10.5826/dpc.1303a190
Introduction: Sunlight is the major source of vitamin D, thus, the use of sunscreens could result in vitamin D insufficiency or deficiency.
Objective: We aimed to assess serum vitamin D levels in healthy children aged 0-18 years in the winter and determine the association between sunscreen use and sun protection behaviors on vitamin D status.
Methods: The demographic data, clothing style, skin type, history of sunburn, history of visiting seaside towns in summer, sun protection behaviors including sunscreen use, wearing sunglasses and hats, and further detailed information about sunscreen use were recorded. Vitamin D status was assessed by measuring blood levels of 25(OH)D during winter.
Results: Three hundred seventy-six children (172 boys and 204 girls) with a mean age of 128.38±56.39 months were enrolled. The mean serum level of 25(OH)D was 15.32±8.64 ng/mL. The mean values of vitamin D were associated with age, sex, traditional clothing style, having a sunburn history, and sunscreen use (p&lt;0.05). Adolescents and girls had vitamin D deficiency and inadequacy more than younger children and boys (p&lt;0.05). Sunscreen use in the adequacy group was lower than in the inadequacy and deficiency groups (p=0.001). There was no significant difference between vitamin D status according to the sunscreen details (SPF, product source, season, and body areas) (p&gt;0.05).
Conclusions: Sunscreen use appears to reduce vitamin D levels measured in winter. Children, especially girls and adolescents, should be exposed to sufficient sunlight to maintain normal serum vitamin D levels. Vitamin D supplementation should be given to children, especially during winter.
text/xml
2160-9381
3047
en
Aysin Hanli Sahin
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
vitamin D status in children
Vitamin D Levels in Children During Winter and the Relationship Between Sunscreen and Sun Protection Behaviors
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-12-04
2023-07-31
2023-08-24
e2023190
Dermatol Pract Concept
Introduction: Sunlight is the major source of vitamin D, thus, the use of sunscreens could result in vitamin D insufficiency or deficiency.
Objective: We aimed to assess serum vitamin D levels in healthy children aged 0-18 years in the winter and determine the association between sunscreen use and sun protection behaviors on vitamin D status.
Methods: The demographic data, clothing style, skin type, history of sunburn, history of visiting seaside towns in summer, sun protection behaviors including sunscreen use, wearing sunglasses and hats, and further detailed information about sunscreen use were recorded. Vitamin D status was assessed by measuring blood levels of 25(OH)D during winter.
Results: Three hundred seventy-six children (172 boys and 204 girls) with a mean age of 128.38±56.39 months were enrolled. The mean serum level of 25(OH)D was 15.32±8.64 ng/mL. The mean values of vitamin D were associated with age, sex, traditional clothing style, having a sunburn history, and sunscreen use (p&lt;0.05). Adolescents and girls had vitamin D deficiency and inadequacy more than younger children and boys (p&lt;0.05). Sunscreen use in the adequacy group was lower than in the inadequacy and deficiency groups (p=0.001). There was no significant difference between vitamin D status according to the sunscreen details (SPF, product source, season, and body areas) (p&gt;0.05).
Conclusions: Sunscreen use appears to reduce vitamin D levels measured in winter. Children, especially girls and adolescents, should be exposed to sufficient sunlight to maintain normal serum vitamin D levels. Vitamin D supplementation should be given to children, especially during winter.
Aysin Hanli Sahin
2023/07/31
10.5826/dpc.1303a190
e2023190
Health Science University, Ankara Oncology Training and Research Hospital, Department of Pediatrics, Ankara, Turkey
2160-9381
vitamin D status in children
en
e2023190
O'Riordan DL, Nehl E, Gies P, et al. Validity of covering-up sun-protection habits: Association of observations and self-report. J Am Acad Dermatol. 2009;60 (5):739-744. DOI: 10.1016/j.jaad.2008.12.015. 17. PMID: 19278750. PMCID: PMC3715114.
Vitamin D Levels in Children During Winter and the Relationship Between Sunscreen and Sun Protection Behaviors
https://dpcj.org/index.php/dpc/article/download/3047/2194
          Vitamin D Levels in Children During Winter
         and the Relationship Between Sunscreen and
                  Sun Protection Behaviors
                        Burcu Tugrul1, Hatice Gamze Demirdag2, Aysin Hanli Sahin3


