travel advice regarding sun exposures
and sun protective behaviors.20,21
General Public Perceptions Regarding Sunscreen
Use
Observational studies have demonstrated that the
public often misuses sunscreens for intentional UV
overexposures and knows little about proper sunscreen
protection, selection, and use. In 2001, Wright
and colleagues evaluated attitudes toward sunscreen
effectiveness and found that 47% of study subjects
reported staying out longer in the sun after applying
sunscreen.22 Later, Autier defined this behavior as
sunscreen abuse or the misuse of sunscreens by
sun-sensitive subjects engaging in intentional sun
exposure to increase their duration of exposure without
decreasing sunburn occurrence.23 In 2008, Ezzedine and
colleagues reported the results of a cross-sectional study
on artificial and natural tanning behaviors in a French
national cohort of 7,200 adults.24 The investigators
determined that indoor tanners were also regular
sunbathers unconcerned about the risks of combined
indoor and outdoor UV exposures.24 In a 2009 survey
assessment of sunscreen knowledge, Wang observed
that only 48.2% of survey respondents knew that
‘‘SPF’’ was the acronym for ‘‘sun protection factor.’’25
The confusing measurement systems for UV protection
afforded by sunscreens and photoprotective clothing are
compared in Table 1.18,26,27
The quantity and frequency of sunscreen use are the
most important factors determining sunscreen efficacy.
The international standard quantity of sunscreen
application used to determine SPF is 2 mg/cm2 .28,29
Table 1 Measuring the ultraviolet protection afforded by sunscreens and clothing18,26,27
Measurement system Sun protection factor (SPF)
Definition The minimal erythema dose (MED)
of UVB radiation causing erythema
after applying 2 mg/cm2 of
sunscreen to skin divided by the
dose producing 1 MED on
unprotected skin.
Developed for Sunscreens
Global acceptance International
UV wavelengths protected UVB
Examples SPF 2 protects against 50% UVB;
SPF 8: 88%; SPF 15: 93%; SPF 30:
97%; SPF 50: 98%
∗
Also rated as a 4-star system in the US only: UVA-PF1 = 1 star, PF2 = 2 stars; PF3 = 3 stars; PF4 = 4 stars. There is no standard measurement for UVA protection
outside of the US.
J Travel Med 2013; 20: 108–118
Diaz and Nesbitt
However, Diffey observed that most people apply only
0.5 to 1.5 mg/cm2 of sunscreen and do not reapply
sunscreens after swimming or excessive sweating.29
Recognizing Risk Factors for Photosensitivity
Drug-Induced Photosensitivity Reactions
Drug-induced photosensitivity reactions occur com-
monly and are characterized by cutaneous eruptions in
sun-exposed areas and result from either toxic or aller-
gic reactions between drugs and UV radiation, primarily
UVA.30 – 33 Phototoxic reactions are more common than
photoallergic reactions, which occur when drug hap-
tens combine with skin proteins producing an immune
cellular reaction.31
Chronic therapy with certain photosensitizing drugs
has been associated with the subsequent development
of skin cancers, such as PUVA therapy for psoriasis
which increases risks of SCC and CMM.34,35 In a
retrospective cohort analysis of over 4 million Danes
on short- and long-term therapy with other known
photosensitizing drugs during the period 1995 to 2006,
Kaae and colleagues found that only long-term users
of furosemide and methyldopa had a 20% or greater
chance of developing BCC and SCC, respectively, with
risks increasing with duration of therapy.36
Table 2 stratifies some of the more commonly
prescribed drugs that can induce photosensitivity
reactions by types of reactions and drug classes.30 – 33
Many of the medications listed in Table 2 are frequently
prescribed for travelers, such as antimalarials, or
frequently included in travel first aid kits, such as
analgesics. Travelers taking these medications should
be warned of the potential risks of drug-induced
photosensitivity reactions and encouraged to apply and
to reapply high-SPF (30+) sunscreens whenever sun-
exposed. The management of photosensitivity reactions
includes the identification and future avoidance of the
offending drug, which may require photopatch testing,
anti-inflammatory dressings and ointments, and topical
and/or systemic corticosteroids.31 – 33
UVA-protection factor (UVA-PF) Ultraviolet protection factor (UPF)
The dose of UVA causing observable The ability of fabrics to prevent the
pigment darkening (minimal transmission of UV radiation by
pigment dose [MPD]) after absorption and/or reflection and
applying 2 mg/cm2 of sunscreen to highly dependent on fabric type,
skin divided by the dose producing porosity, color, weight, thickness,
1 MPD on unprotected skin. and other factors.
Sunscreens Clothing
United States only International
UVA UVA, UVB
UVA-PF1 protects against 20–39% UPF cotton 5–10; UPF denim 1700
of UVA; PF2: 40–69%; PF3:
70–95%; PF4: >95%∗
Photoprotection for Travelers 111

Table 2 Some of the more commonly prescribed drugs that can induce photosensitivity reactions30 – 33

Drug classifications by therapeutic indications

Photosensitivity Neurologic/psychiatric
reaction types Analgesics Antimicrobials Cardiovascular drugs drugs Miscellaneous drugs

