Next Article in Journal
Alternative Treatment Option for Actinic Keratosis: 5% Potassium Hydroxide (KOH)
Previous Article in Journal
Combination of Topical Heparin and Levomenol in the Treatment of Atopic Dermatitis: A SCORing Atopic Dermatitis (SCORAD) Analysis
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Dermato
Volume 5
Issue 1
10.3390/dermato5010001
dermato-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Knowledge and Habits of Photoprotection in the Spanish Population: An Updated Survey

by
María Teresa Truchuelo
1,2,*,
María Vitale
2,
Francisca Rius-Diaz
2,3 and
María José Gomez-Sánchez
2
1
Dermatology Department, San Rafael University Hospital, 28016 Madrid, Spain
2
Medical Affairs Department, Industrial Farmacéutica Cantabria SA, 28043 Madrid, Spain
3
Department of Preventive Medicine and Public Health, University of Malaga, 29071 Malaga, Spain
*
Author to whom correspondence should be addressed.
Dermato 2025, 5(1), 1; https://doi.org/10.3390/dermato5010001
Submission received: 27 November 2024 / Revised: 3 January 2025 / Accepted: 7 January 2025 / Published: 13 January 2025
Browse Figures
Versions Notes

Abstract

Background/Objectives: As the incidence of melanoma and skin cancer is increasing, awareness campaigns can be a useful tool to prevent these conditions. To optimize these campaigns, it is important to establish what the population really know about photoprotection and how they comply with photoprotection habits. Methods: We conducted a survey on the knowledge, behavior, and attitudes related to sun exposure in the Spanish population across the country. The results were analyzed globally and also differentiating by age between those under 25 years of age and those over 25 years of age. Results: Responses from 12,597 respondents were analyzed. Globally, 97% associate bad sun exposure habits with skin cancer; however, when we analyze the results in more detail, the prevalence of an association between tanning and skin damage and the prevalence of the correct use of sunscreens and photoprotective attitudes are lower, especially in people under 25 years old. Conclusions: The data from this survey reinforce the idea that dermatologists need to promote greater awareness among the Spanish population regarding both the skin damage induced by solar radiation and the importance of good photoprotection and preventive habits, specifically in men and people under 25 years of age. To our knowledge, this is the biggest survey to date performed in Spain.

1. Introduction

According to WHO (World Health Organization), the incidence of both non-melanoma and melanoma skin cancers has increased over recent decades, with more than 1.5 million new cases estimated in 2022. In 2022, an estimated 330,000 melanoma cases were diagnosed globally [1]. This places skin cancer as an important public health problem. Non-melanoma skin cancers are most frequent in sun-exposed areas of the body, implying that prolonged and repeated exposure to ultraviolet radiation (UVR) is an important causal factor [2].
In Spain, the risk of melanoma has increased in both men and women from 2003 to 2024. Specifically, it has risen from 12.0/100,000 to 15.1/100,000 cases in women and from 12.0 to 15.4 in men, which represents an annual increase of 1.1% and 1.2%, respectively, as reflected by the Spanish Network of Cancer Registries (Redecan) and the Spanish Society of Medical Oncology (SEOM) [3]. The incidence rate of basal cell carcinoma, the most common of all SCs, has reached 253.23/100,000 persons per year in Spain [4].
The most common modifiable risk factor for skin cancer is exposure to UVR [2]. The damaging effects of UVR on the skin include the induction of immunosuppression, oxidative stress, and inflammatory responses and the formation of cyclobutane pyrimidine dimers (CDP) or gene mutations such as to p53 tumor suppressor genes, among others. UVB radiation damage acts more directly on DNA, whereas UVA damage happens indirectly, through the formation of free radicals. These accumulative changes lead to the formation of skin cancer [5], and also play an important role in skin photoaging [6].
Strong evidence (level I), which is the highest level of evidence, suggests that regular sunscreen use decreases the risks of melanoma and NMSC [7,8]. In addition, oral antioxidants may counteract the oxidative stress and reactive oxygen species involved in DNA damage [8]. Among these antioxidants, oral PLE (polypodium leucotomos extract, Fernblock®, Industrial Farmacéutica Cantabria, S.A., Cantabria, Spain) is an oral photoprotector backed by a large number of scientific publications [9,10]. PLE supplementation has been proven to have several photoprotective effects, such as inducing a reduction in acute inflammation via Cox-2 enzyme inhibition, increasing CPD removal, and reducing oxidative DNA damage and p53 activation through post-translational modifications such as phosphorylation, inducing tumor-suppressive activities [11]. Several studies have been carried out which demonstrate that the continuous use of this supplement reduces the appearance of actinic keratoses and skin cancer in susceptible populations and improves the field of cancerization [12,13,14].
Knowing that photoprotection is key not only in the prevention of skin cancer but also in the prevention of phototoxic reactions frequent in countries with a high UV radiation index, the challenge is to effectively impart this message to the general population. Phototoxic reactions can occur in any individual exposed to the corresponding agent and radiation, acting in a dose-dependent manner regarding both the drug and light exposure. Photosensitive reactions are confined to specific regions of the electromagnetic spectrum, primarily occurring in the UVA range (wavelength 315–400 nm), although certain drugs can induce photosensitivity when exposed to UVB radiation (280–315 nm) or even visible light (400–740 nm). A combined effect of different wavelengths has also been observed. The skin reactions vary depending on the particular photosensitizer involved and its respective intracellular target [15]. Thus, basic sun protection messages should be sent (Table 1).
These measures have been published and endorsed by different studies in the scientific literature [8]. However, we do not have clear data on whether the Spanish population know the risks of sun exposure and the appropriate photoprotection measures that they should take or if they really apply them correctly on a day-to-day basis. This is why we decided to carry out the following study based on one of the largest surveys on photoprotection habits in Spain, with the novelty compared to prior research being that in the present survey, answers were obtained from participants from different geographical areas of Spain, not only from specific regions.