1 Ankara Bilkent City Hospital, Department of Dermatology, Ankara, Turkey
2 Private Practice, Dermatology Clinic, Ankara, Turkey
3 Health Science University, Ankara Oncology Training and Research Hospital, Department of Pediatrics, Ankara, Turkey



Key words: vitamin D, sunscreens, sun protection, vitamin D deficiency, vitamin D status in children
Citation: Tugrul B, Demirdag HG, Hanli Sahin A. Vitamin D Levels in Children During Winter and the Relationship Between Sunscreen
and Sun Protection Behaviors. Dermatol Pract Concept. 2023;13(3):e2023190. DOI: https://doi.org/10.5826/dpc.1303a190
Accepted: March 4, 2023; Published: July 2023
Copyright: ©2023 Tugrul et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Hatice Gamze Demirdag, Private Practice, Dermatology Clinic, Ankara, Turkey.
E-mail address: demirdaggamze@gmail.com




   The parents patients in this manuscript have given written informed consent to the publication of their case details.




  ABSTRACT             Introduction: Sunlight is the major source of vitamin D, thus, the use of sunscreens could result in
                       vitamin D insufficiency or deficiency.
                       Objectives: Our study aimed to assess serum vitamin D levels in healthy children aged 0-18 years in
                       the winter season and determine the association between sunscreen use and sun protection behaviors
                       on vitamin D status.
                       Methods: The demographic data, clothing style, skin type, history of sunburn, history of visiting sea-
                       side towns in summer, sun protection behaviors including sunscreen use, wearing sunglasses and hats,
                       and further detailed information about sunscreen use were recorded. Vitamin D status was assessed by
                       measuring blood levels of total 25(OH)D during winter.




Original Article | Dermatol Pract Concept. 2023;13(3):e2023190                                                                      1
                      Results: Three hundred seventy-six children (172 boys and 204 girls) with a mean age of 128.38±56.39
                      months were enrolled. The mean serum level of 25(OH)D was 15.32±8.64 ng/mL. The mean values
                      of vitamin D were associated with age, sex, traditional clothing style, having a sunburn history, and
                      sunscreen use (P < 0.05). Adolescents and girls had vitamin D deficiency and inadequacy more than
                      younger children and boys (P < 0.05). Sunscreen use in the adequacy group was lower than in the
                      inadequacy and deficiency groups (P = 0.001). There was no significant difference between vitamin D
                      status according to the sunscreen details (sun protection factor, product source, season, and body
                      areas) (P > 0.05).
                      Conclusions: Sunscreen use appears to reduce vitamin D levels measured in winter. Children, e­ specially
                      girls and adolescents, should be exposed to sufficient sunlight to maintain normal serum vitamin
                      D levels. Vitamin D supplementation should be given to children, especially during winter.




