Since ancient times, humans have protected themselves from the scorching sun. Back then, it was purely for comfort. It took thousands of years to realize that beyond discomfort, excessive exposure to sun causes physical damage to tissue, including premature wrinkling and skin cancers. The first documented case of skin cancer was in 1787 by Dr. John Hunter; the first documented use of the term melanoma was by the French physician René Laennec in 1806, who described it as a disease entity. It was not until 1918 that sun exposure was first linked to skin cancers by Norman Paul in Australia in an article titled “The Influence of Sunlight in Production of Cancer of the Skin.” It would still be many decades before populations took note. First, we had to go from preferring pale skin to our love affair of bronzed skin and introduction to bikinis.
Our beloved Coco Chanel had much to do with popularizing the tanned look after falling asleep on a yacht in the early 1920s. As a style icon of the time, her preference of being tan influenced generations to come. Until the late 1970s, a tanned complexion was still the hallmark of health and attractiveness, skin cancer from sun was barely spoken about, and sunscreens were still used primarily as a way to spend more time in the sun rather than protecting from skin cancers. It was not until the 1980s that “suntan lotion” was replaced with “sunscreens” and the Skin Cancer Foundation’s Seal of Recommendation was born.
A BRIEF SUNSCREEN HISTORY
The first sunscreen preparations were originally composed of botanicals, which we now know contain antioxidants. The Greeks relied on heavy applications of olive oil, which both moisturized the skin and helped prevent damage. Early Egyptians were a bit more intelligent in their preparations and combined extracts of rice, lupine, and jasmine into creams; ingredients which have since been proven beneficial to ward off sun damage and are still used in antioxidant preparations. In 1936, a French chemist introduced the first synthetic sunscreen. Eugene Schueller launched the brand we still know today as L’Oreal with “Ambre Solaire.” This first preparation contained benzyl salicylate and benzyl cinnamate, ingredients no longer FDA approved for use in sunscreen, which were more of a skin irritant than a protective measure. Various formulas popped up, some ridiculous in their claims and some which were the birth of brands still on shelves today. One of the more notable ones was developed by Benjamin Green in 1944, a Florida pharmacist and former airman; it became a staple in army boxes for years to come. The original formula, “Red Pet Vet,” was made of a petroleum jelly-like substance intended for use in veterinary practices. Its awful texture and propensity to stain clothing made it less than desirable for common use, and it provided negligible protection. It was later improved with the addition of coconut and cocoa oils, and the patent sold to what we now know as Coppertone in early 1950s. In 1946, Swiss chemist Franz Greiter introduced what may have been the first effective modern sunscreen, “Glacier Cream.” His obsession with sun protection continued and nearly 30 years later, in 1974, he went on to introduce the SPF calculations we still use today. It was not until this time that it was realized his original formula only had an SPF of 2. While we have come a very long way since then, there is still quite a way to go.
Understanding Spf And Ultraviolet Radiation
In order to dig deeper into current sunscreens, we have to understand their primary action and what they are protecting us from.
Since the introduction of SPF, the equation has been the cornerstone of the sunscreen conversation, potentially to detrimental effects. Every day, we hear clients proclaim they use SPF 100, and consider that a perfect excuse to stay in the sun all day. SPF measures the fraction of sunburn producing ultraviolet rays blocked during exposure and is an over-simplified measuring system for what we know today. The gist is that an SPF 15 would block one-fifteenth of the burning radiation from reaching skin, assuming sunscreen is applied at two milligrams per square centimeter of skin. This is about six tablespoons of sunscreen for an average body – way more sunscreen than anyone I know applies. Another way of looking at SPF is the length of time a person would burn without sunscreen and multiplying by the SPF. For example, if a light-skinned person generally shows signs of redness after 10 minutes in the sun, the idea is that an SPF of 15 would afford that person 150 minutes in the sun, except that by then most sunscreen ingredients have started to break down. It is generally understood that protection lasts for roughly two hours before it must be re-applied. A five-ounce tube of sunscreen should technically last one full day in the sun. It gets trickier.
The original SPF measured effectiveness against sunburn caused primarily by UVB rays. Preventing damage, whether aesthetic or more serious, is more complicated. Ultraviolet radiation is part of the light spectrum that reaches earth from the sun. There are three types of wavelengths: UVA, UVB, and UVC. UVC is mostly absorbed by the ozone layer and does not reach the earth, so for this conversation, which is confusing enough, we are leaving it out.
