856611

research-article2019
CMSXXX10.1177/1203475419856611Journal of Cutaneous Medicine and SurgeryLi et al

Feature Article

Journal of Cutaneous Medicine and Surgery

Sunscreen Application, Safety, 1­–13

© The Author(s) 2019
Article reuse guidelines:
and Sun Protection: The Evidence sagepub.com/journals-permissions
DOI: 10.1177/1203475419856611
https://doi.org/10.1177/1203475419856611
jcms.sagepub.com

Heidi Li1 , Sophia Colantonio1,2, Andrea Dawson1,2,

Xing Lin1,2, and Jennifer Beecker1,2

Abstract
Recently in Canada, there has been an effort to create consistent messaging about sun safety as there is a lack of up-to-
date evidence-based guidelines regarding sun-protection measures. This review aimed to provide updated, evidence-based
recommendations on sunscreen application, safety, and sun protection regarding the following topics for which there is
clinical uncertainty: physical barriers, sunscreen properties, sunscreen application, and risk-benefit analysis.

Keywords
application, guidelines, photodamage, photoprotection, review, skin cancer, SPF, sun protection, sun protection factor,
sunscreen

Introduction Methods
Skin cancer is the most common form of cancer in Canada, Literature Search
with non–melanoma skin cancer (NMSC) alone accounting
for at least 40% of new cancer cases.1 In 2014, an estimated A list of broad topics on sunscreen use and sun-protection
6500 new cases of melanoma and 76 100 cases of NMSC methods was formulated after a preliminary survey between
occurred in Canada. The incidence of skin cancer is pro- the authors and members of the Dermatology Division at The
jected to rise in the coming decades because of the aging Ottawa Hospital, a Canadian tertiary care hospital. The pro-
population.2 Since most skin cancers are preventable by posed topics included “sunscreen application amount,”
reducing natural and artificial ultraviolet (UV) radiation “application frequency,” “application timing,” “SPF recom-
exposure,3 public education on and advocacy for sun pro- mendation,” “formulation of sunscreens,” “organic vs inor-
tection are essential. Two key messages regarding sun- ganic sunscreens,” “water-resistance of sunscreens,” “lip
safety education are the regular use of sunscreen and protection,” “physical barriers,” “population factors for sun-
physical protective agents, such as clothing, hats, sun- screen use,” and “harms and benefits of sunscreens.”
glasses, and shade.4 A search for relevant studies in MEDLINE (1946 to
Sunscreens have gained tremendous commercial success December 2018) was performed. Our search strategy used all
since their introduction in the United States in 1928 and have combinations of the following key terms: “sunscreening
been incorporated into various moisturizers, makeup, and lip agents,” “application,” “skin pigmentation,” “administra-
products. Worldwide, sun-care product sales have increased tion,” “protective clothing,” “sunburn,” “water resist,” “sun-
7% on average per year over the last 5 years.4 burn,” “sun protection factor,” “skin neoplasms,” “skin
The efficacy of protection by sunscreens has been widely aging,” “photoaging,” and “lip.” Publications were limited to
accepted as indicated by the sun protection factor (SPF), first meta-analyses, systematic reviews, randomized controlled
adopted in 1978 by the US FDA. In Canada, sunscreens are trials, guidelines, comparative studies, evaluation studies, or
approved and regulated by Health Canada. To promote uni-
formity of public health messages in Canada, a National 1
University of Ottawa, ON, Canada
Consensus on Sun Safety Messages was developed in 2016.5 2
Division of Dermatology, The Ottawa Hospital, ON, Canada
In addition, the FDA and Health Canada alike have modified
Corresponding Author:
their sunscreen monographs in the past 5 years.
Jennifer Beecker, The Ottawa Hospital, The Division of Dermatology,
The purpose of this study was to assess the current litera- 737 Parkdale Ave, 4th Floor, Parkdale Clinic, Ottawa, ON K1Y 4E9,
ture on sun-protection measures and methods to derive a set Canada.
of best-practice recommendations. Email: [email protected]
2 Journal of Cutaneous Medicine and Surgery 00(0)