Introduction                                                       behaviors (such as wearing a hat and sunglasses) and vitamin
                                                                   D levels.
The prevalence of vitamin D deficiency and insufficiency
among different pediatric age groups was evaluated by sev-
                                                                   Objectives
eral studies and high percentages of hypovitaminosis D were
reported worldwide [1-3]. Exposure of the skin to sunlight is      Our study aimed to assess serum vitamin D levels in healthy
the major source of vitamin D. Only some food including oily       children aged 0-18 years in the winter season and determine
fish such as salmon, swordfish, tuna, cod liver oil, and sun-      the association between sunscreen use and sun protection be-
dried mushrooms naturally contain adequate v­ itamin D [3].        haviors on vitamin D status.
Vitamin D-fortified milk and orange juice provide another
food source for vitamin D [5]. The main reason for v­ itamin D     Methods
deficiency is inadequate exposure to sunlight [1-6].
    When the human skin is exposed to sunlight, most of this       The study was conducted in dermatology and pediatrics out-
UVB radiation is absorbed in the epidermis and most vitamin        patient clinics between December 2021 and March 2022 in a
D is produced in the living cells in the epidermis [7,8]. Sun-     Training and Research Hospital in Ankara. The study period
light exposure-induced vitamin D synthesis is influenced by        was chosen as winter, with minimum ultraviolet exposure in the
many important variables including the season of the year,         middle region of Türkiye, taking into account the differences in
time of day, latitude, altitude, air pollution, skin color, age,   serum levels of vitamin D that may be shown by the season
area of skin exposed, clothing habits, sunscreen use, sunlight     and sun exposure. Institutional review board protocol approval
passing through glass and plastic, and aging [8,9].                was obtained from the hospital ethics and scientific committee
    Sun protection is widely recommended from childhood            (Approval date: 08.07.2021, Decision number: 2021-07/1273),
to prevent both melanoma and non-melanoma skin cancer              and written informed consent was obtained from the parents
as ultraviolet radiation (UVR) causes sunburn and UVR is           of all the children. This research was conducted in compliance
defined as a carcinogen. Sunscreens were designed to absorb        with the principles of the Declaration of Helsinki.
solar UVB radiation. Concerns have been expressed about               The participants in this study were randomly selected
the negative effects of limiting UVB exposure on vitamin D         from Caucasian children who were admitted to pediatric
status because vitamin D production is associated with direct      outpatient clinics for routine examinations. Healthy children
sunlight exposure [7,10]. The role that sunscreens play in         aged 0-18 years, both girls and boys, were enrolled in the
reducing vitamin D synthesis is still unclear [1]. Although        study. Adolescence is the life stage between childhood and
experimental studies suggest a theoretical risk that sunscreen     adulthood, between the ages of 10 and 19 years; our study
use may affect vitamin D, there are no randomized controlled       groups are classified according to age groups as children aged
trials or longitudinal studies reporting that sunscreens sig-      under 10 years, and adolescents as age 10 years and older.
nificantly suppress cutaneous vitamin D synthesis [9,11].             The demographic data, clothing style, history of sunburn,
    There are only limited real-life studies evaluating the re-    history of visiting seaside towns to swim in summer, and sun
lationship between sunscreen use and serum levels of vitamin       protection behaviors including sunscreen use and wearing
D in children in the recent literature. Less is known about        sunglasses and hats were obtained from each parent and child
the association between other recommended sun protection           through face-to-face interviews. Detailed information about