2. Materials and Methods

A cross-sectional descriptive survey study was carried out in a sample of the Spanish population during 2023. All data were recorded anonymously and treated in strict compliance with Spanish data protection laws (Law 41/2002 of 14 November and Law 15/1999 of 13 December, https://www.boe.es/eli/es/l/2002/11/14/41/com, accessed on 15 November 2024). The study was based on a health survey of sun exposure and protection habits and practices conducted among the general Spanish population.
A questionnaire on knowledge, behavior, and attitudes related to sun exposure was used. The questionnaire was modified and partially based on one previously validated by the group of Troya-Martín et al. [17]. The questionnaire was designed in such a way that it was self-tested and had five sections, and below we provide some of the questions given that were more representative of Spanish population habits:
  • (a) General characteristics: sex, age, skin cancer history (familiar and/or personal), sunburn history.
  • (b) Knowledge of relationship between sun exposure and skin cancer: Do you know that bad habits lead to cancer? Do you associate tanning with beauty, health or skin damage? Do you know that blue light induces skin damage?
  • (c) Topical photoprotection habits: Do you use sunscreen? Do you use SPF 30, 50 or 50+ sunscreen? Do you usually use the sunscreen at specific times or all year round? When do you apply the sunscreen before or after leaving home? Do you reapply the sunscreen? When choosing a photoprotector, do you pay attention to whether it is broad-spectrum? How many solar products do you consume per year? Do you use a different photoprotection depending on the moment?
  • (d) Oral photoprotection habits: Do you know the existence of oral photoprotection?
  • (e) Attitude about screening: Do you know the ABCDE rule for self-examination of moles? How often do you go to the dermatologist?
In addition, we wanted to see if there were significant differences between the sexes and also between those who were expected to have greater awareness about photoprotection. To analyze the latter, we compared respondents aged 25 years or less who, according to our clinical experience, were expected to have less knowledge with respondents who were over 25 years old. Specifically, we selected 25 years of age randomly, as it is the average age at which an individual finishes university in Spain and begins an independent life, so a greater degree of economic independence is assumed from that age onwards. It may be associated with better compliance with good health habits in general.
Statistical analysis: A global descriptive analysis was carried out for each of the survey questions, in which the percentages of the population for each of the possible answers were defined using frequency tables and graphs. In order to contrast the homogeneity of responses between the different groups defined by sex and age, the relevant contingency tables were calculated. As descriptors, the frequencies relative to the group defined by the crossover variable were used and the chi-square test was used as a test of homogeneity. The validity conditions of said test were controlled. In cases of significance of the chi square, we used residual analysis to determine in which situations or cells the significant differences were found. A significant difference was considered when the level of significance was less than or equal to 5% (p ≤ 0.05).
The concern of individuals under 25 years old about the issue of sun damage is considerably lower than that of individuals over 25, resulting in a significantly lower prevalence of individuals who may be sensitive to this topic. However, with a sample size of n = 750 individuals under 25 years of age, we assumed a 5% significance level, with values corresponding to the maximum sample size for proportions (p = q = 0.5) and a maximum margin of error of less than 4%. To analyze the statistical data by subgroup, taking into account the sample distribution, a standardized residual analysis was performed. In fact, due to the relatively large values in the other age categories, it is easy to obtain statistically significant differences. Therefore, the presentation of the results places greater emphasis on the differences from both a descriptive and clinical perspective.
SPSS V23.0 software (SPSS Inc., Chicago, IL, USA) was used for the calculations.

3. Results

The results of the survey were analyzed globally and also differentiating based on sex and age.
Not all of the subjects answered all of the questions, but the average response reached 99.86%.

3.1. General Characteristics

In total, 12,597 inhabitants across Spain responded to the survey. They gained access to the survey via email with prior consent, through social media (72%), through events of foundations that Cantabrialabs works with (15%), the media (1%), or other sources (12%). The demographic findings are shown in Table 2 and Figure 1.
Forty-three percent (5395) of the respondents reported a history of severe sunburn. Regarding sex, the prevalence of a history of severe sunburn was 43% (4925) in women vs. 40% (465) in men, with no significant differences (p > 0.05). Among the youngest group (under 25 years of age), 41% (297) responded affirmatively to this question, without significant differences (p > 0.05) compared to respondents over 25 years old.
Among the respondents, 14% (1792) had a history of skin cancer. Notably, this percentage was maintained in the youngest subgroup under 25 years of age (102 of the youngest participants). Regarding sex, a lower percentage of men reported a skin cancer history vs. women, although this difference is not relevant as it was not significant (11% vs. 14%, respectively, p < 0.05).

3.2. Knowledge of Relationship Between Sun Exposure and Skin Cancer

3.2.1. Association Between Sun Exposure and Skin Cancer

Globally, 97% (12,280) associate bad habits regarding sun exposure with skin cancer. In the youngest subgroup under 25 years of age, this percentage was lower (92%, corresponding to 667 of the respondents in this age subgroup), but this difference not significant compared to older respondents (p > 0.05). Regarding sex, no significant differences were found either.

3.2.2. Association Between Sun Tanning and Skin Damage, Beauty or Health

Up to 55% of respondents (6926) associated sun tanning with skin damage, 22% (2773) with beauty, and 23% (2898) with health (Figure 2). Regarding sex, among women, a significantly higher percentage compared to men associated sun tanning with skin damage: 6395 women (56%) vs. 523 men (45%) (p < 0.01). As for the association between sun tanning and health, a significant higher percentage of men vs. women believed in this concept: 368 men (32%) vs. 2525 women (22%) (p < 0.05). No significant differences among the sexes were found for the association between sun tanning and beauty (23% vs. 22%) (Figure 2).
Within the youngest subgroup, only 48% (346) associated sun tanning with skin damage, which was significantly lower versus respondents over 25 years of age (55%, p < 0.05). As for beauty and health, up to 35% (255) and 17% (123), respectively, associated sun exposure with these characteristics, being significantly higher than for respondents over 25 years of age (p < 0.01 and p < 0.05, respectively) (Figure 2).