UVA is the longest and causes a milder sensation than UVB, but UVA rays travel deeper into the skin, affecting the dermis and subcutaneous layer. These rays are primarily responsible for tanning and pigment irregularities, such as hyper- and hypopigmentation, and are now believed to cause genetic mutation in the sublayers of skin, which ultimately plays a role in premature aging and cancers. UVA rays are the predominant rays in tanning beds.
UVB is known to be the primary cause of actual sunburn and its damage is immediately visible on the skin’s surface. It plays a key role in skin cancer formation, and contributes to photo-aging and tanning. In the United States, UVB rays are most intense between 10 a.m. and 4 p.m. from April through October. In high altitudes, they bounce off of snow and ice and reflect back 80 percent of the radiation, causing a double-hit on skin, remaining a concern year-round.
UVA rays can penetrate glass while UVB cannot. This explains hyperpigmentation through car windows when we have not even gotten pink. Until recently, it was thought that the primary damage, both aesthetic and otherwise, was caused by the burning UVB. It was not until 2004 that UVA was understood as a contributing element to skin cancer formation, and not until the summer of 2013 that the FDA required sunscreen formulations to clearly state whether the product protected against UVA and/or UVB. There is a massive difference between SPF 15 and broad-spectrum SPF 15. Even in that simplified comparison, the actual formulation of ingredients and quality varies drastically from brand to brand. To make matters worse, we are still not sure if sunscreen will actually prevent the deadliest skin cancers.
COMMON SKIN CANCERS
A skin care professional’s primary concern is multi-faceted: Clients expect our expertise in preserving and enhancing their skin’s health, clarity, and beauty. As far as sun exposure is concerned, this is primarily a conversation of wrinkling, sagging, and pigment issues. As a personal commitment to clients, professionals also support the future of their skin and are part of preventing skin cancers.
There are three common skin cancers: Melanoma, basal cell carcinoma, and squamous cell carcinoma.
Melanomas are the deadliest skin cancers and can spread to other parts of the body. According to the National Cancer Institute in 2014, the rate of new melanoma cases among American adults tripled since the 1970s, from 7.89 per 100,000 population in 1975 to 23.57 in 2010. Gaining a deeper understanding of causes and treatments for melanoma is understandably a priority in the medical field, and knowing the early warning signs is a skin care professional’s responsibility in the treatment room. It is assumed that melanomas are caused by sun exposure, but that is over-simplified and dangerous.
Melanoma is more prevalent amongst indoor workers, northern states, and is becoming more common on parts of the body that do not get as much sun exposure. So, although in-vitro studies have shown that genetic mutations caused by ultraviolet exposure can lead to melanoma, the real life findings do not always tell the same story.
Two surprising, very controversial studies were released in 2009. The first questioned not only the rise in melanoma, but the correlation to sun exposure. The authors of the study, presented in the British Journal of Dermatology, proposed that although rates of melanomas have risen statistically, the actual mortality rates have not. The scientists concluded that melanomas are being diagnosed before reaching stage-1, something they call “diagnostic drift,” which proposes that the ability to diagnose early skews the long-range data. They also concluded that the sites where melanomalesions were being found did not correspond to parts of the body generally exposed to sun.
The second study, conducted at The Wellcome Trust Sanger Institute, in Hinxton, UK, concluded that ultraviolet rays cause a genetic mutation to a protective gene, which could ultimately cause melanoma. In the same year, Gregory Daniels, a cancer specialist at UCSD, stated that 95 percent of skin cancers are non-melanomas, but that there is no direct connection between sun exposure and melanoma.
Basal Cell Carcinoma
Basal cell carcinoma (BCC) is the most common skin cancer, occurring in about three out of 10 Caucasians in the United States. Eighty percent of all cases occur on the head and neck, and there is an increase of occurrence on the torso. It primarily occurs in fair-skinned women with a family history. The skin cancer is rarely deadly, but can be disfiguring. Sunlight is a factor in about two-thirds of these cancers, and scientists are more convinced that they are caused by ultraviolet exposure than other skin cancers.
Squamous Cell Carcinoma
Squamous cell carcinoma (SCC) is predominantly a skin cancer but can also be found in various tissues, including the lips, mouth, esophagus, urinary bladder, prostate, lung, vagina, and the cervix. It is most common in people over 50 and light-skinned males. The cause has been directly linked to sunburns and HPV. It can also be linked to chronic skin inflammation, something we can actually cause when we over-use peels and strong exfoliating products.
