Exposure to solar radiation can have positive effects on the human body, but it can also cause damages and melanoma is the most significant among those. The aim of the present study was to gather information about the effects of solar radiation on the human body and to update available knowledge in accordance with new international data. A systematic literature review took place and included both Greek and international books, articles, studies and related papers on the internet (PubMed, Cinahl, Scopus and Iatrotek databases), published from 1998 to this day. Dissertations and “gray literature” (e.g. conference proceedings) were not included in this study. The following terms (“Ultraviolet radiation, skin cancer, sun, sun exposure, electromagnetic spectrum, conjunctiva, cataract, squamous cell cancer , basal cell cancer, cutaneous melanoma”) were used as key-words. UVR may have an impact on the human body according to wavelength. UVA and UVB exposure may cause photoaging and sunburns, and UVC may induce DNA mutations leading to skin cancer. Ozone is the main protective mechanism since it absorbs most of UVR. Ozone layer depletion in the last decades has lead to increased rates of sun-related damages. Most significant damages include cataract and skin damages such as photoaging and skin cancers. Among skin cancers, melanoma has the highest incidence in ever younger ages reducing life expectancy. A good part of the international literature focuses on primary prevention measures and interventions that include mole monitoring.

1. WORLD ACADEMIC JOURNAL OF BUSINESS & APPLIED SCIENCES-MARCH-SEPTEMBER 2013 EDITION
Journal of Health Science (JHS)
SEPTEMBER 2013 VOL.1, No.7
The impact of solar radiation on the human body
Saridi Maria (Corresponding author) Papakonstantinou Elpida & Rekleiti Maria
General Hospital of Korinthos, Greece, 33 Sina str, GR-20100, Korinthos, Greece
Accepted 3 September 2013
Abstract
Exposure to solar radiation can have positive effects on the human body, but it can also cause damages and
melanoma is the most significant among those. The aim of the present study was to gather information about the
effects of solar radiation on the human body and to update available knowledge in accordance with new
international data. A systematic literature review took place and included both Greek and international books,
articles, studies and related papers on the internet (PubMed, Cinahl, Scopus and Iatrotek databases), published
from 1998 to this day. Dissertations and “gray literature” (e.g. conference proceedings) were not included in this
study. The following terms (“Ultraviolet radiation, skin cancer, sun, sun exposure, electromagnetic spectrum,
conjunctiva, cataract, squamous cell cancer , basal cell cancer, cutaneous melanoma”) were used as key-words.
UVR may have an impact on the human body according to wavelength. UVA and UVB exposure may cause
photoaging and sunburns, and UVC may induce DNA mutations leading to skin cancer. Ozone is the main
protective mechanism since it absorbs most of UVR. Ozone layer depletion in the last decades has lead to
increased rates of sun-related damages. Most significant damages include cataract and skin damages such as
photoaging and skin cancers. Among skin cancers, melanoma has the highest incidence in ever younger ages
reducing life expectancy. A good part of the international literature focuses on primary prevention measures and
interventions that include mole monitoring.
Key Words: Ultraviolet radiation, skin cancer, sun, sun exposure, electromagnetic spectrum, melanoma
1. Introduction
Solar radiation can have both positive and negative effects on the human body. Several essential procedures such
as vitamin D synthesis are triggered by solar radiation. Also sun exposure can have beneficial effects on several
diseases (Gies et al, 1998a).
Both UVA and UVB are important for human health. Low levels of solar radiation are crucial for the synthesis of
vitamin D, while overexposure may lead to acute and chronic damage to the skin, the eyes or the immune system
(Zepp et al, 2011a; Lemus-Deschamps & Makin, 2012a). Ozone layer depletion has lead to increased UVB
radiation-induced damages to humans, animals, deep-sea organisms and plants. It has been estimated that a
further 10% depletion of the ozone layer in the following years could cause 300 000 new skin cancer cases
(squamous and basal cell cancer), 4 500 new melanomas and 1.6-1.75 million cases of cataract each year
worldwide (Tourpali et al, 2009a; Aucamp et al, 2010a).
Aim: The aim of the present study was to gather information about the effects of solar radiation on the human
body and to update available knowledge in accordance with new international findings.