3.2.3. Association Between Blue Light and Skin Damage

Globally, up to 54% (6760) of the population knew that blue light induces skin damage. Regarding sex, up to 56% of women (6359) vs. 35% of men (398) knew about this association, which was a significant difference (p < 0.01). This percentage was also significantly lower (48%) in the youngest subgroup compared to those over 25 years of age, p < 0.05.

3.3. Topical Photoprotection Habits

The majority (97%) of respondents reported using sunscreen at some time (daily or at specific times), and specifically, 10,090 of respondents (80%) chose the highest SPF 50+ (Figure 3). Regarding sex, significantly more women than men use the highest SPF50+ (81% (9297) vs. 67% (779), p < 0.05). As for the youngest subgroup under 25 years of age, no significant differences were found compared to respondents over 25 years of age (Figure 4).
Up to 64% (8041) of the surveyed participants affirmed that they use sunscreen regularly throughout the year (Figure 5). This percentage was significantly much lower in men than in women: 21% (239) vs. 68% (7792), p < 0.001 (Figure 5). This percentage was also significantly lower in the youngest group compared to the respondents over 25 years of age: 46% (337) vs. 65% (4169), p < 0.001 (Figure 5).
Up to 87% (11,010) of the surveyed participants apply sunscreen before leaving home. This percentage is significantly lower in men than in women: 61% (705) vs. 90% (10,292), p < 0.001. It was also significantly lower for the youngest participants when compared with respondents over 25 years of age: 75% (546) vs. 88% (10,464), p < 0.01.
Overall, up to 41% (5200) of respondents never reapply sunscreen. This lack of reapplication was even more frequent among the youngest respondents, where up to 356 (49%) never reapply it, although this difference was non-significant compared to respondents over 25 years of age (p > 0.05). No significant differences regarding sex were detected.
Only 51% (6455) of the participants use three or more sunscreen containers per year. In total, 473 (4%) use a container of suncream opened in the previous year, while 5669 (45%) use one or two containers per year. Regarding sex, a significantly lower percentage of men use three or more containers of suncream per year compared to women: 30% (343) vs. 53% (6105), p < 0.001). When comparing those who use three or more containers of suncream in the youngest subgroup under 25 years of age vs. respondents over 25 years of age, the percentages significantly differed: 37% (268) vs. 52% (6187), respectively, p < 0.001.
Regarding the choice of a different sunscreen depending on the moment or body area, globally, up to 17% (2088) combine different products. On the contrary, up to 19% (2386) use the same sunscreen for different areas and situations. Up to 55% (6970) only chose different products for the face or body, regardless of the situation. In total, 1065 respondents (9%) choose a different product for daily use vs. when they go to the beach. Regarding sex, significant differences were found in those who choose different sunscreens according to the area of application or activity, as only 7% (84) of men vs. 18% (981) of women do this (p < 0.001). Among those who use the same sunscreen for different situations or areas, the percentage was significantly higher in men (51%, which was 591 of the men) compared to women (16%, which was 1790 of the women) (p < 0.001). As for the youngest group under 25 years of age, a higher percentage use the same product in different situations compared to respondents over 25 years of age, 25% (183) vs. 19% (2203), respectively, although this difference is non-significant, p > 0.05).
Regarding the question about what consumers look at when choosing a sunscreen, 68% (8623) look at the SPF; 47% (5875) look at the additional characteristics (e.g., sweat resistance, sebum-regulating activity, anti-aging, depigmenting, etc.); 42% (5405) look at the comfort of its application; 37% (4681) look at the brand; 30% (3881) look at the pharmacist’s recommendations; and only 10% (1320) look at whether it is sustainable. No significant differences were found between those under 25 years of age and respondents over 25 years of age. As for women, a significantly higher percentage when compared with men chose sunscreen based on SPF: 70% (7948) vs. 58% (666), p < 0.001); based on the pharmacist’s recommendation: 31% (3583) vs. 26% (296), p < 0.01); and based on additional characteristics such as seborregulation, sweat resistance, etc.: 48% (5426) vs. 40% (447), p < 0.01), respectively. No significant differences were found in the rest of items.

3.4. Oral Photoprotection Habits

The results indicate that 67% (8443) know about the existence of oral photoprotection. However, among the 33% who did not know about oral photoprotection, we found significant differences between the sexes, with 65% of men not knowing about it vs. 30% of women, p < 0.001. In the youngest subgroup, no significant differences were found vs. respondents over 25 years of age (47% vs. 32%, respectively, p > 0.05).
Among the participants who were aware about oral photoprotection, only 15% (1949) regularly use it. This percentage is significantly lower in men than in women (6% vs. 16%, p < 0.001) and among the youngest participants (10%, p < 0.05 vs. respondents over 25 years of age).

3.5. Preventative Screening Attitude

Only 34% (4306) of the participants were aware about the rule of ABCDE signs for nevi screening. This percentage was significantly lower (27%) among the youngest participants when compared to respondents over 25 years of age (35%), p < 0.01. There was also a significant difference (p < 0.001) regarding knowledge of ABCDE signs between men (23%) and women (35%) (Figure 6).
As for visits to the dermatologist, as many as 23% (2929) of the respondents had never visited a dermatologist. Only 26% usually visit the dermatologist regularly every year. Within the youngest group, up to 37% had never visited the dermatologist, a significantly higher percentage than those over 25 years of age (22%), p < 0.001. When comparing between the sexes, the number of men who had never visited a dermatologist was significantly higher than that for women (32% vs. 22%, respectively, p < 0.05) (Figure 7).

