Stats and evidence
This page explains how we know that being exposed to too much UV radiation can cause skin cancer. There is an overview of the scientific evidence and further links so you can find out more if you wish.
On this page
- Overexposure to UV radiation is the main cause of skin cancer
- Some people are at higher risk of skin cancer
- The UV Index and strength of UK sunlight
- Skin type and burn risk
- The shadow rule
- How UV radiation causes skin cancer
- Getting sunburn increases the risk of skin cancer
- Sun protection
There is sufficient evidence to show that overexposure to ultraviolet (UV) radiation is the main preventable cause of skin cancers – both malignant melanoma and non- melanoma skin cancers (NMSC)1 2 3. The sun is the principal source of natural UV radiation. Sunbeds produce artificial UV radiation.
A study published in 2011 estimated that 86% of melanomas in the UK (around 11,100 cases) every year are linked to too much exposure to sunlight and sunbed use4.
Among NMSCs, an estimated 50-70% of squamous cell carcinomas (SCCs) and 50-90% of basal cell carcinomas (BCCs) in fair-skinned people are caused by UV radiation5.
The risk of melanoma is most strongly linked to intermittent sun exposure6. Non-melanoma skin cancers (BCCs and SCCs) are both linked to chronic sun exposure7 8. The risk of BCCs is also linked to intermittent sun exposure9 10.
Some people are more likely than others to develop skin cancer. These people tend to have one or more of the following:
- fair skin that burns easily11 12;
- lots of moles13 14 or freckles15;
- a history of sunburn6 16 and/or having had significant sun exposure throughout your life7 8;
- red or fair hair15;
- light-coloured eyes15;
- a personal17 18 or family history19 20 of skin cancer.
People with naturally dark brown/black skin have a lower risk of skin cancer 21 22 23 But people with darker skin can still burn and develop skin cancers, especially on non-pigmented parts of the body like the soles of the feet 24.
The World Health Organisation (WHO) developed an international UV index to reflect the strength of the sun’s rays or level of UV radiation at the earth’s surface. The level of UV radiation gives an indication of the risk of burning or adverse health effects. The greater the UV index value, the greater the potential for damage and the less time it takes for this damage to occur25 26. The UV index can be used as an indication for the level of protection needed against UV radiation. It is widely accepted that protection is needed only when the UV index is above 327.
The strength of UV radiation reaching the earth’s surface is affected by several factors:
- Time of day, being strongest at solar noon when the sun is highest in the sky26
- Time of year, being strongest in the summer months28
- Latitude, being strongest in locations nearer the equator1
- Altitude – spending time at high altitude increases UV exposure by about 15% for every 1000 metres1 29
- Cloud cover – even on overcast skies, 30-40% of UV radiation will still penetrate through cloud cover30 31 32. For example, if half the sky is covered in clouds, 80% of UV radiation still shines through30 .
- Reflection – snow can reflect up to 85% of the UV radiation that hits it, increasing a person’s exposure33. About 15% of sunburning rays are reflected back from sand, 10% from concrete and 5-10% from water (depending on choppiness)34.
A combination of hair and eye colour, as well as how skin reacts (how often or easily it burns) in the sun can be used to estimate a person’s risk of skin cancer. Experts have identified six different skin types using this skin phototype classification method35 36.
|Skin phototype||Typical Features||Tanning Ability|
|Type I||Tends to have freckles, red or fair hair, and blue or green eyes.||Often burns, rarely tans.|
|Type II||Tends to have light hair, and blue or brown eyes.||Usually burns, sometimes tans.|
|Type III||Tends to have brown hair and eyes.||Sometimes burns, usually tans.|
|Type IV||Tends to have dark brown eyes and hair.||Rarely burns, often tans.|
|Type V||Naturally black-brown skin. Often has dark brown eyes and hair.|
|Type VI||Naturally black-brown skin. Usually has black-brown eyes and hair.|
The Health Protection Agency developed a tool for estimating a person’s risk of burning and the level of protection they need based on their skin type and the UV index37.