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2. Literature review
A comprehensive literature review took place by using Greek and international databases (PubMed, Cinahl,
Scopus, Ιatrotek), relevant books and other relevant sources (WHO, CDC). The survey of the related literature
included material published between 1998-2012, and the following key-words were used: Ultraviolet radiation,
skin cancer, sun, sun exposure, ozon, electromagnetic spectrum, conjunctiva, cataracts, Squamous cell cancer,
Basal cell cancer and melanoma. All related literature includes an abundance of research findings from all over
the world regarding the effects of solar radiation on humans. Australia, USA and New Zealand, due to high
incidence of sun-related health conditions have launched health education programs that stand as an example for
other countries (including Greece) to follow.
2.1 Ultraviolet radiation (UVR)
The Sun is a star in our galaxy that emits energy in the form of electromagnetic radiation, and has a surface
temperature of about 6000 degrees Celsius. The electromagnetic radiation emitted by the photosphere ranges
from very short wavelengths (gamma rays) to long wavelengths and for the most part it reaches the external
layers of the Earth's atmosphere. The radiations that have an effect on human skin are just a fraction of the solar
spectrum. Those radiations are the Infra-Red radiation, visible light, Ultra Violet radiation, gamma and X rays,
radio waves and microwaves (Gies et al, 1998b).
Ultraviolet radiation is a fraction of the electromagnetic spectrum and it has three sub-types (UVC, UVB, UVA),
(Table 1) according to wavelengths (in nanometers) and effects on human skin. UVC rays (wavelength 100 280 nm) are absorbed by ozone, oxygen and carbon dioxide, while UVA (wavelength 315 - 400 nm) and 10% of
UVB (wavelength 280 - 315 nm) reach the surface of the Earth, but not in the same degree, because rays are
absorbed at different rates by the Earth's atmosphere (Zepp et al, 2011b).
2.2 Natural Factors affecting Solar Radiation
There are several factors affecting the intensity of solar radiation (Table 2) (Gies et al, 1998c). The UVR
intensity reaches its peak at noon rather than in the morning, in the summer rather than the winter, and in
equatorial countries rather than Europe (Tourpali et al, 2009b; Aucamp et al, 2010b; Lemus-Deschamps & Makin,
2012b).
UVR is more intense when the sky is clear. Clouds generally decrease the UVR intensity, but that depends
mainly on the clouds' thickness and type. Thin and scattered clouds decrease UVR intensity by a mere 10%,
while low and thick clouds reflect UVR significantly (almost by 80%). When the solar disc is visible, then UVR
reflection is almost negligible.
UVR becomes more intense the farther away from the sea level one moves, since the atmospheric elements that
absorb most of it decrease by height. It has been estimated that 1000 meters from the ground, UVR increases by
10%. Almost 95% of UVR can penetrate water (e.g. the sea) and almost 50% of it can reach a depth of about 3
meters. Consequently when one swims their body is just a few centimeters above sea surface; hence they are
virtually unprotected against UVR. When the sky is clear, UVR is more intense at noon rather than in the
morning or afternoon. When the Sun is at its peak, radiation is also more intense (because solar rays reach the
Earth directly). This is why solar radiation is more intense in the summer rather than the winter (Zerefos et al,
2000a; Lemus-Deschamps & Makin, 2012c).
An object or an individual receives solar radiation directly (from the sky) and indirectly (radiation reflected on
the ground). The amount of the reflected radiation depends on the type of the surface. Trees, grass and water
reflect less than 10% of UVR; on the other hand, fresh snow reflects up to 80% of UVR and dry sand almost
20% of solar radiation. Consequently, those who are in snowy areas or sandy beaches receive more solar
radiation. Some reflection levels according to the surface type: Grass reflects a mere 3%, sea water 5%, sand
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17% and snow 85% (Table 3). Clouds absorb 30-80% of solar radiation (according to height, thickness, etc) but
not all of it (Aucamp et al, 2011c; Lemus-Deschamps & Makin, 2012d).
2.3 Ozone as a Protective Mechanism against Solar Radiation
12-15 km above the surface of the Earth, namely in the stratosphere, a thick layer of ozone exists, a gas that its
molecule consists of three oxygen atoms. Ozone is formed by atmospheric oxygen and ultraviolet radiation from
the Sun. The ozone layer virtually shields the Earth from the damaging effects of solar radiation (Zerefos et al,
2000b; Garane et al, 2006a).