multicentre studies in the English language after 1946. A Results

manual search was also conducted based on references cited
in selected articles generated by the literature search. The initial search yielded 424 studies. After screening the
titles and abstracts for relevance, 84 articles were selected for
full-text review, as summarized in Supplementary Table 4.
Research Questions Here, we review the evidence for each research question to
support the recommendations summarized in Table 1.
The abstracts and titles of articles yielded from the search
were screened to select relevant articles that addressed the
following research questions for subsequent full-text review: Physical Barriers
Is Ultraviolet Protective Clothing Superior to Regular Clothing? 
1. Physical barriers Protective clothing is a simple method of photoprotection.7
a. Is UV protective clothing superior to regular Canadian consumer guidelines for UV protection clothing
clothing? refer to the ultraviolet protection factor (UPF), a standardized
b. What minimum level of UV protection is needed in vitro measurement of the ultraviolet A (UVA) and ultravio-
in sunglasses? let B (UVB) protection of clothing.8 Currently, UPFs 15 and
2. Sunscreen properties 20 are rated as good photoprotection; UPF 25, 30, and 35 as
a. What is the recommended SPF of sunscreens? very good; and UPF 40, 45, 50, and 50+ as excellent. There
b. What is the preferred vehicle of sunscreens? are no Canadian guidelines as to the ideal minimum UPF fac-
c. Should inorganic or organic sunscreens be used? tor, whereas European standards recommend UPF 40+.
d. When should water-resistant sunscreens be UPF ratings are affected by multiple heterogeneous
used? ­factors, including weave density, composition, colour, fabric
e. Lip protection thickness, stretch, moisture, and fabric condition.9 Two
f. Expiry date ­studies10,11 have demonstrated that thicker and heavier-
3. Sunscreen application weight clothing with dark colourants provided more protec-
a. What amount of sunscreen is appropriate to tion. Similarly, an in vitro study12 found that UPF of a replica
apply? England football shirt with white vertical bands of varying
b. How frequently should sunscreen be reapplied? thickness had a UPF of 5 for the thinner bands and 11 for the
Does physical activity affect the frequency of thicker bands, highlighting the importance of clothing thick-
application? ness. For fabric composition, numerous studies demon-
c. How long before sun exposure should sunscreen strated that Lycra/elastane fabrics were the most likely to
be applied? have UPFs of 50 or higher, followed by plastic, nylon, and
d. Does application of sunscreen vary for different polyester.9 Thus, it is important for consumers to check the
skin types? UPF tag when selecting garments for UV-protection pur-
4. Risk-benefit analysis poses. If UPF tags are not available, generally consumers
a. Is sunscreen harmful (ie, risks of compounds/ should choose garments with greater fabric weight, thick-
ingredients)? ness, tighter weave, darker colours, and those of made of
b. Are sunscreens safe for infants? Lycra/polyester, as these characteristics typically result in
c. Does sunscreen prevent skin damage/aging/ greater photoprotection.7 Additionally, consumers should be
wrinkles? aware that garments that are worn thin, wet, or stretched may
d. Does sunscreen prevent skin cancer? offer reduced UV protection as UPF values decreases with
stretch, wetness, and numerous washes.7
Although all types of clothing provide some degree of
Critical Appraisal and Recommendation
UV-light protection, recent studies have demonstrated that
The research design and quality of all relevant publications some regular clothing garments do not provide sufficient UV
were assessed using the Canadian Task Force on Preventive protection.13 UV-protective clothing is specifically designed
Health Care (CTFPHC) grading of recommendations, assess- to block out UV light and may provide more effective broad-
ment, development, and evaluation (GRADE) definitions spectrum photoprotection. Numerous studies, including two
(see Supplementary Tables 1 and 2).6 The levels of evidence in vitro studies14,15 found that athletic clothing (yellow soc-
for all articles included in the systemic review are presented cer jersey, blue shorts, sweatshirt, baseball cap, cycling jer-
in Supplementary Table 3. Studies relevant to the same topic seys) all offered excellent protection. There are only a few
were evaluated together to derive an overall recommenda- studies comparing the photoprotection of regular clothing
tion. The level of evidence for each recommendation was with that of photoprotective clothing. A small study16 dem-
ranked based on the CTFPHC GRADES of Recommendation onstrated that regular clothing provided similar UVA/UVB
as “strong” or “weak” (see Table 1).6 protection as photoprotective clothing, although their study
Li et al 3

Table 1.  Summary of Recommendations for Each Research Question and Strength of Recommendations as Evaluated Using the
CTFPHC GRADE System.

Research Question Recommendation Strength

Physical Barriers UV protective clothing is superior to regular clothing as it provides excellent consistent Weak
light-weight photoprotection with clear UPF ratings.
When choosing regular clothing items with no UPF tags, choose garments with tighter Strong
weaves, increased fabric weight, thickness, darker colours, and Lycra/polyester
composition and that cover more skin. Moisture, fabric stretching, and fabric degradation
could also decrease the UPF factor.
Sunglasses that provides UV absorption up to 400 nm should be worn during daily activities Weak
(eg, driving) in conjunction with hats. In particular, this message should be reinforced with
men and minorities, the most at-risk groups.
SPF A broad-spectrum sunscreen with UVA and UVB filters and SPF of at least 30 should Strong
be applied, and even higher SPF sunscreens may be used to compensate for common
underapplication of sunscreen.
Patient education is needed on the meaning of SPF and other factors affecting effectiveness Strong
of sunscreen apart from the SPF value alone.
Vehicle of Sunscreen Water-in-oil emulsion is the recommended formulation of sunscreens to achieve highest Weak
SPF and water resistance.
Organic vs Inorganic A broad-spectrum sunscreen containing a balance of UVA and UVB filters is recommended, Strong
Sunscreens regardless of whether the components are organic or inorganic.
When using sunscreens with primarily nonmicronized inorganic filters, education to avoid Strong
underapplication is especially important.
Water Resistance Water-resistant sunscreen (for 40 or 80 minutes) should be worn in conditions in which Strong
there is significant sweating, water immersion, increased skin friction via physical contact,
or contact with sand.
Lip Protection Lip sunscreen should be applied generously to cover the whole lip. Strong
High-SPF products (≥ 30) and reapplication should be used to compensate for Strong
underapplication.
Expiry Date Do not use sunscreens that are past the manufacturer-specified expiry date or Weak
recommended period after opening. Sunscreens should be stored at room temperature
to ensure stability.
Sunscreen Apply liberally (approximately 45 ml) to all exposure areas. Strong
Application Reapplication within an 8-hour period is necessary only after activities that may remove the Strong
sunscreen layer (swimming, sweating, friction).
Apply prior to sun exposure and at least 20 minutes prior to water activities. Weak
Individuals of colour should use photoprotection, including sunscreen. Weak
Sunscreen Safety Safe overall with a favourable risk-benefit profile. Strong
Stratum corneum is an effective barrier, thus systemic absorption should not be a concern. Strong
Risks: photoallergy (most common, but rare), reproductive toxicity, decreased fertility Strong
(lack of evidence), hazardous to coral (more research needed; direct association with
sunscreen not established).
Limit the use of sunscreen in children younger than age 6 months. Weak
Benefits Sunscreen prevents photoaging. Strong
Sunscreen prevents melanoma and non–melanoma skin cancer. Strong

