In ‘chemical’ sunscreens the active ingredient is an organic compound that works by absorbing UV radiation and dissipating the energy as heat or light  (see Fig. 1). Most absorb UVB radiation, a few absorb in the UVA2 range (320–340 nm), and there is only one FDA-approved organic sunscreen, avobenzone, that absorbs in the UVA1 range (340–400 nm)  (see Fig. 2).
It is important that physicians correctly interpret the terminology used to classify sunscreens and educate their patients to ensure they get the protection they need.
Sun protection factor
Sun protection factor is a laboratory measure of sunscreen efficacy that is based on erythema. Because UVB radiation is about 1000 times more erythemogenic than UVA radiation, SPF is primarily a measure of UVB protection . It is defined as the ratio of the least amount of UV radiation required to produce minimal erythema on sunscreen-protected skin to that required to produce the same erythema on unprotected skin . The SPF of a product is not related to the duration of UV exposure , despite common misperception. Additionally, the relationship between SPF and UVB protection is not linear, meaning that a sunscreen with double the SPF rating does not necessarily mean one can remain in the sun twice as long before becoming sunburnt.
Given the recent discoveries illustrating the role of UVA radiation in skin cancer development, UVA protection is an important consideration when evaluating a sunscreen's ability to block UV radiation .
Substantivity and photostability
Substantivity refers to the ability of a sunscreen to remain effective in the presence of adverse conditions, primarily water and sweat. The current US FDA final ruling has banned the use of the terms ‘sunblock,’ ‘water proof,’ or ‘sweat proof.’ Instead, the label ‘water-resistant’ (40 min) or ‘water-resistant’ (80 min) is given to reflect the actual water-resistant testing that is required to be done [30,31▪▪]. Furthermore, sunscreens cannot claim to provide sun protection for more than 2 h without reapplication.
New compounds and combinations
Given the high standards to be met by sunscreens, new compounds and combinations have been developed in efforts to prevent photodegradation, as well as to increase SPF levels, provide broad-spectrum UVA and UVB protection, and follow FDA filter maximum limits within sunscreens. An example of this is the addition of octocrylene to prevent the destruction of the photosensitive compound avobenzone. Over the past decade, two newer compounds, Ecamsule (Mexoryl SX, patent-protected by L’Oreal) and avobenzone and oxybenzone (Helioplex, patent-protected by Neutrogena Corp.), have been added to sunscreen formulations, providing broad-spectrum UVA protection and high SPF .
Many controversies surround the use of sunscreens and these concerns have led to misconceptions and confusion among the public. Physicians should be prepared to answer inquiries related to these issues and alleviate concerns and/or confusion.
The observation that sunscreens protect against sunburn led to the common expectation that they also would protect against malignant melanoma. Surprisingly, some case-controlled studies actually showed a higher incidence of melanoma among sunscreen users [5,32]. However, careful analysis found that these studies were flawed due to the failure to adequately control for confounding factors between melanoma and sunscreen use . For example, persons with fair skin are both more likely to use sunscreen to prevent sunburns, and at higher risk of developing skin cancer. Furthermore, these studies neglected to consider SPF or the appropriate application of sunscreens. The more recent meta-analyses of case–control studies have not found any association between sunscreen and the development of melanoma . Furthermore, the recent randomized controlled trial published in 2011 suggests regular use of sunscreen can decrease the incidence of melanoma among white adults [35▪▪].
The active ingredients (UV filters) in sunscreens routinely undergo a rigorous safety assessment to explore the possibility of local and systemic toxicity, such as sensitization, irritation, phototoxicity, and carcinogenicity . Despite this, adverse skin reactions and potential systemic influences have been proposed as risk factors related to the use of sunscreens, and, with the development of nanoparticles, the absorption potential of these smaller particles has been questioned.