The take-away is that because we are not certain and scientific methods get stronger every day, correlations justify a cautious approach. Some cancers can be prevented through smart sunscreen use but this should not be the only approach.
HOW SUNSCREEN WORKS
There is enough evidence to show a potential link between excessive sun exposure and skin cancers, and the ultimate role of sunscreen is to reduce exposure. There are two types of FDA-approved sunscreens: chemical and physical. Chemical sunscreens, such as those containing oxybenzone and Parsol 1789, absorb ultraviolet rays, while mineral sunscreens, containing titanium dioxide and zinc oxide, reflect, absorb, and scatter ultraviolet rays. There are currently 15 FDA-approved chemical sunscreen ingredients and two mineral. In Europe and other parts of the world, there are other ingredients, and some of the United States-approved ingredients are banned in Europe. The Sunscreen Innovation Act, introduced in 2014 by United States Congress, aims to speed up FDA approval of new sunscreen ingredients, primarily UVA blockers, and was heavily lobbied for by companies such as L’oreal and Coppertone. Of the approved ingredients, some are broad spectrum and some are not.
The actual talk of sunscreen is a very, very tricky one. There are sides of the conversation that link certain sunscreen ingredients to health issues. Oxybenzone and octinoxate have been linked to multiple hormone disruptive issues and high incidences of skin allergies. Octisalate and octocrylene have also been linked to photosensitivity concerns and skin allergies. Of the current FDA-approved ingredients, zinc, titanium, and avobenzone are considered the safest broad-spectrum sunscreens, although avobenzone is still linked to skin allergies.
In the summer of 2013, new FDA labeling requirements were introduced to help consumers make better sunscreen choices. The term “sunblock” has been eradicated, anything over SPF 50 has been outlawed, and more stringent labeling has been required to highlight broad-spectrum. The term waterproof is no longer allowed, and, to claim water-resistant, manufacturers must show how long the resistance lasts. Powder sunscreens have been banned due to inability to ensure adequate application, and spray sunscreens are under scrutiny. These are all steps in a good direction, but are only part of the story. We are just learning how other ingredients in a formulation react to sunlight.
PHOTOSENSITIZERS AND PHOTOTOXICS
The active ingredients make up between two to 20 percent of a formula. Sunscreens also contain ingredients to stabilize, preserve, moisturize, and ultimately provide a pleasant experience. Antioxidants and fragrances are added to products to enhance appeal and fillers are added to reduce manufacturing cost.
Phytophotodermatitis is a phototoxic reaction of erythema (with or without blistering) and delayed hyperpigmentation. Phototoxicity is an immediate or delayed inflammatory reaction caused by the combination of a topical or oral ingredients followed by ultraviolet exposure. Many common ingredients in skin care are known as phototoxic and/or photosensitizers. These ingredients can either be used in a formulation or taken internally. For instance, taking ibuprofen before sun exposure can cause a higher sensitivity to sunburn. Topically, common photosensitizing ingredients found in skin care are retinyl palmitate (and any vitamin A derivative including retinol), salicylic and glycolic acids, hydroquinone, citrus essential oils, and citrus-based preservatives (unless bergaptene-free). Of these, retinyl-palmitate, citrus oils, and hydroquinone are the most common photosensitizers found in sunscreens, but all the mentioned ingredients are found in some day-use, topical products.
According to the Environmental Working Group, nearly 20 percent of current sunscreen formulations contain retinyl palmitate, a vitamin A derivative. Vitamin A is a major ally in promoting cell turnover, anti-aging, and giving clients the glow they expect from the spa. Retinyl palmitate is a low-cost way to add vitamin A to products but has been shown to wreak havoc on skin when exposed to sun. Vitamin A increases cell turnover, exposing new skin cells to sun. When clients come to us for peels and exfoliation, we generally recommend sun avoidance for three to seven days after to prevent hyperpigmentation and sensitivity. Yet, we often retail day-use products that contain vitamin A. Although the strength of exfoliation is significantly lower than a professional peel, there is still cell turnover happening while skin is exposed to the sun. Can you see how this goes against a skin care professional’s directions? A study by United States government scientists suggests retinyl palmitate may speed the development of skin tumors and lesions when applied to the skin in the presence of sunlight. This study was not conclusive, and left many questions, but rather than aim for a conservative approach until we know further, the FDA requested more studies and allowed retinyl palmitate to remain in day-use personal care products for now.
