Assessment of sunscreen effects in photosensitivity under UV exposure during COVID-19 pandemic

2.1 Study setting and data collection

This study was conducted in Abbottabad, Khyber Pakhtunkhwa, which is in the northwestern part of Pakistan's Khyber Pakhtunkhwa (KP) region, at a height of 1256 m above sea level. It has an area of 1967 square kilometers. The region's elevation ranges from 600 to 2800 m as shown in Fig. 1 (Waseem et al., 2021).

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Fig. 1

(A) Abbottabad map (B) study flow diagram.

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2.2 Evaluating the effects of sunscreen use on skin melanin and erythema contents

2.3 Statistical analysis

To summarize and analyze the data, Microsoft Excel 365 was used. The questions were classified on ordinal and nominal scales. The significant difference was determined by Pearson Chi-Square using IBM SPSS version 23.0. A paired sample t-test was performed to find the significant difference between baseline and day 7 visits. The level of significance was set at p < 0.05.

3.1 Demographic characteristics

400 questionnaires were distributed for the study, resulting in a response rate of 96 %. 384 participants within the age range of 18 to 50 years of both genders were included, of whom 71.35 % were aged between 18 and 28 years., 23.55 % were aged between 29 and 39 yrs. and 4.16 % were aged 40–50 years, 33.07 % were males, while 66.92 % were females. Among them 38.55 % were married, and 61.45 % were unmarried. 49.47 % of the participants were employed, and 50.52 % were unemployed (Table 1). Photosensitivity was observed in both males and females of all ages.

3.2 Fitzpatrick (FST) skin types

Scores of the frequency distribution for Fitzpatrick skin types among the population of Abbottabad are represented in Table 2 while graphically, it is explained in Fig. 3A. The Fitzpatrick skin classification is commonly used to estimate photo-damage and skin cancer risk (Sharma et al., 2018). According to our study, most of the participants had dark brown eyes, and i.e., 34.9 %, while 31.0 % of the participants had brownish-black eyes. 25.8 % of the participants had hazel or light brown eyes, 5.2 % of the participants had light blue, light gray or light green eyes. 3.1 % of the participants had blue, gray, or green eyes. 46.9 % of the participants had dark brown natural hair color, 43.8 % had black hair color, and 7.6 % had blonde hair, whereas 1.8 % of the participants had red or light blonde hair, while no participants had dark blonde or light brown hair color. 30.5 % of participants had fair to beige skin color, 26.6 % had fair to pale skin, 24.5 % had olive or light brown skin, and 10.2 % of participants had ivory white as their natural skin shade, whereas 8.3 % of participants were dark brown or black skinned. 51.0 % of participants had no freckles on a sun-exposed area of skin, 20.1 % had very few freckles, 17.2 % had a few freckles and 7.8 % had several freckles whereas 3.9 % had many freckles, on the sun-exposed area of skin. 32.0 % showed burns rarely due to sun exposure, 29.7 % showed never burns due to the sun, 25.5 % showed burns moderately, 6.3 % showed often burns, blisters, and peels due to the sun, whereas 4.2 % showed always burns, blisters, and peels due to sun exposure. 31.0 % showed a tan; sometimes burns cause the skin tan, 28.1 % was never burned or tanned, 19.8 % showed it was burned or caused tanning, 14.8 % showed often burned and tanned whereas 6.3 % showed always burn and caused tanning. 38.3 % of participants had experienced a light skin tan, 26 % had experienced mere or no skin tanning, 25.0 % of participants experienced moderate skin tan, 7.6 % experienced deep skin tan, whereas 3.1 % had natural dark coloured skin. 47.1 % of the participants had face sensitivity towards the sun, among which 27.3 % had normal face sensitivity, 10.9 % had very sensitive face skin, 9.9 % were resistant to or never had any problem with sun exposure, and 3.1 % had resistance to sun exposure.

