While photoprotection is often considered an important part of preventing skin cancers, it also has a role in addressing inflammatory diseases and pigmentary disorders, especially among patients with skin of color. At the Skin of Color Update, Amy McMichael, MD, presented on hot topics and controversies of sunscreen use and photoprotection.1 She discussed common misunderstandings regarding sunscreen use and shared tips for counseling patients on photoprotection in an interview with The Dermatologist.
Dr McMichael is the chair and professor of the department of dermatology at Wake Forest School of Medicine in Winston-Salem, SC.
The Dermatologist: What are some of the misunderstandings regarding photoprotection among patients with skin of color?
Dr McMichael: Patients with skin of color do not have a culture of worrying about sun exposure or skin cancer, and so there is not really a culture of using sun protection. This is compounded by the fact that skin of color does not have a very high risk of developing skin cancer. While the risk is not negligible, the mechanisms and connection to sun exposure are still uncertain. We do not know exactly how sun exposure works in skin of color, and the mechanisms for these patients developing skin cancers may be a different mechanism than the mechanism among patients with fairer skin.
Some patients with skin of color do develop nonmelanoma skin cancers and some develop melanomas, but we are unable to connect this as neatly with UV light or sun exposure as we are for lighter skinned patients, particularly ones of European descent. While we are not exactly sure what the mechanism might be, it is still important that all patients wear sun protection to prevent skin cancers.
In addition, UV light exposure can exacerbate or cause other conditions, such as photosensitive diseases (eg, lupus, dermatomyositis), hyperpigmentation, and sun exposure-related disorders (eg, melasma, drug-induced pigmentation).
The Dermatologist: What is the role of using sunscreen for inflammatory disorders or pigmentary disorders?
Dr McMichael: In disorders, such as lupus and dermatomyositis, with a photosensitive component, UV exposure can exacerbate skin findings and sometimes the systemic findings of that disease. When treating primary or secondary hyperpigmentation, I tell my patients that they need to use “sunscreen, sunscreen, and then some sunscreen.” At first, they are confused, but then they understand that they really need to use sunscreen as a part of treating their dyschromia.
I also make sure I explain how I want them to apply sunscreen—it is not just for long periods of time out in the sun, but it needs to be used every single day, regardless of the weather.
I recommend the tinted, inorganic sunscreens to my patients because it is more likely to provide broad‑spectrum coverage, usually with the use of an iron oxide. We now know from various research studies, including ones led by Henry Lim, MD, that tinted sunscreens block visible light, which is an important component of certain inflammatory disease processes and known to worsen the disease.2 In addition to sunscreen, I discuss other photoprotective measures such as wearing wide-brimmed hats, sun-protective clothing, and seeking shade.
There are a lot of cosmetically elegant mineral sunscreens available now; however, if patients are unable to find an inorganic option that suits them, then I recommend a broad-spectrum chemical sunscreen made for sensitive skin.
While we develop a treatment regimen to address the patient’s specific pigmentary concern, the most important aspect of treating their condition is sunscreen. Regardless of how well we can treat hyperpigmentation with medical therapies, without photoprotection the pigmentary changes may come back or not resolve completely.
The Dermatologist: What is the role of sunscreen in frontal fibrosing alopecia (FFA)?
Dr McMichael: FFA is a conundrum. It is difficult for patients because it not only causes their hairline to recede, but it is often associated with itching, burning, and stinging. The first cases were described among postmenopausal White women in the mid‑1990s in Australia.3 Recently, the incidence significantly increased globally, and there are a lot of efforts to figure out what is causing this type of alopecia.4
It was first described in Australia during a time when the country did a very intense skin cancer awareness campaign called “Slip, Slop, Slap.” People started using more chemical sunscreens because the zinc options, although available, were completely opaque. Researchers started to think there might be an association between FFA and sunscreen, due to the rise in incidence after the “Slip, Slop, Slap” campaign.
There were several studies that looked at retrospective data of patients with FFA and oftentimes compared sunscreen use to patients who did not have FFA to see if there was an association. However, there were multiple issues with these studies, including tremendous recall bias because people don’t remember what they did yesterday, let alone what they did 20 years ago. We still do not have any strong data showing an association, and certainly not causation, between FFA and sunscreen use.5
As a result, I recommend my patients use the inorganic sunscreen, which were not available back then. These tend to be less irritating anyway and very protective. This will keep everyone safe, while we continue to look into this disease and explore why the incidence is increasing.
The Dermatologist: What are some of the common concerns around sunscreen and its use, particularly among patients with skin of color?
Dr McMichael: As I mentioned, my patients with skin of color do not always understand the importance of sunscreen. They are also concerned that it will not look natural on them.
In addition, patients are concerned about their vitamin D levels and wonder if sunscreen prevents them from getting enough vitamin D. In general, people with skin of color are not as efficient at producing vitamin D. We have not shown in any studies thus far that sunscreen prevents people from producing vitamin D or that people who use sunscreen with skin of color are vitamin D deficient.
Furthermore, sun exposure does not equal more vitamin D production. Everyone has different machinery that works differently and increasing sun exposure will not address any inefficiencies in the body’s ability to produce more vitamin D. Thus, considering other sources, such as food or supplements, would be a better option.
I recommend all of my patients use sunscreen and, if they are concerned, to check their vitamin D levels with their primary care provider, as well as take a supplement if necessary.
People are also worried about systemic absorption and the environment. First, people have been using sunscreens for years and we have not seen any significant absorption or issues caused by systemic absorption. As far as the environment is concerned, we have lots of data now from people who study oceans and environmental changes that show these changes are not from sunscreen but from plastic.
The Dermatologist: What other pearls should dermatologists keep in mind when counseling patients from different ethnic backgrounds?
Dr McMichael: Different people from various ethnicities have their own cultural ways of understanding photoprotection. For instance, those of Asian descent might feel more comfortable wearing a hat and/or using a parasol vs wearing sunscreen. People of African descent may feel more comfortable using sunglasses and seeking shade vs wearing sunscreen. It is important when dermatologists talk to people about photoprotection that they not just address sunscreen use but also come from where the patient is most comfortable and already practicing photoprotection.
For example, when counseling a patient who is already comfortable using a hat to protect against sun exposure, a dermatologist can recommend they increase their use of sunscreens by encouraging the patient to apply it to the portion of the face and parts of the neck that are not protected by the hat.
A lot of people forget about sun protective clothing as well. Some of these styles are now very cool and can be used for hiking or in the heat. I wear sun protective clothing every single time I go outside for a walk, which I’ve been doing a lot of since the pandemic.
Overall, dermatologists should work within the patients’ cultural identification and how they are already using photoprotection, and then add to it.
1. McMichael A. Hot topics & controversies in photoprotection: making sense of it all. Presented at: Skin of Color Update; September 13, 2020; virtual.
2. Lyons AB, Trullas C, Kohli I, Hamzavi IH, Lim HW. Photoprotection beyond ultraviolet radiation: A review of tinted sunscreens. J Am Acad Dermatol. Published online April 23, 2020. doi:10.1016/j.jaad.2020.04.079
3. Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol. 1994;130(6):770-774.
4. Mirmirani P, Tosti A, Goldberg L, Whiting D, Sotoodian B. Frontal fibrosing alopecia: an emerging epidemic. Skin Appendage Disord. 2019;5(2):90-93. doi:10.1159/000489793
5. Robinson G, McMichael A, Wang SQ, Lim HW. Sunscreen and frontal fibrosing alopecia: a review. J Am Acad Dermatol. 2020;82(3):723-728. doi:10.1016/j.jaad.2019.09.085