Phototoxic NSAIDs: Antibacterials: ß-Blockers: Anticonvulsants: Dermatologicals:

reactions Diclofenac Quinolones Atenolol Carbamazepine Coal tar
Ibuprofen Sulfonamides Sotalol Valproate Psoralens
Naproxen Tetracyclines ACEIs: Antipsychotics: Retinoids
Piroxicam Trimethoprim Captopril Phenothiazines Topical antimicrobials
Antifungals: Enalapril Chemotherapeutics:
Griseofulvin Calcium channel Fluorouracil
Voriconazole blockers: Methotrexate
Antimalarials: Verapamil Vemurafenib
Chloroquine Diuretics: Hypoglycemics:
Quinine Bumetanide Metformin
Furosemide Sulfonylureas
Thiazides Miscellaneous additives:
Miscellaneous: Furocoumarins
Amiodarone
Methyldopa
Photoallergic NSAIDs: Antibacterials: Cardiovascular drugs: Antipsychotics: Some topical antimicrobials
reactions Ketoprofen Quinolones Quinidine Phenothiazines Some topical sunscreen ingredients:
Piroxicam Sulfonamides Thiazides Avobenzone
Antifungals: Cinnamates
Griseofulvin Ensulizole
Oxybenzone PABA
derivatives
Sulisobenzone
ACEIs, angiotensin-converting enzyme inhibitors; PABA, para-amino-benzoic acid.

Special Populations at Increased Risks of UV-Induced Skin
Cancers
Besides fair-skinned persons, other special populations
at increased risks of UV-induced skin cancers include
children, organ transplant recipients (OTRs), and
persons with sun-sensitive genetic skin diseases.
Children
Epidemiological evidence now supports the observa-
tions that children who have suffered repeated sunburns
are more likely to develop CMM as adolescents and
adults than children who have never had sunburns.6,7,37
In 2012, Gamble and colleagues used ultraviolet pho-
tography to examine the relationships between severity
of prior sun exposure damage and phenotypic CMM
risk factors in children and demonstrated that degree of
sun damage correlated with all known CMM risk fac-
tors including non-Hispanic Caucasian race, red hair,
blue eyes, increased facial freckling, and greater number
of nevi (all p values < 0.001).6 In 2012, Vranova and
colleagues reported the results of a case-control study
on the risks of prior sun exposures in childhood on the
subsequent incidence of CMMs and found the number
of sunburn episodes to be significantly associated with
CMMs in adolescents and adults.7
Organ Transplant Recipients
Epidemiological investigations have now supported
associations between UV exposures and NMSCs in
immunosuppressed OTRs.38,39 In 2009, Terhorst and
colleagues assessed the risk factors for NMSCs in
OTRs in a survey study that enrolled 70 OTRs who had
developed skin cancer after transplantation compared
to 69 matched OTRs who had no history of skin
cancer.38 The investigators found the skin cancer group
to have fairer skin color than controls (p < 0.05), to have
received greater recreational sun exposures (p < 0.05),
and to have received a transplant at younger ages (p <
0.001) for longer time periods (p < 0.001) than controls.
In addition, the skin cancer group was more likely to
have a past or present history of immunosuppression
with azathioprine (p < 0.05). In another study, the
same group enrolled 120 well-matched subjects in
a 2-year prospective case-control study to assess the
preventive effects of regular sunscreen use on the
incidence of SCC and BCC.39 At the end of the study,
investigators reported that sunscreen users developed
no new invasive SCC versus eight in the nonusers, and
two new BCC versus nine in the nonusers.
Persons With Sun-Sensitive Genetic Skin Diseases
Lastly, patients with two rare genetic skin diseases, epi-
dermodysplasia verruciformis and xeroderma pigmentosum
(XP), are also at increased risks of developing UV-
associated skin cancers in sun-exposed body sites.40
XP patients have mutations that inhibit DNA repair
following UV-induced DNA damage and demonstrate
a significant propensity to develop NMSCs following
UV exposures, up to 5,000 times that of the general
population.40

J Travel Med 2013; 20: 108–118

112 Diaz and Nesbitt

Recommended Photoprotection Strategies radiation in swimming pools by reflection and by direct

Practicing Responsible Sun Behaviors
The intensity of UV radiation is significantly influenced
by time of day, season, weather, altitude, latitude,
reflective surfaces, degree of shade, and UV transmission
through glass.41 – 43 In Denmark, a prospective
observational study demonstrated that 50% of the total
daily solar UV dose reached the earth between 12 am
and 3 pm, corrected as indicated for daylight saving
times.41 The average increase in UVB intensity per
degree of latitude toward the poles is about 3%.42
Travelers enjoying winter mountaineering, skiing,
and trekking vacations may be unaware of the
necessity to apply sunscreens despite their cold-exposed
skin temperatures because of increased UV radiation
exposures at high altitudes and UV reflection off
snow and ice. At higher altitudes, the atmosphere is
thinner, absorbs less UV radiation, and increases the
intensity of UV radiation by 4% for every 300 m of
higher elevation.42 Snow can reflect up to 90% of UV
light, significantly more than sand (15%–30%) and
seawater.43
Summertime travelers may also be unaware of
increased sun exposures and perceived need to apply
sunscreens while swimming and boating because of
cooler water temperatures and sea breezes bathing skin
surfaces. Swimmers can be exposed to substantial UV
penetration to depths as great as 1 m.44
Wearing Photoprotective Clothing
Although sunscreens are classified for their photo-
protective effects by SPF, which primarily represent
protection against UVB, photoprotective clothing is
classified for its sun protective effects by UV protection
factors (UPF), which represent protection against both
UVA and UVB.44 UPFs are influenced by several factors
including fabric type, color, weight, porosity or weave
thickness/tightness, and even the manner in which the
clothing is washed and worn—tight or loose-fitting
(Table 3).45 – 47 Light-weight fabrics, such as nylon, can
be impregnated with UVA- and UVB-absorbing inor-
ganic particles, such as titanium dioxide, that enhance
UPF and offer the same cool and light-weight feel of
cotton.45 Popular and inexpensive fabrics well suited for
the tropics like cotton can be treated during clothing
manufacture with thin layers of titanium or the appli-
cation of titanium hydrosol with fluorescent whiten-
ing agents to enhance UPF and maintain brightness.44
Some untreated textiles, such as light-weight cotton,
offer limited UV protection; while others, such as heav-
ier denim, offer significant protection.44 Denim has a
UPF of 1,700 compared to cotton which has a UPF of
5 to 9.44 Loose-fitting clothes offer higher UPFs than
tight-fitting, stretched, or wet clothing.46 The UPF is
usually higher for materials that are darker in color

