PracticalDermatology

Despite advancements in formulation, sunscreens still rank among most Americans’ least-favorite skincare products. Sure, there are some premium brands that may be considered luxurious, but most children and families are purchasing and using mass-market sunscreens that can be messy, hard to spread, and get all over clothes. Children may especially dislike applying sunscreen, especially when parents smear product on their faces. Complicating matters, many people don’t apply sunscreen properly, and they fail to re-apply, leading to inadequate protection.

As if that weren’t enough, there are actually restrictions to sunscreen use in certain settings. For example, because sunscreens are regulated by the FDA as OTC drugs, minors in schools cannot apply sunscreen or have sunscreen applied without specific legislation to allow it.

Yet, we know sun protection strategies in youth are essential for a lifetime of healthy skin. We know that the accumulated UV exposure of childhood and adolescence can be sufficient to cause aging skin and skin cancers in patients as early as the fourth decade of life. Thankfully, there are opportunities to improve sun protection for children. Ahead are some top tips.

Think Beyond SPF

Sunscreens are important, but we may rely too heavily on them as the cornerstone of a sun avoidance strategy. Avoiding UV exposure is more important than filtering UV rays. Especially for children—whom we encourage to spend time outdoors being active—UPF can be more critical than SPF. In fact, when I first started the Pediatric Sun Protection Foundation, my mission was to get children to wear protective clothing as an adjunct to sunscreen use.

The UPF or Ultraviolet Protection Factor is a measure of how much UV light—both UVA and UVB—a fabric blocks from penetrating the cloth. The Skin Cancer foundation, which recommends UPF 30 or higher (50+ is excellent, they say), notes that compared to UPF, SPF only takes into account UVB and is an indirect measure of filtering, since it measures an effect on the skin (erythema).

Kids who wear protective clothing—whether it’s UPF-rated swim gear or UPF-rated athletic attire—and a hat can substantially reduce their UV exposure. Unlike SPF, UPF doesn’t wash or rub off in the course of a day; there is no need for reapplication. Furthermore, clothing doesn’t expire the way that sunscreens do. (As clothing wears out over a prolonged time period, it can lose some of its UV filtering capacity, so parents should keep an eye on this.)

If you think of the popular and effective “Slip! Slop! Slap!” program from Australia, the first step is to slip on a shirt. We’ve known for a while that physical protection is essential.

Unfortunately, there is still resistance to UPF clothing. If you think about catalogs and store circulars you’ve seen selling children’s swimwear, there’s a good chance that the boys in the images don’t have on shirts. This has begun to change in recent years, but it still remains a problem. Until UV protective clothing is normalized and viewed as “cool,” there will be reluctance to wear it.

Expand SPF Accessibility

Although there is variability in sunscreen durability—particularly for physical versus chemical sunscreens—the typical recommendation is to re-apply sunscreen every two hours. Now think of parents sending kids off to school after applying sunscreen in the morning. By the time the child gets to school and sits through a morning of classes, s/he may be heading out to recess four hours or more after sunscreen was first applied. These children are due for their second reapplication!

I worked with the American Academy of Dermatology (AAD) and the American Society for Dermatologic Surgery (ASDS) on the SUNucate Initiative. This initiative led to change in federal law that allows for states to loosen restrictions on sunscreen use by children. SUNucate provides model legislation that states can use to enable schools and school-age children to apply sunscreen. At least 25 states have passed SUNucate Legislation. I encourage dermatologists in the remaining states to work with state legislators to pass legislation. More information is available at ASDS.net/asdsa-advocacy/advocacy-activities/sunucate-coalition.

Educate

The best way to change habits and behaviors is through meaningful education. Children and adolescents cannot fathom the impact that their sun behavior now is going to have on their skin when they are adults; it’s human nature. Scare tactics don’t work. The alternative is to try to teach kids about the current benefits of avoiding UV—helping them understand what UV rays do to damage the skin and how to protect their skin through simple strategies.

Of course, few of us see a significant proportion of children coming through our doors. So how can we educate them? I feel it is essential to partner with local schools. I made a point to visit local elementary schools to provide sun safety education for children. I developed resources and a curriculum to educate students, and I worked with colleagues to share these assets. I am honored to expand this project on a large scale through a new partnership with CeraVe and La Roche-Posay (see sidebar above).

We also should continue to reach out to local pediatricians to provide resources and encourage sun safety education. Unfortunately, with the breadth of topics pediatricians are required to cover in a typical visit, sun protection is not always addressed. Furthermore, most pediatricians aren’t as familiar with issues related to SPF and UV avoidance as dermatologists are. One survey of Massachusetts pediatricians, though many years old, is telling. It found that 70 percent of pediatricians said they recommended safe sun practices to more than half of their patients and their parents during summer months. However, counseling on seat belt use, bicycle helmet use, and smoking prevention were ranked higher in priority than sun protection counseling; and nutritional guidelines were the most common concern raised by parents.¹

Expect the Unexpected

Having turned my focus to sun protection in children, I have found that it is often challenging to anticipate the effects of seemingly straightforward actions. I donated sun protective shirts to a local camp one year only to be rebuffed when I repeated the offer the following year. There was no particular reason for the disinterest other than the fact that pools and camps are in the business of selling “Fun in the Sun,” and the “un-cool” swim shirts didn’t reflect the vibe. I’ve had schools refuse sunscreen samples and pediatrician offices refuse educational materials. When I had my foundation, I faced charges I was just “selling sunscreens.” The problem is: I wasn’t selling anything. I advocate for patients to use sunscreen, but I have no financial interest in which product they use, nor do I benefit financially when they practice UV safety.

More importantly, though, for each obstacle there will be innumerable successes. There’s no way to tell how much a single individual will benefit over a lifetime from early UV avoidance and use of sunscreen but, without question, if we make the effort, then we can expect to have an impact.

1. Geller AC, Robinson J, Silverman S, Wyatt SA, Shifrin D, Koh HK. Do pediatricians counsel families about sun protection?: a Massachusetts survey. Arch Pediatr Adolesc Med. 1998 Apr;152(4):372-6.