Community Pharmacists’ Guide to Counseling Individuals on Sun Protection for All Skin Types and Tones

This article was sponsored by Neutrogena^®.

Skin cancer remains a major public health issue. It is the most prevalent cancer in the United States; over the last 3 decades, more cases of skin cancer have been noted among Americans than have cases of all cancers combined.¹ An estimated 1 in 5 White people in the United States will develop nonmelanoma skin cancer by 70 years of age; further, the risk of developing melanoma over a lifetime is 1 in 38 among White individuals, 1 in 167 for the Hispanic population, and 1 in 1000 for Black individuals.^1-4 Pharmacists play a major role in educating individuals about sun protection and prevention of skin cancer, especially given the low public awareness regarding sun damage across different skin types, tones, and melanin levels.^5,6

The Fitzpatrick skin type scale is a tool used by health care professionals to help assess a person's risk of skin cancer based on the amount of melanin in the skin and the likelihood that skin will burn on exposure to sunlight.¹ Traditionally, discussions on sun protection have largely focused on White individuals (Fitzpatrick skin types I and II), who are at the highest risk of burns, damage from UV radiation, and skin cancer; however, skin types that may not burn as easily (types IV-VI) still require protection (Figure).^1,7,8

The Fitzpatrick scale can be helpful when categorizing skin type, but it is an imperfect tool that may not account for the wide range of skin tone and types, especially within skin types IV to VI. Pharmacists can use the Fitzpatrick scale as a first step when recommending individualized sun care options; however, they must understand that it may not accurately reflect a person's skin cancer risk across various races and skin tones.^1,7,8

There are several health benefits of sun protection beyond its importance in preventing skin cancer. Compliance with sun protection behaviors can prevent photoaging, shield skin that has drug-induced photosensitivity, and diminish the appearance of hyperpigmentation and melasma.^1,9,10

ADDRESSING SUNBURN RISK AND LOW RATES OF SUN PROTECTION COMPLIANCE ACROSS ETHNICITIES

The number of days with high UV index in the United States has increased over the years, reinforcing the importance of daily photoprotection.¹¹ Sun protection behaviors and sunscreen use among most adults must improve. According to a 2022 survey by the American Academy of Dermatology, 62% of adults gave themselves an overall grade of excellent or good for sun protection in 2021, yet 63% reported getting a tan—a 9% increase from 2020.¹²

There are also disparities among specific populations regarding sun protection and compliance patterns. Generally, more women than men practice sun protection (eg, staying in shade, 43% vs 31%, respectively; use of sunscreen with a sun protection factor [SPF] ≥ 15, 40% vs 22%; sun avoidance, 49% vs 34%; use of protective clothing, 34% vs 44%).¹³ Results from an online survey of 1742 adults who identified as having White, Black, Hispanic, or Asian heritage showed differences in sun protection practices among ethnicities. Overall, sunscreen use among White respondents was higher than that for Black or Hispanic participants; likewise, use was substantially lower among Black participants than for Hispanic or Asian respondents.¹⁴ Similar results were shown in a survey of Black adults (N = 2187), of whom 31% reported always participating in at least 1 sun protection effort, and 63% reported never using sunscreen in their lifetimes.¹⁵ In a separate survey, Black adults were twice more likely than White adults to report not needing to use sunscreen.¹⁶

Sunburn Experiences Vary By Skin Tone

Just 1 sunburn can increase an individual’s risk of developing skin cancer, whereas 5 or more sunburns can double the risk of melanoma.^13,17 In an analysis of 2015 National Health Interview Survey data from US adults (N = 31,162), 34% of respondents reported that they were sunburned in the past year.¹³ Sunburn was most common among those who were younger, sun-sensitive and physically active, across ethnicities.¹³

Everyone can experience sunburn, but presentation varies across different ethnicities. An online survey evaluated the experience of sunburn among 3597 adults of diverse races and ethnicities (White, Black, Hispanic, and Asian individuals). Among White respondents, the dominant signs and symptoms were skin that was hot to the touch and red in color; Black individuals described sunburn as being painful and causing peeling and itchy skin. The most severe and painful sunburns were self-reported by Black and Hispanic people and those with skin types III to VI.¹⁸

If asked for help to address peeling skin, pharmacists may recommend products intended for use after sun exposure that can moisturize and provide relief from sunburn (eg, aloe vera, Neutrogena Sun Rescue^® After Sun).¹⁹