Table 3 UV-protective clothing: physiochemical characteristics, mechanisms of UV-protection, and recommended selections
for travelers45 – 48

Physiochemical characteristics Mechanisms of photoprotection Recommended selections for travelers

Fabric weave Tightly woven fabrics block UV more than loosely Select newer synthetic fabrics with tight
woven fabrics. weaves.
Material composition Synthetic materials block and reflect more UV than Select nylon and newer synthetic materials.
natural materials.
Fabric weight Thicker and heavier fabrics (denim) block more UV Layer clothing made of lighter synthetic
than thinner and lighter fabrics (cotton). fabrics to increase thickness.
Fabric color Dark-colored fabrics absorb more UV than Select darker colored sun protective clothing.
light-colored fabrics.
Fabric fit Lax materials provide more UV protection than Avoid tight fitting, stretched clothing.
stretched materials.
Fabric moisture Dry materials absorb and reflect more UV than wet Change out of wet clothing.
materials.
Shrinkage Prewashed and preshrunk fabrics provide more UV Select prewashed, preshrunk fabrics.
protection than fabrics labeled ‘‘no shrinkage after
washing.’’
Cleaning method Fabrics labeled dry cleaning only will absorb and Select fabrics that require dry cleaning.
reflect more UV than fabrics labeled ‘‘home
washing permitted.’’
Bleach Unbleached fabrics absorb and reflect more UV than Avoid bleached fabrics.
bleached fabrics.
Stain resistance Fabrics that have been treated for stain resistance Select stain-resistant fabrics.
absorb and reflect more UV than stain-sensitive
fabrics.
Sunscreen-treated fabrics Fabrics treated with broad-spectrum UV absorbers∗ Select fabrics treated with broad-spectrum
will absorb and block more UV radiation than UV absorbers.∗
untreated fabrics.
∗
UV absorbing fabric treatments: Tinosorb®, Rit Sun Guard®.

J Travel Med 2013; 20: 108–118

Photoprotection for Travelers
and have undergone either fabric preshrinkage or fabric
shrinkage after having been laundered.26
Recently, several photoprotective laundry additives
have been developed to enhance the UPF and brightness
of frequently washed clothing. Rit Sun Guard® is a
photoprotective laundry additive that contains the broad
spectrum sunscreen, Tinosorb®, which absorbs both
UVA and UVB.48 Edlich and colleagues have reported
that a single laundry treatment of clothing with Rit
Sun Guard ‘‘sustains a UPF of 30 for approximately 20
launderings.’’48
Today, photoprotective clothing lines are individu-
ally tested and rated for their UPFs which are displayed
on the clothing hangtags. The consumer-traveler can
gauge the sun protection offered by clothing by read-
ing the UPF on the clothing hangtag with the higher
protection factor numbers indicating greater sun pro-
tection.
Although sun protective clothing is rated by UPF,
hats are rated for their sun protective effects by SPF,
adding to consumer confusion. Hats, like sunscreens, are
rated for their degree of sun protection by the amount of
protection they offer to unprotected head and neck skin
from minimal erythema.44 This degree of protection is
principally determined by hat brim circumference and
width. Most hats will have SPFs ranging from 0 to 7
depending on their brim circumferences and widths.44
For example, a hat with a baseball-visor brim that shades
the chin (SPF 2) and has a neck-flap (SPF 5) would be
assigned a SPF of 7.44 Hats with 360◦ brims with brim
widths greater than 7.5 cm are highly recommended
and will offer greater sun protection to the chin (SPF
2), cheeks (SPF 3), neck (SPF 5), and nose (SPF 7).44
Adding a neck flap to such a hat would result in an SPF
of 22.44
Light-weight, titanium-impregnated nylon and
cotton fabrics will offer the greatest comfort and sun
protection in hot and humid regions and can be layered
in cooler and dryer regions. Washing clothing with
photoprotective laundering agents, such as Rit Sun
Guard, will offer photoprotection through one’s favorite
clothes at low cost. Besides responsible selection of sun
protective clothing, the consumer-traveler should be
a responsible wearer of photoprotective clothing by
Table 4 Existing national standards for UV-protective sunglasses
Australia
Standard designations AS/NZS 1067:203
Transmission ratings 0–4
Maximum UV filtered (nm) 380
Driving restrictions Rating 4 only
Hangtag requirement Required
Handtag label (UV: ultraviolet) UV 0, 2, 3, or 4
Source Standards Australia∗
∗
http://www.standards.org.au/cat.asp?catid=43&contentid=296&News=1.
†
http://www.esa-sunglasses.com/downloadarchiv/ARTICLE_ON_PPE_STANDARDS_SUNGLASSES_ETC_2-april26.04.doc.
‡
http://www.ansi.org/news_publications/media_tips/sunglasses.aspx?menuid=7.
113
avoiding wet and tightly fitted clothing and gaps of
uncovered skin at the ankles, wrists, waist, and neck
between the shirt collar and hat.
Wearing Sunglasses
In addition to wide-brimmed hats and photoprotective
clothing, sunglasses also provide photoprotection for
the skin and, most importantly, the eyes and eyelids, by
preventing the development of several ocular disorders
including periorbital skin cancers, cataracts, pterygia,
photokeratitis, snow blindness, and possibly retinal
melanomas and age-related macular degeneration.48,49
There is no world standard UV protection rating system
for sunglasses. The first national standard rating system
for UV protection for sunglasses was introduced by
Australia in 1971. The existing national standard UV
protection rating systems for sunglasses are compared
in Table 4. Travelers should choose the highest UV
protection-rated sunglasses as indicated on the required
hangtags.
Sunglass UV protection depends on several factors
including shape and fit, and lens color and UV-filtering
and reflecting abilities.48,49 Sunglass lenses should
fit close to the face, not touch the eyelashes, hug
the temples, and merge into broad temple arms or
straps. Darker lenses do not necessarily filter more UV
light and can trigger pupillary dilation which allows
unfiltered wavelengths of UV and visible-spectrum
blue light (400–440 nm) to reach the retina.50 Chronic
retinal exposure to visible-spectrum blue light in the
wavelength range of 400 to 440 nm is a risk factor for
age-related macular degeneration.50 – 53 The color of
sunglass lenses can influence contrast, color vision,
and depth and width perception.50 – 53 Orange and
yellow lenses provide the best protection from both
UV and visible blue light, with blue and purple lenses
providing insufficient protection.50 – 53 The effects of
sunglass lens colors on visual perception are compared
in Table 5.50 – 53
A variety of special use sunglasses are recom-
mended for travelers engaging in active water sports,
such as body-boarding, jet-skiing, kite-boarding,
wake-boarding, wind sailing, and water skiing.
European Union United States
EN 1836:2005 ANSI Z 80.3-2001
0–2–6–7 Not applicable
380 400
None None
Required Required
UV 0, 2, 6, or 7 UV 400
Requirements of European Directives American National Standards Institute‡
and Standards Relating to Sunglasses†
J Travel Med 2013; 20: 108–118
114 Diaz and Nesbitt