Abbreviations: CTFPHC, Canadian Task Force on Preventive Health Care; GRADE, grading of recommendations, assessment, development, and
evaluation; SPF, sun protection factor; UPF, ultraviolet protection factor; UV, ultraviolet; UVA, ultraviolet A; UVB, ultraviolet B

was very limited in terms of the number and type of garments cost, whereas typical normal clothing may provide inade-
tested. Furthermore, UV-protective clothing is also designed quate to excellent protection.
to be more lightweight and breathable compared with normal Recommendation: There is fair evidence to support the
clothing, making it the ideal consumer choice for hot sum- use of photoprotective clothing as it provides excellent con-
mer weather and outdoor physical activities. Although cer- sistent photoprotection with clear UPF ratings, allowing the
tain items of normal clothing such as denim jeans provide a consumer to know the exact amount of photoprotection
high UPF (1700), they are not practical for athletic activities.9 offered. Although certain regular clothing items may pro-
Although the evidence is limited, UPF clothing provides vide comparable photoprotection, regular clothing is more
excellent photoprotection with few disadvantages other than variable with a broader spectrum of photoprotection
4 Journal of Cutaneous Medicine and Surgery 00(0)

ranging from inadequate to excellent, making it potentially visible minorities and men were significantly less likely to
difficult for the consumer to definitively evaluate the pho- wear sunglasses than Caucasians and women, respec-
toprotection offered. In addition, as it may be difficult to tively. 63% of Caucasians vs 44% of visible minorities
make regular clothing lightweight, photoprotective cloth- reported always wearing sunglasses, and women were
ing is an ideal choice for consumers in hot summer weather, 78% more likely to wear sunglasses than men.21 A system-
if affordable. When choosing regular clothing items with atic review22 found that sunglasses were the most com-
no UPF tags, consumers should choose garments with monly reported sun-protective behaviour of outdoor
tighter weaves, increased fabric weight, thickness, darker workers; however, this varied widely between groups of
colours, and of Lycra/polyester composition and that cover workers as 80% of lifeguards wore sunglasses compared
more skin. A practical tip to assess regular clothing is to with British or Japanese construction workers, who rarely
hold the garment up to a light source to see whether the wore sunglasses.
light shines through. Consumers should also be aware that Recommendation: For daily activities, patients should
moisture, fabric stretching, and fabric degradation decrease wear general-purpose sunglasses in conjunction with a
the UPF factor. Further studies that compare a variety of broad-brimmed hat to reduce the amount of UVR reaching
UPF clothing and normal clothing under different condi- the eyes. Better-quality studies are needed to further quan-
tions are needed. tify the absolute risk reduction of wearing sunglasses and
Grade of Recommendation: STRONG in combination with broad-brimmed hats. Physicians
should specifically emphasize the importance of sun-
Minimum Protection in Sunglasses. Chronic UV radiation glasses to groups who are most at risk, namely individuals
(UVR) is a known risk factor for cataracts, age-related macu- who experience high-UV occupational exposure as well as
lar degeneration, and pterygium.2 There is also the risk of men and minorities. Greater efforts should be made to
skin cancer involving the delicate skin adjacent to the eye simplify labelling so patients can easily identify the pur-
that is typically not protected by sunscreen. The Canadian pose of sunglasses (cosmetic, general purpose, or special
sunglass industry is self-regulated, and manufacturers com- activity).
ply with voluntary standards when classifying their sun- Grade of Recommendation: STRONG
glasses as cosmetic (block 0%-60% visible light and UVA
and 87.5%-95% of UVB), general purpose for daily activi-
Sunscreen Properties
ties (block 60%-92% visible and UVA and 95%-99% of
UVB), or special purpose, ie, for skiing (block up to 97% of What is the Recommended Sun-Protection Factor of Sunscreens?
visible light, up to 98.5% of UVA, and at least 99% of UVB History of Sun-Protection Factor and Increasing Sun-Protection
rays), as outlined in Health Canada 2010 guidelines. How- Factor.  The ideal SPF to recommend to the public has been
ever, Dain et al.17 demonstrated that 17% of the 646 pairs of difficult to define. The Canadian Dermatology Association
sunglasses tested failed to meet voluntary standards, despite (CDA) currently recommends using broad-spectrum sun-
being labelled as such. screens with SPF values of 30 or higher. This message is now
Health Canada 2010 guidelines recommend only general- echoed throughout Canada based on the National Consensus
purpose sunglasses for driving and special-purpose glasses Process on Recommended Core Content for Sun Safety Mes-
for prolonged sun exposure. General-purpose sunglasses are sages in Canada.
often marketed as “UV absorption up to 400 nm,” the equiv- Although there is a common misconception that SPF
alent of 100% UV absorption. values are multiplicative (SPF 30 sunscreen is in fact not
Ophthalmologists and optometrists also recommend the twice as effective compared with SPF 15), there is abun-
combination of a hat with sunglasses to minimize light from dant evidence suggesting that higher SPF is indeed more
entering from the side or top of sunglass frames and then effective at sun protection. A randomized, double-blind,
reflecting off the inner surface of the lens and into the eye.18 split-face, natural sunlight exposure clinical trial23 demon-
A study by Sliney et al19, using simulated ocular geometry, strated that SPF 100+ sunscreen was significantly more
demonstrated that the human eye receives at least 5% of the effective in protecting against sunburn than SPF 50+ sun-
UVR dose when wearing clear lenses opaque to the UVR screen, with 55.3% of their participants more sunburned on
because of the lack of protection above and to the sides of the SPF 50+ protected side compared with 5% on the SPF
sunglasses. This is also why the “wrap-around” style of sun- 100+ protected side. In addition, 40.7% exhibited
glasses is often recommended. increased erythema scores on the SPF 50+ -protected side
Patients should be aware that darker sunglasses do not as compared with 13.6% on the SPF 100+-protected side.
necessarily provide superior ocular UV protection, as darker Similarly, Russak and colleagues demonstrated statisti-
glasses could result in greater pupil dilation and increased cally significantly lower cases of sunburn with application
UV exposure to the lens.2 of SPF 85 sunscreen compared with SPF 5024 and Pissavini
Culture may influence sunglasses usage; this may be a and Diffey showed that SPF 30 application had only 11%
consideration for targeted sun-awareness campaigns. A of skin exhibiting erythema as compared with 46% with
cross-sectional study of US postal workers20 found that SPF 15.25
Li et al 5