Potential systemic influences
Sunscreen products with organic UV filters may penetrate the skin in small amounts (0.1–5% of dissolved filter) , whereas UV filters existing as inorganic filters (e.g. titanium dioxide) do not penetrate the skin, posing no potential risk of systemic toxicity .
Much effort has been made to address the cosmetic shortcomings of inorganic UV filters, zinc oxide, and titanium dioxide. Since the cosmetically driven development of nanoparticles (single particles with a diameter <100 nm) that do not make the skin white and pasty upon topical application and their approval for use in sunscreens by the FDA in 1999, in-vivo studies using both animal and human skin have shown penetration of nanoscale zinc oxide and titanium dioxide is limited to the stratum corneum and, therefore, their in-vitro toxicity profiles are of no consequence to human health [3,39].
Because Vitamin D3, a precursor for the biologically active vitamin D, is formed in the skin after exposure to UVB radiation, there is ongoing concern that sunscreen use could potentially lead to vitamin D deficiency by absorbing UVB radiation and inhibiting vitamin D production. Considering that vitamin D synthesis may be reduced by more than 98% with proper use of SPF 15 sunscreen, some suggest regular sunscreen use may cause vitamin D insufficiency; however, others have shown long-term sunscreen use has minimal to no effect on vitamin D levels and function [3,24,40▪▪,41,42].
The Skin Cancer Foundation advises children and adults under age 70 who regularly practice sun protection to obtain the recommended 600 IU of vitamin D a day from food sources such as oily fish, fortified dairy products and cereals, and supplements. For infants under 12 months old and people 70 and older, the recommended daily dose is 400 and 800 IU, respectively. For those who are vitamin D-deficient, it is acceptable to take 1000–2000 IU doses daily for limited periods .
RECOMMENDED USE OF SUNSCREENS
The failure of sunscreens to prevent sunburn is usually due to the way sunscreens are applied by the consumer.
Despite explicit recommendations and evidence supporting daily sunscreen use, many people do not use sunscreen on a daily basis, and, instead, use sunscreen solely on a short-term basis during outdoor activities, or even to increase duration of UV exposure during tan acquisition. A review examining the association between sunscreen use and sun exposure found that sunscreen use increased the duration of intentional sun exposure between 13 and 39% . The use of sunscreen to extend sun exposure for tan acquisition is considered an abuse of the product and can actually increase the risk of skin cancer and photoaging by exposing a person to increased UVA radiation .
The American Academy of Dermatology (AAD) has developed guidelines to reduce UV exposure including recommendations for the proper sunscreen use  (see below). Despite the reality of their use, sunscreens should be considered a third line of defense after clothing and shade.
- Measures to reduce UV exposure
- Seek shade and avoid the sun between 10 a.m. and 4 p.m. when UV radiation peaks
- Wear protective clothing including long-sleeved shirt, pants, sunglasses, and a wide-brimmed hat
- Be careful in the setting of water, snow, and sand as these surfaces reflect UV rays
- Avoid tanning beds
- Proper use of sunscreens
- Who: Everyone, including people of all skin colors
- What: Broad-spectrum, water-resistant sunscreen with a minimum SPF of 30
- Where: All exposed areas of the body not protected by clothing
- Pay particular attention to vulnerable sites such as the nose, shoulders and dorsal feet
- How: Apply generously and uniformly
- Use enough sunscreen to fill a shot glass (1 oz)
- When: every day and year-round
- 15 min before going outdoors
- Reapply every 2 h especially after swimming or heavy perspiration
Sunscreen and infants
Because the skin of infants and toddlers is thinner, less concentrated with melanin, and immunologically immature, UV radiation can penetrate the skin more deeply and there is less of an immune response mounted against UV damage, putting them at higher risk for cumulative UV damage and skin cancer [47▪]. For these reasons, the American Academy of Pediatrics (AAP) has developed guidelines for UV protection in infants (see Table 1).
