Learn the facts on the dangers of sun exposure and the formulations available for skin protection.
For the past few years, American readers have been all abuzz about the fan fiction book Fifty Shades of Gray
and its sequels. People seem to have a love-it, hate-it, leave- it, or censor-it opinion about these popular books. Wouldn’t it be wonderful if pharmacists could get the American public as interested in the “Fifty Shades of Red” associated with sun exposure? Let’s use some frequent criticisms of the Fifty Shades
series to learn about tanning, sunburn, and sunscreens.
For the books, it’s all about sex. For sun exposure, it’s all about knowledge about sun exposure and cancer. The medical community wishes that this disturbing fact was common knowledge: the sun exposure increases risk for squamous cell carcinoma, ocular melanoma, and deadly skin melanoma.1-3
The actress Coco Chanel started our obsession with tanning in the 1920s when she returned from vacation with an accidental tan. Bronze shoulders became a fashion “must” as well as a status symbol, and Americans began worshipping the sun. The very rich could tan year-round if they traveled, but regular mortals sported tans only during the warmer months.
By the early 1980s, indoor tanning under artificial sources of intermittent UV radiation have eliminated the gap between the haves and have-nots. Today, well-structured research shows it’ s easier to find a tanning salon than a Starbucks or a McDonald’s.4
Roughly 30 million Americans use tanning salons annually.5
And increased tanning has led to increased rates of skin cancer.
Everything Is a Shade
The Fifty Shades
author describes everything in gray shades—charcoal, steel, smoky. Sun exposure also has its own spectrum from “just a little color” on one end, to bronzed in the middle, to blistering red at the other end. Many Americans believe that light tanning and indoor tanning are harmless. In fact, any amount of sun exposure that leads to skin color change indicates skin insult and causes cumulative damage. People who begin tanning younger than age 35 years or experience severe burns in youth have a 75% higher risk of melanoma.2
For this reason, many states are banning tanning beds for minors or requiring parental permission.6
The Fifty Shades
series is so-called “fan fiction”—writing that emulates or mimics a popular author’ s work, sometimes adding a little spice missing from the original. Certain fictions appeal to tanning fans, too. In addition to the myth that light tanning is harmless and a base tan is protective (not!), they often believe that tanning (ie, ultraviolet light or UVB light) is necessary to acquire vitamin D. Again, this is false. In some areas of the country, even long sun exposure won’t provide enough vitamin D. Dietary sources such as milk, yogurt, cereal, fortified orange juice, and fish (eg, salmon, mackerel, and tuna) are better sources.7,8
Tanning fans often believe that clouds offer protection, but ultraviolet light (UV) rays are present even on overcast days. Another fiction: dark-skinned people don’t have to worry about sun damage. They do, and are at increased risk for the hard-to-diagnose, deadly acral lentiginous melanoma (ALM). Bob Marley, the reggae legend, died from ALM. ALM develops in areas that are hard to see (palms and soles, underneath nails, and on mucous membranes) and resembles bruises or nail streaks at first.9 One last myth—sunscreens provide complete sun protection.
Some critics of Fifty Shades
books say they are repetitive to the point of exasperation. For sun exposure, repetition is important in 2 ways: (1) cumulative UV damage occurs with each sun exposure, and (2) sunscreen efficacy depends on repeated applications. Sunscreen effectiveness depends on the individual’ s propensity to burn, the UV rays’ intensity, and the sunscreen amount and application frequency. Sweating, swimming, showers, and high humidity can decrease sunscreen effectiveness; some sunscreens are water resistant, but none are truly waterproof (Table).
New Federal Rules
books are sexually explicit; sunscreen products are becoming more “informationally” explicit. New federal rules for sunscreens took effect in 2012, and consumers will have better information when they select sunscreens this year. For the first time, some manufacturers can label their products “broad-spectrum UV protection”—if they meet specific criteria measuring proportionality of UVA to UVB protection. The FDA has identified and forbidden the use of misleading terms, such as “waterproof,” “sweatproof,” and “sunblock.”