Table 5 Sunglass lens color attributes and traveler-specific recommendations50 – 53

Lens color Contrast Color distortion Depth perception Blue-light protection Recommendations for travelers in specific activities

Blue No effect No effect No effect None Not recommended

Brown Increase Some No effect None Nondrivers
Gray No effect None No effect None Elderly drivers
Green No effect None No effect None Elderly drivers
Orange Increase Increase Increase Good Boaters, fishers, hunters, pilots, shooters, persons over age
50 years, persons with intraocular lenses
Purple No effect No effect No effect None Not recommended
Red No effect None No effect Some Younger drivers
Turquoise Increase Little No effect None Early AM and late PM use, including driving
Yellow Increase Increase Increase Good Boaters, fishers, hunters, pilots, shooters, persons over age
50 years, persons with intraocular lenses

Water sunglasses (goggles) have air vents to prevent
fogging and increased buoyancy to prevent sinking
if lost. Glacier sunglasses (goggles) provide more
UV filtration and reflection and are recommended
for travelers engaging in winter and high altitude
sports, such as cross-country skiing, downhill ski-
ing, snowboarding, glacier hiking, and mountain
climbing.
Special populations at increased risks of UV
radiation-induced eye damage include persons older
than 50 years and persons who have undergone cataract
extractions and intraocular lens insertions.50 People
older than 50 years face increased risks of UV-
associated cataracts, pterygia, and eyelid skin cancers.50
Elderly persons who have had cataracts removed and
intraocular lenses placed face increased risks of retinal
damage from UV exposures.50 For additional protection
from blue visible light (400–440 nm) not essential
for sight, Roberts has recommended that persons
over age 50 wear ‘‘specially designed sunglasses or
contact lenses to reduce the risk of age-related macular
degeneration.’’50
Application of Sunscreens
Historically, sunscreens were developed for protection
from sunburn from UVB only. Today, most sunscreens
are composed of combinations of organic chemicals
to absorb UV light (padimate, oxybenzone), inorganic
chemicals to filter and reflect UV light (titanium
dioxide, zinc oxide), and newer organic particles to
both absorb and reflect UV light (Parsol®, Tinosorb®,
Uvinul®).
Several factors can significantly affect the protective
capabilities of a sunscreen’s SPF number including
amount of initial sunscreen applied, altitude, season,
time of day, sweating, water exposure, UV reflection
by snow or water, and skin type. Cool air or water
temperatures bathing skin surfaces may influence
personal perception of the felt need to apply sunscreens.
Cool skin temperatures do not offer UV protection.
Sunscreens should be applied to sun-exposed skin
throughout the year, even during the coldest seasons,
and especially when solar UV radiation can be magnified
at altitude or by reflections off ice, snow, or water.
A sunscreen with an SPF of 15 properly applied
(defined as 2 mg/cm2 of sun-exposed skin) will protect
one from 93% of UVB radiation; SPF 30 is protective
against 97% of UVB; SPF 50 is protective against
98% of UVB.28 Sunscreens should always be broad-
spectrum products that block both UVA and UVB rays;
and hypoallergenic and noncomedogenic, so as not to
cause rashes, or clog pores, causing acne.28 For children
younger than 6 months, always use hats, clothing, and
shading, rather than sunscreens.28 For children older
than 6 months, always use photoprotective clothing and
sunscreens of SPF 15 and higher depending on skin
types.28
Reapplications of sunscreens, especially after
swimming or excessive sweating, are important practices
for vacationing travelers to adopt in high UV index
areas.29,44 Rai and Srinivas have recommended that
individuals should initially apply sunscreens (2 mg/cm2 )
30 minutes prior to sun exposures and reapply every 2
to 3 hours thereafter.44 However, earlier reapplications
are indicated following vigorous activities that remove
sunscreens, such as swimming, sweating, and towel
drying.44 Using sunscreens labeled as sweat resistant,
water resistant, or waterproof are recommended for
vigorous activities, and should also be reapplied
as follows: (1) 30 minutes after heavy sweating for
sunscreens labeled ‘‘sweat resistant,’’ (2) 40 minutes after
swimming for sunscreens labeled ‘‘water resistant,’’ and
(3) 80 minutes after swimming for sunscreens labeled
‘‘waterproof.’’45
The concurrent applications of commercially
available insect repellents and sunscreens are also of
special significance for travelers to temperate and
tropical areas where both UV exposures and arthropod-
borne infectious diseases pose health risks. Although
few investigations have studied the potential for adverse
effects following concurrent applications of insect
repellents and sunscreens, concurrent applications of
commercially available insect repellents containing
N , N -diethyl-m-toluamide (DEET) and sunscreens
containing oxybenzone have been studied in animal