4. Discussion

To our knowledge, with 12,597 surveyed volunteers, this is the largest survey on photoprotection habits conducted in Spain to date. This survey was administered to members of the Spanish population across the country during the year 2023. Different locations have different degrees of sun exposure at different times of the year. The average daily UV radiation values in January of 2023 were 437 J/m2 and 921 J/m2 in Coruña city (north of Spain) and Almeria city (south of Spain), respectively. In August, the average levels of UV were 4000 J/m2 in Coruña and 4543 J/m2 in Almería. We think that this could be helpful for planning awareness-raising and health education actions regarding knowledge of the effects of sun exposure and photoprotection habits. This also supports the proposals that affirm that sun protection campaigns are needed to raise awareness of UVR’s potential damaging effects0 and to achieve changes in lifestyles that will arrest increasing trend regarding skin cancers [15].
According to the results, most of the participants were aware of the relationship between sun exposure and skin cancer. However, when asked about tanning, up to 45% of those surveyed did not associate it with skin damage (with this value being even higher, 52%, among those under 25 years, and 55% in the male subgroup). It is also notable that among women, the percentage that associate tanning with health and beauty is similar (22% in both items), while among men, the association of tanning with health is greater than with beauty (32% and 23%, respectively).
When exploring photoprotection habits, we found that 80% of those surveyed confirmed that they use SPF50+ sunscreen, which is higher than the percentages observed in 2016, when photoprotection habits were studied in a community in eastern Spain (Catalonia). The authors Mir JF et al. surveyed 5530 participants and observed that only 57.1% reported using an SPF 50+ sunscreen [18]. Further studies regarding the evolution of photoprotection habits over the years would be interesting. The subgroup of men should improve their use of SPF 50+ compared to women (67% vs. 81%).
Some points to improve, based on the results of our survey, would be the use of photoprotection all year round, the reapplication of photoprotectors, and subsequently the number of containers of solar photoprotection consumed. Only 64% of the respondents use sunscreen throughout the year, and only 7% reapply their sunscreen more than three times during the day, while to 41% do not reapply their sunscreen at all. This percentage was significantly lower in the subgroup under 25 years of age. In parallel to what was previously mentioned, only 47% of those under 25 years of age use sunscreen all year long. Among the subgroup of men, compared to women, the data reflect that they should increase their daily use of sunscreen all year round.
Knowledge about oral photoprotection should also be improved. In addition to improving knowledge of oral photoprotection, the regular taking of it should be implemented, since only 15% take it regularly.
As for the acute consequences of sun exposure, we observed that within the youngest population under 25 years of age, 41% had a previous history of severe sunburn. These data in young people demonstrate some improvement compared to data published in a study on 270 teenagers (between 14 and 17 years old) from the Costa del Sol (south of Spain, with a higher UV index up to an average daily UV radiation value of 4284 J/m2 in August), where 74.4% experienced sunburn during the previous summer. In this study, sunscreen was used by 47.8% of participants, and 1.1% wore long sleeves or trousers. Up to 60.7% stated they felt better when they were tanned, slightly higher than in our study, where 52% found it to be associated with healthy or beauty [19]. Reviewing previously published data on photoprotection in our country, we found a study carried out on preschool-age children in the population of southern Spain that collected data from 420 community colleges, finding that 67.1% of the schools did not have written sun protection policies [20]. The photoprotection measures reported included the mandatory use of a cap or hat (3.3%), the use of sunglasses in outdoor areas (30%), and the active encouragement of students to use sunscreen (50.7%) [20].
Specifically, we proceed to analyze the photoprotection data in a particular population, such as the Spanish sports population. To note, in this population, most of the members are men and under 25 years of age, which in our survey were the subpopulations with lower percentages of knowledge and use of photoprotection. One study including 129 handball players on a beach in Cádiz (South of Spain) found that up to 76.9% had suffered at least one sunburn event during the last year, with this percentage being 81.25% among the younger participants. Although up to 68% used sunscreen with a protection factor of 30 or higher, 35.4% of the younger participants did not reapply it. Up to 94% had not examined their body for skin damage during the previous year [21]. A similar study conducted on 240 elite aquatics athletes (71% men) obtained a mean rate of sunburn during the previous season of 76.7% [22]. These results were similar to those obtained in a survey of 72 elite Kitesurf participants, where most respondents had suffered at least one sunburn [23]. In another survey conducted among 657 marathon runners (72% men), only 61.9% applied sun protection factor (SPF) > 15 sunscreen [24]. Among beach guards of the Costa del Sol (South of Spain), up to 77.1% had experienced at least one painful sunburn during the previous summer [25]. In another population subgroup consisting of 1018 cyclists from the Andalusian federation (Southern Spain), in which 87.6% were male, 45.6% had experienced sunburn during the previous year, and only 39.2% reported using sunscreen. In addition, 61.0% did not examine their skin regularly, despite the fact that 34 subjects (3.4%) reported a personal history of skin cancer [26]. We found other studies in specific populations such as physical education teachers, health personnel, and the school population of the Costa del Sol (southern Spain), all concluding that photoprotection habits should be improved [4,27,28].
The data extracted from this Spanish survey, although they could be improved, are nevertheless better than those obtained in other surveys carried out in other countries.
In an online survey that included 3,540,000 panelists across the world, the authors found that 80% percent of participants knew that sunlight can cause skin health problems (lower than the 97% found in our survey) [29]. The percentage of facial application of sunscreen daily was 60%, which was similar to the 64% found in our survey. Globally, the percentage of individuals associating tanned skin with beauty was 72%, although this association was weaker in Asian countries and among individuals with dark skin phototypes. Up to 83% reported a history of sunburn, (higher than the percentage found in our survey), mainly in Australia, Canada, the USA, Germany, France, and Russia [29].
In another survey carried out on 5964 volunteers from Asian countries, although 76% and 55% of participants reported being aware that solar radiation contributes to premature aging and skin cancer, respectively, only 21% of respondents regularly applied sunscreen, and only 36% understood the significance of photoprotection during winter [30]. In the United States, a recent nationwide survey explored sunscreen application habits among over 2200 volunteers. This study also revealed that 82% of respondents said that protecting their skin from the sun was more important to them now than it was five years ago, yet only a fraction consistently apply sunscreen [31].
According to the results of our study, people younger than 25 years old had significantly less awareness and worse sun-protection habits. In addition, according to the previous published data commented on above, in more sporty population subgroups, it is striking that the percentage of sunburn is higher than the 42% obtained in the general population. This situation is worrisome, since the solar damage accumulated in the first decades of life is decisive for the subsequent appearance of cancerous skin lesions. This same pattern is repeated when comparing the subgroup of men with that of women, where men have less knowledge and worse photoprotection habits than women. This supports the suggestion that awareness about the effects of the sun on our skin should encourage greater photoprotection. Dermatologists could play a crucial role in improving this point, impacting the cost–benefit ratio of educational interventions such as sun-safe habit programs and sun protection/sunscreen promotion [32].
Another point that should be improved is the screening attitude, as up to 23% of those surveyed (and 37% of those under 25 years of age and 41% of men) had never visited a dermatologist. In addition, only 34% knew the ABCDE rule, with these percentages being even lower in the youngest subgroup and men (27% and 23%, respectively).
From these data, it can be deduced that it is necessary to update and develop guidance programs on the effects of solar radiation and photoprotection habits that convey adequate information on solar effects and try to change the beauty canon by rejecting the concept of tanning being something beautiful and healthy, or by recommending the use of self-tanners instead of sun exposure for those who do not want to give up a darker skin tone. The main population targets for these campaigns would be young people under 25 years of age and men, as we found significantly less consciousness about UV radiation damage and lower use of photoprotection sunscreens, as well as less use of screening methods.
The limitations of this study include its design based on self-reported data and its cross-sectional design, leading to an inability to assess incidence or make a causal inference. In addition, the arbitrary selection of the subgroup of respondents under 25 years of age, which resulted in a lower number of respondents, could also distort the data.

