Exposure to UV radiation is the main cause of the most common forms of skin cancer. Surfers can be ‘sun smart’ by simply taking some precautions to protect their skin: 

• Protect your skin with clothing, and remember to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
• Stay in the shade at peak UV radiation exposure times, typically between 11am and 3pm when it is sunny in Northern hemisphere locations. Step out of the sun before your skin has a chance to redden or burn. 
• Apply plenty of broad-spectrum, water-resistant, SPF 30 or higher sunscreen 15 to 30 minutes before going out into the sun, and reapply frequently throughout the day and straight after coming out of the water and drying off with a towel.
• Remember, sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
• Consider purchasing UV protective beach wear (i.e. boardshorts, rash vest, surf hat, etc.) which can particularly assist in protecting your skin.

Answered by Alex Kelleher, MD

Anyone can develop a skin cancer and this risk increases with time and cumulative exposure. However, some people are more likely to do so than others and these include those who have: 

• Fair skin that burns easily
• Light coloured eyes, e.g. blue, grey, or hazel
• Naturally fair blonde or red hair
• Numerous freckles
• An outdoor occupation and/or intense sun exposure at present or in the past*
• An outdoor pursuit such as surfing, cycling, gardening, etc.* 
• Frequent use of artificial sun lamps and/or sunbeds
• Experienced sunburnt skin
• A history of skin cancer
• An organ transplant recipient
• A compromised immune system, e.g. those who have a blood disorder such as leukaemia, or those who are taking immunosuppressive medications

*Note: Without the use of sunscreen

Answered by Alex Kelleher, MD

The commonest cause of skin cancer is exposure to UV radiation, e.g. from sunlight or sunbeds. Hence, protecting yourself from UV radiation exposure can drastically reduce your chance of getting skin cancer. Read the next question on how to stay safe.

Answered by Alex Kelleher, MD

Firstly, you should protect your skin with clothing, i.e. wear a hat that covers your face, neck, and ears, a pair of UV protective sunglasses for when you’re back on shore, and a UV protective rash vest and boardshorts.

Answered by Alex Kelleher, MD

Apply plenty of broad-spectrum, water-resistant, SPF 30 or higher sunscreen to exposed/uncovered skin 15 to 30 minutes before going out into the sun, and reapply frequently throughout the day and straight after coming out of the water and drying off with a towel. Remember, sunscreens should not be used as an alternative to clothing and/or shade, rather they offer additional protection. No sunscreen will provide 100% protection.

Answered by Alex Kelleher, MD

The Sun Protection Factor (SPF) is commonly thought of as how much longer skin covered with sunscreen takes to burn compared with unprotected skin. Let’s say you would typically start to burn after 10 minutes in the sun, then using a SPF 15 rated sunscreen, would imply that you can safely remain in the sun for 10 min x 15 = 150 minutes before burning. Or with an SPF 50 rated sunscreen, you can safely remain in the sun for 50 times as long as compared to no sunscreen. If you’d do the math, that would be 10 min x 50, which would result in 500 minutes. Just be aware that sunscreen wears off during surfing, sweating and due to other activities. So the 50x times only can be assumed if you re-apply your sunscreen regularly.

Another way of thinking about SPF, rather than as time extended in the sun, is in dose/exposure-related terms. If you spend a certain time in the sun, wearing sunscreen with a given SPF would reduce the UV dose to 1/SPF of that which you would experience by spending the same time in the sun but without sunscreen – e.g. applying an SPF30 sunscreen results in a UV exposure of one-thirtieth of that which you would have received had you not worn sunscreen. Of course, one caveat applies, this assumes perfect application, which is rarely achieved. Most people in real life apply less sunscreen than the amount required, and they typically apply it less uniformly leaving patches of skin without adequate protection. As a rule-of-thumb, the protection actually achieved is only about one-third to one-half of the labelled SPF!

