Sun Damage: Protecting the Skin and Eyes

Many individuals attempt to be proactive about their overall health, but they often underestimate the importance of taking care of their skin—that is, until a dermatologic issue occurs.

Although sunburn is the most common dermatologic issue caused by excessive exposure to ultraviolet radiation (UVR), UVR can also contribute to premature aging, cataracts, and wrinkles (also known as photoaging).¹ Moreover, studies dating back to the 1950s show a strong correlation between chronic, excessive, and unprotected sun exposure and carcinoma of the skin.¹

It is important to increase awareness about sun protection and avoiding excessive exposure to UVR to decrease the incidence of skin cancer, premature skin aging, and other long-term dermatologic issues.¹ According to the Skin Cancer Foundation, skin cancer is the most common form of cancer in the United States: more than 3.5 million cases are diagnosed every year; in 2012 alone, an estimated 76,250 individuals were diagnosed with malignant melanoma.^1,2 The foundation also reports that an estimated 90% of nonmelanoma skin cancers are associated with excessive exposure to UVR sun and up to 90% of the visible dermatologic changes commonly attributed to aging are caused by the sun.^1,2 Moreover, the foundation reports that 42% of the population gets an episode of sunburn at least once a year and that an individual’s risk of developing skin cancer may double if 5 or more episodes of sunburn are experienced at any age.^1-3 Having 1 or 2 cases of blistering sunburn during childhood may even double an individual’s chance of developing melanoma later in life.^3,4

If detected early, melanoma can be treated and many cases of nonmelanoma skin cancers can be cured.¹ For additional information on the 2 types of UV rays, UVA and UVB, and how they can damage the skin, see Table 1.^1,5-8

Risk Factors for Sunburn and Development of UVR-Induced Problems

While all types of skin complexions have the potential to burn or develop other UVR-induced issues due to excessive sun exposure, certain factors may put some individuals at greater risk. Examples include^1,9:

• Having fair skin

• Having an autoimmune disease

• Using immunosuppressive drugs

• Family history of melanoma

• Previous growth on skin caused by UV exposure

• Individuals with a history of 1 or more serious or blistering sunburns

• Infants and children, since their skin is more sensitive than adult skin

• Individuals taking certain pharmacologic agents associated with photosensitivity reactions

• Having blonde or red hair

• Individuals who use tanning beds or sun lamps

• Being exposed to the sun during peak hours (10:00 am to 4:00 pm) without using UV protection

How Sunscreen Products Work

Sunscreens protect the skin by absorbing or reflecting UVA and UVB rays. Their routine use is crucial in protecting the skin from both the short- and long-term damaging effects of sun exposure, as they can decrease incidences of sunburn, premature skin aging, photodermatoses, and skin cancer.¹ Many studies have demonstrated that when applied correctly, sunscreen can block most of the sun’s harmful UV rays.¹

In June 2011, the FDA announced updated requirements for all OTC sunscreens, stating that all sunscreens labeled “broad spectrum” (meaning they protect against both UVA and UVB rays) must pass the FDA’s new standardized broad-spectrum procedure, which measures a product’s UVA protection relative to its UVB protection.^1,10 More detailed information about this FDA ruling can be found at www.fda.gov/ Drugs/ResourcesForYou/Consumers/ BuyingUsingMedicineSafely/Under standingOver-the-CounterMedicines/ ucm258468.htm.

Finding the Best Sunscreen

Pharmacists should be prepared to assist patients in selecting a sunscreen product that suits their individual needs. Sunscreen products are available in various forms (lotions, creams, and sprays) and SPF ranges, and can be water-resistant, as well. The higher the SPF, the more effective the product is at preventing sunburn1; however, an SPF higher than 30 may not afford extra protection. Topical sunscreen products can be divided into 2 categories: chemical and physical. See Online Table 2 for additional information on both.^1,11-13

Table 2: Types of Sunscreen

Chemical Sunscreens

Physical Sunscreens

Absorb and block the transmission of UVR to the epidermis.

Reflect then scatter UVR, rather than absorb the rays.

May contain amino benzoic acid and its derivatives, anthranilates, benzophenones, cinnamates, dibenzoylmethane derivatives, or salicylates.

Often used on small areas, such as the nose or top of ears, and contain zinc oxide or titanium. Especially useful for individuals allergic to the ingredients found in chemical sunscreens.

^{Adapted from references 1, 11-13.}

When selecting a sunscreen, a consumer may consider several factors to find the product that best suits his or her needs, including cost, skin type and complexion, reasons for use, ease of use, formulation, SPF, history of sunburn, and medication history (since some pharmacologic agents may be associated with photosensitivity reactions).^1,14,15 Many of these products—such as broad-spectrum sunscreens, lip balms, cosmetics, and skin moisturizers—contain a combination of ingredients. The Environmental Protection Agency recommends the use of a broad-spectrum sunscreen with a minimum SPF of 30 even on cloudy days.^1,13 Sun protective clothing and sunglasses are also recommended.