The FST scale may also be used to assess how various skin types respond to popular cosmetic/dermatological treatments, making it a helpful tool in cosmetic dermatology. 58.6 % of participants had skin type III, 29.4 % had type IV, and 9.1 % had type II. According to the study, 47.1 % of participants had sensitive face areas to the sun. Sun damage, photoaging, and the risk of melanoma and non-melanoma skin malignancies are higher in skin types I-III (Sachdeva, 2009).

3.3 The presence of photosensitivity

The presence of photosensitivity in the population of Abbottabad is represented in Table 3. UV and visible light are the most common sources of photosensitivity. This energy is absorbed by chromophores (molecules found in the skin) to cause biological reactions such as photosensitivity (Lankerani and Baron, 2004). This study showed that 54.1 % of the participants had a history of photosensitivity, whereas 44.1 % had no history of photosensitivity. 43.5 % of the participants didn’t experience photosensitivity; 27.9 % experienced it last month, 18.2 % of the participants experienced photosensitivity some days ago; and 10.4 % of the participants experienced it regularly. 38.0 % of the participants experienced skin redness after sun exposure, 28.4 % experienced other issues related to skin after sun exposure, 19.3 % experienced sun burns, and 14.1 % experienced itchiness. 74.2 % of participants protect their skin, whereas 25.8 % of participants do not protect their skin. 71.6 % of the participants did not have any lesions in the sun-exposed area, whereas 28.4 % of participants had lesions in sun-exposed areas.

3.4 Photoprotection behaviour

Photoprotection behaviour found in the population of Abbottabad is represented in Table 4. The use of sunscreen products has increased as the incidence of photo-damaging effects induced by UV radiation has increased (Serpone et al., 2007). From the data obtained, it was detected that most of the participants used sunscreen for their skin protection, with 38.0 % using sunscreen sometimes when they were exposed to the sun, 24.5 % never using sunscreen, and 21.1 % always using sunscreen when they were exposed to the sun, whereas 16.4 % usually use sunscreen when they are exposed to the sun. 40.4 % of participants were using SPF 30+, 24.2 % of participants were using SPF 50+, and 23.9 % were using SPF 30, whereas 11.6 % were using SPF 20. Most of the participants applied sunscreen before going out, i.e., 27.3 %. 20.4 % of participants applied once a day, 14.3 % applied sunscreen rarely, and 12.2 % applied sunscreen twice a day. 32.2 % of participants did not use sunscreen because they did not remember to use it. 25.8 % of participants thought that they did not get any sunburns, and 20.1 % of participants had other reasons for not using sunscreen, 9.4 % of participants felt uncomfortable while using sunscreen. 8.1 % of participants did not use sunscreen because it is expensive, whereas 4.2 % did not use sunscreen because it causes skin allergies.

3.5 Photosensitivity cases (2020–2021)

The association between gender and photosensitivity is represented in Fig. 2A. After the application of the chi square test, it was found to be insignificant. The association between age categories and photosensitivity is represented in Fig. 2B. After the application of the chi square test, it was found to be significant, i.e., P < 0.001. The association between marital status and photosensitivity is represented in Fig. 2C. After application of the chi square test, it was found to be insignificant, i.e., p = 0.3. The association between sun protection and photosensitivity is represented in Fig. 2D. After the application of the chi square test, it was found to be significant. The observed cases, risk ratio, and incidence of photosensitivity among different age categories are represented in Table 5. The age, categories, and incidence of photosensitivity, Abbottabad in 2021 are represented in Fig. 3B. The association between photoprotection behaviour and photosensitivity is represented in Table 6. After application of the chi square test, it was found to be significant.

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Fig. 2

(A). Association between gender and photosensitivity. (B). Association between age categories and photosensitivity. (C). Association between marital status and photosensitivity. (D). Association between sun protection and photosensitivity.

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Fig. 3

(A). Frequency distribution of Fitzpatrick skin types among the population of Abbottabad (N = 384) (B). Age categories and Incidence rate 20–21. (C). Skin erythema and melanin contents with optimal use (N = 22) (D). Skin erythema and melanin contents with typical use (N = 22).

