The most important Dermatologist appointment this summer

By Jennifer Banarez

It is the beginning of summer and Jane Doe is commuting to her first dermatology appointment with Dr. Derma. In the exam room she sits in a black stationary chair. There is a green swivel chair we often see in exam rooms and a desk with a computer on it.  It is the with bold face letters “Sun Safety” on the wall that catch Jane Doe’s attention right before there is a knock on the door. It opens and Dr. Derma walks in wearing a crisp white doctor’s coat with a file in hand.
“Good morning Jane how are you doing today?”
“I am doing okay. I am just here for a mole check-up. Though I do notice the posters on the wall and would like to learn more about sun safety.”
“Of course! I am glad you are here and being an advocate for your health.”

This is when the doctor usually examines moles according to the ABC’s (asymmetry, border, color) and may use an instrument called a Dermatoscope to do so. If anything seems suspicious to Dr. Derma then a biopsy will be scheduled. A biopsy procedure is performed by extracting a tissue sample from a patient and examining it under a microscope for any abnormalities. It is commonplace in medicine and no need for alarm. Nearly all medical specialties perform biopsies.
 
“Excellent news your moles do not look suspicious!”
“Phew that’s great to hear.”
“Now you asked to hear more about sun protection and I am here to answer all of your questions and offer some recommendations.”
 
I noticed a lot of Korean skincare in Sephora lately and I wanted to know which sunblock is better to use?

Great question! Well the best sunblock is always the sunblock you will definitely use.  However, U.S. and Korean sun blocks are classified differently in their respective countries.  Korean sun blocks are regulated under the Ministry of Food and Drug Safety as a “functional cosmetic.” American non-prescription sun blocks are classified as “over the counter” drugs.   The FDA categorizes sunscreen as an OTC via something known as a “sunscreen order.” The main purpose of the order is to ensure that the active ingredient in the sunscreen product is not a new drug on the market. In 2014 The Sunscreen Innovation Act (SIA) was passed in the U.S. In theory this act could be used to widen the pool of known sunscreen filters or active ingredients currently on the U.S. market.
 
The specific testing for safety and efficacy are similar for both countries and include: irritation tests, phototoxicity tests and carcinogenicity tests. A major difference I noticed that distinguished American from Korean safety testing was the specific category, “post-marketing surveillance”.  This form of testing is found in phase IV of drug clinical trials. The aim of this phase is to detect rare or long-term adverse effects. Drugs are actually on the market during this phase but can be withdrawn if any of the aforementioned occurs.
 
Wow the U.S. seems really strict! Can you tell me what makes California and Hawaii different from the rest of the U.S.A with regards to sunscreen?
 
California has warning labels on their sunscreens containing benzophenone. Those labels state “benzophenone, a chemical known to the state of California to cause cancer.”
In Hawaii on May 5th, 2018 a bill was passed that banned the sale of products containing oxybenzone and octinoxate with the hope that their corals will be saved.
 
What does broad spectrum mean and why is it recommended?
 
There are two types of rays from the sun that we are concerned about, UV-B and UV-A. They differ by how far they can penetrate your skin. The skin is made up of 3 layers from outer to inner; epidermis, dermis and subcutaneous. Then each of those layers is divided into more layers.  We are concerned about the epidermis which is divided into 5 layers. It is the bottom-most epidermal layer, the stratum basale where the effects of UV-A rays that cause skin cancer are mostly found. In America unfortunately only 2 of the approved sunscreen filters “avobenzone and zinc oxide” offer good UV-A protection. 
For a sunscreen product to be labelled “Broad Spectrum” at least three active ingredients are called for that cover UV-A and UV-B rays. For UVB it can include PABA derivatives, salicylates, or cinnamates and for UV-A it can include ingredients such as benzophenones, avobenzone, titanium dioxide, or zinc oxide.
 
I thought excessive sun exposure only caused burns, are you telling me that it also causes premature aging?
 
Yes, unfortunately this is true. It is the UV-A rays specifically that cause premature wrinkles.  They do this by the up regulation of enzymes. Enzymes are capable of adding, taking away, transferring or speeding up specific biological processes. In this case the enzyme is called metalloproteinase. This enzyme specifically degrades our elastin and collagen which are proteins that keep our skin firm. Collagen and elastin naturally degrade as we age, however increased sun exposure without proper protection speeds up that process. No need to worry just yet! Where there is knowledge there is also power. The guidelines for sun safety set forth by the Skincancer Foundation and the American Academy of Dermatology equip us with all the necessary tools we need to fully protect ourselves from those harmful rays.
 
Should I buy a different sunscreen for my daughter that is 5 months old over my daughter than is 11 years old?
 
"The FDA considers the pediatric population when assessing safety, specifically making sure that the safety margin is acceptable according to their scientific judgment. There is no difference between using an adult or a child sunscreen when it comes to safety, provided she is older than 6 months of age. For children under 6 months, it is best to have her wear protective clothing and avoid direct sunlight. Infants have a thinner stratum corneum and a higher surface area-to-body weight ratio. It is for these reasons, that this age group is considered to have highly sensitive skin making them more susceptible to sun rays and sunblock ingredient penetration.
 