5. Conclusions

In conclusion, this is the first and largest study to assess sun protection habits in the global Spanish population including data gathered from all over the country. The most needed improvement in awareness is regarding the association between being tanned and skin damage. This knowledge could lead to a greater compliance with sunscreen use, such as daily use of sunscreen and its reapplication throughout the day, or oral sun photoprotection. It is also important to increase education on self-examination as well as awareness of the need to go to the dermatologist regularly.
Further studies are required to assess educational strategies in order to reduce the desire to have a suntan and improve sun protection practices like the proper use of oral photoprotection and habits targeted at more specific at-risk groups, such as people under 25 years of age, men, outdoor sporty population groups, etc.

Author Contributions

Conceptualization, M.V. and M.J.G.-S.; methodology M.V. and M.J.G.-S.; software, F.R.-D.; validation, M.V., M.J.G.-S. and M.T.T.; formal analysis, M.T.T.; investigation: M.V., M.J.G.-S. and M.T.T.; resources, M.J.G.-S.; data curation, F.R.-D.; writing—original draft preparation, M.T.T.; writing—review and editing, M.V., M.J.G.-S. and M.T.T.; visualization, M.V., M.J.G.-S. and M.T.T.; supervision, M.J.G.-S.; project administration, M.J.G.-S.; funding acquisition, M.J.G.-S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Dataset available on request from the authors. The raw data supporting the conclusions of this article will be made available by the authors on request.

Acknowledgments

We acknowledge María Valdés and Paloma Valverde for their administrative support.

Conflicts of Interest

The authors M.V., M.T.T., F.R.-D. and M.J.G.-S. declare that they are employed by Industrial Farmacéutica Cantabria SA. Their employer’s company was not involved in this study, and there is no relevance between this research and their company. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