Answered by Alex Kelleher, MD

Sure, from a sun protection perspective that’s ideal. Remember, it’s best to stay in the shade at peak UV radiation exposure times, typically between 11am and 3pm when it is sunny in Northern hemisphere locations. Make sure you step out of the sun before your skin has a chance to redden or burn.

Answered by Alex Kelleher, MD

Often the first thing noticeable on a bottle of sunscreen is the SPF rating on the front. If you turn over to the back label you can usually find the Star rating, typically ranging from one-to-five stars, as shown below. 

The higher the number of stars, the more balanced protection offered, i.e. blockade of UVA and UVB radiation. The star rating represents the ratio of UVA-to-UVB protection afforded. You may sometimes see an encircled UVA logo (refer below) on the label, this indicates that the product has been approved by the EU. In practice, it is an equivalent way of saying that the product provides good balanced protection against both UVA and UVB.

Answered by Alex Kelleher, MD

Some researchers have raised concerns that, despite being an unquestionably important tool in reducing the risk of skin cancer development, the formulation of sunscreen may need to be improved to contain safer ingredients.

In 2019 the US Food and Drug Administration (FDA) – one of the two main global regulators of sunscreen ingredients along with the European Commission – removed 14 of the 16 chemicals found in sunscreens from its’ GRASE (generally accepted as safe and effective) category.

Answered by Alex Kelleher, MD

There are two types of UV filters employed in sunscreens. Inorganic UV filters, like titanium dioxide and zinc oxide, are broadly considered safe. Organic sunscreen filters such as oxybenzone and octinoxate have become controversial due to environmental concerns.

In 2018, the Environmental Working Group (EWG) reported that two‐thirds of the commercially available sunscreens in the US contained chemicals, namely predominantly organic filters, that were deemed to be harmful to the environment. The deleterious environmental effects of these filters relate to their impacts on coral reefs, as well as their prevalence in the water supplies and in aquatic wildlife. Furthermore, organic filters have been reported to have negative hormonal effects in animal models. There effects in humans continue to be examined.

For those concerned about the environmental impact of organic UV filters, zinc oxide and titanium oxide containing sunscreens could be used. Note: Zinc oxide and titanium oxide are most often used in combination to provide broad-spectrum UV protection.

Answered by Alex Kelleher, MD

The answer is three (3) times a clear NO!

Let’s clarify three huge misconceptions:

1. Surfer’s Ear is NOT an acute thing. Surfer’s Ear is developing slowly over the years. Even once you got it, it starts to progress slowly. Do not confuse Surfer’s Ear with an ear infection (Otitis), which is another topic we will cover another time.
2. Surfer’s Ear is NOT a disease, it is a condition. In other words: an anatomical special feature. But it might cost you a few surf sessions in the future.
3. Surfer’s Ear is NOT dangerous. But it is specific to the sport of surfing and it can be really annoying.

Learn how you can avoid it or slow it down in the Q&As below.

Answered by M. von Grote, MD and M. Goettinger, MD

Surfer’s Ear is a condition that develops slowly, usually over decades.

If not stoped or slowed down can lead to severe problems like hearing loss or reoccurring ear infections. Or it can be just annoying by trapping more water in your ear canals more often.

Surfer’s Ear is a narrowing of your ear canal (“auditory canal”) caused by bone growth of you skull.

This extra bone growth, also called exostosis (or “bony exostosis”) is caused when your ear canal is exposed to cold water. Even more than just cold water, in combination with wind creating a chill factor, this can really speed up bone growth.
In short:

Cold water & wind → cold ear canal → bone growth → narrowing of the ear canal → Surfer’s Ear

The problem is that once your bone has grown, it doesn’t shrink anymore when your ears get warm again. Surfer’s ear won’t ever disappear — but you can slow it down, or avoid it in the first place.

It is called Surfer’s Ear, because it is common among surfers. As surfers we are frequently exposed to water, wind and (depending on where and when you surf) cold conditions. Yes, also swimmers, triathletes, windsurfers or kiters can get it.