I am hearing a lot of commotion about physical and chemical sunscreens, is there any advantage to one over the other?
 
Chemical sunscreens absorb those UV rays and disintegrate them. There are 7 categories.  Physical sunscreens physically block or scatter the UV rays. They include titanium dioxide and zinc oxide. They are known to leave the tell-tale white residue. The best sunscreen is always the sunscreen that you will use.
 
What is the difference between SPF and PA system?
 
The SPF stands for sun protection factor. It only provides protection against the UV-B rays, the sunburn culprit.
PA stands for protection grade against UV-A rays. This is a common rating for Asian sunscreens. It is usually presented in a format like this “PA ++++.”  The amount of “+” that follow the PA represent how much UV-A protection the product provides. If we fall further down the rabbit hole we find that this PA rating is actually the product of another rating known as PPD (persistent pigmentation darkening). This PPD (nothing to-do with Tuberculosis) was developed based on the knowledge that UV-A rays cause the skin to turn brown or to tan. 
 
But there is SPF in my makeup would that be enough?
 
Probably not because the amount needed to achieve maximal protection is not the amount you would normally apply with your foundation or BB cream.
 
Does my sunscreen protect my skin immediately after I apply it?
 
No it does not. In order to get the most bang for your sun protection buck you should factor in time from sunscreen application to going outside.  Depending on what organization you read it differs between applying sunscreen 15-30 minutes before you go outside.
 
How much sunscreen should I apply and how often?
 
It is unanimously agreed that for full body coverage the amount to fill a shot glass is sufficient amount. Reapplication is necessary every two hours. If excessive sweating or water immersion activities are a part of your day then reapplication after said activities is recommended. 
 
Would this UPF rating for my clothes help or is it just hype?
 
UPF stands for ultraviolet protection factor. It is used for clothing and indicates what fraction of the ultraviolet rays penetrate the garments. The skin cancer foundation has a seal of approval if garments meet their standard of at least a UPF of 30. They even have a laundry additive called Sun Guard that increases garments’ sun protection. It is important to consider other factors when deciding if just wearing clothes is a good enough form of protection when going about your day in the sun. This includes type of fabric and tightness of weave. Polyester and wool provide UPF 30 + while cotton, linen and viscose have poor UPF values.  
 
I’ve heard something about tanning addiction.  Can you tell me more about it?
 
Studies have shown that tanning behavior for some people is similar to substance abuse related disorders. This was determined via the CAGE questionnaire and the display of certain symptoms over a 12 month period such as tolerance, withdrawal, difficulty controlling use etc. In order to confirm if tanning could be seen as a substance abuse disorder, withdrawal symptoms were induced via naltrexone. This drug has traditionally been used as a treatment for alcoholism and to prevent relapse in opioid and heroin addiction. It acts as an antagonist of the opioid receptors found in our brain.  
 
It has also been determined that tanning beds cause increased blood flow to the part of the brain responsible for rewards; the ventral tegmental area, nucleus accumbens and prefrontal cortex.  They found that the experimental group (tanning group) had increased endorphins.   Reproducibility is key to a noteworthy finding and more than a few studies resulted in statistically significant increase in endorphins at the conclusion of their UV studies.  


If I avoid the sun how will I get my vitamin D?
 
There are actually two forms of vitamin D. D2 ergocalciferol which is available in plants and D3 cholecalciferol is obtained through sun exposure and milk.  The American Academy of Dermatology and the American Academy of Pediatrics recommends getting your daily dose of vitamin D from your diet. The recommended daily doses for vitamin D is

• 400 International Units for infants/children 0-1 years
• 600 IU for children, teenagers and adults 1-70 years
• 800 IU for adults 71+ years

It is important to note that many foods sold in the U.S. are fortified with Vitamin D as well.  
 
How do I know the type of sunscreen I use is compatible with my skin color?
 
If you have fair skin a sunscreen product with an SPF of 30+ and frequent reapplication is important. If you have darker skin, using chemical sunscreens is usually preferred since physical sunscreens can look chalky on darker skin tones. Fortunately, there are always new formulations coming out with nano-sized particles which should eliminate that unpleasant aesthetic effect.
 
I thought my naturally dark complexion sufficiently protects me from the sun?
 
Every individual has two forms of natural defense against UV rays:
            Epidermal thickening
            Melanin synthesis
It is true that darker skinned individuals have more melanin overall and a type of melanin less susceptible to UV damage. Statistics do show us that light skinned individuals are diagnosed with melanoma more often than dark skinned individuals. Unfortunately, it is important to note that at time of diagnose melanoma in darker individuals it has already progressed into the later stages. 

Current FDA approved active ingredients in sunscreen

About the Author
Jennifer Banarez is an international medical school graduate with an undergraduate degree in Biology. She regularly participates in science policy advocacy work and STEM outreach programs. Her interests include sun safety, nutrition, NASA and medicine, particularly the stem cell field and cardiology. 

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