Sunscreen and skin color
Photoprotection provided by increased epidermal melanin in darker skin offers inherent SPF and in black skin can filter twice as much UVB radiation compared with Caucasian skin, contributing to the low incidence of cutaneous malignancies in darker-skinned groups. Although skin cancers are not as prevalent in people with darker skin, they can have morbidity and fatalities from remaining undiagnosed for a while . Prevalence of sun-protective behaviors in the US population according to race shows few blacks wear sunscreen and instead seek shade [40▪▪]; however, the use of sunscreen is recommended for people of all skin color, as everyone is at risk for skin cancer .
TARGETING THE YOUNG
Up to 80% of total lifetime sun exposure takes place before the age of 18 years .
Young and at risk
Childhood is a particularly vulnerable time for photocarcinogenic effects of the sun; thus sun protection is of utmost importance during childhood and adolescence. Epidemiologic studies show a higher incidence of malignant melanoma in persons with a history of sunburns during childhood and adolescence [11,49▪▪]. A meta-analysis of 51 studies found that ever reporting a sunburn during childhood almost doubled the risk for development of cutaneous melanoma . Moreover, regular sunscreen use during childhood and adolescence could reduce lifetime incidence of NMSC by approximately 78% [4▪].
Timing of interventions
Adolescents and young adults have the lowest skin-protection rates of all age groups, receive large amounts of UV radiation, and increase their UV exposure habits as they move into adulthood, making this a critical period for skin cancer prevention [4▪]. Evidence from a prospective, population-based study showed that over 50% of peri-adolescent children experience sunburns before age 11 and again 3 years later [49▪▪]. During this same period, liking a tan and spending time outside to get a tan significantly increased and the percentage of those appropriately using sunscreen dropped from 50 to 25% [49▪▪]. Therefore, childhood seems to be the ideal time to intervene in terms of sun-protective behaviors and the targeting of children in pediatric offices and community settings regarding unprotected UV exposure may be a practical approach [49▪▪,50]. In fact, interventions aimed at parents, teachers, and children designed to increase children's use of sun protection have already been shown to be effective .
The major challenges for the future relate to optimizing the use of sunscreens and to motivating the general public, especially adolescents, to achieve UV protection by other means . Whereas there may be concerns regarding the long-term safety of UV filters, the benefits of sunscreens clearly outweigh their potential risks. However, the primary barrier to attaining these benefits is patient compliance. Therefore, our future efforts should focus on compliance, rather than technical issues of sunscreens, so that people want to apply sunscreen appropriately and, as a consequence, benefit from the harm reduction that advancements in technology promise to deliver.
Furthermore, continued public health efforts are needed to facilitate sun protection, prevent sunburn, and avoid increases in skin cancer cases. Future skin cancer prevention campaigns should focus on the proper use of sunscreen, emphasize the importance of wearing clothing and seeking shade, as well as put forth major effort to change adolescents’ attitudes towards sun tanning .
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
3. Burnett ME, Wang SQ. Current sunscreen controversies: a critical review. Photodermatol Photoimmunol Photomed 2011; 27:58–67.
4▪. Heckman CJ, Coups EJ. Correlates of sunscreen use among high school students: a cross-sectional survey. BMC Public Health 2011; 11:679.
This article identified specific variables that can be targeted in interventions designed to increase sunscreen use among adolescents.
5. International Agency for Research on Cancer World Health Organization. IARC Handbooks of Cancer Prevention. Volume 5. Lyon: IARC Press; 2001.
6. Young AR. Acute effects of UVR on human eyes and skin. Prog Biophys Mol Biol 2006; 92:80–85.
7. Jou PC, Feldman RJ, Tomecki KJ. UV protection and sunscreens: what to tell patients. Cleve Clin J Med 2012; 79:427–436.
8. Wolber R, Schlenz K, Wakamatsu K, et al. Pigmentation effects of solar-simulated radiation as compared with UVA and UVB radiation. Pigment Cell Melanoma Res 2008; 21:487–491.