2                                                                      Original Article | Dermatol Pract Concept. 2023;13(3):e2023190
sunscreen use, whether sunscreen products were bought              (172 boys and 204 girls) with a mean age of 128.38 ± 56.39
from pharmacies or supermarkets, sun protection factor             months and median age of 132 (min 9-max 216) months.
(SPF) levels (SPF ≤ 30 or SPF 50), applying sunscreen to the       The mean serum level of 25(OH)D was 15.32 ± 8.64 ng/mL.
face and/or body, and applying sunscreen in the summertime,        The mean BMI of the children was 19.22 ± 10.99 kg/m2 and
sunny days or all seasons were also recorded. The weight and       the median was 18.66 kg/m2. The percentages of data and
height of the participants were assessed using a standard pro-     comparisons of demographic data and mean values of vita-
tocol, and body mass index (BMI) was calculated as weight          min D are presented in Table 1. The most seen skin type was
(kg)/height (m)2. The clothing style of participants who wore      Fitzpatrick type 4 with 50%. Fitzpatrick skin types 1 and 6
long sleeves and pants/skirts all year was expressed as tradi-     were not found in the study group. Some 12.5% of children
tional clothing. The children’s skin color was classified us-      had a history of sunburn, and 4.8% wore traditional cloth-
ing the Fitzpatrick skin phototype classification, which was       ing. Nearly 60% of the children regularly visited a seaside
based on the skin’s response to ultraviolet light [12].            town in summer, 64.4% of children wore a hat under the
    Vitamin D status is assessed by measuring blood levels of      sun, and 31.1% wore sunglasses. More than half of the chil-
total 25(OH)D. Serum levels of 25(OH)D were measured us-           dren (58.5%) did not use sunscreens. The mean values of
ing a Roche Cobas E601 Modular Diagnostic System. Data             vitamin D were low in children aged over 10 years old, girls,
were recorded from the laboratory results in the hospital data     those who wore traditional clothing, had a sunburn history,
system. We used the widely used cut-off points as suggested        and sunscreen users (P < 0.05).
by Munns et al [13]. According to their criteria, vitamin D de-       Table 2 presents the details of sunscreen use in the group
ficiency was defined as a serum 25(OH)D level of <12 ng/mL         that used sunscreen; 55% of the group preferred sunscreens
(<30 nmol/L) and insufficiency as a 25(OH)D level between          with SPF ≤30. Sunscreen products were bought almost
12 and 20 ng/mL (30-50 nmol/L). Twenty-five(OH)D levels            equally from both pharmacies and supermarkets. Of the
>20 ng/mL (50 nmol/L) were accepted as adequate.                   children who used sunscreen, half used sunscreens only in
    The exclusion criteria were intake of vitamin D supple-        summer and nearly 95% of children applied sunscreen both
ments during the previous year, risk factors for the develop-      to the face and body. There was no significant difference
ment of vitamin D deficiency, known metabolic bone disease,        between the details of sunscreen use and vitamin D levels
diseases or medicines known to affect vitamin D or calcium         (P > 0.05).
metabolism, acute diseases during the past two months, and            Vitamin D deficiency was recorded in 33.5% (N = 126)
chronic health conditions, e.g., diabetes mellitus, obesity. Ad-   of the children and inadequacy was in 46% (N = 173).
ditionally, children with excessively high and toxic levels of     Seventy-seven (20.5%) patients had adequate levels of
25(OH)D were excluded.                                             vitamin D. There was a significant difference among age
                                                                   groups and sex in terms of adequacy of vitamin D (P = 0.003
Statistical Analysis                                               and P < 0.001, respectively). Adolescents and girls had vi-
Statistical analysis was performed using the Statistical Pack-     tamin D deficiency and inadequacy more than younger
age for the Social Sciences (SPSS) for Windows version 20.0        children and boys. There was a statistically significant differ-
software package. Descriptive statistics are presented as          ence in terms of vitamin D levels according to sunscreen use
numbers and percentages for categorical variables, and mean        (P = 0.001). The rate of sunscreen use in the adequacy group
± standard deviation and minimum-maximum values for                was lower than in the inadequacy and deficiency groups.
numerical variables. In the analysis of numerical data, com-       There was no significant difference between vitamin D de-
pliance with normal distribution was examined using the            ficiency/inadequacy/adequacy groups according to the sun-
Kolmogorov-Smirnov test, and because all numerical vari-           screen SPF, product source, in which season sunscreen was
ables did not show normal distribution, the Mann-Whitney           used, and areas of the body it was used (P > 0.05) (Table 3).
U test was used in the comparison of two independent
groups, and the Kruskal-Wallis H test was used in the com-
                                                                   Conclusions
parisons of more than two groups. Analyses of categorical
variables were performed using the Chi-square test. P values       The present study evaluated the relationship between vita-
less than 0.05 were considered statistically significant.          min D status and sun protection behaviors and sunscreen
                                                                   use in a Turkish pediatric series. It revealed that 79.5% of
                                                                   the patients had deficient and inadequate levels of vitamin D.
Results                                                            Adolescents, girls, and sunscreen users had lower serum lev-
After 44 children who were under supplement treatment              els of vitamin D causing deficiency and inadequacy. History
were excluded, the study group consisted of 376 children           of sunburn and traditional clothing had only a lowering




Original Article | Dermatol Pract Concept. 2023;13(3):e2023190                                                                   3
               Table 1. Demographic data and vitamin D levels in the study group (N = 376).