In order to achieve optimal photoprotection, consumers must understand how to properly apply and reapply sunscreen products, as directed, to maintain protection while in the sun.¹ Sunscreens should be applied liberally to all exposed areas at least 15 to 30 minutes before sun exposure and as often as the product label recommends, or at least every 2 hours.^1,12-14 In general, an estimated onehalf teaspoon should be applied thoroughly to each exposed area to obtain adequate coverage and protection, and sunscreen should be reapplied especially after swimming, towel drying, or excessive sweating.^1,12-14 According to the FDA, sunscreens labeled “water resistant” must maintain their SPF after 40 minutes of water immersion, while those labeled “very water resistant” must maintain their SPF after 80 minutes of water immersion.^1,12-14 If an individual works outdoors, it is recommended that sunscreen should be reapplied often throughout the day.^1,12-14

Conclusion

Despite constant reminders about avoiding overexposure to the sun, many individuals will still experience sunburn because they do not always use sunscreen when outdoors—especially during the summer— or they apply sunscreen incorrectly. During counseling, pharmacists can provide patients with pertinent information about the various products available for proper photoprotection, make suggestions about how to prevent and treat sunburn (Online Tables 3-6), and remind patients that sun protection is equally important during the winter since snow reflects up to 80% of the sun’s rays, which can cause sunburn and damage to exposed skin.¹

Table 3: Tips for Sun Protection

• An SPF of 15 or greater provides the best protection against sunburn.
• Broad-spectrum sunscreens protect against UVA and UVB radiation.
• Always use a sunscreen product with at least an SPF of 15 or higher when outdoors—even on a cloudy day. An estimated 70%-90% of UVR always penetrates clouds.

• Avoid the use of tanning products or tanning beds.

• Always wear protective clothing, such as long-sleeve shirts, pants, wide-brimmed hats, and sunglasses.

• Monitor children and have them play in the shade (when possible), wear protective clothing, and apply sunscreen to protect them from excess sun exposure.

• Routinely examine skin for any signs of visible changes.

• See your primary health care provider yearly for a skin exam.

• Avoid sun exposure between 10:00 am and 4:00 pm, when the sun rays are the most direct and damaging.

^{Adapted from references 1, 12-16.}

Pharmacists are also in a pivotal position to identify patients at risk for possible photosensitivity reactions due to the use of certain pharmacologic agents (eg, tetracyclines, antidepressants, antihistamines, estrogens, sulfonamides, nonsteroidal anti-inflammatory drugs). These patients should be advised to always use a sunscreen when outdoors, especially for extended periods of time.

Table 4: Treating Sunburn

• Apply a cold, damp towel to the affected area for 10 to 15 minutes several times daily.
• Pat your skin dry after a bath or shower to avoid causing more irritation.
• Use skin protectors and moisturizers to soothe your skin.
• Leave blisters alone.
• Maintain hydration.
• Take acetaminophen or a nonsteroidal anti-inflammatory drug, as appropriate, for pain relief.
• Always seek medical care for sunburn in patients younger than 1 year, severe sunburn, sunburn affecting large areas of skin, or if fever or infection is present.

^{Adapted from references 1, 17-18.}

For more in-depth information on the importance of UV ray protection, visit the following websites:

• American Academy of Dermatology: www.aad.org/media-resources/statsand- facts/prevention-and-care/sunscreens

• The Skin Cancer Foundation: www .skincancer.org/prevention/sun-protection/ sunscreen/the-skin-cancer-foundations- guide-to-sunscreens

Table 5: Examples of Sunscreen Products

• Australian Gold
• Aveeno Baby Continuous Protection Sunblock Lotion SPF 55
• Aveeno Positively Ageless Sunblock Face Lotion
• Aveeno Continuous Protection Sunblock Spray SPF 30
• Aveeno Positively Ageless Sunblock Spray SPF 50
• Aveeno Baby Natural Protection Sunblock Stick SPF 50

• Banana Boat Sport Sunblock Lotion SPF 30
• Banana Boat Kids Sunblock Lotion, Dri-Blok, SPF 30
• Sport Performance Sunscreen SPF 85 and 100 Continuous Clear Spray
• Sport Performance Lip Balm SPF 50
• Sport Performance Sunscreen SPF 50 Stick
• Ultra Defense Sunscreen SPF 50 and 85 Continuous Clear Spray
• Kids SPF 50 Sunscreen Stick

• Bull Frog Quik Gel Sunscreen SPF 36 and 50
• Bull Frog Ultimate Sheer Protection Sunblock for the face
• Bull Frog Ultimate Sheer Protection Sunblock SPF 30 and 50
• Bull Frog Mosquito Coast SPF 30 Sunblock with Insect Repellent
• Bull Frog Marathon Mist Continuous Spray Sunblock