SUN PROTECTION PRODUCTS: ALIGNMENT WITH INDIVIDUAL PREFERENCES TO PROMOTE REGULAR USAGE

When asked for a sunscreen recommendation, pharmacists can support product selection and provide information on specialized formulations to encourage daily photoprotection of all skin types and tones. Broad-spectrum sunscreen with an SPF of 30 or higher should be recommended to protect the skin against both UV-A and UV-B rays.^20-22 UV-A rays can cause premature skin aging (wrinkles and age spots), whereas UV-B rays are responsible for sunburn; exposure to both, however, can increase the risk of skin cancer and contribute to hyperpigmentation.²⁰ Visible light can also induce hyperpigmentation in individuals with darker skin tones (skin types III-VI)and contribute to exacerbation of pigmentary disorders.^22,23

Researchers are investigating the effects of visible light and UV-A radiation on all skin tones and the possible benefits of tinted sunscreens and sunscreens with antioxidants.²⁴ Results from a clinical investigation demonstrated that darker skin protected by tinted sunscreen showed less pigmentation than did unprotected skin, and sunscreen with antioxidants worked as well, if not better, than did all sunscreens investigated.¹⁰

Ingredient Considerations

Sunscreens are formulated with mineral and/or chemical UV filters that protect the skin from UV damage. Mineral sunscreens contain the active ingredients zinc oxide and/or titanium dioxide, which block and scatter UV rays.^22,25,26 Chemical sunscreens contain active filters (eg avobenzone, octisalate, octocrylene, homosalate, oxybenzone, and/or octinoxate) that absorb UV rays.²²

SUN PROTECTION TECHNOLOGY FROM NEUTROGENA^® AND AVEENO^®

To increase pharmacist awareness and to support recommendations, the Table provides information on select Neutrogena^® and Aveeno^® sun protection products available in the pharmacy. As leaders in sun care, Neutrogena^® and Aveeno^® have developed innovative resources to help individuals incorporate sunscreen use into everyday behavior and increase compliance.^27,28 Helioplex^® technology from Neutrogena^® ensures that formulas are stable under UV radiation.²⁹ Products containing this technology offer superior UV-A/UV-B protection with aesthetically pleasing formulations. Neutrogena^® uses Purescreen+™ technology in their newest mineral sunscreens. These products contain 100% mineral UV filters (zinc oxide and titanium dioxide) to deliver broad spectrum protection plus skincare ingredients like Vitamin E, which is known for its nourishing properties. These sunscreens do not contain parabens or chemical active ingredients; they are fragrance-free and dye-free and are suitable for sensitive skin.^26,30-32 The new Mineral UV Tint sunscreen features Purescreen+™ and is uniquely designed with neutral undertones to ease blending and to complement natural skin tone.

Product-specific Recommendations

For sun protection use and compliance, the best sunscreen to select is the product that an individual likes to wear and will use consistently.³³ Pharmacists can provide product-specific information on the available broad-spectrum sunscreens that are intended for specific areas of concern (eg, affected by eczema) and skin that is sensitive, acne-prone, dry, or oily. Sunscreens are available in many forms (eg, lotions, sticks, sprays, serums, and face mists). Consider specific needs (eg, clear, invisible, or lightweight formulations of sunscreens) for particular skin types and skin tones. An individual’s activity level may also influence selection. For example, those who participate in outdoor activities may benefit from a water-resistant option (eg, Neutrogena^® Beach Defense^® or Sport Face). For everyday protection, select a daily moisturizing formulation intended for morning use or a tinted sunscreen.^22,34-38

ROLE OF THE PHARMACIST

Along with other members of the health care team, pharmacists can emphasize the importance of compliance with daily sunscreen usage across ethnicities, skin tones and skin types. They can also motivate positive sun protection behaviors, such as seeking shade at peak hours and wearing protective clothing, hats, and sunglasses.²² Greater public education campaigns are needed to target people with darker skin types to promote earlier skin cancer detection and treatment through self-skin examination and to stress the importance of photoprotection.³⁹ As nearly half of melanomas are identified by self-detection, pharmacists can encourage frequent self-monitoring for skin cancer following guidance from the American Academy of Dermatology.^40,41 Additionally, needs of the entire family, including children, must be considered. The results of a 2022 survey showed that 75% of parents say that their children are kept well-protected from sun exposure; however, 65% of children have had 1 or more sunburns in the past year.⁴²

When dispensing prescription topical or systemic photosensitizing medications (eg, acne medications [ie, retinoids, doxycycline, minocycline], certain antibiotics, hormonal
contraceptives, nonsteroidal anti-inflammatory drugs, sulfonylureas, antihistamines, and thiazide diuretics), pharmacists have a unique opportunity to educate patients about sun protection and support selection of the most appropriate sun protection product(s) that can be used regularly and with use of prescription medications.⁴³

Additional resources, including a skin protection guide and checklist for self-assessment of skin cancer, are available from NeutrogenaMD.com to support pharmacists as they advocate for sun health behaviors within the pharmacy.

REFERENCES

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