Sunlight exposure, particularly ultraviolet radiation (UVR), is recognized as a risk factor for skin cancer. Photoprotection may reduce the risk of developing skin cancer. However, what efforts are made to protect the dorsal aspect of hands from UVR is unknown.
There are over a million cases of skin cancer diagnosed each year in the United States (US), and this number is expected to double in the next 30 years [
Several studies have evaluated photoprotective behaviors on anatomic regions that are frequently partially or completely unprotected from UVR damage, such as the scalp, lips, and eyelids [
The primary goal of this survey was to determine if beachgoers protected the dorsal skin of their hands as frequently as other areas of their skin. The secondary goal of this study was to collect additional information about subject demographics and knowledge about skin cancer to determine if these variables were significantly correlated with UVR dorsal hand protection.
Following approval of the study protocol by The University of Texas Institutional Review Board, three of the authors (DW, RR, and JH) distributed anonymous questionnaires developed by authors (the appendices) to a convenience sample of beachgoers on Galveston Island, TX, public beaches who were at least 18 years of age. Data were gathered from late May to early September during 2011 on days with an average temperature greater than 80 F and with less than 50% cloud coverage. Data were collected about subjects’ age, gender, Fitzpatrick Skin Type (FST), UVR skin and hand protection behaviors, duration of time spent at the beach when the survey was performed, and other protective behaviors including hats, umbrellas, shirts, and lip protection, and baseline knowledge questions regarding skin and hand cancer. In order to assess dorsal hand protection among different age ranges, participants were grouped into one of the 4 categories: 18–34 years old, 35–49 years old, 50–64 years old, and 65 years old or older. Associations between two factors were assessed using the Pearson chi-square test. The chi-square test was assessed at the 0.05 level of significance. Data analyses were carried out using PROC FREQ in the SAS system, release 9.2 [
A total of 214 questionnaires were completed and analyzed. The average age of respondents was 40 years old and ranged from 18 to 86 years. The self-reported FSTs among the study population were 4% Type 1, 19% Type 2, 41% Type 3, 22% Type 4, 9% Type 5, and 5% Type 6. The questionnaires included data from 149 participants (70%) who reported sunscreen use somewhere on their bodies and 65 (30%) who did not apply sunscreen anywhere. Among those who used a sunscreen while being at the beach, 65% applied a lotion-based sunscreen and 35% applied a spray. However, the rate of photoprotection to the dorsal hand was not significantly different when comparing lotions versus sprays (
Regarding the dorsal hands, 105 (49%) applied sunscreen while 109 (51%) did not. There was a significant difference (
Gender differences in dorsal hand UVR protection (women are more likely to apply sunscreen to their dorsal hands than men,
Gender | Sunscreen % | No sunscreen % |
---|---|---|
Women | 55.37 | 44.63 |
Men | 40.23 | 59.77 |
| ||
Total | 49.04 | 50.96 |
Only 21% of the respondents reapplied sunscreen during their stay at the beach, but less (13%) reapplied it to the dorsal hands. Length of stay at the beach affected rates of overall sunscreen use: 57% of those who stayed less than 2 hours applied sunscreen compared to 89% of those who stayed longer than 4 hours (
UVR dorsal hand protection in relation to Fitzpatrick Skin Types.
Photoprotection rates for the dorsal hands among self-identified ethnicities were the highest in Whites (57%), followed by Hispanics (44%), Asians (43%), other (27%), and the lowest in Blacks (7%,
Four baseline knowledge questions were also conducted during the survey. Question 1 asked if women were more likely to have skin cancer than men (correct answer is no), and 42% responded yes, 36% chose no, and 22% did not know. Question 2 asked if excessive sun exposure is linked to increased incidence of skin cancer (correct answer is yes) with 91% responding yes, 4% responding no, and 5% not knowing. Question 3 inquired if hand cancer is more common in younger people than older people (correct answer is no), and 51% said no, 16% said yes, and 33% did not know. Question 4 asked if hand cancer is more common in men than women (correct answer is yes), and 16% responded no, 46% said yes, and 38% did not know. Correct knowledge of any of the 4 baseline questions was not associated with significantly higher rates of UVR dorsal hand protection (Q1
Hand cancer is an important skin disease, and its potential outcomes on morbidity and mortality can be substantial [
Our study population showed a low rate of dorsal hand photoprotection (49%) in an environment of high UVR exposure, the beach. Statistically significant differences were observed based on FST, ethnicity, gender, and age. Participants with low FSTs were more likely to apply sunscreen and on the dorsal hands compared to higher FST participants. With regards to ethnicity, the highest rates of dorsal hand protection were found in Whites and the lowest in Blacks. Women were more likely to use sunscreen in general and on the dorsal hands compared to their male counterparts. This later finding is important because hand cancer historically affects males more than females by a 3 : 1 ratio. Several factors are likely responsible for this skewed incidence, including traditional workforce gender imbalances. Inadequate photoprotective behaviors by men also may play a role in their higher rates of dorsal hand cancer compared to women.
