Chapter 147
Optimal Sun Protection: Clothing, Sunscreen, Hat, Glasses, and Shade
In 2003, a campaign for full-body skin screening was launched in Schleswig-Holstein. As a result, the melanoma death rate fell by almost 50 percent by 2008. Given this resounding success, the program was expanded to the entire country in 2009. Unfortunately, five years later there was no notable change in melanoma mortality. The nationwide death rates had even risen slightly, and the apparent benefit in Schleswig-Holstein fell back again to the baseline level. Was the original drop just chance? Some suspected something disgraceful—namely that, because of the financial incentive—15 euros per screening—physicians might have intentionally or unintentionally listed melanomas too infrequently on death certificates, so the program would appear successful. In any case, to date it has not been proven that skin screening saves lives. The USPSTF’s lack of support for regular physician examinations refers only to mass screening of asymptomatic healthy people. Anyone with a suspicious mole or an increased risk of skin cancer because of their personal or family history should definitely discuss it with their doctor. The ABCDE rule, used when a mole raises suspicion for melanoma, the deadliest skin cancer, is: A = asymmetry, B = border is irregular, C = color (uneven pigmentation), D = diameter over 5 millimeters, E = evolution, a change in size, shape, color, elevation, or symptoms (such as bleeding, itching, or crusting). In general, any lesion is suspicious if it appears new, changes, or is unusual (compared to other moles).
Optimal Sun Protection: Clothing, Sunscreen, Hat, Glasses, and Shade
If blanket screening does not protect us from skin cancer, what does? The same thing that reduces risk for all common cancers: primary prevention. In other words: preventing the cancer from occurring in the first place. For that, there are the five measures of the successful Australian SunSmart cancer prevention program: put on clothing, apply sunscreen, put on a head covering, seek shade, and put on sunglasses.
In a child, a sunburn that causes the skin to peel doubles the risk of later developing basal cell or squamous cell carcinomas, whereas consistent sun protection in childhood lowers the risk of these cancers by an estimated 78 percent.
Ideally, protective clothing would completely cover arms and legs. With normal clothing without a UV-protection label, the denser, thicker, darker fabric protects better. (If you hold the garment up to the light, it should not be see-through.) Head coverings should shade the entire head. Wraparound sunglasses protect the sensitive skin around the eyes, where sunscreen may not be applied, and lip sun protection should have at least SPF 30 and be applied generously over the entire surface of the lips.
Oral nicotinamide
After nicotinamide had already been used for decades in anti-aging cosmetics, scientists decided to investigate its protective effect against skin cancer. Normally, studies on non-patentable products that cost only a few cents a day are difficult to finance, but the early results were so extraordinary that Oral Nicotinamide to Reduce Actinic Cancer (ONTRAC) was launched. ONTRAC was a publicly funded phase III study (to determine efficacy) that randomized hundreds of participants with a history of skin cancer to twice daily 500 milligrams of nicotinamide or a placebo for a full year. At the end of the study, there were 463 new skin cancer cases in the placebo group and 336 in the nicotinamide group. That was 25 percent fewer cancers with no significant side effects for a few cents a day. For details, see see.nf/cancernic.
Sensible Sun Exposure?
The UV rays in sunlight are unconditionally carcinogenic, meaning they can not only trigger cancer but also speed its progression and spread. The number of melanomas, the most frightening type of skin cancer, has tripled in recent decades, in part because of increased use of tanning beds. Tanning beds and their UV radiation are class 1 carcinogens, like tobacco, asbestos, plutonium, and processed meat products. More about tanning is available at see.nf/tanning.
Unlike natural sunlight, tanning beds emit predominantly UV-A radiation, which is doubly bad: It increases cancer risk and does nothing for vitamin D production. In most people, sunlight provides 90 to 95 percent of vitamin D. In fact, modeling studies provide data suggesting that a low vitamin D level due to too little sunlight kills more people than skin cancer due to too much sunlight. More on this at see.nf/sun. Bottom line, the benefits of “sensible sun exposure” could outweigh the risks—but why risk anything at all when you can simply swallow the vitamin D you need? The model’s estimates of how vitamin D could protect against internal cancers are based on the results of an intervention study in which participants got their extra vitamin D through dietary supplements, not through UV radiation. The question of how much sun exposure is sensible gets reduced to choosing between two evils: skin cancer or vitamin D deficiency. This does not take into account that there is a third option: vitamin D as a supplement.
The scam of the “black salve”
Normally, skin cancer is cut out, but could “black salve” be an alternative? The FDA has put it on the list of ineffective cancer cures, and the American Academy of Dermatology dismisses it as well, yet on the internet it is still advertised as a “natural alternative cure for skin cancer.” How harmful and dangerous it can be, I describe in see.nf/salve.
Some cancer patients fall for this misinformation, but many who refuse conventional cancer therapy described their oncologists as “impersonal” or “intimidating, cold, callous, unnecessarily rough, think they are God, or didn’t even know [my] name.” When they asked questions about the recommended treatment, they felt “attacked.” Only a few patients believed their doctors were acting in their interest, and many reported that they would have been more likely to agree to conventional therapy if the doctors had been “more caring” and treated them with respect.
Sunscreens Prevent Cancer
As already stated, randomized controlled trials showed that regular use of sunscreen can stop skin aging and even skin damage from UV radiation, as proven by biopsies. But are there also intervention studies showing that sun protection prevents cancer? Yes. It can even reverse the progression of precancerous skin growths so that they regress spontaneously and disappear. I present this incredible study in see.nf/sunscreenuse. The body can sometimes heal itself once we stop bombarding it with so many cancer-causing rays.
The Proper Use of Sunscreens
For it to fully work, you have to apply sunscreen correctly. Various studies showed that this is rarely the case, since only one in 25 follows the recommendations. In the same video see.nf/sunscreenuse I explain how to use the “teaspoon rule” to determine the optimal amount, why SPF 50+ is often recommended even though, in theory, SPF 15 is sufficient to prevent cancer, why a cloudy sky is sometimes even worse, and when you should apply sunscreen before and after being in the water or in the sand.
Black and white
Black skin has, on average, a natural SPF of 13; white skin, only SPF 3. Although there are no studies on how effective sunscreen is as skin-cancer prevention in people with dark skin, SPF 13 is not considered sufficient sun protection; therefore, the American Academy of Dermatology recommends that people of all skin types regularly use sunscreen with a sun protection factor of at least 30. Unfortunately, in one survey only about 12 percent of African Americans and 31 percent of Hispanics reported using sunscreen regularly; among non-Hispanic Whites it was 44 percent. Nevertheless, the incidence of melanoma, the deadliest type of skin cancer, is five times lower in Hispanics than in Whites, and even 25 times lower in African Americans. However, the mortality rate, when melanoma spreads, is higher in African Americans, presumably because the diagnosis is made too late.
Photoaging seems to show less as wrinkles in dark skin and more as pigment disorders, such as uneven skin coloration, melasma (dark patches), or dermatosis papulosa nigra (small dark bumps on the face). To combat skin aging and cancer risk, transparent chemical sunscreens are often marketed to people with dark skin because mineral sunscreens (such as titanium dioxide and zinc oxide) often leave white traces. However, micronized mineral sunscreens are now available that are far less visible after application.