2294 IADVL TEXTBOOK OF DERMATOLOGY

Table 59.27: Peeling Agents

2 Carbons 3 Carbons 4 Carbons 6 Carbons 6 Carbons ring 8 Carbons

Glycolic acid Lactic acid Malic acid Citric acid Monophenyl glycolic Mandelic
acid acid
Pyruvic acid Tartaric acid Gluconic acid
Diphenyl glycolic acid
Alpha-methyl lactic acid Glucuronic acid

and hyaluronic acid. They also decrease ultraviolet
ray induced oxidative damage to the cells.374
The common indications for the AHAs include
ichthyosis, xerosis, photoaging, acne, rosacea,
melasma, brittle nails and actinic keratosis. They
are also used as cosmeceutical agents for skin
rejuvenation.
SUNSCREENS
The skin being an entirely exposed organ is
extremely prone to photodamage. Till recently
sunscreens were used as medicinal preparations
only, as per therapeutic requirement. But now
sunscreens have become an essential component
of one’s daily skin care regimen. Though they are
traditionally used to prevent the deleterious effect
of the ultraviolet radiation on the skin, recent stud-
ies have also demonstrated the harmful effects of
visible light, especially in skin phototypes IV to VI,
thus indicating that sunscreens may be effective in
preventing these too.
Sunscreens guard the skin against the immedi-
ate and long-term effects of ultraviolet rays. The
ultraviolet spectrum includes UVA, UVB and UVC
components (Table 59.28).
The US FDA which supervises sunscreens as OTC
agents has approved 16 drugs to be used in sun-
screen formulations (Table 59.29). FDA-approved
sunscreen formulations include creams, oils, gels,
lotions, ointments, pastes, butters, sticks, sprays
and hot wipes, towels, powders, body washes and
shampoos.
Types of Sunscreens
Sunscreens have been divided into chemical
(or organic) sunscreens and physical (or inor-
ganic) sunscreens (Table 59.30). Organic sun-
screens are aromatic compounds with a carbonyl
group. They absorb the high energy UV rays to
emanate lower-energy rays and thereby prevent
the harmful rays from reaching the skin. In con-
trast, the inorganic or physical blockers are inert
agents that reflect or scatter the UV rays.376
Usage
Sunscreens are indicated in a variety of condi-
tions375 (Table 59.31). The “sun protection fac-
tor” (SPF) of a sunscreen is used as a guideline
for its effectiveness. It is defined as the dose of
UV ray required to produce 1 minimal erythema
dose (MED) on protected skin (after application of
2 mg/cm2 of the product) divided by UV ray to
produce 1 MED on unprotected skin.377
This index takes into account the sunburn ­factor
only and indicates the UVB induced erythema
and not a broad spectrum protection. So in
2007, FDA proposed the index to be changed to

Table 59.28: Ultraviolet Spectrum

UV Wavelength Percentage of total UV Mechanism of skin Effects

component radiation reaching earth (%) damage

UVA 320–400 nm 95–98 Deepest penetration Tanning

Produces reactive Photoaging
oxygen species;
Causes Photocarcinogenesis
immunosuppresion

UVB 290–320 nm 2–5 Most severe damage Acute damage:

sunburn
Affects cellular DNA & Long-term effect:
proteins cancer

UVC 200–290 nm Negligible; absorbed by NA NA

ozone layer

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 CHAPTER 59: Topical Therapy in Dermatology 2295

Table 59.29: Classification of Sunscreens

Chemical sunscreens: Chemical sunscreens: Physical blockers Newer generation broad

UVA protective UVB protective spectrum (UVA + UVB)

Benzophenones(UVB PABA derivatives Zinc oxide Ecamsule (Mexoryl SX)*

and UVA2 absorbers) Padimate O Titanium dioxide Silatriazole (Mexoryl XL)*
Red petrolatum Bemotrizinol (Tinosorb S)*
Oxybenzone, Cinnamates
Bisoctrizole (Tinosorb M)*
Sulisobenzone,
Octinoxate, Cinoxate
Dioxybenzone
Salicylates
Avobenzone
Octisalate, Homosalate,
(UVA1 absorber)
Trolamine salicylate
Meradimate
Octocrylene
(UVA2 absorber)
Ensulizole
*Not approved by FDA

Table 59.30: Indications for Use of
Sunscreens375
Ephelides
Photoaging
Skin cancer
Photosensitivity disorders: Polymorphous light
eruption, solar urticaria, chronic actinic dermatitis,
persistent light reaction, lupus erythematosus,
xeroderma pigmentosa, albinism
Photoallergic and phototoxic drug reactions
Postinflammatory hyperpigmentation
of SPF can be labelled as 50+ since higher SPFs
have not shown to be more beneficial.378 Other
UV protection indices include Japanese standard,
Australia/New Zealand standard, European Union
Guidelines, and the British Boots Star rating sys-
tem.375 A “water-resistant sunscreen” and a “very
water-resistant sunscreen” denote ones that
maintain their SPF after 40 minutes or 80 minutes
respectively of sweating or swimming. Sunscreens
need to be applied regularly to all sun-exposed
parts of the body in a concentration of 2 mg/cm2,
15–30 minutes before stepping outdoors. Ideally,
it should be reapplied after 2 hours as well as after
swimming and heavy perspiration.

Photoaggravated dermatoses: Melasma Side Effects

Sunscreens may cause contact dermatitis and
Table 59.31: Topical Medications for photosensitivity reactions, especially those con-
Androgenetic Alopecia taining aminobenzoic acid and its esters such as
PABA. The fragrances, lanolin, alcohol and pre-
Minoxidil (2%, 5%, 10%) servatives may irritate the skin and eye and also
cause sensitization. Nitrosoamines in certain sun-
Prostaglandin analogues: Bimatoprost 0.03%,
latanoprost 1% screens containing padimate-O may be carcino-
genic in high quantities.377 Known sensitivity to
Tretinoin any active ingredient or vehicle is a contraindica-
tion for sunscreen application. Contact urticaria
Azelaic Acid, zinc
and worsening of acne can occur. They are also
Topical estrogen to be avoided in children less than 6 months of
age. The recent controversy regarding the use of
Ketoconazole shampoo
sunscreens is that its use may lead to deficiency
Cell culture medium with insulin, thyroxine and of vitamin D which in turn can increase the risk of
growth hormone skin cancers. Studies published so far on this sub-
ject have shown conflicting results.379

“sunburn protection factor.” A broad spectrum TOPICAL AGENTS FOR ANDROGENETIC

sunscreen should therefore have an SPF of at least
15 to prevent sunburn and on proper usage, along
with other sun-protection measures, decrease
the risk of skin cancer and early photoaging. FDA
further ruled in 2011 that the maximum value
ALOPECIA (Aga)
Various topical agents have been tried in andro-
genic alopecia. Though Minoxidil was the first drug
to be approved by FDA, subsequently various

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