Ozone absorbs the solar radiation and transforms it to heat. Solar light gets filtered while traveling through the
atmosphere and dangerous wavelengths (cosmic radiation, gamma and X rays, UVC) are blocked. Should this
protection mechanism cease to exist, life as we know it (flora, fauna, bacteria and viruses), would perish (Isaksen
et al, 2005a).
The role of ozone is twofold:
(a) It absorbs part of UVR and transforms it to heat; and
(b) It blocks the dangerous types of UVR that otherwise would have had a devastating impact on the ecosystem.
The depletion of the ozone layer mainly because of chemical agents such as chlorofluorocarbons (CFCs) in the
last decades of the 20th century is a globally acknowledged problem that has alarmed scientists, governments and
the public. It has been estimated that when ozone decreases by 1% and UVB increases by 2%, squamous and
basal cell cancers and melanomas increase by 1-3% (Zerefos et al, 2000c; Isaksen et al, 2005b; Garane et al,
2006b).
The ozone hole in the southern hemisphere increases every years, although its size varies according to season. It
has been estimated that in the winter ozone decreases by 10% every ten years. Ozone generally increases in the
summer because of higher temperatures that speed up chemical reactions involving volatile hydrocarbons and
nitrogen oxides from factories and cars that help increase the amount of ozone. On the other hand, lower
temperatures slow down the chemical reactions and thus the photochemical smog is a rare incidence. Thus, the
synthesis of tropospheric ozone is favoured during the warmer months of the year (late spring and summer)
(Isaksen et al, 2005c; Garane et al, 2006c).
Ozone levels in Greece, according to daily measurements from November 1978 to April 1993, have increased
–mainly in late winter and early spring. On the contrary no significant increase has been established for summer
months. Nevertheless, in Greece overall ozone levels have not changed dramatically, as in other countries such as
Australia or New Zealand, a fact that could explain also the lower skin cancer incidence in Greece compared to
those countries (Varotsos, 1998; NASA's TOMS, 2005).
2.4 Biological Effects of Solar Radiation
The organs most exposed to sun rays are the skin and the eyes. Exposure to solar radiation could result in direct
or chronic disorders of the skin, the eyes and the immune system (Haake & Holbrook, 1999a; Lagerlund et al,
2002).
Exposure to solar radiation may have sunburns or photokeratitis as a direct impact. Cancer and premature skin
aging are among the chronic effects. UVA affects the subcutaneous tissue and can alter collagen and elastin
structure. Cataract, pterygium and keratopathy are also among chronic conditions due to exposure to solar
radiation.
UVR can lead to the restructuring of DNA, something that can lead to mutations. The ability of the human body
to heal and restore solar radiation-induced damages decreases by age. As a rule of thumb, the shorter the
wavelength, the higher the risks associated with UVR exposure (Haake & Holbrook, 1999b).
2.5 The Beneficial Effects of Solar Radiation
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Moderate sun exposure can have several positive effects on the human health and mood. The sun is vital for life
on Earth. It activates provitamin D3, which exists on the skin, to vitamin D3 which regulates calcium and
phosphorus metabolism; D3 deficiency can cause rickets, especially in children. Solar radiation can also
ameliorate some skin diseases, such as psoriasis and acne, and it also activates the synthesis of melanin, a
procedure that thickens the keratin layer and consequently is seen as the most important protection mechanism
against sunburns (Haake & Holbrook, 1999c).
Sun exposure can also affect in a positive way the autonomic nervous system by activating several vitamins,
hormones and enzymes. It stimulates blood circulation, boosts hemoglobin synthesis and lowers blood pressure.
It also makes the body less prone to some bacterial and fungal infections because of its drying effects on the skin.
Moderate sun exposure improves mood and creates positive and optimistic feelings (Gies et al, 1998d; Zepp et al,
2011a).
The sun is also a well-known heat source and an exploitable source of energy; it also is a key-factor for
photosynthesis, a process vital for plants and animals and for the water cycle the procedure responsible for the
continuous movement of water on the Earth and provides fresh water to rivers, lakes and underground water
reservoirs. Consequently, running water can be used as a source of hydroelectric energy, and solar radiation may
be used as a sustainable alternative source of energy (photovoltaic systems) (Zepp et al, 2011b).