So, cold, water and wind, that’s it?
Not quite. How bad it gets varies from person to person as your genes also have a role in this. So, sometimes people seem to be more prone to develop Surfer’s Ear than others, even if the had the same water+wind+cold exposure. Thank your parents. 😉

Answered by M. von Grote, MD and M. Goettinger, MD

It is called Surfer’s Ear, because it is common among surfers. As surfers we are frequently exposed to water, wind and (depending on where and when you surf) cold conditions. Yes, also swimmers, triathletes, windsurfers or kiters can get it.

Not to be confused with Swimmer’s Ear, or Otitis externa, which is an inflammation of the ear canal. However, having Surfer’s Ear make your more likely to catch such an Otitis externa, which often presents with ear pain, swelling of the ear canal, and occasionally decreased hearing.

Answered by M. von Grote, MD and M. Goettinger, MD

You can’t.
(Without Surgery)

We get your thought: if cold causes it, then warmth will make it go away. Sadly that is not the case.

Once your bone has grown, it doesn’t shrink anymore when your ears get warm again. Think of it how your other bones grow — you start of as a small child, over the time bone grows but it will never shrink again. (Unless you break it, impacts it or because of diseases like osteoporosis occurring mostly in elderly people.)

Surfer’s ear won’t ever disappear — but you can slow it down, or avoid it in the first place.

So, there is this ONE way to make Surfer’s Ear go away: surgery. If your bone growth in the ear canal becomes severe, the only way to have it removed is by surgery. There are currently two major techniques, one where the extra bones get drilled, the other one got chiseled out. While chiselling sound more brutal, it turned out to be the more precise technique leading to better results.

So, yeah, surgery can make it go away, but that is definitely not the most pleasant way. And while surgery buys you time, it doesn’t mean your bone will never grow back when exposed to cold water afterwards. In short: Surgery is the last option! Hence our strong recommendation to avoid Surfer’s Ear as good and as early as possible.

Answered by M. von Grote, MD and M. Goettinger, MD

Not quite. How bad it gets varies from person to person as your genes also have a role in this. Some people seem to be more prone to develop Surfer’s Ear than others, even if the had the same amount of time off “water + wind + cold” exposure. Thank your parents if you are a slow grower. 😉

Answered by M. von Grote, MD and M. Goettinger, MD

1. Water in your ears
   When your ear canal gets narrower due to the bone growth (exostosis), it is harder to get the water out that has gotten in your ears during surfing. Hence, experiencing water stuck in your ears after surfing can be a first sign of developing Surfer’s Ear. (There are other reasons for stuck water too, so don’t freak out if you got water in your ears. Just get them checked.)
   
2. Acute ear infections
   With water being stuck in your ears more frequently and for longer, your ears get worse at drying. This “more humid climate” in your ear canal increases your risk of catching acute ear infections.Also, if the water you surf in is polluted, dirt, chemicals and germs can get stuck in your ear with the water. In healthy ears this nasty stuff gets out quickly again after the surf. If you have surfer’s ear, the nasty pollutants can work its magic for longer, causing increasingly frequent ear infections.
   
3. Hearing loss
   So, by now you know Surfer’s Ear is caused by bone growth in your ear canal. In other words the canal where the sound gets in get narrower and narrower until at some point you will notice a hearing loss. Usually this occurs at a very, very late stage of Surfer’s Ear. Or the other way round: if you start working about Surfer’s Ear when you start hearing less, your only option left is probably surgery.

You have some of those symptoms and wonder if you got Surfer’s Ear? Read on to find out how you can find out.

Answered by M. von Grote, MD and M. Goettinger, MD

First of all: Relax! Surfer’s Ear is not dangerous. It is not a disease, it is a condition. In other words: an anatomical special feature. But it might cost you a few surf sessions in the future. And this is what we are concerned about as your ‘Surf Docs’ and this is why Surfing Medicine International is working on this project.