                                                                       N (%)           Vitamin D Mean±SD              P value
 Age, years
                                                                     153 (40.7)             17.49±10.58
   <10                                                                                                                <0.001
                                                                     223 (59.3)              13.93±6.54
   >=10
 Gender
                                                                     172 (45.7)              16.64±8.27
   Male                                                                                                                 0.001
                                                                     204 (54.3)              14.32±8.73
   Female
 Skin type
                                                                       29 (7.7)              15.47±5.14
   Type 2
                                                                     119 (31.6)             15.75±10.43
   Type 3                                                                                                               0.772
                                                                     188 (50.0)              15.26±8.19
   Type 4
                                                                      40 (10.6)              14.80±6.18
   Type 5
 Clothing style
                                                                       18 (4.8)              11.53±5.30
   Veiled                                                                                                               0.023
                                                                     358 (95.2)              15.58±8.68
   Normal
 History of sunburn
                                                                      47 (12.5)              12.95±5.95
  Yes                                                                                                                   0.020
                                                                     329 (87.5)              15.73±8.85
   No
 History of visiting seaside in summer regularly
                                                                     224 (59.6)              15.06±7.36
  Yes                                                                                                                   0.792
                                                                     152 (40.4)             15.86±10.13
   No
 Wearing a hat
                                                                     242 (64.4)              15.06±7.11
  Yes                                                                                                                   0.864
                                                                     134 (35.6)             15.97±10.76
  No
 Wearing sunglasses
                                                                     117 (31.1)              14.58±6.85
  Yes                                                                                                                   0.484
                                                                     259 (68.9)              15.74±9.25
  No
 Sunscreen usage
                                                                     156 (41.5)              14.13±6.54
   Yes                                                                                                                  0.030
                                                                     220 (58.5)              16.27±9.70
   No

SD = standard deviation.


Table 2. The details of sunscreen usage in the group using sunscreen (N =156) and vitamin D levels.
                                                          N (%)                Vitamin D Mean±SD                   P value
 Sunscreen SPF
                                                         86 (55.1)                 14.37 ± 6.23
   SPF 30/less than 30                                                                                               0.625
                                                         70 (44.9)                 13.84 ± 6.95
   SPF 50
 Usage season
                                                         84 (53.8)                 13.51 ± 6.14
   Only summer
                                                         35 (22.4)                 14.01 ± 5.48                      0.337
   Sunny days
                                                         37 (23.7)                 15.67 ± 8.10
   All seasons
 Product source
                                                         79 (50.6)                 13.67 ± 6.22
   Market                                                                                                            0.385
                                                         77 (49.4)                 14.61± 6.96
   Pharmacy
 Areas used
                                                          8 (5.1)                  17.48 ± 7.53
   Only face                                                                                                         0.149
                                                        148 (94.9)                 13.95 ± 6.47
   Face and body

SD = standard deviation; SPF = sun protection factor.




4                                                                     Original Article | Dermatol Pract Concept. 2023;13(3):e2023190
 Table 3. Vitamin D deficiency, inadequacy, and adequacy according to demographic characteristics,
                           sun protection behaviors and sunscreen details.
                                                                                       Adequacy
                                                     Deficiency <12    Inadequacy 12- >20 (N=77) N
                                                     (N =126) N (%)   20 (N=173) N (%)     (%)         P value
 Age, years
                                                       42 (27.5)          67 (43.8)       44 (28.8)
   <10                                                                                                 0.003
                                                       84 (37.7)         106 (47.5)       33 (14.8)
   >=10
 Gender
                                                       50 (29.1)         71 (41.3)        51 (29.7)
   Male                                                                                                <0.001
                                                       76 (37.3)         102 (50)         26 (12.7)
   Female
 Skin type
                                                        8 (27.6)         17 (58.6)        4 (13.8)
   Type 2
                                                       36 (30.3)         57 (47.9)        26 (21.8)
   Type 3                                                                                              0.737
                                                       67 (35.6)         81 (43.1)        40 (21.3)
   Type 4
                                                       15 (37.5)          18 (45)         7 (17.5)
   Type 5
 Clothing style
                                                         9 (50)           7 (38.9)        2 (11.1)
   Veiled                                                                                              0.279
                                                       117 (32.7)        166 (46.4)       75 (20.9)
   Normal
 History of sunburn
                                                        19 (40.4)         24 (51.1)        4 (8.5)
  Yes                                                                                                  0.090
                                                       107 (32.5)        149 (45.3)       73 (22.2)
   No
 History of visiting seaside in summer regularly
                                                       72 (32.1)         112 (50)         40 (17.9)
  Yes                                                                                                  0.130
                                                       54 (35.5)         61 (40.1)        37 (24.3)
   No
 Wearing a hat
                                                       81 (33.5)         110 (45.5)       51 (21.1)
  Yes                                                                                                  0.921
                                                       45 (33.6)          63 (47)         26 (19.4)
  No
 Wearing sunglasses
                                                       42 (35.9)          51 (43.6)       24 (20.5)
  Yes                                                                                                  0.777
                                                       84 (32.4)         122 (47.1)       53 (20.5)
  No
 Sunscreen usage
                                                        53 (34)          85 (54.5)        18 (11.5)
   Yes                                                                                                 0.001
                                                       73 (33.2)          88 (40)         59 (26.8)
   No
 Sunscreen details in suncreen usage group (n=156)
                                                                                         Adequacy
                                                     Deficiency <12   Inadequacy 12-    >20 (N=18) N
                                                      (N=53) N (%)    20 (N=85) N (%)        (%)       P value
 Sunscreen SPF
                                                       27 (31.4)          49 (57)         10 (11.6)
   SPF 30/less than 30                                                                                 0.743
                                                       26 (37.1)         36 (51.4)         8 (11.4)
   SPF 50
 Usage season
                                                       32 (38.1)         44 (52.4)          8 (9.5)
   Only summer
                                                       10 (28.6)         22 (62.9)          3 (8.6)    0.432
   Sunny days
                                                       11 (29.7)         19 (51.4)         7 (18.9)
   All seasons
 Product source
                                                       27 (34.2)         47 (59.5)         5 (6.3)
   Market                                                                                              0.105
                                                       26 (33.8)         38 (49.4)        13 (16.9)
   Pharmacy
 Areas used
                                                        1 (12.5)          5 (62.5)         2 (25)
   Only face                                                                                           0.277
                                                       52 (35.1)         80 (54.1)        16 (10.8)
   Face and body