2.6 Adverse effects of solar radiation
2,6,1 Effects of Solar Radiation on the Eyes
Ultraviolet radiation can lead to several eye conditions. More than 99% of UVR is absorbed by the outer eye
layers and only a fraction can reach the photo-sensitive retina (Haake & Holbrook, 1999d; Lucas, 2010a; Zepp et
al, 2011c). Prolonged exposure to UVR can damage the eye and even lead to sight loss. Scientific findings have
established that everyone, both children and adults, are susceptible to such risks. UVA can also damage the retina,
since it penetrates much deeper into the eye although it has lower energy. Increased exposure of the eye to the
sun increases the risk of sun-related eye damage. Persons that are exposed to the sun for long periods of time
because of their profession or other activities are running a higher risk of eye damage (Fitzpatrick et al, 2003a;
Lucas, 2010b). The most significant harmful effects of solar radiation on the eye are the following:
Cataract is one of the most important causes of poor eye sight and sight loss worldwide. Laboratory studies have
shown that UVR can cause cataract.
Macular degeneration is the main cause of poor eye sight in people over 55 years of age. Laboratory experiments
have shown that exposure to UVR and visible spectrum radiation can cause damage to the retina.
Pterygium is a tissue-like formation on the white of the eye that extends to the cornea and can hinder eye-sight. It
usually affects people that work outside and are exposed to the sun; its presence is related to the amount of
ultraviolet radiation a person has been exposed to. It can be surgically removed but it frequently recurs and could
cause sight loss if not properly treated.
Photokeratitis is in essence a burn of the cornea which is caused because of excessive UVB exposure. It is
reversible and treatable. It usually affects people who spend much time at the beach or in snowy areas without
protecting their eyes. It can cause acute pain for 1-2 days and temporary sight loss.
2.6.2 Effects of Solar Radiation on the Skin
The skin protects the human body from damaging factors. The skin’s surface performs two main functions:
keratinopoiesis and melanogenesis. Keratinopoiesis is the formation of the hard keratin layer, and melanogenesis
is the synthesis of the skin pigment, melanin. Melanin not only sets the skin colour but it also protects the cells
by absorbing UVR. When the skin is under exposure to the sun, melanin production increases and the skin colour
gets darker (Lucas, 2006 & 2010c).
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The reactions of the skin after prolonged sun exposure are acute or chronic. Acute or direct effects are noticeable
within hours or days after exposure; chronic effects are usually the result sun exposure for prolonged periods of
time (Berg & Allan, 2001).
Skin redness is usually a short-term, temporary skin condition. It is caused by expansion of the skin capillaries
and becomes apparent 2-3 hours after sun exposure, reaching its peak 12-14 hours later. More intense redness
accompanied by pain, itchiness, swelling, blisters or even fever and nausea is considered to be a sunburn.
Sunburn is an acute temporary skin inflammatory reaction due to exposure to solar radiation or non-natural
sunlight (solarium). It causes damage on the ‘gatekeepers’ of the skin, the squamous layer cells. It is a temporary
condition that leaves no scars and at the final stages leads to skin resurfacing. Simple redness that is no longer
exposed to the sun disappears after 24-36 hours, while more serious sunburns may take 4-8 days to heal. The
existence of at least one serious sunburn during childhood or adolescence is a risk factor for skin cancer later in
life.
Solar dermopathy – Photo-ageing. A recurrent skin damage due to the sun over many years can lead to a
syndrome called solar dermopathy. It is the result of excessive or prolonged sun exposure over many years. This
syndrome is in fact the result of the cumulative results of sun exposure. Thin and deep wrinkles appear mainly
around the mouth, above the upper lip, the cheeks and the neck. The skin appears to be yellow actinic elastosis.
Solar lentigo. These are benign brown to black blemishes in white people. There are three types of such localized
blemishes: freckles, juvenile lentigo and solar lentigo. Sun exposure may increase their number and cause them
to become darker. If there is no sun exposure, they become lighter and in the winter they may disappear
altogether. Juvenile lentigo appears in childhood; the spots do not increase in number, they do not change size or
get darker after sun exposure.
Actinic Hyperkeratosis is a premalignant condition and is usually the result of lont-term sun exposure. Actinic
keratosis usually appears in groups in people of fair complexion. Fair complexion and long-term sun exposure
are the main risk factors for actinic keratosis. The lesions appear usually on the face, the arms, the hands, the skin
of the head, and rarely on the shoulder blade, the shoulders, the legs and the feet. Clinically, actinic keratosis
appears as a ragged, thick lesion covered by yellow wing-like formations.