Citrus oils are the other rampant trouble makers. Most citrus oils contain furocoumarins, which are photosensitizing. In 1990, the European Scientific Committee on Cosmetology recognized furocoumarins to be photomutagenic and photo-carcinogenic. The committee created very strict rules for furocoumarin containing ingredients in beauty products, with particular attention to sunscreens. In the United States, we are way behind. Most of us adore the scent of a lemony body butter and because it is natural, it is often given a green light. Consumers believe natural products are safe, but this is not always true.
In tropical locations, skin issues tied to exposure to citrus are given cheeky names such as “Lime Disease” and “Margarita Dermatitis.” These names come from bartenders and tourists enjoying lovely citrus-based fruits and cocktails in the sun and ending up with a red or brown spot as a souvenir. In skin care products, manufacturers will often claim to use such a small amount that it does not matter. We know that even at one percent, many ingredients are active on the skin, and this holds true for citrus. Professional aromatherapists are trained to avoid citrus oils on skin, and will caution clients to avoid sun for as long as 48 hours after exposure. Yet, in the products industry, we often keep the citrus conversation under wraps because citrus sells, and, when not exposed to sunlight, citrus can actually help lighten sun spots. It is important to note that very high quality, cold-expressed citrus oils contain less or no furocoumarins, but until proper labeling is required, manufacturers must be expected to disclose this information.
Hydroquinone has also been linked to photosensitivity. It has been reported that after four to five months of regular use, many clients begin to see a blueish-color stain in the areas where hydroquinone was used. Leading experts in hydroquinone have proposed that clients use it for no more than five months at a time. The skin must be given a break to allow it to stabilize.
All this information is enough to make us want to stay indoors, in a bubble of safety, and wrapped in a sun-shielding blanket. Then we would be unhappy and vitamin D deficient!
OTHER IMPORTANT ELEMENTS
Along with well-formulated sunscreens, providing skin the elements it needs for a more positive relationship with the sun is one of the skin care professional’s most powerful tools. Tea extracts, strawberry extract, alpha lipoic acid, and bilberry extract have all shown an ability to support the skin’s natural protective mechanisms, internally and topically, and are an exciting area of investigation in skin care. Scientists have been able to show tissue exposed to ultraviolet radiation while covered in certain antioxidants has a lower negative response than uncovered tissue. Other exciting findings include certain ingredients which may increase our natural resistance to skin cancer and skin damage through internal supplementation. An example is astaxanthin, produced by the microalgae Haematococcus pluvialis to protect itself from ultraviolet radiation. Carotenoids, which give fruits and vegetables their bright orange or red colors, are also known to help protect the skin from sun damage.
Dr. Wilhelm Stahl, Ph.D., an author of a study published in American Journal of Clinical Nutrition, showed that after 12 weeks of supplementation with beta-carotene and vitamin E, sunburn was statistically reduced, and the skin created its own SPF of about two to three. Two to three, for most of us, means a little bit of safe, delicious time in the sun. Other studies have shown that regular exposure to sun versus intermittent exposure leads skin to build a defense mechanism. In tropical locations, one of the long-standing, old wives tale is that eating adequate avocados and coconuts helps protect the skin. As skin care professionals, we innately understand that if the skin has adequate internal healthy fats, it is more resilient to damage. There is plenty of information proving that good health and beauty habits holds true for sun protection as well: eat fruits and vegetables, drink tea, eat good fats, and use good, quality products.
When I make a client recommendation regarding sunscreen, I generally point to zinc/titanium-based protection in simple bases. I ask clients to use a powerful antioxidant underneath, such as stable vitamin C or tea extracts. I make sure they are maintaining a healthy diet, their loose-leaf tea consumption is adequate, and that they are being smart. I let clients know it is acceptable to enjoy a bit of sun. I keep up with current information. If at some point scientists point in a totally different direction, my clients trust me to point it out for them. I have made a commitment to never get stagnant in my thought process or tied to one certain theory. Clients do not expect us to know everything. Instead, they need us to never stop asking the hard questions, continue digging into the science, and keep the conversation fresh and bright.
Melissa Picoli has been an aesthetician since 2003, and has worked in a variety of setting, including luxurious spas, salon, and medical clinics. She is the founder of BijaBody Health and Beauty, a line of anti-aging body care and beauty-tea blends based in Montana. Picoli has created spa menus and consulted with spa managers throughout the country to ensure our clients are offered the most luxurious services possible while still ensuring the spa business itself can be run cost-effectively.