How Effective Is Sunscreen?

Today, we take a close look at the effectiveness of sunscreen, and we start with the results of a randomized controlled trial to see if it can actually slow skin aging.

Considered the single most important practice for maintaining youthful skin: the daily application of sunscreen, and taking other protective measures, like wearing a hat. All other things you can do for your skin pale in comparison, especially for those with pale skin.

Up to 90 percent of visible facial aging among people with lighter skin tones is due to exposure to sunlight. Those with darker skin are relatively protected due to their built-in melanin sunscreen, but they are still affected. Sun damage in darker skin tends to be less about wrinkles and more about pigmentation issues, such as uneven skin tone, dark patches, and small dark bumps on the face. Either way, dermatologists now agree that there is nothing more important to slow the signs of aging than to protect your skin from the sun.

Factors like sun exposure and smoking can make us look up to 11 years older. Compare that to extensive cosmetic surgery—a face lift and a neck lift, and removing excess skin from both the upper and lower eyelids, and a forehead lift, which combined, can make us look about eight years younger. So, a healthy lifestyle may work even better.

Protecting your skin from the sun should be a lifelong endeavor. This can involve applying sunscreen, wearing sun-protective clothing, hats, and sunglasses, and avoiding direct sunlight during the peak hours of 10 AM to 4 PM and instead seeking shady, covered areas. Sunbathing is frowned upon, even with sunscreens like zinc oxide or titanium dioxide that offer broad-spectrum protection against both UV-A and UV-B rays. We now know that other wavelengths, such as near infra-red, that are not covered by sunscreens, also contribute to skin aging. Men and women who use tanning beds appear significantly older than those who don’t, and white women who sunbathe appear years older than they actually are––similar to what is seen with smoking.

UV-A rays are primarily responsible for skin aging, whereas UV-B are the rays that cause sunburn. But a broad-spectrum sunscreen covering both is recommended, since both types of UV contribute to cancer risk. To prevent skin cancer, the American Academy of Dermatology recommends sunscreen with an SPF of 30 or higher, but an SPF even as low as 15 can help prevent skin aging. How do we know? Because it’s been put to the test.

Despite the widespread belief that the use of sunscreen would prevent skin aging, all we had were data on hairless mice. That is, until ten years ago. Nine hundred adults were randomized either to years of daily sunscreen use or to continue with their own discretionary use. (It was considered unethical to withhold protection by giving people placebo sunscreen.) In the end, 77 percent in the recommended daily sunscreen group were applying sunscreen at least three to four days per week, compared with only 33 percent in the discretionary use group. Would that be enough of a difference to make a difference? Yes, there was significantly less skin aging in the instructed daily use group. In fact, they suffered no detectable increase in skin aging over the four-and-a-half-year study. The researchers concluded “Regular sunscreen use retards skin aging in healthy, middle-aged men and women.”

In our next story, sunscreen is put to the test to see if it can actually prevent skin cancer.

Decades ago, studies started bubbling up, reporting that not only was the use of sunscreen not found to be protective against skin cancer, but it was associated with significantly elevated risk. But subsequent studies offered the obvious explanation of this paradox. People who use sunscreen are more likely to be sunbathers. That’s like finding that those who use motorcycle helmets are more likely to die on the highway. It’s not that sunscreen and helmets aren’t protective; it’s just that they are associated with engagement in risky activities. But you don’t know, until you put it to the test.

As I noted in my last video, randomized controlled trials have shown that regular use of sunscreen can arrest visible signs of skin aging, including biopsy-proven reductions in UV-related skin damage. But are there interventional trials proving sunscreen can prevent cancer? Yes.

Organ transplant recipients are highly susceptible to skin cancers, because they have to be given immune suppressants to prevent organ rejection. A group of 120 organ recipients were equally informed about sun protection measures, but half were given free, broad spectrum SPF 50+ sunscreen for daily application to their head, neck, forearms, and hands. After two years, there were nine new basal carcinomas in the control group, versus only two in the sunscreen group. That sounds good, but it may have just been a fluke. In contrast, there was a highly significant difference in the proportion of patients who got new invasive squamous cell carcinomas. Eight new cases in the control group, versus zero in the sunscreen group. But wait until you hear about what happened to their actinic keratoses, the precancerous growths that can turn into skin cancer.