J Travel Med 2013; 20: 108–118

Photoprotection for Travelers
Table 6 Know your skin type and select the right sunscreen59
Skin type by the
Fitzpatrick Scale57 Skin color Skin tone or other common descriptors
I Pale white Pale or albino, freckles common
(Celtic)
II White Light or fair (European)
III White Light-intermediate (Dark European)
IV Light brown Olive with/without brown tint
(Mediterranean)
V Dark brown Brown
VI Black Black
models and demonstrated that DEET permeation is
potentiated by sunscreens and could promote DEET
neurotoxicity, especially in children.54,55 According to
the American Academy of Pediatrics, insect repellents
containing DEET should not be applied to children
under 2 months of age, and DEET concentrations
ranging from 10% to 30% are recommended for all
other children.56
As the broad-spectrum sunscreens were designed
for their transdermal as well as topical effects, they
should be applied prior to the application of insect
repellants.56 Single-product combinations of insect
repellents and sunscreens are not recommended by
the US Centers for Disease Control and Prevention
(CDC) because the instructions for applying sunscreens
and insect repellents usually differ.57 In most cases,
insect repellents offer longer protection and do not
need to be reapplied as frequently as sunscreens.57
Select the Right Sunscreen for Your Skin Type
Dark-skinned persons are protected from UV radiation
by increased epidermal melanin and have significantly
lower annual incidence rates of NMSCs.58 Epidermal
melanin in dark-skinned persons filters twice as much
UVB radiation as does that in Caucasians.58 Dark
epidermis transmits 7.4% of UVB and 17.5% of UVA
rays to the dermis, compared with 24 and 55% in
white epidermis, respectively.58 The six skin types, their
definitions, and the recommended SPF for sunscreens
appropriately applied by skin type are listed in
Table 6.59
Do Sunscreens Prevent Skin Cancer?
Randomized controlled trials have demonstrated that
regular sunscreen use can prevent the development
of AK.60 As AK is a precursor of SCC, sunscreens
can prevent the development of SCC arising in
AK.60 In 1999, Green and colleagues in Queensland
reported their results of a 4.5-year community-based
randomized controlled trial among 1,621 adult residents
of Nambour, a subtropical Australian township in
Queensland.61 Compared to those randomized to using
sunscreen at their discretion if at all, study subjects
115
Sun exposure effects Recommended sunscreen SPF
Always burns, never tans 30+
Always burns, rarely tans 30+
Sometimes burns, sometimes tans 15+
Tans easily, burns less 15+
Tans easily, rarely burns 15+
Does not burn 15+
randomized to the daily use of a broad-spectrum SPF
15+ sunscreen showed a 40% reduction in SCC.61
Although there was no effect on the incidence of
BCC during the study period, there was a trend
to increasing intervals between BCCs among daily
users compared with discretionary sunscreen users who
developed multiple BCCs.61 Eight years after cessation
of the 4.5-year sunscreen intervention, participants
randomized to the daily sunscreen use group continued
to show a 40% decrease in SCC incidence.62 Their
BCC incidence was also 25% lower in the last 4 years of
post-intervention follow-up, although not significantly
so.62 At present, the daily use of broad-spectrum SPF
15+ sunscreens appears to have a greater impact on
reducing the incidence of SCC than BCC, and this
protection from SCC appears to be maintained over
time.61 – 63
In 2011, Green and colleagues reported the results
of a study designed to evaluate whether the long-term
application of sunscreens decreased the risks of CMM
in 1,621 randomly selected residents, age 25 to 75 years,
in Nambour.64 Beginning in 1992, study participants
were randomly assigned to daily or discretionary
sunscreen application to head and arms in combination
with 30 mg of beta carotene or placebo supplement
until 1996; and then observed by surveys, pathology
reports, or cancer registries for CMM occurrences.64
Ten years after the trial cessation, 11 new primary
melanomas had been identified in the daily sunscreen
group compared to 22 in the discretionary group
(p = 0.051).64 The reduction in invasive melanoma was
even greater with 3 in the daily sunscreen group versus
11 in the discretionary group (p = 0.045).64 The authors
concluded that regular sunscreen use by adults may
prevent CMM. Nevertheless, the study of Green and
colleagues on CMM prevention by daily sunscreen
use prompted an immediate series of subsequent
editorials that challenged the external validity of the
reported findings as a result of (1) low power to
detect significant differences if present, (2) variable
interpretations of CMM invasiveness by pathologists,
(3) selection of less rigid test statistics, (4) unblinded
investigators, (5) exclusions of CMMs on the trunk and
extremities, (6) limited application to populations other
J Travel Med 2013; 20: 108–118
116
than light-skinned Australians in Nambour, and (7) the
borderline significance of p-values near 0.05.65 – 67
Future double-blinded randomized controlled trials
of regular sunscreen use to prevent CMM in larger
populations, stratified and matched by several effect
modifiers, such as age, gender, skin type, and smoking,
will be needed to confirm the findings of Green and
colleagues. At present, clinical investigations support
the regular use of broad-spectrum sunscreens (1) to
prevent the development of AK in sun-exposed subjects,
