applying sunscreen

Sunscreen season is here, and Practical Dermatology® spoke with Murad Alam, MD, MSCI, a dermatologist and Mohs surgeon based in Chicago, about the latest developments in sunscreen and how they should be best utilized to protect against skin cancer.

How would you describe the state of the sunscreen market and the sunscreens that are available in the United States currently?

Dr. Murad Alam: The sunscreens available in the US are safe and effective, and they come in a variety of formulations that are sufficient for just about everybody to find something that feels good on their skin, that they feel comfortable using, and that works with their skin color and complexion.

How much should skin color, complexion, and health be considered when selecting a sunscreen?

Dr. Alam: There are some scientific factors that help us differentiate sunscreens. The higher the SPF number, the greater the protection against ultraviolet B (UVB) rays. A broad-spectrum sunscreen protects against both UVB and ultraviolet A (UVA). So, regardless of age, skin color, skin sensitivity, and other factors, high SPF and broad spectrum are two characteristics that are generally good for everyone. Beyond that, there are differences that can affect whether a sunscreen is right for you. To some extent, there are simple factors such as what is less messy. Patients often say that one sunscreen feels funny or irritating on their skin, but another feels good. People with very sensitive skin might benefit from so-called mineral sunscreens with less liquid and more of a packed powder. Skin color is a separate issue; there are sunscreens available that have tints of various kinds, so they do not make your skin look different. People can even use sunscreens with two different tints and blend them together to get the exact shade that works for your skin type.

With the European Union approving so many more sunscreen formulations than the US Food and Drug Administration (FDA), are there any non-FDA-approved sunscreens that intrigue you?

Dr. Alam: I prefer not to go into specifics, but the simple answer is that we have a problem. There are many sunscreens that are approved in Europe and elsewhere in the world that are not approved in the US and for which a pathway to approval in the US is not clear. There are certain things that the FDA wants, and there are certain things that the companies that would be marketing these sunscreens in the US want. There has not been a meeting of minds regarding those two, so these sunscreens that we know are safe—based on not only experimental data but years of use by millions of Europeans and others—are still not available in the US. This is unfortunate because many of these sunscreens offer a variety of benefits that would be helpful to US consumers and patients. That is not to say US sunscreens do not work, but often, more modern products offer a variety of potential benefits and just greater variety. So, this is a problem. American Academy of Dermatology (AAD) leadership has tried to bring the manufacturers and the FDA together, and there have been some promising connections, but we are not quite there yet. I certainly hope that this issue does resolve over time because it is a problem. It limits the choices of U.S. consumers, and it prevents the availability of sunscreens that we know are safe and effective in the U.S. Of course, if you are traveling to Europe, you can certainly purchase those sunscreens in Europe and bring them back to the US for personal use, but they cannot be sold here. That is how it works right now. It is frustrating for a lot of people, but that is not to say that the sunscreens we have are ineffective.

The claim has been made that some sunscreens in the U.S. may be harmful. Are there any ingredients in some sunscreens that people might want to avoid?

Dr. Alam: I do not think they are harmful. Obviously, anything can be misused. If someone ingested sunscreen, that would not be good for them. A number of years ago, there was concern that sunscreens might be harming coral reefs, but the evidence there appears to be very limited. Similarly, some experimental data indicated that, to a certain extent, sunscreens might be absorbed through the skin; however, that is true of almost anything you apply to the skin, and there is no indication that the absorption of sunscreens causes any harm to people. The general consensus remains that sunscreen is safe and effective.

How important are moisturizers and other products that have photoprotective capabilities?

Dr. Alam: Sunscreen is increasingly getting into personal care products, which is a good thing. Sunscreen moisturizer, for instance, is very good because certain kinds of skin cancer, such as melanoma, are caused by blistering sunburns in childhood. Other kinds of skin cancer, including basal cell carcinoma and squamous cell carcinoma, which collectively afflict more than 5 million people each year in the US, are not caused necessarily by blistering sunburns but by cumulative sun exposure, so lower-intensity sun exposure day after day can increase the risk of these. It is very important to use super protective sunscreen when on the beach to avoid a blistering sunburn and minimize risk of melanoma, but it is equally important to use a daily moisturizer with 15 or 30 SPF because that protects against daily doses of lesser amounts of sun that collectively add up and increase the risk of basal cell and squamous cell carcinoma. Everyone should be using something that they do not find annoying every day if they are out and about, so that the face, backs of arms, ears, and neck are protected; then, in the event of intense sun exposure, use very high SPF sunscreen.

How important are factors beyond the formulations themselves, such as frequency of application?