SPF = sun protection factor.
effect on mean serum levels of vitamin D but not the ade-         Conflictingly, Pulungan et al [27] found no significant differ-
quacy of vitamin D status in children.                            ence between vitamin D insufficient and vitamin D sufficient
    The prevalence of vitamin D deficiency observed varied        children related to types of clothing, among whom all girls
from 24% to 99% in different studies and regions [14,15]. In      wore hijabs (long sleeves, long skirts, and headscarves).
Türkiye, the prevalence of vitamin D deficiency for children         Vitamin D levels were lower in children with a sun-
was 39.8% in a meta-analysis review [4]. In this study, vita-     burn history; however, no significant difference was found
min D deficiency was found similarly at 33.5%. In a study         between vitamin D deficiency, inadequacy, and adequacy
with children aged 6-9 years, according to values measured
                                                  ​​              among children with a sunburn history. Having sunburn pre-
throughout the year, vitamin D deficiency was observed in         viously may direct to more sun protection behaviors, there-
5.6% of children and insufficiency in 18.6% [16]. We found        fore, vitamin D levels may decrease. Linos et al found that
a deficiency in 27.5% and inadequacy in 43.8% of those            sunscreen was more frequently used in subjects who were
aged less than 10 years. The higher rate in our results may be    more likely to get sunburn [29].
due to the season. The study was conducted in winter when            To protect against UVR, almost all medical associations
most children stay indoors. The average temperature in An-        and societies recommend seeking shade during midday hours
kara is 1.4°C and the mean duration of sunshine is 3 hours        and wearing protective clothing, a hat with a wide brim, and
per day during winter [17]. Researchers found that vitamin        sunglasses, besides using broad-spectrum sunscreens [29,30].
D levels increased in summer [15,18] and decreased in win-        Although there was no relationship between vitamin D lev-
ter [16,19-22]. Outdoor physical activities are also limited in   els and wearing a hat and sunglasses, sunscreen users had
winter. Thus, vitamin D deficiency continues to be a severe       lower levels of serum vitamin D. Wearing a sunhat or using
problem, especially in non-sunny seasons.                         sunscreen was not associated with lower vitamin D status in
    Vitamin D deficiency increased with age in our study.         some studies [10,29]. In Hansen et al study, seeking shade
In recent studies, older children and adolescents had lower       and wearing protective clothing were significantly associated
median vitamin D levels than younger children, compatible         with lower vitamin D status in adults but not in children
with our results [6,15,18,22-25]. In the current study, the       [10]. In another study, Danish school children who used hats
prevalence of vitamin D deficiency in adolescents was 65.1%       rarely/never had 12.1 nmol/L higher vitamin D levels com-
and insufficiency was 58.1%. By contrast, the prevalence of       pared with school children who always/often used hats [31].
low concentrations of 25(OH)D in adolescents was found as         There is no clear relationship between vitamin D concentra-
75% in Feketea et al study [6]. In adolescents from Kuwait,       tions and sun exposure guidelines because, in real life, there
81% and 15% of adolescents were vitamin D deficient or vi-        is no certainty if children pay attention to sun protection [6].
tamin D insufficient, respectively [24]. Vitamin D deficiency        Sunscreens limit the absorption of UVB radiation over the
was highly prevalent (61.6%) in Qatari adolescents aged           skin and applying sunscreens is encouraged in time to prevent
11-16 years. Older skin seems to synthesize less vitamin D        sunburn, skin aging, and skin cancer development [9,32]. Us-
than younger skin [23].                                           ing sunscreens and their effect on vitamin D synthesis still