(2) to prevent the development of SCC from new AK
in sun-exposed subjects, (3) to possibly prevent the
development of CMM in children and adults, and
(4) to possibly prevent the development of BCC in
OTRs.38,39,60 – 63
Conclusions
Observational studies have demonstrated that the public
knows little about sunscreen protection, selection,
and use, and often misuses sunscreens for intentional
solar overexposures. Sunbathing, swimming, skiing, and
other outdoor pursuits remain popular activities among
travelers despite associations between excessive UV
radiation and skin cancer. Some special populations
are at high risks of solar UV radiation-associated
skin cancers, including children, persons taking certain
photosensitive drugs, organ transplant recipients, and
persons with rare genetic skin diseases.
Recommended photoprotection strategies for every-
one and especially for travelers to high UV index regions
should include: (1) practicing responsible sun expo-
sure behaviors, (2) wearing photoprotective clothing,
(3) wearing sunglasses, (4) applying broad-spectrum
sunscreens, and (5) selecting the right sunscreen for
one’s skin type. Travel medicine practitioners should
always advise their patients to avoid sunburns that could
spoil vacations and damage skin and should encourage
them to reapply broad-spectrum sunscreens frequently
and to wear photoprotective clothing, including broad-
brimmed hats. Hotels and resort communities should
encourage their guests to adopt responsible sun exposure
and protection behaviors by making sunscreens available
at swimming pools, tennis courts, golf courses, and all
other outdoor venues enjoyed by vacationers. Although
the impact of UV radiation on the development of
CMM, retinal melanoma, and macular degeneration
will require further study, travelers may anticipate
future advances in sunscreen composition including
the addition of silica-shell microencapsulated UV fil-
ters to enhance UV protection, antioxidants to limit
DNA damage, and DNA repair stimulants to repair any
sun damage.68
Declaration of Interests
The authors state they have no conflicts of interest to
declare.
J Travel Med 2013; 20: 108–118
Diaz and Nesbitt
References
1. Bains R, Peach H. The role of travel guides in the
prevention of skin cancer. Plast Reconstr Surg 2008;
121:153–154.
2. Fesq H. Sunscreens for UV protection and
repellants—who needs what? Fortschr Med 2007;
149:32–35.
3. Darie H, Crepy P. Sun and skin and eye protection. Med
Trop 1997; 57:493–496.
4. Brash DE, Rudolph JA, Simon JA, et al. A role for
sunlight in skin cancer: UV-induced p53 mutations in
squamous cell carcinoma. Proc Natl Acad Sci U S A
1991; 88:1024–1028.
5. Ziegler A, Leffell DJ, Kunala S, et al. Mutation hotspots
due to sunlight in the p53 gene of non-melanoma skin
cancers. Proc Natl Acad Sci U S A 1993; 90:4216–4220.
6. Gamble RG, Asdigian NL, Aalborg J, et al. Sun damage
in ultraviolet photographs correlates with phenotypic
melanoma risk factors in 12-year-old children. J Am
Acad Dermatol 2012. Published online 12 March
2012. Available at http://www.eblue.org/article/SO190-
9622(11)02231-6/abstract.
7. Vranova J, Arenbergerova M, Arenberger P, et al.
Incidence of cutaneous malignant melanoma in the Czech
Republic: the risks of sun exposures for adolescents.
Neoplasma 2012; 59:316–325.
8. Hall HI, Saraiya M, Thompson T, et al. Correlates of
sunburn experiences among US adults: results of the
2000 National Health Interview Survey. Public Health
Rep 2003; 118:540–549.
9. Narayanan DL, Saladi RN, Fox JL. Ultraviolet radiation
and skin cancer. Intl J Dermatol 2010; 49:978–986.
10. Diepgen TL, Mahler V. The epidemiology of skin cancer.
Br J Dermatol 2002; 61:1–6.
11. World Health Organization. Skin cancers.
http://www.who.int/uv/faq/skincancer/en/print.html.
(Accessed 2011 Sep 22)
12. Preston DS, Stern RS. Nonmelanoma cancers of the skin.
N Engl J Med 1992; 327:1649–1662.
13. Brougham ND, Dennett ER, Tan ST. Non-melanoma
skin cancers in New Zealand—a neglected problem. N Z
Med J 2010; 123:59–65.
14. Rittié L, Kansra S, Stoll SW, et al. Differential ErbBI
signaling in squamous cell versus basal cell carcinoma of
the skin. Am J Pathol 2007; 170:2089–2099.
15. Salmon PJM, Chan WC, Griffin J, et al. Extremely high
levels of melanoma in Taraunga, New Zealand: possible
causes and comparisons with Australia and the northern
hemisphere. Australas J Dermatol 2007; 48:208–216.
16. Guy GP, Ekwueme DU. Years of potential life lost
and indirect costs of melanoma and non-melanoma
skin cancers: a systematic review of the literature.
Pharmacoeconomics 2011; 29:863–874.
17. Gallagher RP, Hill GB, Bajdik CD, et al. Sunlight
exposure, pigmentary factors, and risk of nonmelanocytic
skin cancer. I. Basal cell carcinoma. Arch Dermatol 1995;
131:157–163.
18. Lautenschlager S, Wulf HC, Pittelkow MR. Photopro-
tection. Lancet 2007; 370:528–537.
19. Gallagher RP, Hill GB, Bajdik CD, et al. Sunlight
exposure, pigmentary factors, and risk of nonmelanocytic
skin cancer. II. Squamous cell carcinoma. Arch Dermatol
1995; 131:164–169.
Photoprotection for Travelers
20. Ezzedine K, Guinot C, Mauger E, et al. Travellers to
high UV-index countries: sun-exposed behavior in 7,822
French adults. Travel Med Infect Dis 2007; 5:176–182.
21. Ezzedine K, Guinot C, Mauger E, et al. Expatriates in
high UV-index and tropical countries: sun exposure and
protection behavior in 9,416 French adults. J Travel Med
2007; 14:85–91.