Protect yourself

Depending on how severe your Surfer’s Ear is and how old you are you should consider wearing ear plugs and/or a hood. If you keep surfing in cold water the bone will keep growing. And if you surf in dirty water you will get infections way easier then surfers without Surfer’s Ear. So, get surgery and be done with it once and for all? Nope, sorry. Surgery is no easy solution since once the bone has been drilled or chipped away it will grow back if you don’t protect your ears in the water.
With the current knowledge about Surfer’s Ear these are the advantages and disadvantages of earplugs and a hood:

Ear Plugs

We do not sell any. So we have no interest in talking you into wearing them. Except for the fact that they seem to do a great job:

• Good wind protection
• Good protection from cold water
• No major change of your looks
• Injury protection (Owen Wright busted his eardrum in competition 2007 in Portugal, Sally Fitzgibbons 2015 in Fiji)

Many surfers choose not to wear them. Because no matter which brand you buy: You have to remember to bring them, put them in, take them out, not loose them, clean them every once in a while. It is a pain. And with many of them your hearing is impaired. People feel disconnected from their environment and many surfers say it affects their equilibrium. For the good ones that feature a membrane and promise less hearing impairment you have to pay around 60 Dollars, check out Doc’s Proplugs / Surfears or EQ Ear Plugs for good quality. Loosing them is pretty annoying. For cheap ones that will keep the water out just as good but the sound as go to Home Depot or a drugstore.

Neoprene Hood

• Good wind protection
• Keeps the whole head warm
• Injury protection
• Sun protection for your eyes and face

Why nobody wears them unless it is freezing? Probably because of the Kook-Look. Yes, even Julian Wilson doesn’t seem that pretty anymore with a hood on. People might drop in on you. From a medical point of view we think they protect you better against Surfer’s Ear than ear plugs because they keep the whole head warm. Let’s see if the data we are collecting supports this theory. A famous hood wearing surfer is Dr. Renneker from Ocean Beach California. He usually wears two hoods (a thin short one and a normal one with a neck part) and is probably the only surfer who spent over 40 Years surfing cold water and does not have Surfer’s Ear!

Other things that work

Care

Ear plugs and hoods are not your thing? There is still something you can do. Just like some people have drier skin than others and use lotion to take care of it, every person’s ear canal hat a different anatomy and you should look after it.

Glycerol/Alcohol (aka ‘Swimmer’s ear drops’)

Most common is the mixture with glycerol and ethanol. It fits well into the natural environment of your ear canal, especially the PH level. Depending on the country you can get the drops in drugstores, supermarkets and pharmacies. Some pharmacists can even mix them themselves. You can put a couple of drops in your ears after every surf especially when the water is dirty. They might not delay the growth of the bone but they will certainly avoid infections and blockage of your ear canal. If you do not like them (some people say they sting) talk to your pharmacist. There are other options.

Hydrogen peroxide/ agua oxigenada/ H202

This solution is easy to buy all over the world. And it is not bad to clean your ears either. However, it is more aggressive than the drops mentioned above. Most important is that you never use a mixture with more than 3% H2O2 and if your ear canal is sensitive it is better to use other drops and to dry your ear gently (for example with a blow-dryer). So if your ear is fully blocked or you surf really dirty water once a month this is a great option. If you need to use drops several times a week use the drops above.

Blow-dryer

You have water stuck in your ear and you can not get it out? This is not only irritating. Bacteria love it when it is moist, the odds to get an ear infection increase. Take a blow-dryer to get rid of the water in your ear canal. It is a simple and effective solution, you will feel the difference. Just don’t hold it too close to your ear and don’t take an extra hot one.

Answered by M. von Grote, MD and M. Goettinger, MD

Just like many ‘therapies’ out there, some are better than others. Few even can worsen the healing, like toothpaste on burns (Nope, don’t do that) or pee on jellyfish stings (Nope, don’t do that either).

Also for Surfer’s Ear there as some Urban Myths, proven to either be ineffective or even causing more harm than doing good.

Here some examples we advise you NOT to do:

• Vinegar
  We met quite a few surfers who put vinegar in their ears to clean them. This is ok, you will not destroy your eardrum doing it once. But honestly, your ears deserve better. So some of the drop recommended above are better.
  