UV exposure varies depending on the time of day but is highest between 10am and 3pm, international organisations such as IARC (International Agency for Research on Cancer) and WHO (World Health Organisation) recommend limiting sun exposure during these times 38 47. A simple guide has been developed to help indicate when UV exposure might be high, called Holloway’s rule, which states that when your shadow is shorter than you are tall, the sun is more likely to burn you39.
UV radiation from the sun damages DNA, which can lead to the development of cancer40.There are two main types of UV rays that damage skin:
- UVB is responsible for the majority of sunburns and it can cause skin cancer 41 47.
- UVA penetrates deeper into the skin. It ages the skin, but contributes much less towards sunburn41 42 43.
Both UVA and UVB can damage DNA in the skin, which can lead to skin cancer3 44. DNA damage caused by UV radiation leads to a number of changes in the body. Blood vessels dilate, producing a red colour and increasing the surface temperature (because hot blood is rushing to the surface). The widened blood vessels also allow immune cells and inflammatory chemicals to rush to the site of the damage, which cause the swelling and pain that accompanies sunburn. If skin cells are too heavily damaged, they are destroyed and peel away. Your body has ways of repairing most of the damage. But it is not perfect, and some damaged DNA can be left behind47.
A third type of UV ray, UVC, is the most dangerous of all, but it is completely blocked out by the ozone layer and doesn’t reach the earth's surface47.
Sunburn is a sign of DNA damage by too much UV radiation. It is the skin’s reaction to UV-induced damage47 48 49
A survey by Cancer Research UK and Nivea Sun showed that 37 per cent of people admitted the last time they were sunburnt was in the UK50.
It is widely agreed that a combination of measures including using shade, clothing and sunscreen, offers the best protection against over-exposure to UV radiation from the sun47 51. And research suggests that shade and clothing may offer better protection from UV rays than sunscreen52 53 54
Shade structures can provide protection from the sun. Staying under shade, such as a tree or umbrella, can reduce your overall exposure to UV, but not completely. Many shade structures are more likely to filter than to block UV radiation. Only very broad and thick shade such as thickly wooded areas and widely overhanging structures provide enough protection55.
Covering up with clothes, hat and sunglasses is a commonly recommended and effective way of protecting yourself from UV rays56.
Clothes tend to provide more protection if they57:
- Are dark-coloured
- Are made of synthetic fabrics
- Are dry – when some fabrics get wet, their protection can be halved
- Have a close weave or are knitted.
Wide-brimmed hats provide the most UV protection for the whole face and head. Caps protect the nose and forehead but provide poor protection for other parts of the face58 59.
Sunglasses can protect your eyes from too much UV exposure. Poorly-fitting sunglasses offer poor protection as sunlight can reflect off the back face of the lens back into the eye. Wraparounds are recommended60 .
Sunglasses should state that they block out 100% of UVA and UVB rays. Alternatively, look for the ‘CE Mark’ and British Standard, or a UV 400 label. Remember that the UV-protective chemical on sunglasses is invisible, so the colour of the lens is not an indication of protection - in fact, the darkest sunglasses may cause pupil dilation and actually let more light in61 .
Using sunscreen for ‘non-intentional’ sun exposure, such as walking, gardening, sport or other daily activities, could reduce the risk of sunburn 65 66. However, using sunscreen for ‘intentional’ sun exposure (e.g. sunbathing) has been linked with people spending longer in the sun overall and being no less likely, perhaps even more likely to get sunburnt66. This was particularly seen when people used higher SPF sunscreens67.
Because of this, we recommend that sunscreen should be used together with clothing and shade to protect the skin from sun damage, and should never be used to spend longer in the sun.