Sun-Protection Factor and Application of Sunscreen. Numer- water contact.33 The efficacy of an O/W emulsion is dimin-
ous studies have demonstrated that the typical underap- ished as soon as it comes into contact with water.33 However,
plication of sunscreen ranges from 20% to 50% of the as W/O emulsions generally contain more oils than water,
recommended 2 mg/cm2.26 The exact relationship between they should be avoided on oily skin.34 Of note, certain W/O
SPF and the amount of sunscreen applied, however, is contro- formulations with different concentration of filters may
versial, as some studies of sunscreens with SPF less than 50 absorb oil excess and thus may also have noncomedogenic
have demonstrated an exponential relationship27,28 whereas properties.34
other studies with high-SPF sunscreens (≥ 70) have reported Recommendation: The W/O emulsion is the recom-
a linear relationship.29,30 Regardless, all studies confirmed mended formulation for sunscreens to achieve highest SPF
that SPF value decreases with inadequate application. This and water resistance. Generally, sunscreens labelled as water
suggests that a high-SPF sunscreen, such as greater than 50, resistant with higher SPFs are typically W/O emulsions,
is preferred to compensate for the typical insufficient appli- whereas those without water-resistant labelling are typically
cation of sunscreen. O/W emulsions. However, patient preference for a vehicle
with O/W because of its lighter feel and noncomedogenic
Caveats. Despite the various advantages of high-SPF properties can significantly affect use and therefore may take
products, ultrahigh SPF values such as greater than 70 are precedence.
more difficult to measure and reproduce during production. Grade of Recommendation: WEAK
In addition, public misinterpretation of higher SPF values
as the single most important aspect of photoprotection can Should Inorganic or Organic Sunscreens Be Used? Inorganic
lead to a false sense of security. Autier et al showed patients (physical) sunscreens were traditionally thicker and whiter
using SPF 30 sunscreen had increased mean cumulative sun formulations, which were not aesthetically pleasing. In a
exposure and mean duration of sunbathing when compared small study, most people applied only about 65% of the quan-
with the SPF 15 group.31 Recent FDA-proposed changes to tity of inorganic sunscreens compared with organic sun-
the 2011 FDA sunscreen monograph state that the maximum screens. As a result, the measured SPF of inorganic sunscreens
proposed SPF value on sunscreen labels should be SPF 60 was less than half the organic (chemical) ones.35 Since the
or higher, and sunscreens with an SPF value of 15 or higher development of micronized particles, many current micron-
should also be required to provide broad-spectrum protec- ized inorganic sunscreens are much less visible on the skin.36
tion. Although media controversy has risen in recent decades
Recommendation: A broad-spectrum sunscreen with UVA regarding systemic absorption of inorganic micronized par-
as well as UVB filters and SPF of at least 30 should be ticles and its potential harms, studies have failed to demon-
applied, and even-higher SPF sunscreens may be used to strate this proposed harm. An in vitro assessment determined
compensate for common underapplication of sunscreen. that less than 0.03% of a nanoparticulate zinc oxide sun-
Patients should be educated on the importance of proper screen formulation penetrated the uppermost layer of the
application and other important factors affecting effective- stratum corneum (SC), and no particles could be detected in
ness of sunscreen apart from the SPF value. the lower SC. These findings were confirmed by 2 studies
Grade of Recommendation: STRONG conducted under in vivo conditions that demonstrated that
titanium oxide and zinc oxide nanoparticles were absent or
What is the Preferred Vehicle of Sunscreens? The vehicle of their levels were too low to be tested under the SC, thus mak-
sunscreen is critical for its efficacy and uptake in usage. The ing significant penetration toward the underlying keratino-
formulation of a sunscreen is primarily determined by the cytes unlikely.37,38 The safety of sunscreens is further detailed
emulsifier system.4 The Mintel global New Products Data- in the risk-benefit analysis section of this review.
base shows that, worldwide, emulsion products such as Recommendation: A broad-spectrum sunscreen contain-
lotions and creams/gel creams are the most popular.4 Broadly, ing UVA and UVB filters is recommended, regardless of
the emulsion type can be either oil in water (O/W) or water whether the components are organic or inorganic. When
in oil (W/O). In general, the O/W systems are often preferred using sunscreens with primarily nonmicronized inorganic
because of their lighter feel on the skin.21 filters, it is especially more important to educate the patient
Sohn and colleagues studied in vitro application of sun- regarding adequate application amount since evidence shows
screens containing the same filters in different vehicles of underapplication tends to occur.
W/O, O/W cream, O/W spray, gel, and a clear lipo-alcoholic Grade of Recommendation: STRONG
spray. The W/O resulted in significantly higher SPF than all
other formulations. This appears to be due to its more When Should Water-Resistant Sunscreens Be Used? Water-
homogenous and thicker film distribution over the applied resistant labelling of a sunscreen is determined by how well
area.32 W/O emulsions also have a low hydrophilic-lipo- it binds to skin and withstands adverse conditions such as
philic balance and use water-insoluble emulsifiers, making swimming, sweating, friction, and removal through other
them more water-insoluble, thus preventing loss through physical contact.36 Currently, Health Canada’s 2018 primary
6 Journal of Cutaneous Medicine and Surgery 00(0)

