Let the sun shine, but not sink in
Dermatologists must consider patients’ skin tone, lifestyle, and other important factors to recommend appropriate sunscreens and protective measures.
An important dermatologist tenet is that sunscreen and skin protection is a year-round responsibility. For patients to accomplish this, they require proper education and individualized recommendations based on their skin phototype, geographical location, and lifestyle. At a minimum, dermatologists recommend the daily use of a sunscreen with a Sun Protection Factor (SPF) of 30 or greater on the face, neck, and hands, which are at the greatest risk of sun damage, premature aging, and skin cancer formation.
“In daily practice, dermatologists can help patients build lifelong, sun-smart habits by reinforcing sunscreen as a routine skin care step, not just a beach day essential. Understanding a patient’s skin type, tone, lifestyle, and cultural preferences allows for more personalized and practical recommendations,” said Sandy Tsao, MD, FAAD.
Dr. Tsao and her husband, Hensin Tsao, MD, PhD, FAAD, both practice at Massachusetts General Hospital (MGH) in Boston. Dr. Sandy Tsao is founding director of the Pigmentary Disorders Clinic at MGH, and Dr. Hensin Tsao is the director of the MGH Melanoma and Pigmented Lesion Center.
Third rock from the sun
That big ball of gas in the sky, also known as the largest and closest star to our planet, emits three types of UV radiation. UVA rays have the longest wavelength and deepest penetration into the skin, followed by UVB and UVC rays. Fortunately, UVC is sufficiently attenuated so that its damaging effects are not felt on the planet’s surface, said Dr. Hensin Tsao.
Of course, there’s more to the conversation than that. Walk into any drugstore or retail store and the vast array of SPF options is overwhelming. It’s no wonder patients feel deterred or unprepared to select what will work best for them or their family.
Perhaps this is why patients at a dermatologist’s office often respond to, “Do you regularly use sun protection?” the same way patients at a dentist’s office respond to, “Do you floss daily?” Everyone knows what they’re supposed to say, but that doesn’t mean it’s true in real life.
Consumer confusion
One of the first decisions people face is choosing between chemical and mineral sunscreens.
Hensin Tsao, MD, PhD, FAAD
Mineral sunscreens contain natural metals, such as zinc oxide or titanium dioxide, which remain on the skin’s surface and mostly reflect — rather than absorb — UV rays.
“[Mineral] sunscreens can be gentler on sensitive or acne-prone skin, have no known hormone-disrupting effects, are safe for oceans, and offer broad-spectrum protection,” Dr. Hensin Tsao said. “Unfortunately, mineral sunscreens can leave a visible white cast, especially on darker skin tones, though newer formulas reduce this appearance.”
It is this less-desired visual result that often sways consumers to reach for chemical sunscreens on the shelf, said Dr. Sandy Tsao. She highly urges the use of mineral sunscreens on babies, children, and people who are pregnant for increased safety and protection as well as tinted versions for patients with darker phototype skin to minimize the white sheen.
SPF is more than just a number
The next “factor” to consider is which SPF number is the adequate SPF number. SPF only measures the effects of UVB (i.e., predominantly sunburn), not UVA radiation, which is known to cause tremendous photodamage and possibly skin cancer. The higher the number is, the lower the risk of sunburn, assuming a person reapplies at least every two hours, said Drs. Tsao. However, SPF 60 is not twice as protective as SPF 30, they said, and it is unclear whether higher SPF numbers lead to a proportionate reduction in the risk of developing skin cancer.
Sandy Tsao, MD, FAAD
Dr. Hensin Tsao said there is continued controversy in scientific studies on the actual amount of chemicals the body absorbs and what safety concerns or warnings should be warranted.
“The small circulating amounts of chemical sunscreen have not been directly linked to any definitive health risk,” he said, “although there is certainly an emerging body of evidence from correlative studies that chemical sunscreens could have potential hormonal effects.”
There are also differing opinions on the impact sun protection products have on oceanic life, particularly coral reefs. Dr. Sandy Tsao said researchers in experimental laboratory conditions have identified certain chemicals, like oxybenzone and octinoxate, as having the ability to damage coral DNA, cause bleaching, and interrupt growth.
“These chemicals can accumulate in marine environments, especially in popular tourist areas, prompting bans in places like Hawaii and Palau,” she said. “However, some scientists argue that factors like rising ocean temperatures and pollution play a far larger role in coral decline. More real-world studies are needed to confirm sunscreen’s environmental impact.”
Light at the end of the tunnel
Innovative technology trends, such as nanotechnology, have helped to improve sunscreen formulations without compromising protection, said Drs. Tsao. New products reduce the unappealing white shade and offer antioxidant and anti-aging benefits as well as better moisturization.
For example, bemotrizinol is a highly photostable UV filter that absorbs UVA and UVB rays. The agent is available in Europe and Australia but is still under review by the U.S. Food and Drug Administration (FDA). If approved, it would become the first new active ingredient in the country’s over-the-counter sunscreen monograph since 1999.
Other chemical filters, such as Uvinul A Plus (diethylamino hydroxybenzoyl hexyl benzoate) and Uvinul T 150 (ethylhexyl triazone), are photostable, long-lasting, and compatible with other UV filters.
Another emerging sunscreen ingredient is iron oxide, which provides protection beyond traditional UVA and UVB rays to any visible light.
“Visible light is increasingly recognized for its role in developing hyperpigmentation and photoaging — especially in individuals with darker skin tones,” Dr. Sandy Tsao said. “Iron oxide provides protective coverage for UVA1 and visible light, often not covered by traditional sunscreens. Tinted sunscreens with iron oxides not only protect but also offer cosmetic benefits by helping to even out skin tone, minimizing the white sheen of mineral sunscreens, and limiting the development of hyperpigmentation, making them particularly valuable for people with skin of color who may be more affected by visible light-induced hyperpigmentation.”
Iron oxides are considered safe with minimal side effects and rare allergic reactions. The ingredient is also noncomedogenic and less harsh than some more common chemical UV filters.
Full circle
In everyday practice, Drs. Tsao said dermatologists should work with their patients to develop and maintain practical habits that can protect their skin throughout the year — summer, winter, or in between. Take the time to understand each patient’s skin tone and type as well as age and lifestyle. Noncomedogenic formulas may be better for teenagers who are more prone to breakouts, while people with hyperpigmentation may fare better using a tinted sunscreen with iron oxide.
Concomitant use of skin protective clothing, hats, and sunglasses should be recommended for additional sun protection. Personalizing the approach and utilizing shared decision-making, said Dr. Hensin Tsao, will often result in improved compliance and outcomes.
“Culturally competent care also means being mindful of barriers, such as cost, access, or cosmetic concerns, that might discourage regular use,” he said.
“Ultimately, effective sun protection is about more than just avoiding sunburn,” said Dr. Sandy Tsao. “It is about preserving skin health, preventing cancer, and promoting confidence in patients across all skin types and ages. And it all starts with the right sunscreen.”