Dr. Alam: I generally advise against using spray-on sunscreens; people find them less messy, but that is because there is less volume being applied, which also means less protection. That is not to say spray-on sunscreen cannot be used effectively, because they definitely can, but they are more challenging. You need to really make sure you use them correctly. Something else that dermatologists often suggest is for people to reapply sunscreen as they sweat it off or as they wash it off at the beach. That is the right thing to do, but in my personal practice, I am just happy if people remember to apply it once a day. That is hard enough. Yes, it is better to reapply it, but if you cannot reapply it or you forget, please at least apply it once before you go out of the house.

What else is important for dermatologists to communicate to patients specifically regarding sunscreen?

Dr. Alam: It is not just skin cancer. Sometimes for younger people, skin cancer seems very remote, but it is also a matter of getting dull, wrinkly, leathery skin much sooner than you otherwise might. Physical appearance and attractiveness can be diminished by getting tremendous amounts of sun exposure, which can be mitigated. It is important to realize that sunscreen is not a magic potion; “sun slow” would be a better term because sunscreen and sunblock suggest that nothing is getting through. Sun is getting through. It is just getting through more slowly than it otherwise would. If a person is wearing a fairly protective sunscreen, then 5 hours of sun outside is like a half-hour without sunscreen. However, if you spend 10 hours a day in a lot of sun, you will still be affected, even through the sunscreen. So, mitigating overall sun exposure is important as well. When nothing exciting is happening, don’t just sit out there and bask. Sun avoidance also can involve taking measures such as wearing a wide-brimmed hat that is 4 in or 10 cm all the way around; a cap really only protects your nose and parts of your cheeks, but it does not protect your ears, the side of your neck, etc. Additionally, for children, in particular, but also for adults, sun-protective clothing can help. It does not need to be a winter coat; there is very, very good sun-protective clothing that looks very light, airy, and transparent, but is treated in such a way that it blocks out much of the sun.

What conversations need to be had specifically for skin of color?

Dr. Alam: For many years, we thought that if a patient was Latino, Asian, or African-American, they did not need to really worry about skin cancer because it just did not happen much to them. Now, a number of studies have addressed that subject, and it turns out that skin cancer is much more common in skin of color than we thought. It is still not as common as it is in Irish people, but it does happen. It is more frequent in cases of lighter skin, greater genetic susceptibility, and more cumulative sun exposure. We need to study that more and better understand what the factors are that predispose some people with skin of color so we can better counsel them regarding sunscreen. More and more people have mixed ethnicities, and those are very complicated because it can be difficult to determine what the children’s susceptibility is, and it can vary. Until we understand more about all these factors, the message is that we want to avoid people tanning and we want to avoid people burning. Sunscreen is not only for very, very fair blonde and redhead people. Everyone should consider using it, especially if they are getting tremendous sun exposure. On a personal note, I am of Pakistani descent, and as a child, I went to a beach in Kenya one day with no sunscreen on, and I burnt to a crisp; sheets of skin were peeling off me. People need to be sensible. If someone has very dark skin and is going to go out for 5 minutes in the middle of winter on a day with little sun, they probably do not need sunscreen. 

What studies on that topic have been done so far?

Dr. Alam: A lot of work is being done trying to estimate the incidence of skin cancer in patients with skin of color. We are not getting the message out in terms of surveillance. Cancers excised from patients with skin of color often are larger than cancers in patients who are lighter skinned. We believe that is largely because those patients are not screened as well. They are not being neglected deliberately—although lack of access could be an issue as well—but the patients themselves and their physicians often do not think this is something that needs to be monitored as closely for darker skin. If you have a little bump on your nose and you are Irish, you think it could be skin cancer and you go to the dermatologist, who immediately biopsies it. But if you are Mexican and Indian, and you have a little bump on your nose, you might think it is just a bump, and your doctor might also think it is probably nothing. They might not biopsy until it gets bigger, bleeds, or causes discomfort and is sticking around for too long. Eventually, it gets a biopsy, but by then, it is bigger than it would be at a similar site in a similar person with lighter skin. So, the message to all of us who are physicians is that we need to be vigilant and we need to not overlook the fact that somebody of a different ethnicity or with darker skin can have skin cancer. That should always be in our differential diagnosis.

Is there anything you would like to see 20 years from now in terms of really groundbreaking developments that would make sunscreen more effective?

Dr. Alam: All of the innovations in nanotechnology and so forth. What are the pain points in sunscreen? It takes time to apply it. So, if there was an easy way to apply it quickly and evenly, that would help. It feels funny on the skin, so if there was a way to make it feel less noticeable, that would help. Of course, in the distant future, it would be nice if you could just molecularly and genetically engineer skin to avoid getting sun damage to begin with, or if it had enough repair mechanisms so it could deflect the sun damage. That would likely be in the distant future, however.

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