References

  1. Skin Cancer. Available online: https://www.iarc.who.int/cancer-type/skin-cancer/ (accessed on 20 November 2024).
  2. Watson, M.; Holman, D.M.; Maguire-Eisen, M. Ultraviolet Radiation Exposure and Its Impact on Skin Cancer Risk. Semin. Oncol. Nurs. 2016, 32, 241–254. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
  3. Red Española de Registros de Cáncer (Redecán). Sociedad Española de Oncología Médica (SEOM). 2024. Available online: https://seom.org/images/22.05.2024_Nota_de_prensa_Melanoma_cut%C3%A1neo.pdf (accessed on 20 November 2024).
  4. De Castro-Maqueda, G.; Gutierrez-Manzanedo, J.V.; Fernandez-Santos, J.R.; Linares-Barrios, M.; Martín, M.D.T. Sun Protection Habits and Sun Exposure of Physical Education Teachers in the South of Spain. Photochem. Photobiol. 2019, 95, 1468–1472. [Google Scholar] [CrossRef] [PubMed]
  5. Narayanan, D.L.; Saladi, R.N.; Fox, J.L. Ultraviolet radiation and skin cancer. Int. J. Dermatol. 2010, 49, 978–986. [Google Scholar] [CrossRef] [PubMed]
  6. Benjamin, C.L.; Ananthaswamy, H.N. p53 and the pathogenesis of skin cancer. Toxicol. Appl. Pharmacol. 2007, 224, 241–248. [Google Scholar] [CrossRef] [PubMed]
  7. Green, A.C.; Williams, G.M.; Logan, V.; Strutton, G.M. Reduced melanoma after regular sunscreen use: Randomized trial follow-up. J. Clin. Oncol. 2011, 29, 257–263. [Google Scholar] [CrossRef] [PubMed]
  8. Green, A.; Williams, G.; Nèale, R.; Hart, V.; Leslie, D.; Parsons, P.; Marks, G.C.; Gaffney, P.; Battistutta, D.; Frost, C.; et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: A randomised controlled trial. Lancet 1999, 354, 723–729. [Google Scholar] [CrossRef] [PubMed]
  9. Perez, M.; Abisaad, J.A.; Rojas, K.D.; Marchetti, M.A.; Jaimes, N. Skin cancer: Primary, secondary, and tertiary prevention. Part I. J. Am. Acad. Dermatol. 2022, 87, 255–268. [Google Scholar] [CrossRef] [PubMed]
  10. Kohli, I.; Shafi, R.; Isedeh, P.; Griffith, J.L.; Al-Jamal, M.S.; Silpa-Archa, N.; Jackson, B.; Athar, M.; Kollias, N.; Elmets, C.A.; et al. The impact of oral Polypodium leucotomos extract on ultraviolet B response: A human clinical study. J. Am. Acad. Dermatol. 2017, 77, 33–41.e1. [Google Scholar] [CrossRef]
  11. Zattra, E.; Coleman, C.; Arad, S.; Helms, E.; Levine, D.; Bord, E.; Guillaume, A.; El-Hajahmad, M.; Zwart, E.; van Steeg, H.; et al. Polypodium leucotomos extract decreases UV-induced Cox-2 expression and inflammation, enhances DNA repair, and decreases mutagenesis in hairless mice. Am. J. Pathol. 2009, 175, 1952–1961. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
  12. El Mansouri, M.; Essaddouki, S.; Mouradi, M.; Oukerroum, A.; El Fatoiki, F.Z.; Truchuelo, M.T.; Vitale, M.A.; González, S.; Chiheb, S. Evaluation of the effectiveness and safety of combined oral and topical photoprotection with a standardized extract of Polypodium leucotomos (Fernblock®) in a Moroccan population with xeroderma pigmentosum. Photodermatol. Photoimmunol. Photomed. 2023, 39, 607–612. [Google Scholar] [CrossRef] [PubMed]
  13. Pellacani, G.; Peris, K.; Ciardo, S.; Pezzini, C.; Tambone, S.; Farnetani, F.; Longo, C.; Chello, C.; González, S. The combination of oral and topical photoprotection with a standardized Polypodium leucotomos extract is beneficial against actinic keratosis. Photodermatol. Photoimmunol. Photomed. 2023, 39, 384–391. [Google Scholar] [CrossRef] [PubMed]
  14. Lamberti, A.; Cartocci, A.; Donelli, C.; Cortonesi, G.; Trovato, E.; Milani, M. Prevention Strategies in Patients affected by Actinic Keratosis of the Head: A 12-Month, Prospective, Assessor-Blinded, Controlled Study with Lesion-Directed Treatment Associated with Medicalized Photoprotection. J. Clin. Exp. Dermatol. Res. 2022, 13, 620. [Google Scholar]
  15. Hofmann, G.A.; Weber, B. Drug-induced photosensitivity: Culprit drugs, potential mechanisms and clinical consequences. JDDG J. Dtsch. Dermatol. Ges. 2021, 19, 19–29. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
  16. Garbe, C.; Forsea, A.-M.; Amaral, T.; Arenberger, P.; Autier, P.; Berwick, M.; Boonen, B.; Bylaite, M.; del Marmol, V.; Dreno, B.; et al. Skin cancers are the most frequent cancers in fair-skinned populations, but we can prevent them. Eur. J. Cancer 2024, 204, 114074. [Google Scholar] [CrossRef] [PubMed]
  17. de Troya-Martín, M.; Blázquez-Sánchez, N.; Rivas-Ruiz, F.; Fernández-Canedo, I.; Rupérez-Sandoval, A.; Pons-Palliser, J.; Perea-Milla, E. Validación de un cuestionario en español sobre comportamientos, actitudes y conocimientos relacionados con la exposición solar: Validation of a Spanish questionnaire to evaluate habits, attitudes, and understanding of exposure to sunlight: “the beach questionnaire”. Actas Dermosifiliogr. 2009, 100, 586–595. [Google Scholar] [PubMed]
  18. Mir, J.F.; Estrada-Campmany, M.; Heredia, A.; Rodríguez-Caba, C.; Alcalde, M.; Espinosa, N.; Monnier, J.; Pérez-Anker, J.; Yélamos, O.; Puig, S.; et al. Role of community pharmacists in skin cancer screening: A descriptive study of skin cancer risk factors prevalence and photoprotection habits in Barcelona, Catalonia, Spain. Pharm. Pract. 2019, 17, 1455. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
  19. Fernández-Morano, T.; De Troya-Martín, M.; Rivas-Ruiz, F.; Blázquez-Sánchez, N.; Del Boz-González, J.; Fernández-Peñas, P.; Buendía-Eisman, A. Behaviour, attitudes and awareness concerning sun exposure in adolescents on the Costa del sol. Eur. J. Dermatol. 2014, 24, 85–93. [Google Scholar] [CrossRef] [PubMed]
  20. García-Harana, C.; de Gálvez Aranda, M.V.; Blazquez-Sanchez, N.; Rivas-Ruiz, F.; Rodriguez-Martinez, A.; de Troya-Martín, M. Sun Protection Policies and Practices in Preschool and Elementary Schools in Andalusia (Spain). J. Cancer Educ. 2022, 37, 819–828. [Google Scholar] [CrossRef] [PubMed]
  21. De Castro-Maqueda, G.; Gutierrez-Manzanedo, J.V.; Lagares-Franco, C.; Linares-Barrios, M.; de Troya-Martin, M. Photoprotection practices, knowledge and sun-related skin damage in Spanish beach handball players. PeerJ 2019, 7, e7030. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
  22. De Castro-Maqueda, G.; Gutierrez-Manzanedo, J.V.; Ponce-González, J.G.; Fernandez-Santos, J.R.; Linares-Barrios, M.; De Troya-Martín, M. Sun Protection Habits and Sunburn in Elite Aquatics Athletes: Surfers, Windsurfers and Olympic Sailors. J. Cancer Educ. 2020, 35, 312–320. [Google Scholar] [CrossRef] [PubMed]
