A CLINICIAN’S PERSPECTIVE
Here comes summer (and
sunscreen conversations)!
Warren R. Heymann, MD
Marlton, New Jersey
A s the summer solstice approaches, patients
will be asking questions about the efficacy
and safety of sunscreens (personally and
environmentally).
Mineral sunscreens contain inorganic ultraviolet
(UV) filters (zinc oxide and titanium dioxide),
offering broad-spectrum UV coverage by
absorbing, reflecting, or refracting UV radiation.
Chemical sunscreens contain UV filters that absorb
UV radiation and, when used in combination, can
provide broad-spectrum UV filtration that is at
least equal to that of mineral sunscreens.1
In this issue of the Journal of the American
Academy of Dermatology, Kohli et al2 compare the
sunburn protective efficacy of SPF 501 and SPF
1001 chemical sunscreens under actual use at the
beach in a prospective, randomized, double-blind,
split body/face study of 55 healthy individuals.
Clinical evaluation of erythema and objective
assessments (colorimetry and diffuse reflectance
spectroscopy) were performed. After 5 days, 31
(56%) participants had more sunburn on the SPF
501 side and 4 (7%) had more on the SPF 1001 side.
The researchers concluded that SPF 1001 was
significantly more effective in protecting against
UV-induced erythema and sunburn than SPF 501
in actual use at a beach vacation setting.2 It would be
intriguing to perform a similar study using mineral
sunscreens.
Matta et al3 assessed the systemic absorption
and pharmacokinetics of 6 active ingredients
(avobenzone, oxybenzone, octocrylene, homosa-
late, octisalate, and octinoxate) in 4 sunscreen
products in randomized clinical trial performed in
48 healthy people. They found that all 6 of
the tested active ingredients were systemically
absorbed and had plasma concentrations that
surpassed the US Food and Drug Administration
safety threshold.3 The fact is that we do not know if
this has any health implications whatsoever. More
From the Cooper Medical School of Rowan University, Marlton.
Funding sources: None.
Conflicts of interest: None disclosed.
IRB approval status: Not applicable.
Reprints not available from the author.
studies are warranted. Even Matta et al conclude,
‘‘These findings do not indicate that individuals
should refrain from the use of sunscreen (p 267).’’3
As of January 2021, Hawaii will ban sales of
sunscreens containing oxybenzone and octinoxate
because of concerns about coral reef bleaching.
Although in vitro studies of oxybenzone have caused
coral reef bleaching, so can warmer water
temperatures. Warm water induces corals to expel
their algae, causing the coral to turn white
(bleached).4 Even if climate change is the prominent
provocateur of coral reef bleaching, dermatologists
should be sympathetic with patients concerned
about our environment. It is much easier to alter
sunscreen use as an individual than to affect climate
change in general.
Other controversies include sunscreens’ role in
causing frontal fibrosing alopecia (data are
inconclusive)5 and a potential lack of vitamin D
generation with high SPF sunscreens, which can
easily be addressed by oral supplementation.
As dermatologists, we must be frank about the
incontrovertible data that sunscreen use decreases
sunburn risk, skin cancer (especially squamous cell
carcinoma), and photoaging. When patients obsess
about sunscreens, it is incumbent on us to remind
them that these agents are only one part of a sun
protection strategy that includes avoidance of
the midday sun, seeking shade, and wearing
appropriate clothing. Focusing on sunscreens
without consideration of other avoidance
techniques is akin to relying on car airbags without
concern for driving sober in a well-maintained
automobile.
REFERENCES
1. Adamson AS, Shinkai K. Systemic absorption of sunscreen:
balancing benefits with unknown harms. JAMA. 2020;323:223-
224.
2. Kohli I, Nicholson CL, Williams JD, et al. Greater efficacy of SPF
1001 sunscreen compared with SPF 501 in sunburn
Correspondence to: Warren R. Heymann, MD, 100 Brick Rd, Ste
306, Marlton, NJ 08053. E-mail: wrheymann@gmail.com.
J Am Acad Dermatol 2020;82:821-2.
0190-9622/$36.00
Ó 2020 by the American Academy of Dermatology, Inc.
https://doi.org/10.1016/j.jaad.2020.02.004
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prevention during 5 consecutive days of sunlight exposure: a
randomized, double-blind clinical trial. J Am Acad Dermatol.
2020;82:869-877.
3. Matta MK, Florian J, Zusterzeel R, et al. Effect of sunscreen
application on plasma concentration of sunscreen ingredients:
a randomized clinical trial. JAMA. 2020;323:256-267.
J AM ACAD DERMATOL
APRIL 2020
4. Narla S, Lim HW. Sunscreen: FDA regulation, and environmental
and health impact. Photochem Photobiol Sci. 2020;19:66-70.
5. Robinson G, McMichael A, Wang SQ, Lim HW. Sunscreen and
frontal fibrosing alopecia: a review. J Am Acad Dermatol. 2020;
82(3):723-728.