Sunscreen Safety: What Every Pharmacist Needs to Know

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According to the Skin Cancer Foundation, more than 9500 individuals are diagnosed with skin cancer each day, with more than 2 people dying from the disease every hour.1 Considering that more people in the US are diagnosed with skin cancer each year than all other cancers combined,1 and that 90% of nonmelanoma skin cancers are associated with exposure to UV radiation from the sun,1 it's safe to say that knowledge of sun protection is crucial for protecting patients' health.

Bottle of sunscreen on sandy beach / Ольга Голубева - stock.adobe.com

Sunscreen Basics: Guidance, Vehicles, and Combinations

The American Academy of Dermatology (AAD)2 offers a basic template for the types of sunscreens that hasn't varied much over the past several years: broad spectrum (UVA and UVB); a sun protection factor (SPF) of 30 or higher; and sunscreens that are water-resistant.2 "Chemical sunscreens," the organization noted, "work like a sponge, absorbing the sun's rays. They contain 1 or more of the following active ingredients: oxybenzone, avobenzone, octisalate, octocrylene, homosalate, and octinoxate. These formulations tend to be easier to rub into the skin without leaving a white 'cast.'"

Conversely, physical or mineral sunscreens work like a shield. These products sit on the skin's surface and reflect the sun's rays. "Some physical sunscreens also absorb the sun's rays," the AAD explained. "Physical sunscreens contain the active ingredients zinc oxide and/or titanium dioxide. Opt for this type of sunscreen [the latter] if you have sensitive skin."2

According to Sherry Cohen, FNP-BC, a nurse practitioner specializing in dermatology in Columbia, Maryland, the sunscreen vehicle is important as well. "GRASE [generally recommended as safe and effective] vehicles are oils, lotions, gels, creams, butters, pastes, and sticks, and ointments; non-GRASE vehicles are sprays and powders."

It's also important to not mix sunscreen and bug sprays: "Sunscreen is applied much more frequently than insect repellent, and reapplication of a combined product can lead to unnecessary exposure to the chemicals in bug sprays," Cohen explained.

Other factors that should be considered when recommending sunscreen include a patient's medical history and the product's directions for use. In an email interview with Drug Topics, Danielle M. Alm, PharmD, BCPS, BCPPS, a clinical associate professor at Philadelphia College of Pharmacy at Saint Joseph's University, and Luz Rosario and Colleen Huzinec, PharmD candidates at the Philadelphia College of Pharmacy at Saint Joseph's University, explained why product use is such an important consideration: "We recommend reapplication every 2 hours while outside. Creams are preferred for maximum coverage; it's easier to miss parts of the body using spray sunscreen. Easily missed body parts when applying sunscreen include [the] tops of feet, ears, neck, lips, and [the] top of [the] head. It's important to advise patients to buy face and lip protection in addition to sunscreen for the body. It is also important to consider patient preferences, medical history, and lifestyle that may impact the selection of sunscreen products." (Sidebar 1)

The use of sunscreen should be avoided for patients aged younger than 6 months, they noted; instead, counsel parents and caregivers to utilize nonpharmacologic approaches such as keeping infants in the shade as much as possible, and dressing them in lightweight, long-sleeved clothing and wide-brimmed hats when outside.

Product expiration date is an important consideration as well. The FDA requires that sunscreens retain their original strength for 3 years of use. "If it has been more than 3 years, or [is] past the listed expiration date on the product, it's time to purchase new sunscreen," Alm, Rosario, and Huzinec explained.

Buyer Beware: Certain Substances Are a Cause for Concern

Over the past several years, a number of studies have been published cautioning against the use of certain substances in sunscreens.3 In an article published in the Journal of Cosmetic Dermatology,3 the authors noted, "Oxybenzone (benzophenone-3) is an emerging human and environmental contaminant used in sunscreens and personal care products to help minimize the damaging effects of ultraviolet radiation.…Oxybenzone can also react with chlorine, producing hazardous by-products that can concentrate in swimming pools and wastewater treatment plants."3

The FDA responded to these concerns by updating its own GRASE guidelines: A deemed final order was published on September 24, 2021, which set new requirements for marketing OTC sunscreen products; an additional proposed order was also published, which reflects proposals for future requirements.4 Based on "new data and changed conditions" since the initial OTC monograph was published in 1999, the agency order proposes that sunscreens containing zinc oxide and titanium dioxide be granted GRASE status; not GRASE status is appropriate for sunscreens containing aminobenzoic acid, trolamine salicylate, cinoxate, dioxybenzone, ensulizole, homosalate, meradimate, octinoxate, octisalate, octocrylene, padimate O, sulisobenzone, oxybenzone, and avobenzone.4