They all started out covered in them: a total of 191 detected in each group. In the subsequent 24 months, the control group developed 82 new ones. How many did the sunscreen group develop? Negative 102. More than 100 precancerous growths in the sunscreen group spontaneously regressed and vanished completely (compared to 82 new growths developing in the control group without a single one disappearing). Their body, even in their immunocompromised state, could heal itself once it just stopped being bombarded with so many cancer-causing rays.

Other randomized controlled trials have shown similar findings, but generalizability is limited. The studies all used high-risk populations––for example, those living in subtropical climates or with a personal history of precancerous lesions. So, cancer prevention efficacy in the general population would be expected to be less. On the other hand, the studies could have also underestimated the impact, since they were relatively short-term (not exceeding four years), and ethically had to allow control group participants to slather on their own sunscreen, which would dilute the difference between groups.

For maximum effectiveness, sunscreen needs to be applied properly, which apparently rarely happens in the real world. In a study of nearly 5,000 skiers and snowboarders, almost no one, only about 4 percent, were fully compliant with sunscreen recommendations. First, there’s the amount. The FDA standard is two milligrams per square centimeter. What does that mean? Use the teaspoon rule: one teaspoon for your face, one for your head and neck, one for the front of your torso, another for your back, one teaspoon for each arm, and two teaspoons for each leg. That’s a total of nine teaspoons. That’s about the total volume equivalent of a golf ball or shot glass, to help you visualize.

Unfortunately, the average sunscreen user may only apply a quarter of the recommended amount. This is why high SPF sunscreens are often recommended, like 50+ SPF. Although the FDA recommends a minimum SPF of only 15 to prevent skin cancer, under normal consumer conditions, even an SPF of 50 may effectively give you only an SPF of 12.5, because most people don’t put on enough. Randomized double-blind, head-to-head, split-face experiments, where you are randomized to apply one sunscreen on one side of your face, and another sunscreen to the other side, show that in real life use, SPF 100+ sunscreen works significantly better than SPF 50+ sunscreen. More than 50 percent of the participants were sunburned more on their SPF 50+ side, compared to only about 5 percent on their SPF 100+ side.

Now, a potential downside of higher SPF sunscreens is that they could provide a false sense of security. Those randomized to an SPF 30 sunscreen ended up spending more cumulative time in the sun than those receiving an SPF 10 sunscreen––as much as five times longer in some cases.

What else? Well, people tend to remember to use sunscreen on a sunny day at the beach. But sun protection is needed even on cloudy days, since the UV rays are not dampened as much as visible light. There’s even a phenomenon known as “cloud enhancement” where overcast skies can sometimes result in even more UV reaching the Earth’s surface compared to clear skies.

Sunscreen labels often suggest waiting at least 15 minutes after application before going outdoors, but when put to the test, sunscreen was found to start working immediately, with the full effect apparent by minute 10. However, if water resistance is required, it may be prudent to wait the full 15 to 30 minutes after application before taking a dip. The terms “waterproof” or “sweatproof” appear to be meaningless marketing, as no difference in retention was noted between “waterproof” products and those merely labeled “water-resistant.” Both were better than non-water-resistant products, though, which lost nearly all their protective effects within 20 minutes of water immersion.

The suggestion that sunscreen should be reapplied every two to three hours only applies under conditions in which it is rinsed off by water or sweat, or rubbed off by friction from clothing or sand. Even after allowing sunscreen to dry first for 20 minutes, between 15 to 60 percent of its protective effect can be lost after contact with sand. Otherwise, if the recommended amount is applied and the sunscreen layer is not disturbed, SPF can be maintained for as long as eight hours.

Finally today, the FDA has concluded that only two sunscreen ingredients can be considered safe: zinc oxide and titanium dioxide.