The SPF or ‘factor’ of a sunscreen is a measure of the amount of sun protection it provides. Experts have found that SPF 15 sunscreen provides sufficient protection when used appropriately47 68. In the UK, a minimum of SPF 15 is recommended by NICE (National Institute for Health and Care Excellence)69.
SPF measurements are based on the assumption that people apply 2mg/cm2 of sunscreen on their body47. But using this quantity of sunscreen may be unachievable in practice70. Research has shown that people don’t apply enough71. One study found that people only apply 0.5-1mg/cm2 72.
- around two teaspoonfuls of sunscreen if you're just covering your head, arms and neck.
- around two tablespoonfuls if you're covering your entire body, while wearing a swimming costume.
As SPF increases, sunscreens provide less and less extra protection. An SPF15 sunscreen filters out 93% of UVB radiation, while an SPF30 sunscreen filters out 96%78.
Sunscreens that provide UVA protection are recommended51 79. The star rating system measures the balance between UVA and UVB protection and awards products a rating of 0-5 stars. It is not an absolute measure, but depends on the SPF rating of the sunscreen it is applied to.
Over-exposure to the sun during childhood can affect the risk of melanoma later in life 80, 81.
When parents use sun protection such as hats, shade, sunscreen and clothing, their children are more likely to use these sun protection methods too 82. It's important to establish good sun protection habits early on in life 83.
Parents are advised to keep babies under 6 months out of direct sunlight 84, 85.
According to IARC there is sufficient evidence that sunbed use causes malignant melanoma, and limited evidence that sunbed use causes SCC 3.
According to a recent meta-analysis sunbed use at any age increases the risk of SCC by 67%, and increases BCC risk by 29% 86.
A comprehensive review published in 2012 of studies on sunbeds and cancer concluded that using a sunbed for the first time before the age of 35 increases the risk of malignant melanoma by 59%, and use at any age increases malignant melanoma risk by 20-25% 87.
A large study of Norwegian and Swedish women found that using sunbeds once a month or more increases the risk of melanoma by 55% in all age groups from 10-39 88.
Sunbeds are marketed as a 'controlled' way of getting a 'safer' tan 89. But actually, sunbeds are no safer than exposure to the sun itself 90. It is a common misconception that sunbeds emit only UVA radiation, and not UVB, the type which causes more sunburns. But all sunbeds emit some measure of UVB, and even this tiny proportion is enough to cause substantial damage to our skin 91.
UVA can also damage the skin and the levels of UVA from sunbeds can be over 10 times higher than that of the midday sun 92. A recent study found that the average skin cancer risk from sunbeds can be more than double that of spending the same length of time in the Mediterranean midday summer sun 93.
Studies have shown that up to half of all sunbed users suffer from sunburn 94.
In addition to carcinogenic effects, sunbeds can promote photoageing - UV-induced premature ageing of the skin - by destroying collagen and other large molecules. The consequences of UVA-induced damage in the skin include the formation of wrinkles, sagging, leathery appearance, fragility and impaired healing ability 95.
A French study found that women who frequently used sunbeds over the course of 5 years developed saggier skin with a loss of elasticity that resembled premature ageing 96. Another study of 59 people who used sunbeds over 3 months found that their skin cells showed a 2.4 fold increase in the levels of a common fault in mitochondrial DNA that is firmly associated with photoageing 97.
Far from being a sign of health, a tan is a reaction to DNA damage in the skin. It is a sign that your body is trying to repair damage that has already happened 98, 99. And pre-holiday tans or sunbed tans offer very little protection against the sun. Some studies have found that tans only offer protection equivalent to using factor 3 sunscreen 100, 101.
'Fake tan' lotions, sprays, creams and mousses are topical products containing the active ingredient dihydroxyacetone (DHA), typically in concentrations of between three and five per cent 102, 103. DHA is a type of carbohydrate which reacts with the amino acids in the top layer of the skin, to form brown-black compounds called melanoidins 102, 104. The depth of the colour change is related to DHA concentration 103. DHA-containing 'fake tan' products are considered to be non-toxic 103, 104.
