Study Overview
Objective. To develop and test a photoaging app designed for melanoma prevention through enhancing sun protective behaviors.
Design. Cross-sectional pilot study.
Setting and participants. 25 students (56% male) with a median age of 22 years (range 19–25) attending the University of Essen in Germany.
Intervention. The researchers tested a free mobile app called Sunface. The app has the user take a self-portrait (selfie) and then photoages the image based on self-reported Fitzpatrick skin type and individual UV protection behavior. The 6 categories of skin on the Fitzpatrick Scale are Type I – always burns, never tans; Type II – usually burns, tans minimally; Type III – sometimes mild burn, gradually tans; Type IV – rarely burns, tans with ease; Type V – very rarely burns, tans very easily; Type VI – never burns, tans very easily. Afterward, the app explains the results and provides recommendations on sun protection as well as the ABCDE rule for skin cancer detection (asymmetrical shape, border, color, diameter, evolution). An interviewer walked up to each student, asked for oral consent, handed them an iPod Touch with the app pre-installed, and let them use the app.
Main outcome measures. Student attitudes about the app as collected on an anonymous paper and pencil questionnaire. Items were statements (see Results below), and responses were on a Likert scale ranging from fully agree to fully disagree.
Results. The majority of students (82%) stated that they would download the app, that the intervention had the potential to motivate them to use sun protection (92%) and that they thought such an app could change their perceptions that tanning makes you attractive (76%). Only a minority of students disagreed or fully disagreed that they would download such an app (2/25, 8%) or that such an app could change their perceptions on tanning and attractiveness (4/25, 16%).
Conclusion. Based on previous studies and the initial study results presented here, it is reasonable to speculate that the app may induce behavioral change in the target population. Further work is required to implement and examine the effectiveness of app-based photoaging interventions within risk groups from various cultural backgrounds.
Commentary
The relationship between skin cancer and ultraviolet radiation is well established [1]. Despite the known risks, tanning behavior, including use of tanning beds, is common. Indoor tanning is prevalent, particularly among female adolescents, and aligns with other risk behaviors, appearance-related factors, and intentional sunbathing [2]. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection against ultraviolet radiation [1].Significantly lower frequencies of almost all recommended sun-protective measures are found in younger patient subgroups (age 14 to 25 years) [3]. Thus, it makes sense to target interventions at the adolescent age-group.
Counseling adolescents regarding the dangers of tanning can be difficult due to the pressure the media places on young women and men to enhance their appearance. As a result, appeals to the negative cosmetic impact of sun and indoor tanning may be more effective than health-based appeals [4].
In this pilot study, the authors tested a creative sun protection app that photoages the user’s image based on skin type and aging algorithms. The underlying aging algorithms are based on publications showing UV-induced skin damage by outdoor as well as indoor tanning. Afterward, the app explains the visual results and aims at increasing self-competence on skin cancer prevention by providing guideline recommendations on sun protection and the ABCDE rule for melanoma self-detection. The app was very well received by the partipating college students, and the researchers concluded that the app may aid in the prevention of melanoma by enhancing the adoption of sun protective behaviors. However, this study was very small.
Mobile phone apps are proliferating and they are recognized as a potential low cost way to deliver health interventions [5]. A previous trial by Buller [6] used a randomized controlled design to evaluate a smartphone app that delivered real-time advice about sun protection, such as alerts to apply or reapply sunscreen or wear a hat. Only 1 out of 7 sun-safety practices was used more frequently by intervention versus control participants. The authors of an evidence review of the effectiveness of mobile phone apps in achieving health-related behavior change note that adequately powered and relatively longer RCTs are needed to better determine the effectiveness of app-based interventions [5].
Applications for Clinical Practice
Warnings on the dangers of sunburn and indoor tanning at any age should be emphasized, and there is an important role for primary care physician and other clinician counseling as well as public health outreach. Phone apps have the benefit of being able to reach large numbers at low cost and can offer an interactive and personalized health education experience. Such nontraditional strategies offer promise. Further studies should shed light on what app features are most important to users and whether their deployment can have a measurable impact on cancer prevention.