Total skin protection from UVR exposure is the best primary prevention for decreasing the incidence of UVR related skin cancers, but previous research indicates that specific anatomic locations such as the lips, eyelids, and scalp are less protected by beachgoers. More public education focused on dorsal hand protection from UVR damage is necessary to reduce skin cancers in this location. This educational need is also evident based on responses to the baseline knowledge survey regarding hand cancer. Although the majority of people understand that UVR is a risk factor for skin cancer (91%), only 51% were aware that hand cancer is more common in the elderly and that men are more affected than women (46%). Protection of the dorsal hands from sunlight may also delay or prevent the appearance of photoaging in this anatomic location. Helpful strategies to inform the public about hand cancer could come from pamphlets about skin cancer found in healthcare providers’ offices and other health promotion activities. Sunscreen manufacturers could also list commonly neglected areas of photoprotection with the directions for product use. Media campaigns should focus on reaching younger demographics as this study found that the 18–34-year-old population was the least likely to protect the dorsal hands (37%). This younger population would potentially benefit the most from such photoprotective intervention due to less lifetime cumulative exposure to this frequently encountered environmental carcinogen. These preventative efforts may improve public awareness and hopefully lower the future incidence of hand cancers.
Surveyed Galveston beachgoers were less likely to protect their dorsal hands from UVR injury than other areas of skin. UVR protection of the dorsal hands deserves emphasis in public health messages about skin cancer protection, along with other identified body locations such as the scalp, lips, and eyelids.
Age (must be 18 or older for survey)
Gender:
(1) Female
(2) Male
Skin Type:
(1) Pale white; always burns, does not tan
(2) White; burns easily, tans with difficulty
(3) Cream/Light Brown; tans after initial sunburn
(4) Brown; burns minimally, tans easily
(5) Dark Brown; rarely burns, tans easily
(6) Black; never burns, tans easily
Ethnicity
(1) Asian/Pacific Islander
(2) Black
(3) Hispanic
(4) White
(5) Other
Do you currently have sunburn anywhere?
(1) No
(2) Yes
How many hours have you been at the beach today?
(1) 0–2 hours
(2) More than 2 hours but less than 4 hours
(3) More than 4 hours but less than 6 hours
(4) More than 6 hours
Did you apply sunscreen on today? What is SPF?
(1) No
(2) <15 SPF
(3) 15–30 SPF
(4) >30 SPF
(5) Yes, but I don’t know what is SPF
If yes, what type of sunscreen did you use?
(1) Lotion
(2) Spray
Did you apply sunscreen to the
(1) No
(2) Yes
(3) Not sure
If No, why not?
(1) Did not think about it
(2) Did not like feel of it (oily, greasy, etc.)
(3) Other
Did you apply sunscreen to your
(1) No
(2) Yes
(3) Not sure
If No, why not?
(1) Did not think about it
(2) Did not like feel of it (oily, greasy, etc.)
(3) Other
How many applications of sunscreen did you use on your skin today?
1
2
3
4 or more
How many applications of sunscreen did you use on the
1
2
3
4 or more
How many applications of sunscreen did you use on your
1
2
3
4 or more
Why did you
(1) Did not reapply
(2) Time for another application
(3) Sweating/swimming
(4) Skin redness
(5) Other reason? Please tell us
Why did you
(1) Did not reapply
(2) Time for another application
(3) Sweating/swimming
(4) Skin redness
(5) Other reason? Please tell us
Why did you reapply sunscreen to your
(1) Did not reapply
(2) Time for another application
(3) Sweating/swimming
(4) Skin redness
(5) Other reason? Please tell us
Did you use any of the following forms of skin sun protection today:
Clothing:
(1) only bathing suit
(2) short-sleeved shirt or shorts
(3) long-sleeved shirt or pants
Hat:
(1) none
(2) Cap (no ear protection from sun)
(3) Hat with brim of 3 inches or less
(4) Hat with brim of more than 3 inches
Umbrella/Shade:
(1) No
(2) Yes
Lipstick or Lip Balm with SPF:
(1) No
(2) Yes
Eyewear:
(1) No
(2) Yes
How many sunburns have you had this summer?
Sunburn = redness > 24 hours and/or peeling, pain, swelling, blistering
Do you use tobacco products?
(1) No
(2) Yes
Do you have more than 5 alcoholic drinks per week?
(1) No
(2) Yes
While at work, do you spend part of your time outdoors?
(1) No
(2) Yes
Did you use indoor tanning salons in the past year?
(1) No
(2) Monthly
(3) Weekly
(4) Daily
Did you or a family member ever have a skin cancer?
(1) No
(2) Self
(3) Immediate Family
(4) Extended Family
(5) I don’t know
Did you or a family member ever have a skin cancer on the
(1) No
(2) Self
(3) Immediate Family
(4) Extended Family
(5) I don’t know
Did you or a family member ever have a skin cancer on the
(1) No
(2) Self
(3) Immediate Family
(4) Extended Family
(5) I don’t know
(1) Women are more likely to get skin cancer than men?
(1) No
(2) Yes
(3) I don’t know
(2) Excessive sun exposure to the skin can increase the risk of skin cancer?
(1) No
(2) Yes
(3) I don’t know
(3) Hand cancer is more common in younger people than older people?
(1) No
(2) Yes
(3) I don’t know
(4) Men get more hand cancer than women?
(1) No
(2) Yes
(3) I don’t know