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Witnessing ultraviolet (UV) radiation-induced facial aging firsthand may be a useful tool to convince youth to slather on the sunscreen, a new study suggested.

In a randomized trial of high school teens in southeast Brazil, daily use of sunscreen increased among those who were educated on using a free face-aging mobile app -- from 15% to 23% (P<0.001) in the subsequent 6 months, reported Titus Brinker, MD, of the German Cancer Research Center in Heidelberg, and colleagues.

There was also a near doubling in the proportion of teens who performed a minimum of one skin self-exam among those who were taught to use the face-aging app (25.1% to 49.4%, P<0.001), the researchers wrote in their study online in .

Engagement in risky skin behaviors also decreased, with a significant decline in tanning rates -- from 18.8% to 15.2% (P=0.04), the team reported. In contrast, none of these skin-protecting behaviors changed in the control group of teens who didn't use the app.

Interestingly, use of the face-aging app was far more effective among girls than in boys, with a number needed to treat of eight in girls to see a difference in daily sunscreen use versus 31 for boys.

The cluster-randomized clinical trial used the , which works by the user taking a front-facing close-up picture of his or her face and then selecting skin tone from six graded options. Users can then see a simulated image of how they would look after being aged 5, 10, 15, 20, or 25 years in the future, and how the images differ if the person used or did not use sun protection or underwent weekly tanning.

The simulated images present the user with varying degrees of wrinkles, age spots, discoloration, and loss of volume, as well as showing precancerous and cancerous spots on the face. The app also includes a feature showing how skin cancer risks increase according to these three skin practices -- for example, weekly tanning would increase the risk of melanoma and carcinoma by 4.12 times and 2.5 times, respectively.

The study included 1,573 students from eight secondary schools in Itauna, Brazil. In an with JAMA Dermatology web editor Ade Adamson, MD, Brinker explained that the team chose this site in Brazil because of the lack of regular healthcare screenings and for the low melanoma survival rates (which are below the global rates).

"You have a lot of people with European ancestry in Brazil, who are at high risk, so you have high incidence of melanoma in Brazil, but poor detection of melanoma and poor awareness of melanoma," Brinker explained, also noting the high UV-index in Brazil.

Half of the students underwent a school-based intervention in the form of a 45-minute module on using the Sunface app and sun protection behaviors given by medical students. Among the 734 teens in this intervention group, nearly 20% reported having had a tanning session within the past 30 days. Among the teens who used the app, their altered, aged selfies were presented in front of the class for all the individual's classmates to see, which Brinker says may also have played a role in the changed behaviors.

"All in all we were quite satisfied with the effects [of the intervention]," he said.

Writing in an , Sherry Pagoto, PhD, of the University of Connecticut in Storrs, and Alan Geller, MPH, RN, of the Harvard T.H. Chan School of Public Health in Boston, praised the study for being well designed and said it "represents an exciting direction for the science of skin cancer prevention in adolescents."

"Because snapping selfies and using filters to modify them are popular activities of this age group, a selfie mobile app-based intervention engages them with technology that is compatible with their day-to-day habits," Pagoto and Geller said.

They also pointed out that despite the effectiveness to monitor sun damage, UV photography is very expensive, and a free app like this could be a cost-effective alternative.

However, one drawback to the study the editorialists highlighted was a high dropout rate among the intervention group, which was three times higher than in the control group after 6 months, despite students calling the app "fun." Pagoto and Geller suggested that this could have been attributed to the public display of the altered selfies plastered in front of the class, which may have led to negative feelings like shame, embarrassment, bullying, and loss of privacy.

"Future studies using selfies should explore negative peer reactions that occur after the intervention, the psychosocial effect of sharing unattractive selfies with peers, and the degree to which participants would voluntarily share selfies with peers," the editorialists wrote. "That adolescents constantly share selfies and other content with each other on social media gives us an opportunity to explore how to create sun safety content they would want to share with their peers, thereby nudging them to become intervention disseminators."

Brinker noted that his group plans to build upon these findings, to see if the same effects can be achieved in different countries and across different cultural groups. He added that the team also plans to dig deeper into why the number needed to treat was so different between girls and boys, beyond the obvious stereotype that "a girl is more concerned with her outward appearance than a boy is."

"You can't leave out boys from skin cancer prevention," Brinker said.

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