• Pure alcohol
  Alcohol is another effective fluid against germs but not the best care for your eardrum. It is a sensitive region and even if there are not enough vessels in your ear canal to get you drunk pure alcohol is too aggressive for this part of your body.
  
• Oil
  Olive oil is a cure for everything? Not quite. Due to Surfer’s Ear your ear canal is very tight. It will be harder to get the olive oil out of there than the sea water. We are not saying it harms you. It might even have a good effect if you put some drops of oil in your ear before the surf since a fatty surface rejects water. But good luck getting it back out. Olive oil can be put to one very good use (besides in the kitchen): to get insects out of your ear. Sometimes small insects get trapped in the canal. If you pour olive oil in your ear canal they will drown and slide right out.
  
• Limes / Lemons
  Just a clear ‘No’!. It won’t help in Surfer’s Ear, nor in Swimmer’s Ear. “But if it doesn’t harm…?” Well, that’s exactly the point. Just forget about it.

Answered by M. von Grote, MD and M. Goettinger, MD

Risk assessment before going into the water

• Before getting into the water, let someone know! Ideally, you should always go surfing with a partner, especially if you are not a very experienced surfer. But this isn’t always possible, in which case make sure you tell someone that you’re going surfing, including the location and the time you expect to be back.
• When choosing a surf spot, make sure to inform yourself about the local weather and surf forecast and before paddling out, give yourself some time while standing on the shore to observe the current conditions. Be honest with yourself regarding the suitability of the conditions for your skill level.
• Factors you should consider include, but are not limited to: familiarity with the surf spot, especially with regards to possible local hazards (e.g. potentially dangerous rock formations, shallow reef, occurring rips), suitability of your equipment (board, leash and wetsuit) for sea and weather conditions, compatibility of your surfing skill level AND fitness for the wave conditions, time of day (how much daylight is left), UV exposure and sufficiency of current UV protection, etc.
• Also, when surfing at an unfamiliar spot, asking locals about surfing conditions and potential hazards can give you a big heads up and make your surf experience safer and a lot more fun.
• These simple steps may seem trivial, but constitute basic measures of precaution you can take before going surfing.

Risk assessment while in the water

• The best surfer in the water is the one having the most fun AND keeping safe!
• Sea and wave conditions can rapidly change, so make sure you stay observant of your surroundings during your session.
• Things you should be looking out for include, but are not limited to: constantly changing tide levels and the possible exposure of low lying sea bed e.g. reef and rocks, changing daylight levels, rapid change in size or power of waves, rip tides and currents, surrounding fellow surfers and their skill levels (do you trust them to behave safely around you?!), marine threats (jellyfish, urchins, men in grey suits), and remember to also assess yourself, especially regarding your own personal health and well-being – How are you feeling? Are you having fun? Are you feeling tired or fatigued? How long since you last had something to eat and drink? Are your muscles starting to cramp up? Could you be suffering from low blood sugar, dehydration, hypo- or hyperthermia? Do you feel safe?
• We all love pushing ourselves to our limits, but unnecessary, avoidable accidents can overshadow even the perfect surf day, so it is therefore important to know when you’ve had enough and consequently head back to shore, when the current conditions start to make you feel unsafe.

Emergency plan for an accident during the session

• Hopefully you will never need to use an emergency plan, but it is very important to have one ready at hand. It goes without saying that an emergency plan should be organised before entering the water and that various precautionary measures should therefore be taken in advance.
• Things you might want to incorporate in your emergency plan include, but are not limited to: Someone knows where and when you are going surfing at all times, you have identified the best way to exit the water safely by yourself or while helping someone else, you know how to perform basic CPR (ideally you have already mastered and internalized the BSLS (Basic Surf Life Support) and/or ASLS (Advanced Surf Life Support) course J), you have a first aid kit nearby, you have a phone handy, you know the local emergency contact numbers and the location to the nearest hospital.