sunscreen monograph defines a sunscreen product as either high-SPF products (≥ 30) and reapplication is empirically
water/sweat resistant for 40 or 80 minutes if it retains protec- recommended to compensate for underapplication.
tive properties for 40 minutes and 80 minutes, respectively, Grade of Recommendation: STRONG
following moderate activity in 23°C to 32°C (73°F to 90°F)
indoor fresh water. Furthermore, “waterproof” or “sweat- Expiry Date. The literature search yielded no published
proof” labels are considered misleading and thus should not studies on the effectiveness of sunscreens past the expiry
be used, reflecting the lack of evidence behind claims of pro- date. Thus, it may be logical to recommend use of sun-
longed protection. Stokes and Diffey39 found that nearly all screen only within the expiry date to avoid any potential
the protective effect of non–water-resistant products disap- harm, although this is not supported by any evidence. Most
peared after 20 minutes of water immersion, and there were sunscreen manufacturers also have a recommended period
no significant differences between SPF retention in “water- after opening (POA), which is the maximum duration over
resistant” compared with “waterproof” products. which the consumer may use the product after opening.
Other than water resistance, friction- or rub-resistant prop- Although the POA for many sunscreens is 12 months, the
erties could affect the photoprotective effect of sunscreens as rationale is unclear. A study has shown that expiry dates
well. Stokes and Diffey measured SPF values prior to and relate to the conditions of sunscreen usage, storage, formu-
after agitation with sand and found that even after allowing 20 lation, and form.44 All sunscreens sold in Canada require an
minutes for the sunscreen to dry, 15%-60% of the photopro- expiry date on the label.45
tective effect was lost after contact with the sand.39 When placed in temperatures ranging from −20°C to
Recommendation: Water-resistant sunscreen should be 60°C (−4°F to 140°F) for 8 hours, some sunscreens were
worn in conditions where there is significant sweating, water shown to have phase changes and discolouration at the
immersion, increased skin friction via physical contact, or extremes of temperatures. However, it is unclear whether
contact with sand. Immediate reapplication is necessary to these macroscopic changes observed would decrease sun-
compensate for loss of photoprotective effects after any of screen efficacy.46
these activities. Recommendation: Sunscreens should be stored at room
Grade of Recommendation: STRONG temperature to ensure stability. There is a lack of evidence to
support whether it is safe or unsafe to use sunscreens past the
Lip Protection.  Lip protection is an important component of manufacturers’ specified expiry date or recommended PAO.
safe-sun practice. UVR has been well demonstrated as a risk Grade of Recommendation: WEAK
factor for the development of lip cancers.40 UV filters are
available in many commercial products such as lip balm, lip
Sunscreen Application
gloss, and lipstick. Use of photoprotective lip products
among female farmers has been correlated to decreased risk What Amount of Sunscreen Is Appropriate to Apply?  The FDA
of lip cancers.41 and international protocols recommend applying 2 mg/cm2 of
There are no specific recommendations regarding SPF sunscreen or 35 mL per application to adequately cover
and application of lip sunscreens from the FDA or Health 1.73 m2, the average adult body surface area.36 This recom-
Canada. When applied to the lip, the SPF value of lipsticks mendation is well supported by numerous studies.29,36,47 In
was on average 1.2 units lower than the label SPF of 16.42 particular, a multicentre study29 found a linear dependence of
Although this margin between in vitro and in vivo lip appli- the SPF on the quantity applied (0.5, 1.0, 2.0 mg/cm2) and
cation is much smaller compared with sunscreen application concluded that 2 mg/cm2 is ideal. However, for the consumer,
on the rest of the body, the authors suggest the practical SPF the 2 mg/cm2 measurement makes little practical sense. Stud-
of lip products must be considered as lower than the manu- ies show that consumers typically apply much less, usually
facturer’s label. between 0.5 and 1.5 mg/cm2.31,48 The most important factor in
Similar to body sunscreens, underapplication of lip sun- the application of sunscreen is to apply a liberal quantity,35
screens also occurs. Maier et al showed an application thick- and this is the wording used in Canada’s updated sun-safety
ness of less than 1 mg/cm2 for lipsticks during laboratory messages.49 In children, Diaz and colleagues found that appli-
conditions. In the field experiment in which participants cation with a controlled device such as a pump or squeeze
applied lipstick according to their own habits while skiing, bottle yielded higher quantity.50 Ou-Yang et al30 found sun-
the thickness increased to 1.58-1.76 mg/cm2. This was attrib- screens with SPF 70 and above may compensate for underap-
uted to increased use in outdoor conditions, where the mois- plication by consumers.
turizing effects of the lipstick encouraged more use. The Recommendation: Sunscreens should be applied liberally
median daily frequency of application was 2.2-3 times.43 to all exposed areas. As a practical estimate to the consumer,
There are no other data to guide frequency of lip-sunscreen approximately 45 ml (the amount of 1 shot glass) would be
application. more than enough to cover the entire body surface of most
Recommendation: Lip-photoprotective products should average-sized individuals, or 2-3 tablespoons for the body
be applied generously to cover the whole lip. The use of and 1-2 teaspoons for the face and neck.45
Li et al 7