  23. de Castro Maqueda, G.; Gutiérrez-Manzanedo, J.V.; González-Montesinos, J.L.; Pardal, C.V.; Ruiz, F.R.; de Troya Martín, M. Sun Exposure and Photoprotection: Habits, Knowledge and Attitudes Among Elite Kitesurfers. J. Cancer Educ. 2022, 37, 517–523. [Google Scholar] [CrossRef] [PubMed]
  24. García-Malinis, A.J.; Gracia-Cazaña, T.; Zazo, M.; Aguilera, J.; Rivas-Ruiz, F.; de Troya Martín, M.; Gilaberte, Y. Sun Protection Behaviors and Knowledge in Mountain Marathon Runners and Risk Factors for Sunburn. Hábitos y conocimientos sobre fotoprotección y factores de riesgo para quemadura solar en corredores de maratones de montaña. Actas Dermosifiliogr. 2021, 112, 159–166. [Google Scholar] [CrossRef]
  25. de Troya Martín, M.; Sánchez, N.B.; Harana, C.G.; Leiva, M.C.A.; Arjona, J.A.; Ruiz, F.R.; de Gálvez Aranda, M.V. Beach Lifeguards′ Sun Exposure and Sun Protection in Spain. Saf. Health Work. 2021, 12, 244–248. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
  26. Molinero, D.D.; Paulano, M.R.; Ruiz, F.R.; Sánchez, N.B.; de Gálvez Aranda, M.V.; de Castro Maqueda, G.; de Troya Martín, M. Sun Protection Behaviour and Sunburns in Spanish Cyclists. J. Cancer Educ. 2022, 37, 957–964. [Google Scholar] [CrossRef] [PubMed]
  27. de Troya-Martín, M.; Padilla-España, L.; Férnandez-Morano, T.; Delgado-Sánchez, N.; Sánchez, N.B.; Rivas-Ruiz, F.; Herrera-Ceballos, E.; de Gálvez-Aranda, M.V. Sun Protection Habits and Attitudes Among Healthcare Personnel in a Mediterranean Population. J. Cancer Educ. 2016, 31, 789–795. [Google Scholar] [CrossRef] [PubMed]
  28. Blázquez-Sánchez, N.; Rivas-Ruiz, F.; Bueno-Fernández, S.; Fernández-Morano, M.T.; Arias-Santiago, S.; Rodríguez-Martínez, A.; DeCastro-Maqueda, G.; DeTroya-Martín, M. Photoprotection habits, attitudes and knowledge among school communities in the Costa del sol (Spain). Eur. J. Public Health 2021, 31, 508–514. [Google Scholar] [CrossRef] [PubMed]
  29. Passeron, T.; Lim, H.W.; Goh, C.L.; Kang, H.Y.; Ly, F.; Morita, A.; Ocampo-Candiani, J.; Puig, S.; Schalka, S.; Liu, W.; et al. Sun exposure behaviours as a compromise to paradoxical injunctions: Insight from a worldwide survey. J. Eur. Acad. Dermatol. Venereol. 2023, 37, 2481–2489. [Google Scholar] [CrossRef] [PubMed]
  30. Yan, S.; Xu, F.; Yang, C.; Li, F.; Fan, J.; Wang, L.; Cai, M.; Zhu, J.; Kan, H.; Xu, J. Demographic differences in sun protection beliefs and behavior: A community-based study in Shanghai, China. Int. J. Environ. Res. Public Health 2015, 12, 3232–3245. [Google Scholar] [CrossRef] [PubMed]
  31. Norman, K.G.; Loretz, L.; Kowcz, A.; Kaufman, L.E.; Ruvolo, E.; Traudt, M.; Santos, I.; RoseMansfield, R.; Nash, J.F. Application habits and practices of regular sunscreen users in the United States: Results of an online survey. Food Chem. Toxicol. 2023, 181, 114093. [Google Scholar] [CrossRef] [PubMed]
  32. Shih, S.T.F.; Carter, R.; Heward, S.; Sinclair, C. Skin cancer has a large impact on our public hospitals but prevention programs continue to demonstrate strong economic credentials. Aust. N. Z. J. Public Health 2017, 41, 371–376. [Google Scholar] [CrossRef]
Dermato 05 00001 g001
Figure 1. Distribution of participants based on the different age groups of the 12,597 survey participants. In total, 11,873 were over 25 years of age (94%) and 724 were younger than 25 years old (6%).
Figure 1. Distribution of participants based on the different age groups of the 12,597 survey participants. In total, 11,873 were over 25 years of age (94%) and 724 were younger than 25 years old (6%).
Dermato 05 00001 g001
Dermato 05 00001 g002
Figure 2. Sun tanning and its association with different issues (skin damage vs. beauty or health) in the global population and in subgroups according to sex (women/men) and according to age over 25 years/under 25 years. The figure reflects the knowledge about sun tanning and skin effects. It shows the perception of the meaning of being tanned as representing skin damage or, on the contrary, as a sign of beauty or health in the global population (left column: it should be noted that up to 45% of the surveyed people do not associate tanning with skin damage) Differences among different subgroups are also shown, including according to sex, as shown in the second and third column, with (*) reflecting the significant differences between the sexes. A significantly higher percentage of women associated tanning with skin damage (*). In contrast, we found a significant higher association of tanning with health in male respondents (*). In the right-hand columns, the figure reflects the differences between those over 25 years of age and the youngest surveyed (under 25 years of age), with (*) reflecting significant differences between these age groups. A significantly higher percentage of respondents under 25 years of age associated sun tanning with beauty and health, p < 0.01 and p < 0.05, respectively (*), compared to those respondents over 25 years of age. p < 0.05 (*).
Figure 2. Sun tanning and its association with different issues (skin damage vs. beauty or health) in the global population and in subgroups according to sex (women/men) and according to age over 25 years/under 25 years. The figure reflects the knowledge about sun tanning and skin effects. It shows the perception of the meaning of being tanned as representing skin damage or, on the contrary, as a sign of beauty or health in the global population (left column: it should be noted that up to 45% of the surveyed people do not associate tanning with skin damage) Differences among different subgroups are also shown, including according to sex, as shown in the second and third column, with (*) reflecting the significant differences between the sexes. A significantly higher percentage of women associated tanning with skin damage (*). In contrast, we found a significant higher association of tanning with health in male respondents (*). In the right-hand columns, the figure reflects the differences between those over 25 years of age and the youngest surveyed (under 25 years of age), with (*) reflecting significant differences between these age groups. A significantly higher percentage of respondents under 25 years of age associated sun tanning with beauty and health, p < 0.01 and p < 0.05, respectively (*), compared to those respondents over 25 years of age. p < 0.05 (*).