Melanocytic nevi (Moles). These benign lesions are so common that no white person without even one nevus
exists. Apart from the common nevi, there are also several clinical-histological varieties. Since melanocytic nevi
can change into a melanoma, correct diagnosis is substantial for a person’s life. Some nevi have a greater risk of
changing into a melanoma. Dysplastic nevi (atypical moles) are among those that carry a high risk of changing
into a melanoma. Studies have shown that both genetic and environmental factors (e.g. solar radiation) are
involved in these cases. It has been suggested that the existence of a large number of moles can increase the risk
of melanoma. Estimates vary but the risk increases by 10-60 times (Habif, 2002a; Alexandrescu, 2009a). Not all
changes in the appearance of a mole indicate a malignant condition. But a thorough examination by an
experienced pshysician is necessary. The ABCD rule is a well-established method to monitor melanocytic nevi
(Table 4).
Basal Cell Carcinoma (BCC). BCC is a malign skin tumor that damages and penetrates locally the skin, rarely
metastasizes, and is considered to be the most common skin cancer in white people. It usually affects adults and
it appears on the skin excluding palms and sole. BCCs are generally considered to be more benign than SCCs
since they develop slowly and are localized. BCC incidence in males is higher than that of females, although in
the last decades females have increasing incidence rates as well. Annual BCC incidence in the USA is 146 cases
out of 100 000 persons, and in Europe 132 cases per 100 000 persons. Worldwide there are significant
fluctuations in BCC incidence rates (Haake & Holbrook, 1999e; Lemus-Deschamps & Makin, 2012e). In recent
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years, BCC frequency has increased considerably in Europe, Australia (5%) and the US (4.5%). Data from
Greece have shown a similar trend. BCCs usually develop after the age of 40 and their frequency increases by
age. In recent years BCCs have been shown to increase alarmingly in younger ages too (Armstrong & Kricker,
2001; Lucas, 2010d). Although solar radiation has been assumed to be the main factor for the development of
BCCs, the causal relation between them remains rather vague compared to the one between solar radiation and
SCCs. It seems that after an upper limit of accumulated radiation, further sun exposure does not increase the risk
for the development of BCCs (Habif, 2002b; Alexandrescu, 2009b).
Squamous Cell Carcinoma (SCC). SCCs develop due to a malign growth of skin keratocytes, affecting both the
skin and the mucous membrane. Consequently, SCCs can affect the mouth (tongue, palate, mouth angle, and
inner buccal surface), the genitals and the anus. Its most common site is the lower lip semi-mucous membrane
(Zepp et al, 2011d). In the USA alone, more than 1.000.000 persons are affected by some kind of skin cancer
every year. The frequency of SCC varies considerably from country to country. Its highest rate is in Australia
with an incidence of 250 cases per 100.000 people. It is noteworthy that within five years SCC incidence went up
by 50% and males doubled SCC frequency compared to females. The risk of SCCs has been linked to the
accumulated solar radiation over the years and a person’s phototype (Habif, 2002c; Alexandrescu, 2009c).
Thus, people of fair complexion who have freckles, ginger or blond hair, blue eyes and do not tan, but sunburn
easily are considered to be skin cancer-prone. People that are exposed to the sun because of their profession (e.g.
farmers, sailors) and fail to take sun-protection measures are in dramatically higher risk of developing SCC
(English et al, 1998a; Karagas et al, 1999a; American Cancer Society, 2002).
Malign Melanoma (MM). Epidemiological studies focus regularly on melanomas because of their exceptional
interest. The fact that melanoma affects more and more white persons and its relation to solar radiation, has
attracted scientific interest. According to epidemiological studies, melanoma is an extraordinary neoplasm, of
rapidly increasing incidence in Western countries, and some authors suggest that it is an epidemiological
phenomenon. The most common risk factors for melanoma are: fair complexion with many moles or dysplastic
moles, excesive and prolonged dun exposure and esxesive exposure during childhood or adolescence (Siegel et
al, 2012).
It has been observed that cases of melanoma have been increasing for all age-groups and both genders, although
this increase is higher for people 20 to 40 years old. In Europe, almost 26.000 men and 33.300 women are
diagnosed every year with melanoma and almost 8.300 men and 7.600 women die from it. The highest incidence
rates are in Northern and Western Europe, although mortality rates do not show any significant variations
(English et al, 1998b; Karagas et al, 1999b).