Grade of Recommendation: STRONG Grade of Recommendation: STRONG

How Frequently Should Sunscreen Be Reapplied? Does Physical How Long Before Sun Exposure Should Sunscreen Be
Activity Affect the Frequency of Application?  Several studies Applied?  Several review articles state that sunscreen should
have addressed sunscreen reapplication. Heerfordt showed be applied liberally to exposed sites 15 to 30 minutes prior to
that double sunscreen application optimizes sunscreen use sun exposure.35,36,55 These recommendations are based on
compared with a single application as the median partici- how the sunscreens were tested, as there was a complete lack
pant had applied between 13% and 100% more sunscreen of evidence to support this practice in our literature review.
at the selected skin sites after double application than sin- Sunscreen-testing protocols mandate drying times of 15-20
gle application51. In a study of 30 office workers, where minutes before SPF testing can begin (to ensure water resis-
half were randomly assigned to having SPF 15-30 sun- tance): Mandatory labelling reflects this instruction. There
screen reapplied after 3 hours, no significant difference in are no data to suggest that there is a delay in sunscreen effi-
absorption readings (taken at 20 minutes and then hourly cacy; in fact, a recent study showed sunscreen offered imme-
for 1-6 hours after initial application) was found in the diate protection when applied.56
reapplication group52. Similar findings in a split-face Recommendation: Sunscreen should be applied prior to
design study by Rigel et al.24 found no difference in ery- sun exposure. It would be reasonable to wait 15-30 minutes
thema with reapplication 2 hours after UV exposure in after application of sunscreen before water exposure to
golfers. Bodekaer et al53 studied the persistence of sun- ensure water resistance.
screens during physical activity, hot environment, and Grade of Recommendation: WEAK
bathing during an 8-hour period and concluded that one
application is sufficient to reduce erythema caused by Does Application of Sunscreen Vary for Different Skin
UVB, although this is assuming the recommended formu- Types?  Although skin cancer accounts for only 1%-2% of all
lation and amount is applied. neoplasms in African Americans and 2%-4% in Asian Amer-
To test the recommendation made by many public health icans as compared with 20%-30% of Caucasians, there is a
agencies to reapply sunscreen every 2-3 hours, Diffey and higher morbidity and mortality in individuals of colour as
Grice35 derived a mathematical model to determine how sev- their diagnoses and treatments are often delayed.36 The aver-
eral factors, including the time of sunscreen reapplication, age SPF of black skin is 13.4 as compared with white skin,
influence photoprotection. The resultant recommendation is which is 3.4.57
reapplying to exposed sites 15-30 minutes after sun exposure A cross-sectional study using the American Cancer
begins and after vigorous activity that could remove sun- Society’s sun surveys I and II, a randomized, telephone-
screen, such as swimming, toweling, and excessive sweat- based, nationally representative survey of the US population
ing/rubbing. Reapplying sunscreen during sun exposure is of teens age 11-18 years (n = 1187 in 1998; n = 1931 in
useful to compensate for initial underapplication and replac- 2004)58 found there was a significant difference between
ing sunscreen that may have been removed by water, friction, Caucasians and non-Caucasians or Hispanic individuals in
and/or sweat. Interestingly, SPF 30 sunscreens have been their knowledge of the risks of UVR causing cancer and the
shown to accumulate in the skin when applied 3 times daily, importance of photoprotection including sunscreen.
providing a higher SPF.53 More research is needed to support However, the cosmetic appearance of a tan was significantly
these findings, however. less desirable for non-Caucasians or Hispanics than
An important consideration when applying sunscreen Caucasians.
during physical activity is the effect of sweating on sun- A cross-sectional study of African American patients
screen protection and vice versa. A controlled, randomized, (n = 55) attending a primary care medical clinic for dermato-
split-face and split-arm clinical study with 24 female partici- logical concerns found 74% of respondents had never used
pants conducted by Ou-Yang et al54 found no significant dif- sunscreen and that only 15% sunscreen users and 11% non-
ferences in either skin temperatures or sweat rates between sunscreen users had ever been counselled to wear sunscreen
the treated (application of sweat-resistant sunscreen) and by either a parent or a medical professional59. In contrast,
untreated control skin sites during exercise. As sweating is a 23% of sunscreen users had experienced a sunburn vs 11% of
crucial process in skin cooling and thermal regulation, this nonusers had experienced a sunburn, and the majority of all
study highlights the safety of using water- or sweat-resistant respondents (62% of sunscreen users and 73% of nonsun-
sunscreen during exercise. screen users) were unaware that African Americans could get
Recommendation: If the appropriate amount of sunscreen skin cancer59.
is initially applied, reapplication is necessary only after A cross-sectional study using the dermatology section of
activities that may remove the sunscreen layer, such as swim- 2003-2006 National Health and Nutrition Examination
ming, sweating, and friction. There is no clear evidence to Survey found that African Americans were 86% less likely
suggest a specific frequency of reapplication in the absence than Caucasians to wear sunscreen, and Mexican Americans
of these activities within an 8-hour period. were 25% less likely to wear sunscreen than Caucasians. Of
8 Journal of Cutaneous Medicine and Surgery 00(0)