Even more worrying is benzene, a chemical found in sunscreens that has carcinogenic properties. In 2021, internal testing at Johnson & Johnson identified the presence of benzine in 5 Neutrogena and Aveeno aerosol sunscreen products, leading to a voluntary recall of those products.5 In a recent issue of Drug Topics' sister publication Dermatology Times®, Editor-in-Chief Christopher Bunick, MD, PhD, discussed the dangers of benzene: "The alarming truth is that benzene has infiltrated numerous dermatological products, such as sunscreens, after-sun products, moisturizers, skin treatments, and other aesthetic-based formulations. For perspective, benzene concentrations in these products can range from 5000- to 60,000-fold higher than ambient air benzene exposure ([approximately] 0.0003 ppm as reported by the EPA in 2010)."6

Bunick continued: "The catalyst for heightened awareness came in May 2021, when Valisure, a quality control company based out of New Haven, [Connecticut], exposed the presence of benzene in 69 different brands of sunscreen and after-sun care products."6

Bernard A. Cohen, a professor of pediatrics and dermatology at Johns Hopkins University School of Medicine in Baltimore, Maryland, echoed Bunick's statement, noting, "[These are] good data, that benzene can function as a carcinogen, especially in liquid sunscreens. It should be avoided at all costs."

The Relationship Between Sunscreen and Medications

Before recommending a sunscreen product, pharmacists should review a patient's current medication list because certain antibiotics are known to cause additional sensitivity to the sun. In their email, Alm, Rosario, and Huzinec explained, "Photosensitivity is [an adverse] effect of certain antibiotics and should be taken very seriously. If a patient works outside in the sunlight or knows they will be excessively exposed to sunlight, they should make this known to their prescriber, especially if getting prescribed an antibiotic." Drug classes with this potential adverse effect include tetracyclines, fluoroquinolones, and trimethoprim-sulfamethoxazole. "As [pharmacists], it is our responsibility to address and stress the seriousness of this [adverse] effect with patients so they utilize skin protection and take preventive measures throughout their course of therapy."

In 2015, the FDA compiled a list of medications that may lead to photosensitivity reactions (Table 1).7 However, the agency cautioned that not every individual who uses a medication on this list will experience a reaction—nor does a one-time reaction mean an adverse reaction will occur again.

Table 1. Medications that may increase sensitivity to the sun7

Sunscreen and Skin Type

As with any medical condition, there are circulating myths that health care providers must address. When it comes to sun safety, one of the more pervasive myths is that individuals with skin of color are not at risk for skin cancer—a myth that providers and advocacy groups have worked to debunk. If you have skin, you're at risk for skin cancer, regardless of skin color or phototype (see Sidebar 2 to learn more about skin phototype). Although skin cancer does occur more frequently in individuals with lighter skin, those with darker skin experience higher rates of mortality associated with skin cancer diagnoses. "It is often diagnosed later, at a more advanced stage, because both [providers] and patients may not even be considering the possibility of skin cancer developing on darker skin until it's too late," said Saira George, MD, an associate professor in the Department of Dermatology, Division of Internal Medicine, at The University of Texas MD Anderson Cancer Center in Houston, Texas.8

Henry W. Lim, MD, FAAD, former chair of the Department of Dermatology at Henry Ford Hospital in Detroit, Michigan, echoed this sentiment in a statement from the AAD.9 "We know that the lighter a person's skin, the higher their risk for skin cancer," Lim said. "While people with darker skin have a lower risk for skin cancer, it can still develop." Lim pointed out that individuals with darker skin are also at a higher risk that UV rays and visible sunlight "will cause dark spots, also known as hyperpigmentation, on [the] skin. This is because darker skin has different types of melanin…than those with lighter skin. For that reason, we recommend sun protection for everyone."9

Table 2. Fitzpatrick skin phenotypes15,16

One issue that may be reducing sunscreen use in people of color is aesthetics, according to surveys of consumer preference.10 A 2016 study published in JAMA Dermatology reviewed both the characteristics of and the "most commonly cited positive and negative features" by consumers of highly rated sunscreen products.11 According to study investigators, "cosmetic elegance" was the most cited positive feature in 61% of comments. But people of color frequently noted the presence of an "undesirable white residue" after sunscreen application as an impediment to use.12

"A mineral sunscreen containing zinc oxide or titanium dioxide is ideal," Alm, Rosario, and Huzinec noted in their email. "Since this option may leave a white cast, a tinted and/or lightweight option" may be preferred by patients with skin of color. And, the AAD noted, "the recent development of tinted sunscreens provides people of all skin tones with sun protection that will blend well with their natural skin tone. Broad-spectrum, water-resistant, tinted sunscreen with an SPF of 30 or higher will provide protection from both [UV] rays and visible light from the sun."9

Making Product Recommendations

Quickly scan the sunscreen aisle in any retail store, and it's easy to see why patients might be confused. Dozens of sunscreen brands are available, each offering a range of SPF, broad spectrum protection, and water resistance—and that's before skin conditions such as acne, dryness, or allergies come into play.