22. Wright MW, Wright ST, Wagner RF. Mechanisms of
sunscreen failure. J Am Acad Dermatol 2001; 44:781–784.
23. Autier P. Sunscreen abuse for intentional sun exposure.
Br J Dermatol 2009; 161:40–45.
24. Ezzedine K, Malvy D, Mauger E, et al. Artificial and
natural ultraviolet radiation exposure: beliefs and behavior
of 7,200 French adults. J Eur Acad Dermatol Venereol
2008; 22:186–194.
25. Wang SQ, Dusza SW. Assessment of sunscreen
knowledge: a pilot survey. Br J Dermatol 2009;
161:28–32.
26. Kullavanijaya P, Lim HW. Photoprotection. J Am Acad
Dermatol 2005; 52:937–958.
27. Lim HW, Cooper K. The health impact of solar radiation
and prevention strategies. Report of the Environmental
Council, American Academy of Dermatology. J Am Acad
Dermatol 1999; 41:81–84.
28. Sunscreens: an update. Med Lett 2008; 50:70–72.
29. Diffey BL. When should sunscreen be reapplied? J Am
Acad Dermatol 2001; 45:882–885.
30. Allen JE. Drug-induced photosensitivity. Clin Pharm
1993; 12:580–587.
31. Epstein JH. Phototoxicity and photoallergy. Semin Cutan
Med Surg 1999; 18:274–284.
32. Drucker AM, Rosen CF. Drug-induced photosensitivity:
culprit drugs, management and prevention. Drug Saf
2011; 34:821–837.
33. Gould JW, Mercurio MG, Elmets CA. Cutaneous
photosensitivity diseases induced by exogenous agents.
J Am Acad Dermatol 1995; 33:551–573.
34. Lindelof G, Sigurgeirsson B, Tegner E, et al. PUVA and
cancer risk: the Swedish follow-up study. Br J Dermatol
1999; 141:108–112.
35. Stern RS. The risk of melanoma in association with long-
term exposure to PUVA. J Am Acad Dermatol 2001;
44:755–761.
36. Kaae J, Boyd HA, Hansen AV, et al. Photosensitizing
medication use and risk of skin cancer. Cancer Epidemiol
Biomarkers Prev 2010; 19:2942–2949.
37. US Centers for Disease Control and Prevention. Skin
cancer module: practice exercises. Module 10: Skin can-
cers. http://www.cdc.gov/excite/skincancer/mod10.htm.
(Accessed 2011 Sep 22)
38. Terhorst D, Drecoll U, Stockfleth E, Ulrich C. Organ
transplant recipients and skin cancer: assessment of risk
factors with focus on sun exposure. Br J Dermatol 2009;
161:85–89.
39. Ulrich C, Jurgensen JS, Degen A, et al. Prevention of
non-melanoma skin cancer in organ transplant patients
by regular use of sunscreen: a 24 month, prospective,
case–control study. Br J Dermatol 2009; 161:78–84.
40. Kraemer KH, Lee MM, Scotto J. Xeroderma
pigmentosum. Cutaneous, ocular, and neurologic
abnormalities in 830 published cases. Arch Dermatol
1978; 123:241–250.
41. Thieden E, Philipsen PA, Heydenrich J, Wulf HC.
Ultraviolet radiation exposure related to age, sex,
occupation, and sun behavior based on time-stamped
117
personal dosimeter readings. Arch Dermatol 2004;
140:197–203.
42. Rigel DS, Rigel EG, Rigel AC. Effect of altitude and
latitude on ambient UVB radiation. J Am Acad Dermatol
1999; 40:114–116.
43. Kromann N, Wulf HC, Eriksen P, Brodthagen H.
Relative ultraviolet spectral intensity of direct solar
radiation, sky radiation and surface reflections. Relative
contribution of natural sources to the outdoor radiation
of man. Photodermatol 1986; 3:73–82.
44. Rai R, Srinivas CR. Photoprotection. Indian J Dermatol
Venereol Leprol 2007; 73:73–79.
45. Baron ED, Kirkland EB, Santo Domingo D.
Advances in photoprotection. Dermatol Nurs 2008; 20:
265–272.
46. Hatch KL, Osterwalder U. Garments as solar ultraviolet
radiations screening materials. Dermatol Clin 2006;
24:85–100.
47. Khazova M, O’Hagan JB, Grainger KJ. Assessment of
sun protection for children’s summer 2005 clothing
collection. Radiat Prot Dosimetry 2007; 123:288–294.
48. Edlich RF, Cox MJ, Becker DG. Revolutionary
advances in sun-protective clothing—an essential step
in eliminating skin cancer in our world. J Long Term Eff
Med Implants 2004; 14:95–106.
49. Young S, Sands J. Sun and the eye: prevention and
detection of light-induced disease. Clin Dermatol 1998;
16:477–485.
50. Dolin PJ. Ultraviolet radiation and cataract: a review
of epidemiological evidence. Br J Ophthamol 1994;
78:178–182.
51. Roberts JE. Ultraviolet radiation as a risk factor for
cataract and macular degeneration. Eye Contact Lens
2011; 37:246–249.
52. Glazer-Hockstein C, Dunaief JL. Could blue-light
blocking lenses decrease the risk of age-related macular
degeneration? Retina 2006; 26:1–4.
53. Margrain TH, Boulton M, Marshall J, Sliney DH.
Do blue light filters confer protection against age-
related macular degeneration? Prog Retin Eye Res 2004;
23:523–531.
54. Ross EA, Savage KA, Utley LJ, Tebbett IR. Insect
repellent interactions: sunscreens enhance DEET (N,
N-diethyl-m-toluamide) absorption. Drug Metab Dispos
2004; 32:783–785.
55. Gu X, Wang T, Collins DM, et al. In vitro evaluation
of concurrent use of commercially available insect
repellent and sunscreen preparations. Br J Dermatol 2005;
152:1263–1267.
56. http://www.healthychildren.org/English/safety-preven
tion/at-play/pages/Insect-Repellents. (Accessed 2012
April 20)
57. http://www.cdc.gov/ncidod/dvbid/westnile/qu/insect_
repellent.htm. (Accessed 2012 April 20)
58. Gloster HM Jr, Neal K. Skin cancer in skin of color. J
Am Acad Dermatol 2006; 55:741–760.
59. Fitzpatrick TB. Soleil et peau. J Med Esthet 1975;
2:33–34.
60. Thompson SC, Jolley D, Marks R. Reduction of solar
keratoses by regular sunscreen use. N Engl J Med 1993;
329:1147–1151.
61. Green A, Williams G, Neale R, et al. Daily sunscreen
application and beta carotene supplementation in
prevention of basal cell and squamous cell carcinomas
J Travel Med 2013; 20: 108–118
118 Diaz and Nesbitt