    The serum levels of vitamin D were significantly lower        seems to be confusing. Some studies showed that sunscreen
among girls compared with boys in our study, in line with         agents caused a defect in the cutaneous synthesis of vitamin
most other studies [14,15,18,19,22-26]. In contrast to these      D [33-35]. Sunscreen use on the entire body blocked ultra-
results, some studies found no significant difference be-         violet-induced vitamin D synthesis, if >19% of total body
tween the sexes in mean levels of vitamin D [6,16,21,26,27].      surface area was not applied with sunscreen, vitamin D lev-
Al-Taiar et al. supposed that an indoor lifestyle might be        els increase significantly [35]. Similarly, Holick et al reported
more common in girls and may exacerbate vitamin D defi-           that daily application of sunscreen with SPF 8 on all sun-ex-
ciency [24]. Taking into account this sex disparity, improving    posed body areas decreased vitamin D production by the
vitamin D levels among adolescents should focus on girls by       skin [3]. Individuals with low sun exposure and regular use
supporting safe sunlight exposure and/or intake of vitamin        of sunscreens had an odds ratio of hypovitaminosis D [21].
D-rich foods and supplements [24].                                Some studies found that sunscreens did not prevent the pro-
    We found lower mean vitamin D levels in children who          duction of sufficient vitamin D. Vitamin D production can be
wore traditional clothing. Vitamin D status was affected by a     reduced by the strict use of sunscreens at recommended con-
covered style of dress that prevented exposure to direct sun-     centrations of 2 mg/cm2; however, their inadequate applica-
light [4,10,14]. Vitamin D insufficiency and deficiency were      tion (<2mg/cm2), mostly done by average users, does not lead
found more common among Turkish adolescent girls, par-            vitamin D deficiency [5,9]. Marks et al [36] concluded that
ticularly those wearing concealing clothing [28]. In Sherief      sufficient exposure to the sun was achieved during the Aus-
et al study among healthy Egyptian adolescents, all females       tralian summer to allow adequate vitamin D production in
were wearing hijabs and all had vitamin D deficiency [8,14].      subjects who regularly applied sunscreens. Farrerons et al [37]



6                                                                     Original Article | Dermatol Pract Concept. 2023;13(3):e2023190
showed that 1,25(OH)2D levels did not change significantly        reported in self-reports of these behaviors in questionnaires
in either the sunscreen user group or the control groups          and intervention research [40].
with the season of the year. Serum 25(OH)D concentrations             In conclusion, keeping the risk of sunburn and skin can-
in winter decreased by 17–40% in sunscreen users and by           cer in mind, children should benefit from the sun adequately
31–35% in the controls. The use of sunscreen was not asso-        during the winter. Special attention should be given to girls
ciated with vitamin D deficiency even when analyses were          and adolescents because they have more vitamin D inade-
restricted to adult subjects using sunscreens with SPF >15        quacy and deficiency. Vitamin D supplementation should be
or SPF >30 [29]. Some studies showed that the use of oral         given to children, especially during winter. Further studies
vitamin D supplements was associated with higher vitamin          including vitamin D measurements from various cities and
D levels compared with sunlight exposure [38,39]. Most            all seasons are required to clarify the effects of sun-protective
(65%) observational studies found no association between          behaviors on vitamin D levels.
sunscreen and vitamin D concentration [33]. Results from
existing trials and observational studies support the low risk.
    In this current study, children who used sunscreens had
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