Note that products labeled before December 17, 2012, may remain on shelves and manufacturers of products with sales of less than $25,000 per year have an additional year to bring those products into compliance. All sunscreen-containing products, including cosmetics, must conform to these new rules.13
Pharmacists should recommend broad spectrum products with SPF ratings of 30 or higher, and water resistance of 40 to 80 minutes. These products should be applied at least 15 minutes before sun exposure and reapplied at least every 2 hours.
Every story needs a cliffhanger—and the Fifty Shades books have many. The sun exposure story has several, too. Some researchers are concerned that blocking UVB rays could lead to vitamin D deficiency. The American Academy of Dermatology (AAD) reports that routine use of sunscreen may increase the likelihood of vitamin D deficiency, a problem that can be addressed with vitamin D supplementation.7
It is important to remember that the benefits of using sunscreen outweigh the risk of vitamin D insufficiency.8
Most researchers believe that sensitivity and toxicity from regular sunscreen use are rare, but caused by para-aminobenzoic acid or oxybenzone when they occur. Patients who experience these problems often have photodermatoses or eczema and report localized burning and stinging. Having patients try products one at a time that contain avobenzone, sulisobenzone, octinoxate, and padimate may identify tolerable alternatives.7
The Fifty Shades
books started as fan fiction based on the popular Twilight
series, which leads to our final point. Most people don’t need sun protection at twilight. UV rays tend to peak at midday (10 AM to 2 PM), and then decrease as the sun sets. Geographic location (eg, Alaska), altitude, and current weather conditions can amplify UV rays, so individuals need to consider their unique circumstances, especially if they burn easily. Always remind patients to reapply sunscreen generously at least every 2 hours when in the sun, and more often if they’re in places where reflection is a concern, such as near water, sand, or snow.14
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance clinical writer.
Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer Epidem Biomarkers Prev. 2010;19:1557-1568.
International Agency for Research on Cancer Working Group on Artificial Ultraviolet (UV) Light and Skin Cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2007;120:1116-1122.
Vajdic CM, Kricker A, Giblin M, et al. Artificial ultraviolet radiation and ocular melanoma in Australia. Int J Cancer. 2004;112:896-900.
Hoerster KD, Garrow RL, Mayer JA, et al. Density of indoor tanning facilities in 116 large U.S. cities. Am J Prev Med 2009;36:243-246.
Geller AC, Balk SJ, Fisher DE. Stemming the tanning bed epidemic: time foraction. J Natl Compr Canc Netw. 2012;10:1311-1314.
National Conference of State Legislators. Indoor Tanning Restrictions for Minors - A State-by-State Comparison. www.ncsl.org/issues-research/health/indoor-tanning-restrictions.aspx. Accessed April 15, 2013.
Sambandan DR, Ratner D. Sunscreens: an overview and update. J Am Acad Dermatol. 2011;64:748-758.
Gilchrest BA. The A-B-C-Ds of sensible sun protection. Skin Therapy Lett. 2008;13:1-5.
Battie C, Gohara M, Verschoore M, Roberts W. Skin cancer in skin of color: an update on current facts, trends, and misconceptions. J Drugs Dermatol. 2013;12:194-198.
Labeling and effectiveness testing; sunscreen drug products for over-the-counter human use. Fed Regist. 2011;76:35620-35665.
Nash JF, Tanner PR, Matts PJ. Ultraviolet A radiation: testing and labeling for sunscreen products. Dermatol Clin. 2006;24:63-74.
Diaz JH, Nesbitt LT Jr. Sun exposure behavior and protection: recommendations for travelers. J Travel Med. 2013;20:108-118.
American Academy of Dermatology. A new day for sunscreen; product labeling to highlight broad-spectrum protection. www.aad.org/dermatology-world/monthly-archives/2012/june/a-new-day-for-sunscreen#page1. Accessed April 15, 2013.
Quatrano NA, Dinulos JG. Current principles of sunscreen use in children. Curr Opin Pediatr. 2013;25:122-129.