of the skin: a randomized controlled trial. Lancet 1999;
354:723–727, Erratum in Lancet 1999; 354:1038.
62. Pandeya N, Purdie D, Green AC, Williams G. Repeated
occurrence of basal cell carcinoma of the skin and
multi-failure survival analysis: follow-up study from the
Nambour Skin Cancer Prevention Trial. Am J Epidemiol
2005; 161:748–754.
63. Van der Pols JC, Williams GM, Pandeya N, et al.
Prolonged prevention of squamous cell carcinoma of
the skin with regular sunscreen use. Cancer Epidemiol
Biomarkers Prev 2006; 15:2546–2548.
64. Green AC, Williams GM, Logan V, Strutton GM.
Reduced melanoma after regular sunscreen use:
randomized trial follow-up. J Clin Oncol 2011;
29:249–250.
65. Gimotty PA, Glanz K. Sunscreen and melanoma: what is
the evidence? J Clin Oncol 2011; 29:349–350.
66. Golderhersh MA, Kowlowsky M. Increased melanoma
after regular sunscreen use? J Clin Oncol 2011;
29:e557–e558.
67. Doré J-F. Is sunscreen use for melanoma prevention valid
for all sun exposure circumstances? J Clin Oncol 2011;
29:e425–e426.
68. Sambandan DR, Ratner D. Sunscreens: an overview and
update. J Am Acad Dermatol 2011; 64:748–758.

This is an advertisement for sunscreen on a bus in Hong Kong, Recommended photoprotection strategies for travelers should
include avoiding intense sunlight, wearing photoprotective clothing, wearing sunglasses, as well as selecting the right sunscreen
for their skin type (see the article by Diaz et al, pages 108–118). A sunscreen with an SPF (sun protection factor) of 15 properly
applied (defined as 2 mg/cm2 of sun-exposed skin) will filter out 93% of UVB radiation; SPF 30 filters out 97% of UVB and SPF
50 as advertised here filters out 98% of UVB. Setting: Hong Kong Photo Credit: Eric Caumes

J Travel Med 2013; 20: 108–118