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3.6 The incidence

Photosensitivity is seen in both males and females of all ages. Genetic and environmental influences may interfere with the prevalence of photosensitivity (Oakley and Badri, 2019). The prevalence of photosensitivity across Europe is 10–20 % of the population. Excessive contact with UV rays also leads to skin cancer (Kim and Chong, 2013). A study in the UK showed that 86 % of skin cancers are induced by exposure to UV radiation coming from the sun (Parkin et al., 2011).

Self-reported photosensitivity refers to any skin-specific or systemic unpleasant responses that a person has in response to sun exposure over a period (Foering et al., 2012). Excessive exposure to UV radiation without protection plays an important role in photosensitivity (Narbutt et al., 2019). Table 5 showed that among males, there were 15 observed cases of photosensitivity under the 25-year age group with a risk ratio of 0.33, and the incidence rate of photosensitivity was 90/1000 of the population. There were 31 observed cases under the age category 25–30 with a risk ratio of 0.51, and the incidence rate of photosensitivity was 207/1000. In the above 30 age categories, there were 9 observed cases with a risk ratio of 0.43. The incidence rate of photosensitivity was 132/1000. Among females, there were 80 observed cases with a risk ratio of 0.66 under age 25. The incidence rate was 482/1000. Between the age groups 25–30, there were 63 observed cases of photosensitivity, with a risk ratio of 0.71 showing an incidence rate of 420/1000. Whereas, at an age above 30, there were 17 observed cases with a risk ratio of 0.36. The incidence rate was 250/1000. At an age below 25, observed cases were 95, a risk ratio of 0.99, and the incidence rate was 572/1000. Between age group 25–30, total observed cases were 94 a risk ratio of 1.22. The incidence rate was 627/1000. In the total population, above the age of 30, the observed cases of photosensitivity were 26, a risk ratio of 0.79. The incidence rate was 382/1000.

3.7 Photoprotection in medical staff and patients that were recovered from COVID-19 infection (N = 200)

Our study was able to provide a comprehensive overview of the photosensitivity among COVID-19 recovered participants, although it also had limitations. Sunlight aids in the healing of a variety of illnesses, including respiratory infections such as influenza and severe acute respiratory syndrome (Cory and Kling, 2018; Geier et al., 2018). Longer periods of sunlight exposure are linked to greater incidences of COVID-19 recovery among patients because sunlight increases vitamin D production, which boosts the immune system (Asyary and Veruswati, 2020; Ventenilla et al., 2018). The data was collected from the medical staff and the patients that recovered from COVID-19 infection. Table 7 shows that 63.5 % of the participants agreed to specific skin related manifestations of COVID-19, and 36.5 % did not agree. 65 % of the participants agreed that preventive measures for COVID-19 infection made their skin sensitive, whereas 35 % did not agree. 53.5 % of the participants showed enhanced photosensitivity of the skin after taking preventive measures, while 46.5 % showed no response. 63.5 % of participants agreed that the use of hand sanitizers made their skin sensitive while 36.4 % did not agree. 58.5 % of participants agreed that the use of sunscreens was helpful in treating photosensitivity, whereas 41.5 % of participants did not agree.

3.8 The effects on skin melanin and erythema

Fig. 3C and D represents effects on skin melanin and erythema contents with optimal and typical use of sunscreens with respect to time. There was a decrease in skin melanin and erythema values with optimal use of sunscreen SPF 50+ and an increase in skin melanin and erythema values with typical use of sunscreen SPF 50+ with time. After the application of the paired sample t-test, there was a significant difference between them. Many people are unaware of the optimal use of sunscreen and guidelines (Narbutt et al., 2019). Sunscreen application by consumers is frequently insufficient for ultraviolet radiation protection according to the advertised sun protection factor (SPF). Although sunscreen SPFs are labelled based on testing at a 2 mg/cm² application density, actual protection is generally much lower due to consumer application densities ranging from 0.5 to 1 mg/cm² (Li et al., 2019).