What kind of sunscreen should you use? Cream-based is preferable to spray-on, since the completeness of application is more readily visualized. To help with adequate coverage, spray-on sunscreens should be rubbed on immediately after spraying. Aerosolized sunscreens are flammable and can combust on the skin upon exposure to an open flame, even after the sunscreen has dried. What’s more, the safety of breathing in aerosolized sunscreen chemicals has not been adequately studied, though frankly the same thing could be said about rubbing them on your skin.

The concerns surrounding sunscreen safety are three-fold: increased intentional sun exposure, vitamin D deficiency, and untoward effects from systemic absorption of sunscreen chemicals.

In the 1800s, we first learned that UV-B caused sunburns and formulated sunscreens to block it. Nearly a century later, we learned about the contribution of UV-A. Now, a full century later, we are realizing that infra-red and visible light may also be contributing to cancer and premature skin aging. Sunlight comes to us in three major bands: visible light, ultraviolet, and infra-red. Visible light includes the colors of the rainbow—red, orange, yellow, green, blue, indigo, and violet, or ROYGBIV. Ultraviolet—UV—is to the right of violet in ROYGBIV, and infra-red to the left of red. Sunscreen can protect us against the free radical damage of UV, but half of the free radical formation in our skin from the sun may be from the visible or infrared spectrums, which sunscreens may not adequately cover. So, that’s where sun avoidance strategies come in. But you can imagine how shade-seeking could be undermined by the solacement of a sunscreen security blanket.

What about vitamin D? The theoretical concern about sunscreen affecting vitamin D status does not seem to manifest in the real world, likely because the UV dose necessary for vitamin D production is so low––well before skin turns a pinker shade.

However, concerns about the systemic absorption of sunscreen chemicals were underscored by the recent FDA bombshell that not a single one of sunscreen chemicals in current use can be considered generally recognized as safe. Only two active ingredients got the green light: the two non-chemical “mineral” sunscreens: titanium dioxide and zinc oxide. The revelation was based on a growing body of evidence that transdermal (meaning through-the-skin) absorption of sunscreen chemicals was greater than we previously thought, raising unevaluated safety concerns. Unevaluated, because we previously didn’t think so much got into our bloodstreams.

In 2019, a study published in the Journal of the American Medical Association found that under maximum usage conditions over a period of days, the blood levels of all of the sunscreen chemicals they tested exceeded the FDA threshold that could potentially waive further safety testing. Then, in 2020, they found that just a single application of all of the chemical sunscreens they tested surpassed the threshold. Now, just because they’re absorbed into our system, doesn’t necessarily mean they’re unsafe. It just means they need to be tested for safety, which, the FDA determined, the multibillion-dollar sunscreen industry has so far failed to do.

The FDA concluded that two ingredients can be considered safe— zinc oxide and titanium dioxide, and two can be considered unsafe—PABA and trolamine salicylate. And the other 12 ingredients that are currently marketed have yet to be sufficiently safety tested. According to a review of more than 700 sunscreen brands, it appears PABA and trolamine are no longer being marketed in sunscreens sold in the United States. But they still may be available in other countries. Until the data are in on the rest of the chemical sunscreens, I would recommend sticking to the two mineral sunscreens. Historically, they’ve tended to be thicker and whiter, which could lead to even more severe underdosing. But newer micronized formulations with smaller mineral particle sizes tend to be less noticeable.

This is particularly an issue for those with darker skin. The average built-in SPF of black skin (also known in the medical literature as “ethnic skin” or “SOC,” skin of color) is around 13 naturally, compared with only about three for white skin. Though there haven’t been any interventional studies on sunscreen effectiveness for skin cancer prevention in people with dark skin, SPF 13 is not considered sufficient sun protection. So, the American Academy of Dermatology recommends regular sunscreen use with an SPF of 30 or higher for people of all skin types.

Unfortunately, only about 12 percent of non-Hispanic Blacks, and 31 percent of Hispanics report regularly using sunscreen, compared to around 44 percent of non-Hispanic whites. Despite this, the incidence of melanoma, the deadliest skin cancer, is five times lower in Hispanics compared to whites, and more than 25 times lower among Blacks. However, the mortality rate if you do get it is higher among African-Americans, presumed to be due to delayed diagnosis.