Sunscreen and Dermatologists

Dermatologists have a complicated love affair with sunscreen. We love the fact that it protects ourselves and our patients from sunlight and advocate strongly (and sometimes with bias) for its use, yet we often forgive its shortcomings. Recently, however, two events have forced many dermatologists to rethink their sunscreen usage.

First, new regulations in Hawaii, Key West, and potentially other areas banning the use of oxybenzone and octinoxate as of January 1, 2021 have sent shockwaves through the industry. These laws avoided an outright ban on titanium dioxide, but the website Hawaii.com does discourage “sunscreens with high levels of titanium dioxide” as well as those containing petrolatum or mineral oil. They even go so far as to provide a list of acceptable sunscreens, few of which have ever been considered good sunscreens by dermatologists. To say that the sunscreens listed on Hawaii.com are high-quality would be a severe overstatement.

The second blow to sunscreen-as-normal was the recent JAMA article¹ that showed absorption of sunscreen in study participants with “normal” amounts of usage. Participants were studied under strict conditions, which, although clearly in line with what dermatologists preach, are also out of step with the realities of everyday use for nearly every patient.

This brings up the question as to whether dermatologists and their governing bodies should once again go to the mat for the sunscreen industry. I have already seen countless national mentions of the importance of essentially disregarding this study that was done by the FDA under exactly the guidelines that we, as dermatologists, tell our patients to use sunscreen. To me, this challenges the limits of what we should be doing. The study raises legitimate questions, on top of the continued concern about sunscreens’ effect on coral bleaching.²

Our primary job is to protect our patients. This study shows that diligent patients may actually achieve meaningful levels of certain ingredients (avobenzone, oxybenzone, octocrylene, and ecamsule) in the blood. The ramifications of this are not known in adults, children, or pregnant women. This alone should make us rethink our blind allegiance to manufacturers who have not done the requisite studies to determine the effects of their products on the end-user.

What is needed—sooner rather than later—is a study that corroborates or disproves the data in this study and investigation into newer forms of sunscreen. Sadly, the FDA has clearly not done the public any favors with its lack of approval of newer forms of sunscreen. This may be due to the lack of testing and rigor that was evidenced in the JAMA study, but if there are now concerns on the table, every effort should be made to analyze older, as well as potentially newer, sunscreens for harmful properties.

My approach to sunscreen has changed significantly over the past year, as well. Due to the recent data, I am no longer recommending chemical sunscreens for pregnant women or children. Additionally, I am focusing on reef-safe sunscreens for any of my patients who go in the ocean. Clearly, this is a small percentage of all sunscreen use, but one that must be acknowledged. I do tell my patients that reef-safe doesn’t necessarily mean unsafe for any other activity. But I worry that this, in combination with the new study showing blood levels, will be the death-knell for our best chemical sunscreens.

Additionally, I am now doing more to relate the need for sun-protective clothing and hats, as well as sun avoidance, of course. These are words that usually fall on deaf ears, but still are important to relate. It may be that in a few years, our only options are physical sunscreens that have less coverage and less cosmetic elegance, but I would rather take my chances with that than endorsing something that already has the writing on the wall for troubles to come.

1. Matta MK, Zusterzeel R, Pilli NR, et al. Effect of Sunscreen Application Under Maximal Use Conditions on Plasma Concentration of Sunscreen Active Ingredients: A Randomized Clinical Trial. JAMA. Published online May 06, 2019321(21):2082–2091. doi:10.1001/jama.2019.5586

2. Downs, CA et al. Toxicopathological effects of the sunscreen UV filter, oxybenzone (benzophenone-3), on coral planulae and cultured primary cells and its environmental contamination in Hawaii and the US Virgin Islands. Archives of Environmental Contamination and Toxicology