• Coppertone Sunblock Lotion SPF 30
• Coppertone Kids Continuous Spray Sunscreen SPF 50
• Coppertone SPORT Continuous Spray SPF 90
• Coppertone SPORT Lotion SPF 100
• Coppertone ultraGUARD Lotion SPF 90+
• Coppertone KIDS
• Coppertone Waterbabies Pure & Simple Sunscreen Lotion SPF 50

• Hawaiian Tropic Sheer Touch Sunscreen SPF 30 Plus
• Hawaiian Tropic Island Sport Clear Spray SPF 30
• Hawaiian Tropic Baby Crème Lotion SPF 50

• Neutrogena Ultra Sheer Dry Touch Sunblock SPF 70
• Neutrogena Sensitive Skin Sunscreen Lotion SPF 30Neutrogena Spectrum+ Advanced Sunblock Face SPF 100+
• Neutrogena Ultimate Sport Sunblock Spray with Helioplex SPF 85 and 100
• Neutrogena Ultimate Sport Spray SPF 85 and 100
• Neutrogena Age Shield Face Sunblock Lotion SPF 110
• Panama Jack

• Solar Sense Clear Zinc, Advanced Sun Protection, For Face SPF 45
• Solar Sense Clear Zinc Sport SPF 50 Continuous Spray
• Solar Sense Clear Zinc SPF 45 Continuous Spray
• Solar Sense Clear Zinc Baby Tear Free SPF 50

Table 6: Protecting the Eyes from Sun Damage

• Patients should always select sunglasses that block 99% to 100% of ultraviolet A and B rays. Patients prone to light sensitivity should select darker lenses.

• Patients should select sunglasses that fit their face properly and are large enough to shield their eyes from most angles. Wrap-around sunglasses are the best.

• When possible, patients should wear sunglasses and a wide-brimmed hat when outdoors, especially for long periods of time.

• Patients should wear sunglasses (1) even on cloudy days since the sun’s rays can pass through clouds and (2) during the winter since snow reflects up to 80% of the sun’s rays.

• Patients should minimize sun exposure when possible, especially between 10:00 am and 2:00 pm, when sunlight is most direct. Patients should never look directly into the sun.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Crosby K. Prevention of sun-induced skin disorders. In: Krinsky D, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Skin cancer facts. Skin Cancer Foundation website. www.skincancer.org/Skin-Cancer-Facts/. Accessed February 20, 2015.
• Facts about sunburn and skin cancer. Skin Cancer Foundation website. www.skincancer.org/prevention/sunburn/facts-about-sunburn-and-skin-cancer. Accessed February 20, 2015.
• SunWise program summary. US Environmental Protection Agency website. www.epa.gov/sunwise/summary.html. Accessed February 20, 2015.
• Understanding UVA and UVB. Skin Cancer Foundation website. www.skincancer.org/prevention/uva-and-uvb/understanding-uva-and-uvb. Accessed February 20, 2015.
• UV radiation. US Environmental Protection Agency website www.epa.gov/sunwise/doc/uvradiation.html. Accessed February 20, 2015.
• UV radiation. World Health Organization website. www.who.int/uv/faq/whatisuv/en/index2.html. Accessed February 20, 2015.
• Shining light on ultraviolet radiation. Skin Cancer Foundation website. www.skincancer.org/prevention/uva-and-uvb/shining-light-on-ultraviolet-radiation. Accessed February 20, 2015.
• Risk factors for sunburn. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/sunburn/basics/risk-factors/con-20031065. Accessed February 20, 2015.
• Questions and answers: FDA announces new requirements for the over the counter (OTC) sunscreen products marketed in the U.S. FDA website. www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/ucm258468.htm. Accessed February 20, 2015.
• How to choose the right sunscreen for your type of skin. Skin Cancer Foundation website. www.skincancer.org/prevention/sun-protection/sunscreen/choosing. Accessed February 20, 2015.
• Facts about sunscreens. American Melanoma Association website. www.melanomafoundation.org/prevention/facts.htm.
• Sunscreen: the burning facts. US Environmental Protection Agency website. www.epa.gov/sunwise/doc/sunscreen.pdf. Accessed February 20, 2015.
• Sunscreen FAQs. American Academy of Dermatology website. www.aad.org/media-resources/stats-and-facts/prevention-and-care/sunscreens. Accessed February 20, 2015.
• Sunscreen: how to select, apply, and use it correctly. www.cdc.gov/MMWR/preview/mmwrhtml/rr5104a3.htm. Accessed February 20, 2015.
• Prevention tips. Skin Cancer Foundation website. www.skincancer.org/prevention/scf-tips.html. Accessed February 20, 2015.
• Treating sunburn. American Academy of Dermatology website. www.aad.org/dermatology-a-to-z/for-kids/about-skin/skin-cancer/treating-sunburn. Accessed February 20, 2015.
• Five ways to treat sunburn. Skin Cancer Foundation website. www.skincancer.org/prevention/sunburn/five-ways-to-treat-a-sunburn Accessed February 20, 2015.