all the participants who reported having a severe sunburn, longer time to pregnancy. In another study by Janjua66,
African Americans had a 7-fold lower likelihood of wearing although oxybenzone (also known as BP-3) and octinoxate
sunscreen than their white counterparts.4 were systemically absorbed after 1 week’s application, no
Currently, there are no studies that assess the absolute risk significant change in reproductive hormone levels was
reduction of sunscreen use and skin cancer in people of detected. However, a recent systematic review67 suggests
colour (African, Asian, or Latino descent). There is a need to exposure to BP-3 is statistically associated with reproduc-
quantify this risk reduction as 1 in 5 Canadians identified as tive toxicity in humans and animals, but the clinical signifi-
visible minorities in 201160. cance is unclear. In human studies, high levels of BP-3
Recommendation: People of colour tend to underuse pho- exposure were shown to be linked to an increase in male
toprotection, including sunscreen. More data are needed to birth weight but a decline in female birth weight and male
understand the risk reduction provided by sunscreen, beyond gestational age, but not other reproductive outcomes, includ-
just sunburn. ing semen motility, female fecundity, male idiopathic infer-
Grade of Recommendation: WEAK tility, spontaneous abortion, male genital abnormalities, and
reproductive hormone levels. Animal studies, however,
demonstrated negative reproductive outcomes including
Risk-Benefit Analysis decreased egg production, hatching, testosterone, and epi-
Is Sunscreen Harmful (ie, Risks of Compounds/Ingredients)?  didymal sperm density as well as prolonged estrous cycles.
There has been lots of media attention surrounding the poten- The prevalence of total exposure to BP-3 by the general
tial harmful health effects of sunscreen. Recently the FDA public is high, as phenolic compounds like BP-3 are preva-
issued a new amendment to its sunscreen monograph and lent in the air, drinking water, food, and personal care prod-
changes to its designation of ingredients labelled as “gener- ucts.68 Although the safety threshold of BP-3 exposure is
ally recognized as safe and effective” (GRASE). Although unclear, studies report a systematic absorption of BP-3 in
there are no urgent safety concerns, more safety and efficacy humans at a rate of up to 2% after dermal application.
data on 12 organic (chemical) sunscreen ingredients (cinox- Oxybenzone is used in a variety of other products, such as
ate, dioxybenzone, ensulizole, homosalate, meradimate, plastics as a photostabilizer, and cosmetic products, includ-
octinoxate, octisalate, octocrylene, padimate O, sulisoben- ing shampoo, cream, lotion, hairspray, nail polish, and per-
zone, oxybenzone, and avobenzone) are required before sun- fume. Overall, no consensus appears to exist regarding the
screens with those ingredients can be labelled as GRASE. estrogenic and antiandrogenic activity of UV filters and the
These compounds have not been deemed unsafe, but it is felt clinical relevance remains uncertain.
more information is needed. Currently, the inorganic (physi- In addition, environmental concerns about some UV fil-
cal) filters titanium dioxide and zinc oxide are considered ters have been raised. An in vitro study demonstrated that
GRASE for use in sunscreens, whereas PABA and trolamine BP-3 may pose a hazard to coral reefs and their resiliency to
salicylate are not GRASE because of safety issues. climate change as it produces morphological deformities,
As mentioned in the inorganic vs. organic section above, damages their DNA, and acts as an endocrine disruptor.69
concerns regarding the potential systemic absorption of Similarly, a review showed that BP-3 may be a contributor to
nanoparticles found in physical sunscreen formulations have coral reef bleaching, although the role of warming ocean
been alleviated by studies showing lack of absorption temperatures and pollutants is a strong confounder.70
through the stratum corneum.37,38 Furthermore, they found the presence of organic UV filters
Components in chemical sunscreens have been impli- in almost all water sources and various fish species world-
cated in photoallergic contact dermatitis, particularly benzo- wide, and that these UV filters are not easily removed by
phenone-3, octyl methoxycinnamate, and octocrylene.61,62 common wastewater treatment-plant technique. The current
Similarly, a review found that although allergy to sunscreen concentration these agents in the water is not at a toxic level
represents a small proportion (<1%) of allergic contact der- for coral reefs, but these important signals require further
matitis reactions in North America, it is one of the most com- study, as these concentrations may rise in the future with
mon causes of photoallergy63. On the other hand, a BP-3 and other filters in so many daily-use products.
meta-analysis64 of 64 exaggerated-use studies found that Recommendation: There are no definitive data to support
sunscreen products formulated with 1%-6% oxybenzone do that sunscreen filters cause any toxicity in humans. There are
not possess a significant sensitization or irritation potential some signals that there is a need for further study on the
for the general public and that the incidence rate is actually effect of certain UV filters on the environment. The SC
overestimated in the literature. appears to be an effective barrier against the penetration of
Concern has also been raised regarding benzophenone inorganic zinc and titanium dioxide nanoparticulates; there-
UVR filters and their reported estrogenic and antiandro- fore, significant systemic absorption should not be a concern.
genic activity. A prospective cohort study65 found that male The most common adverse effect of using chemical sun-
exposure to select UV filters (BP-2 and 4-hydroxybenzo- screens is the risk of photoallergy, and overall the prevalence
phenone) may diminish couples’ fecundity, resulting in a is quite low. There is currently a lack of evidence to suggest
Li et al 9

sunscreens containing benzophenone filters lead to decreased photoaging, including rhytides, pigmentary changes, and
fertility. Although a recent laboratory study suggests oxyben- telangiectasias.
zone may pose a hazard to coral, more research is needed, From biopsy-specimen analysis, Phillips and colleagues
particularly because a direct association between sunscreen concluded that daily use of sunscreen reduces UV exposure-
posing a threat has not been established, especially given its related skin damage compared with intermittent use of equal
abundance in various other products. or higher SPF products.73 Similarly, Seité demonstrated that
Grade of Recommendation: STRONG daily moisturizers with broad-spectrum sunscreen protected
against solar UV-induced skin damages in the epidermis and
Are Sunscreens Safe for Infants?  Health Canada recommends dermis and daily application prevents UVA radiation-induced
sunscreen use for children older than age 6 months and to transcriptional expression of genes that are directly linked to
consult a health care practitioner regarding its use in younger skin aging and also reflect the skin’s antioxidative stress
children (Health Canada 2015). Avoidance of sun and pro- defense response.74
tective clothing are the mainstay for sun safety in infants A photostable sunscreen with SPF 55 and high UVA pro-
younger than age 6 months. The CDA, the Canadian Pediat- tective factor provided proportionately high protection
rics Society (CPS), and the American Academy of Pediatrics against multiple cellular damage markers known to contrib-
(AAP) state that sunscreen can be applied to small areas that ute to photoaging.75 Meinke et al found that sunscreens even
clothing cannot cover such as the face or back of the hands offer protection in the infrared spectrum, which, as in the
(CDA 2016, CPS 2011, AAP 2015), but should be washed UV-wavelength range, also generates free radicals, contrib-
off when sun protection is no longer needed. The CDA and uting to photoaging.76
the CPS recommend using a sunscreen with an SPF of 30, Hughes et al77 published the results of a pivotal randomized
whereas the AAP recommends sunscreen with an SPF of 15 controlled trial. A total of 903 adult Australians were random-
or greater. There are no studies that directly evaluate the ized to daily use or discretionary use of sunscreen (control).
safety of sunscreens in infants younger than age 6 months. The daily sunscreen group showed no detectable increase in
Young infants have a higher body surface-to-mass ratio and skin aging after 4.5 years; skin aging from baseline to the end
absorptive area in combination with their underdeveloped of the trial was 24% less in the daily sunscreen group than in
skin, including a thinner SC and epidermal thickness and the discretionary sunscreen group. In fact, a systematic review
lower lipid-to-protein ratio, allowing for more sunscreen to of randomized controlled trials shows that evidence, though
be potentially absorbed.71 In particular, newer sunscreens limited, supports beneficial effects of sunscreen application on
contain nanoparticles, and this risk has not been quantified photoaging.78 Similarly, another review of clinical trials dem-
for infants who have thinner SCs than adults.37 A cohort onstrates that sunscreens containing Ecamsule (Mexoryl SX),
study of 54 pairs of mothers and babies found UV filters a widely used chemical sunscreen filter, prevent the impact of
were present in 85% of breast milk samples, only 55% of UVA on skin photodamage.79
women reporting using sunscreens72, suggesting that some Recommendation: There is strong evidence in the litera-
women are exposed to UV filters in their other cosmetic ture, including results from randomized controlled trials, that
products or there is potentially recall bias. The health impli- sunscreen prevents photoaging.
cation of these UV filters in breast milk requires further Grade of Recommendation: STRONG
elucidation.
Recommendation: There is a lack of evidence examining Does Sunscreen Prevent Skin Cancer? A randomized con-
the pharmacokinetics of sunscreens in young infants that trolled trial of adult Australians80 found that after prolonged
contributes to recommendations based largely on theoretical follow-up, squamous cell carcinoma tumour rates were
harm vs empirical data. Clinical trials in this vulnerable age decreased by almost 40% in people randomized to daily
group are very difficult to design to meet today’s ethical stan- sunscreen use compared with those with discretionary use.
dards. It is reasonable given the paucity of evidence to con- Basal cell carcinoma tumour rates tended to decrease as
tinue to limit the use of sunscreen in children younger than well, but not significantly. Another randomized controlled
age 6 months as physiologically their skin is immature and trial found daily use of sunscreen prevents and/or retards the
there are theoretically potential risks of nanoparticles and development of solar keratoses among adults.81 Moreover,
UV filters being absorbed. Photoprotection should be based regular use of sunscreen has been shown to be cost effective
largely on behavioural modification in this group, such as in NMSC and actinic keratosis prevention.82 Ten years after
avoiding peak UV hours, seeking shade, and using protective the Australian randomized controlled trial cessation, 11 new
clothing. primary melanomas were identified in the daily sunscreen
Grade of Recommendation: WEAK group and 22 in the discretionary group, showing that mela-
noma may also be preventable by regular sunscreen use in
Does Sunscreen Prevent Skin Damage/Aging/Wrinkles?  Cumu- adults.83
lative UV exposure is a major contributing factor in aging Conflicting data presented in a systematic review and
skin. Regular use of sunscreen protects against signs of meta-analysis84 showed no association between sunscreen
10 Journal of Cutaneous Medicine and Surgery 00(0)