9. Miyamura Y, Coelho SG, Wolber R, et al. Regulation of human skin pigmentation and responses to ultraviolet radiation. Pigment Cell Res 2007; 20:2–13.
10. Dennis LK, Vanbeek MJ, Beane Freeman LE, et al. Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis. Ann Epidemiol 2008; 18:614–627.
11. Pustisek N, Sikanić-Dugić N, Hirsl-Hećej V. Acute skin sun damage in children and its consequences in adults. Coll Antropol 2010; 34 (Suppl 2):233–237.
12. Sjerobabski Masnec I, Poduje S. Photoaging. Coll Antropol 2008; 32 (Suppl 2):177–180.
14. Jou PC, McCormick TS, Baron ED. UV immunosuppression and cutaneous malignancies. Expert Rev Dermatol 2011; 6:61–74.
15. Wang Y, Digiovanna JJ, Stern JB, et al. Evidence of ultraviolet type mutations in xeroderma pigmentosum melanomas. Proc Natl Acad Sci U S A 2009; 106:6279–6284.
16. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens-Part D: radiation. Lancet Oncol 2009; 10:751–752.
17. Kwon HT, Mayer JA, Walker KK, et al. Promotion of frequent tanning sessions by indoor tanning facilities: two studies. J Am Acad Dermatol 2002; 46:700–705.
18. Dellavalle RP, Parker ER, Cersonsky N, et al. Youth access laws: in the dark at the tanning parlor? Arch Dermatol 2003; 139:443–448.
19. Miller SA, Hamilton SL, Wester UG, Cyr WH. An analysis of UVA emissions from sunlamps and the potential importance for melanoma. Photochem Photobiol 1998; 68:63–70.
20. Gerber B, Mathys P, Moser M, et al. Ultraviolet emission spectra of sunbeds. Photochem Photobiol 2002; 76:664–668.
22. Gonzaga ER. Role of UV light in photodamage, skin aging, and skin cancer: importance of photoprotection. Am J Clin Dermatol 2009; 10 (Suppl 1):19–24.
23. Bolognia J, Jorizzo J, Rapini R. Dermatology. 2nd ed. Elsevier Limited; 2008.
24. Sambandan DR, Ratner D. Sunscreens: an overview and update. J Am Acad Dermatol 2011; 64:748–758.
25. Loden M, Beitner H, Gonzalez H, et al. Sunscreen use: controversies, challenges and regulatory aspects. Br J Dermatol 2011; 165:255–262.
26. Palm MD, O’Donoghue MN. Update on photoprotection. Dermatol Ther 2007; 20:360–376.
27. Osterwalder U, Herzog B. Sun protection factors: world wide confusion. Br J Dermatol 2009; 161 (Suppl 3):13–24.
29. Stechschulte SA, Kirsner RS, Federman DG. Sunscreens for nondermatologists: what you should know when counseling patients. Postgrad Med 2011; 123:160–167.
30. Wang SQ, Lim HW. Current status of the sunscreen regulation in the United States: 2011 Food and Drug Administration's final rule on labeling and effectiveness testing. J Am Acad Dermatol 2011; 65:863–869.
The final rule on labeling and testing of sunscreens marks a major step by the FDA in its long history of regulating the safety and efficacy of sunscreen products. Until this enforcement, there had not been comprehensive guidance on the testing and labeling of UVA protection in US sunscreens. The ruling also validates the protective role of sunscreen in preventing skin cancer and skin aging when used appropriately with other photoprotective measures.
32. Westerdahl J, Ingvar C, Masback A, Olsson H. Sunscreen use and malignant melanoma. Int J Cancer 2000; 87:145–150.
33. Diffey B. Sunscreens: expectation and realization. Photodermatol Photoimmunol Photomed 2009; 25:233–236.
34. Huncharek M, Kupelnick B. Use of topical sunscreens and the risk of malignant melanoma: a meta-analysis of 9067 patients from 11 case-control studies. Am J Public Health 2002; 92:1173–1177.