In Greece, melanoma-related studies are scarce. Moreover, a well-coordinated record of all diagnosed cases is
virtually nonexistent (Karagas et al, 1999c; Downard et al, 2007). Since 2000, when Greece joined the European
campaign 'Euromelanoma', public information programs have been launched and also all newly diagnosed skin
cancer cases are being recorded (Gies et al, 1998e; de Vries et al, 2003). Between 2000 and 2004, 2.723 persons
had been examined, the majority being less than 50 years old and females (59%) (MacKie et al, 2002;
Roussaki-Schulze et al, 2005). Most of the participants (76%) had had phototypes II and III. 47% of the
participants reported at least one sunburn during childhood, while 5% had had individual or family history of
melanoma. The clinical examination showed actinic keratosis (14.45%), dysplastic nevi (31.2%), and possiple
skin cancer other than melanoma in 6.4% of the participants. Melanoma is an aggressive tumor that metastasizes
early, being characterized by an uncontrollable increase in the number of the melanocytes. It can appear suddenly
on its own, or at the site of an old mole. Its clinical appearance may vary since it can develop on the face, on the
upper surface of arms and on the shank (Fitzpatrick et al, 2003b). The lesion is characteristically multicoloured,
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ranging from dark brown or black to reddish or purple. It develops slowly and the lesion does not have
well-defined borders (WHO, 2003). Melanomas that arise in pre-existing moles are also quite common. Some
basic diagnostic criteria for melanomas include: a lesion that changes size; skin adjacent to the mole becomes
brown; the lesion is multi-coloured; local infiltration; itchiness; the existence of a surrounding inflammatory halo;
pain; ulceration (Table 4) (CDC, 2003).
3. Conclusions
It is evident that the most substantial way to prevent skin cancer is to avoid sun exposure as much as possible.
Since this is not always a realistic option, protection measures, such as sunscreen, staying in the shade and
appropriate clothing, are essential. The general population should be kept continuously informed about skin
cancer prevention and early detection methods, so that any lesion can be examined or diagnosed as early as
possible. Besides primary and secondary prevention campaigns, health education programs and the adoption of
healthier behaviours from an early age are also absolutely necessary.
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Appendix
Table 1. UVR types (Source: Armstrong, B.K.et. al.)
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9. WORLD ACADEMIC JOURNAL OF BUSINESS & APPLIED SCIENCES-MARCH-SEPTEMBER 2013 EDITION
Type
Wavelength
Characteristics
UVA
(400 - 320 nm)
Long wavelength, low energy radiation. It can infiltrate human
skin and reach the dermis. It can damage the collagen tissues
and reduce skin elasticity and cause skin-ageing.
(320 - 290 nm)
Short wavelength, high energy radiation. It increases in the
summer, reaching its peak at noon. It reaches the epidermis. Can
cause sunburns and skin lesions.
UVA
UVC
(290 - 200 nm)
Short wavelength, high energy radiation. Can cause chemical
and genetic changes in living organisms. Absorbed by
stratospheric ozone.
Table 2. Factors affecting solar radiation intensity
FACTORS AFFECTING SOLAR RADIATION
1. Latitude
2. Season of the year
3. Time of the day (direct or abundant sun light)
4. Altitude
5. Reflection (sand, snow, water)
6. Skin phototype
7. Weather conditions (smog, clouds, humidity)
8. Transport of radiation in the atmosphere
Table 3. Surface Reflection Coefficient
Type of surface
Reflection coefficient
Fresh snow
0.87
Dry sand
0.18
Wet sand
0.09
Conifer forest
0.05
New Cement
0.33
Old cement
0.23
Table 4. The ABCD Rule (Source: Gies,et al)
ABCD rule
A (Asymmetry)
Asymmetrical lesion. If divided in the middle, the two halves are
not identical.
B (Border irregular)
Not well-defined lesion borders. They may be elevated, vague,
blurry, irregular; adjacent skin may turn brown.
C (Color Varied)
Multi-coloured lesion. There are several shades of black, brown,
even areas coloured white, grey, red, pink or blue.
D (Diameter >6 mm)
Usually the lesion diameter is over 6 mm. The lesion has
changed its size, usually becomes bigger.
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