use and risk of melanoma and NMSC in the general popula- and the potential environmental and reproductive toxicity of
tion. However, this review, which included 28 observational sunscreens are supported by weak evidence because of the
studies and only 1 community-based randomized trial, had limited number of studies. Second, this review included
major limitations. First, many of the included case-control studies published only in English, which presents language
trials used primarily UVB sunscreens rather than broad- bias and may limit the analysis of some research questions.
spectrum filters. Second, only 5 of the included studies The inclusion of non-English studies may allow for a greater
addressed NMSC. Although it is plausible that the benefit of ability to answer some research questions or to further
sunscreen use in melanoma development may vary, because increase the strength of some recommendations presented in
of its multifactorial nature, which includes multiple genetic this review. Despite these limitations, the existing body of
factors, squamous and basal cell carcinoma have been shown evidence suggests sunscreen is one of the best-supported
to be more strongly linked to sun exposure.85 Third, there photodamage-prevention options, especially given the rela-
was a low quality of evidence overall due to inconsistencies tively high risk of photodamage and skin cancer associated
among included studies and its retrospective design. Rueegg with UV exposure.
et al found heterogeneous summary estimates for the sun- This in-depth review consolidates the available evidence
screen-melanoma association from observational studies but supporting sun-protection guidelines. The 2016 National
a protective effect of sunscreen against skin cancer in the Consensus study on the Recommended Core Content for Sun
only randomized controlled trial performed.86 Safety Messaging for public education in Canada was the
Recommendation: Regular sunscreen use can prevent most recent up-to-date source of information for clinicians
melanoma and NMSC. The literature that suggests there is since its last update in 1945. This current review adds more
no effect of sunscreen on the development of skin cancer is up-to-date information and an in-depth analysis of the evi-
flawed in that it does not take well-established skin cancer dence to the 2016 consensus study. Clinicians should be
risk factors into account. aware of the strength of evidence when making routine rec-
Grade of Recommendation: STRONG ommendations on sunscreen use. This is particularly impor-
tant when considering that skin cancer is the most common
cancer in Canada and is largely preventable.3
Discussion
Sunscreens are widely used; however, some widely pro- Conclusion
moted sun-safety messages do not reflect current evidence.
In this review, we have evaluated and discussed the strength Our review revealed that the level of evidence supporting
of recommendations relating to the efficacy of physical bar- recommendations for the use of sunscreens and other sun-
riers, sunscreen properties and application, and risk-benefit protection methods varies from fair to good, as assessed
analysis. using the CTFPHC’s GRADE system. Our updated recom-
Our review of 18 years of literature yielded an overall mendations, derived from a critical appraisal of the literature,
lack of high-quality evidence. A total of 84 studies were are a useful educational tool for the practicing dermatologist
included in this review addressing 16 questions that in counselling patients about sun safety.
described the physical barriers, sunscreen properties and
application, and risk-benefit analysis. There is strong evi- Declaration of Conflicting Interests
dence supporting the use of a broad-spectrum UVA and The authors declared no potential conflicts of interest with respect
UVB sunscreen with a minimum SPF of 30, applied liber- to the research, authorship, and/or publication of this article.
ally to all exposure areas including the lips. Higher SPF is
recommended, reapplication may be considered to compen- Funding
sate for underapplication but is not mandatory, and water- The authors received no financial support for the research, author-
resistant sunscreen is recommended for physical activity. ship, and/or publication of this article.
There is strong evidence supporting the safety profile of
sunscreens and their efficacy in photoaging and melanoma Supplemental Material
and NMSC prevention. Supplemental material for this article is available online.
There are several limitations to this review. First, the rec-
ommendations that were graded as weak had a high degree ORCID iD
of heterogeneity or limited data in the existing evidence.
Heidi Li https://orcid.org/0000-0001-6495-088X
There was weak evidence supporting the use of photopro-
tection in children younger than age 6 months, although the
evidence is expected to be inherently weaker as there is a References
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