Pharmacists should try to stock their store's front end with a wide range of products. At baseline, the sunscreen options on offer should be SPF 30 or higher, should provide broad spectrum UVA/UVB protection, and should be water-resistant. To better cater to patients with different skin concerns, offer products that are noncomedogenic, moisturizing, and fragrance-, paraben-, and oxybenzone-free.2

The Skin Cancer Foundation has developed a Seal of Recommendation for skin products,12 which may be added to products that meet the group's criteria for safe, effective sun protection, as determined by expert members of its Photobiology Committee (Sidebar 3).

Understanding the complexities of sunscreen products is worth the challenge, particularly when the outcome is fewer diagnoses of—and deaths from—skin cancers like melanoma. The daily application of sunscreen as low as SPF 15 can, when used as directed, reduce the risk of skin cancers like squamous cell carcinoma or melanoma.17

READ MORE: Dermatology Resource Center

References

1. Skin cancer facts & statistics: what you need to know. Skin Cancer Foundation. Updated February 2024. Accessed April 3, 2024. https://www.skincancer.org/skin-cancer-information/skin-cancer-facts/

2. Sunscreen FAQs. American Academy of Dermatology. Updated April 15, 2024. Accessed April 17, 2024. https://www.aad.org/media/stats-sunscreen 

3. DiNardo JC, Downs CA. Dermatological and environmental toxicological impact of the sunscreen ingredient oxybenzone/benzophenone-3. J Cosmet Dermatol. 2018;17(1):15-19. doi:10.1111/jocd.12449

4. Questions and answers: FDA posts deemed final order and proposed order for over-the-counter sunscreen. FDA. December 16, 2022. Accessed April 9, 2024. https://www.fda.gov/drugs/understanding-over-counter-medicines/questions-and-answers-fda-posts-deemed-final-order-and-proposed-order-over-counter-sunscreen

5. Johnson & Johnson Consumer Inc. issues voluntary recall of specific Neutrogena and Aveeno aerosol sunscreen products due to the presence of benzene. News release. Johnson & Johnson. July 14, 2021. Accessed April 9, 2024. https://www.jnj.com/media-center/press-releases/johnson-johnson-consumer-inc-issues-voluntary-recall-of-specific-neutrogena-and-aveeno-aerosol-sunscreen-products-due-to-the-presence-of-benzene

6. Bunick CG. Dermatological dilemma: unmasking the benzene menace in our products. Dermatology Times. 2024;45(3):10-11. March 7, 2024. Accessed April 9, 2024. https://www.dermatologytimes.com/view/dermatological-dilemma-unmasking-the-benzene-menace-in-our-products 

7. The sun and your medicine. FDA. September 25, 2015. Accessed April 9, 2024. https://www.fda.gov/drugs/special-features/sun-and-your-medicine

8. Taschery S. 10 skin cancer myths debunked. The University of Texas MD Anderson Cancer Center. May 2019. Accessed April 11, 2024. https://www.mdanderson.org/publications/focused-on-health/10-skin-cancer-myths-debunked.h14-1592991.html

9. The latest in sun protection. American Academy of Dermatology. March 25, 2022. Accessed April 8, 2024. https://www.aad.org/news/latest-in-sun-protection

10. Song H, Beckles A, Salian P, Porter ML. Sunscreen recommendations for patients with skin of color in the popular press and in the dermatology clinic. Int J Womens Dermatol. 2020;7(2):165-170. doi:10.1016/j.ijwd.2020.10.008

11. Xu S, Kwa M, Agarwal A, Rademaker A, Kundu RV. Sunscreen product performance and other determinants of consumer preferences. JAMA Dermatol. 2016;152(8):920-927. doi:10.1001/jamadermatol.2016.2344

12. Seal of recommendation: safe and effective sun protection. Skin Cancer Foundation. Updated January 2024. Accessed April 11, 2024. https://www.skincancer.org/skin-cancer-prevention/seal-of-recommendation/ 

13. Goon P, Banfield C, Bello O, Levell NJ. Skin cancers in skin types IV-VI: does the Fitzpatrick scale give a false sense of security? Skin Health Dis. 2021;1(3):e40. doi:10.1002/ski2.40

14. Sommers MS, Fargo JD, Regueira Y, et al. Are the Fitzpatrick skin phototypes valid for cancer risk assessment in a racially and ethnically diverse sample of women? Ethn Dis. 2019;29(3):505-512. doi:10.18865/ed.29.3.505

15. Oakley A. Fitzpatrick skin phototype. DermNet. 2012. Accessed April 11, 2024. https://dermnetnz.org/topics/skin-phototype

17. Ward WH, Lambreton F, Goel N, Yu JQ, Farma JM. Clinical presentation and staging of melanoma. In: Ward WH, FarmaJM, eds. Cutaneous Melanoma: Etiology and Therapy. Codon Publications; 2017. Accessed April 11, 2024. https://www.ncbi.nlm.nih.gov/books/NBK481857/

17. All about sunscreen: Why you need it. How it works for you. Skin Cancer Foundation. Updated July 2022. Accessed April 11, 2024. https://www.skincancer.org/skin-cancer-prevention/sun-protection/sunscreen