Bronzers do not contain the active ingredient DHA and so the colour delivered through these products, for example in the form of tinted moisturisers and powders, can be removed with the aid of soap and water 102.
The FDA (Food and Drug Administration) in the US has approved the use of DHA-containing products for the pigmentation of skin where the products are applied by hand for this allows control over the application process, and the avoidance of the mucous membranes and the area of the eye 105.
Some DHA-containing products also contain sunscreen, but at most a fake tan will only provide the same protection as an SPF4 sunscreen 106, 107. And the protection they offer will last for hours and not for the duration of the colour pigmentation, so regular application of sunscreen is still needed 103.
Our bodies produce vitamin D when our skin is exposed to UV rays from the sun. This is the main source of this vitamin 47. We all need vitamin D to build and maintain strong bones. If you are lacking in vitamin D for a long time then your bones may soften. In serious cases this leads to rickets in children and a condition called osteomalacia in adults 108.
Most people in the UK only need to spend a short amount of time in the sun to make enough vitamin D 109, 110, 111. This is typically less that the time taken to lead to sunburn 112. It should be possible for most people to find a balance between enjoying the beneficial effects of the sun while not increasing the risk of skin cancer.
Once a person makes enough vitamin D, any extra is turned into inactive substances 113. So heavy sun exposure does not improve vitamin D levels beyond a maximum threshold, but it can increase the risk of skin cancer 114. Even leading vitamin D researchers advise using sun protection, such as SPF sunscreens, during long or heavy exposures109.
Vitamin D synthesis is much lower in winter months in countries at higher latitudes like the UK 115. But as long as normal vitamin D level has been built up in the summer, studies show that this will combine with stored vitamin D in fatty tissue to prevent deficiency in the winter 115, 116.
Some groups have a higher risk of vitamin D deficiency, including:
- people with naturally brown or black skin, who need more UV radiation to increase their vitamin D levels than Caucasians 117, 118, 119, 120.
- people who wear clothing that fully conceals them 120, 121.
- older people who don't go outside much, since they have a reduced ability to make vitamin D through their skin 109, 117.
- pregnant women and breast-feeding babies with vitamin D-deficient mothers 122.
The Government recommends that people at risk of vitamin D deficiency should take vitamin D supplements of 10µg a day for adults and 7µg a day for children 123.
In 2010 Cancer Research UK teamed up with other health organisations to bring together evidence on the important but controversial topic of vitamin D. It is endorsed by the British Association of Dermatologists, Cancer Research UK, Diabetes UK, the Multiple Sclerosis Society, the National Heart Forum, the National Osteoporosis Society and the Primary Care Dermatology Society.
Survival for malignant melanoma is strongly related to stage of the disease at diagnosis 124. So getting it diagnosed and treated early could make a real difference to the outcome.
One-year relative survival is highest for patients presenting at stage I, with 101% of men and women surviving for at least one year. In comparison, one-year survival is considerably lower for those diagnosed with stage IV disease (10% for men and 35% for women). As very few patients are diagnosed at stage IV, however, the one-year survival statistics have wide confidence intervals and should therefore be interpreted with caution.
The following can be a sign of skin cancer 125, 126, 127:
- a change such as a new mole, or any moles, freckles or patches of normal skin that change in size, shape or colour.
- a new growth or sore that will not heal.
- a spot, mole or sore that itches or hurts.
- a mole or growth that bleeds, crusts or scabs.
The ABCD (Asymmetry, Border, Colour, Diameter) rule outlines some key skin changes that could be a sign of melanoma skin cancer 128:
- Asymmetry The two halves of the mole do not look the same.
- Border The edges of the mole are irregular, blurred or jagged.
- Colour The colour of the mole is uneven, with more than one shade.
- Diameter The mole is wider than 6mm in diameter (the size of a pencil eraser).
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