Dermato 05 00001 g002
Dermato 05 00001 g003
Figure 3. Habits of photoprotection use with SPF50+, less than SPF50+, or no use of SPF. Remarkably, the majority of participants (80%) use SPF 50+ sunscreen.
Figure 3. Habits of photoprotection use with SPF50+, less than SPF50+, or no use of SPF. Remarkably, the majority of participants (80%) use SPF 50+ sunscreen.
Dermato 05 00001 g003
Dermato 05 00001 g004
Figure 4. Different habits of use of photoprotection cream according to SPF between women and men. Significantly more women choose SPF50+ compared to men, p < 0.05 *. More than 75% (9435) of the participants chose broad-spectrum sunscreens. Regarding sex, a significant higher percentage of women vs. men (76% (8645) vs. 67% (779), p < 0.05) chose broad-spectrum sunscreens. Among the youngest subgroup under 25 years of age, the percentage was significantly lower compared to those over 25 years of age, 59% (427) vs. 76% (9008), respectively (p < 0.01).
Figure 4. Different habits of use of photoprotection cream according to SPF between women and men. Significantly more women choose SPF50+ compared to men, p < 0.05 *. More than 75% (9435) of the participants chose broad-spectrum sunscreens. Regarding sex, a significant higher percentage of women vs. men (76% (8645) vs. 67% (779), p < 0.05) chose broad-spectrum sunscreens. Among the youngest subgroup under 25 years of age, the percentage was significantly lower compared to those over 25 years of age, 59% (427) vs. 76% (9008), respectively (p < 0.01).
Dermato 05 00001 g004
Dermato 05 00001 g005
Figure 5. Habits of use of photoprotection cream throughout the year in the global population and in different subgroups according to sex and to age over or under 25 years. In the general population, up to 2/3 of the respondents use sunscreen daily. According to sex (second and third columns), the data show that a significant lower percentage of men use sunscreen daily (*, p < 0.05). The columns to the right reflect the comparison between the youngest subgroup under 25 years of age and the subgroup over 25 years of age, showing significant differences, as a lower percentage of the youngest respondents use sunscreen daily (*, p < 0.05).
Figure 5. Habits of use of photoprotection cream throughout the year in the global population and in different subgroups according to sex and to age over or under 25 years. In the general population, up to 2/3 of the respondents use sunscreen daily. According to sex (second and third columns), the data show that a significant lower percentage of men use sunscreen daily (*, p < 0.05). The columns to the right reflect the comparison between the youngest subgroup under 25 years of age and the subgroup over 25 years of age, showing significant differences, as a lower percentage of the youngest respondents use sunscreen daily (*, p < 0.05).
Dermato 05 00001 g005
Dermato 05 00001 g006
Figure 6. Preventative screening attitude evaluation based on knowledge of the ABCDE rule. A significantly higher level of knowledge about the ABCDE rule among women compared to men was found. In addition, a significant higher percentage of the surveyed participants knew about the ABCDE rule among respondents over 25 years of age compared to those under 25 years of age (*, p < 0.05).
Figure 6. Preventative screening attitude evaluation based on knowledge of the ABCDE rule. A significantly higher level of knowledge about the ABCDE rule among women compared to men was found. In addition, a significant higher percentage of the surveyed participants knew about the ABCDE rule among respondents over 25 years of age compared to those under 25 years of age (*, p < 0.05).
Dermato 05 00001 g006
Dermato 05 00001 g007
Figure 7. Preventative screening attitude evaluation based on visits to the dermatologist. A significantly higher percentage of men compared to women had never visited a dermatologist (*, p < 0.05). Additionally, a significantly higher percentage of the youngest respondents compared to the subgroup over 25 years of age, had never attended to a dermatologist, (*, p < 0.001).
Figure 7. Preventative screening attitude evaluation based on visits to the dermatologist. A significantly higher percentage of men compared to women had never visited a dermatologist (*, p < 0.05). Additionally, a significantly higher percentage of the youngest respondents compared to the subgroup over 25 years of age, had never attended to a dermatologist, (*, p < 0.001).
Dermato 05 00001 g007
Table 1. Photoprotection messages for the general population [16].
Table 1. Photoprotection messages for the general population [16].
Photoprotection Messages for the General Population
  • Limit exposure during midday hours.
  • Seek shade.
  • Physical protection: Wear protective clothing, a broad-brimmed hat to protect the eyes, face, and neck, and sunglasses.
  • Use and reapply broad-spectrum sunscreen of sun protection factor (SPF) 30–50+.
  • Avoid tanning beds.
Table 2. Key demographic findings. Sex and age distribution.
Table 2. Key demographic findings. Sex and age distribution.
Subgroups according to sex
women11,427 (91%)
men1155 (9%)
Subgroups according to age
over 45 years old7397 (59%)
between 31 and 45 years old3546 (28%)
between 26 and 30 years old930 (7%)
between 18 and 25 years old 484 (4%)
under 18 years old240 (2%)
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Truchuelo, M.T.; Vitale, M.; Rius-Diaz, F.; Gomez-Sánchez, M.J. Knowledge and Habits of Photoprotection in the Spanish Population: An Updated Survey. Dermato 2025, 5, 1. https://doi.org/10.3390/dermato5010001

AMA Style

Truchuelo MT, Vitale M, Rius-Diaz F, Gomez-Sánchez MJ. Knowledge and Habits of Photoprotection in the Spanish Population: An Updated Survey. Dermato. 2025; 5(1):1. https://doi.org/10.3390/dermato5010001

Chicago/Turabian Style

Truchuelo, María Teresa, María Vitale, Francisca Rius-Diaz, and María José Gomez-Sánchez. 2025. "Knowledge and Habits of Photoprotection in the Spanish Population: An Updated Survey" Dermato 5, no. 1: 1. https://doi.org/10.3390/dermato5010001

APA Style

Truchuelo, M. T., Vitale, M., Rius-Diaz, F., & Gomez-Sánchez, M. J. (2025). Knowledge and Habits of Photoprotection in the Spanish Population: An Updated Survey. Dermato, 5(1), 1. https://doi.org/10.3390/dermato5010001

Article Metrics

Back to TopTop