35▪▪. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol 2011; 29:257–263.
This study is the first to provide strong evidence for a reduction in the incidence of invasive melanoma after regular application of broad-spectrum sunscreen in adults. It is unlikely that another trial of comparable scope and rigor will be conducted in the foreseeable future.
36. Nohynek GJ, Antignanc E, Re T, Toutain H. Safety assessment of personal care products/cosmetics and their ingredients. Toxicol Appl Pharmacol 2010; 243:239–259.
37. Gonzalez H. Percutaneous absorption with emphasis on sunscreens. Photochem Photobiol Sci 2010; 9:482–488.
38. Sadrieh N, Wokovich AM, Gopee NV, et al. Lack of significant dermal penetration of titanium dioxide from sunscreen formulations containing nano- and submicron-size TiO2 particles. Toxicol Sci 2010; 115:156–166.
39. Schilling K, Bradford B, Castelli D, et al. Human safety review of ‘nano’ titanium dioxide and zinc oxide. Photochem Photobiol Sci 2010; 9:495–509.
40▪▪. Linos E, Keiser E, Kanzler M, et al. Sun protective behaviors and vitamin D levels in the US population: NHANES 2003–2006. Cancer Causes Control 2012; 23:133–140.
The first large, nationally representative, population-based study to quantify the differential association between sun-protective clothing, shade use and sunscreen, and 25(OH)D levels. Offers a new perspective by considering the impact that recommended sun protective behaviors other than sunscreen have on vitamin D levels and how these factors vary with race.
41. Norval M, Wulf HC. Does chronic sunscreen use reduce vitamin D production to insufficient levels? Br J Dermatol 2009; 161:732–736.
42. Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. Am J Clin Nutr 2004; 80 (6 Suppl):1678S–1688S.
44. Autier P, Boniol M, Doré JF. Sunscreen use and increased duration of intentional sun exposure: still a burning issue. Int J Cancer 2007; 121:1–5.
45. Autier P. Sunscreen abuse for intentional sun exposure. Br J Dermatol 2009; 161 (Suppl 3):40–45.
47▪. Paller AS, Hawk JL, Honig P, et al. New insights about infant and toddler skin: implications for sun protection. Pediatrics 2011; 128:92–102.
Offers insight regarding the features of infant and toddler skin that make them more vulnerable to UV radiation and highlights the importance of sun protection in early years.
48. Gloster HM Jr, Neal K. Skin cancer in skin of color. J Am Acad Dermatol 2006; 55:741–760.quiz 761–764.
49▪▪. Dusza SW, Halpern AC, Satagopan JM, et al. Prospective study of sunburn and sun behavior patterns during adolescence. Pediatrics 2012; 129:309–317.
This is the first prospective study of sunburn and sun behaviors in the peri-adolescent age group. Findings provided good support to the suggestion that targeting children in pediatric offices and community settings regarding unprotected UV exposure may be a practical approach.
50. Lin JS, Eder M, Weinmann S. Behavioral counseling to prevent skin cancer: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2011; 154:190–201.
51. Baade PD, Green AC, Smithers BM, et al. Trends in melanoma incidence among children: possible influence of sun-protection programs. Expert Rev Anticancer Ther 2011; 11:661–664.
52. Branstrom R, Kasparian NA, Chang YM, et al. Predictors of sun protection behaviors and severe sunburn in an international online study. Cancer Epidemiol Biomarkers Prev 2010; 19:2199–2210.
53. Reinau D, Meier C, Gerber N, et al. Sun protective behaviour of primary and secondary school students in North-Western Switzerland. Swiss Med Wkly 2012; 142:w13520.
Keywords:© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
melanoma; pediatric; skin cancer; sunscreen; ultraviolet protection; ultraviolet radiation