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sunscreen

Indications: - prevention of actinic keratoses - prevention of squamous-cell carcinoma of the skin (SCC) [6] - prevention of cutaneous melanoma ? - lack of evidence for prevention of melanoma [6] - daily sunscreen reduces risk of melanoma 50-75% [9] - mixed reports regarding prevention of basal cell carcinoma [6,8] - daily use of sunscreen can slow skin aging associated with middle age [12] Dosage: - apply to exposed areas 30 minutes prior to sun exposure - SPF of 15 or > provides maximum protection. - SPF rates only UVB protection, not UVA protection. [7] - only broad spectrum suncreens with SPF >= 15 provide protection from skin cancer & dermatoheliosis (photoaging) [16] Adverse effects: - contact dermatitis (11%) - photoallergic contact dermatitis (4%) [5] - benzophenone-3 most common offending agent [14] - common active ingredients in sunscreen are absorbed into the blood at a level that warrants systemic safety testing [20] - ingredients include: avobenzone, oxybenzone, octocrylene, ecamsule - for sunscreen applied to 75% of body surface 4 times a day for 4 days - > 0.5 ng/mL of active ingredient in blood on 1st day of exposure - maximum avobenzone concentration: 1.8-4.0 ng/mL - elevated blood levels of active sunscreen ingredients sustained for 3 weeks [21] - clinical significance unknown [20] - 27% of sunscreen products from 69 companies found to contain benzene [22] - J&J recalls Aveeno, Neutrogena spray suncreens July 2021 [22] Mechanism of action: - absorption of UV light - active compounds: a) benzophenones 1] avobenzone (UVA filter) 2] dioxybenzone 3] oxybenzone (UVA/UVB filter) b) cinnamates c) homosalate d) methyl anthranilate - may be used in connection with titanium dioxide e) aminobenzoic acid - para-aminobenzoic acid (PABA) f) titanium dioxide* g) zinc oxide* * only zinc oxide & titanium dioxide generally regarded as safe & effective (GRASE) [18] Special laboratory: - patch testing & photopatch testing should be performed to common UV filters if indicated [14] Notes: - oral sunscreens might help, but are NOT a substitute for topical sunscreens - "broad spectrum" protection is now strictly defined as screening both UV-A & UV-B rays [10] - claims of "waterproof" & "sweatproof" no longer allowed; "water-resistance" is allowed - < 50% of women & < 20% of men regularly use sunscreen on the face [15] - a diagnosis of skin cancer within 1 year is not associated with greater sunscreen use among men, though it is associated with sunscreen use on the face among women [15] - suncreen SPF 100 applied every 2 hours more effective than beach umbrella [17]

Specific

avobenzone (emcamsule, octocrylene, Anthelios SX, Mexoryl SX) ecamsule (Mexoryl SX) oral sunscreen (SunPill, Heliocare)

General

dermatologic combination

References

  1. Drug Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998
  2. Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 985
  3. Prescriber's Letter 11(5):27 2004
  4. Prescriber's Letter 12(7): 2005 Sunscreens, Vitamin D, and Cancer Risk Detail-Document#: 210705 (subscription needed) http://www.prescribersletter.com
  5. Bryden AM et al, Photopatch testing of 1155 patients: Results of the U.K. multicente photopath study group Br J Dermatol 2006, 155:737 PMID: 16965423
  6. Lautenschlager S et al. Photoprotection. Lancet 2007 May 3 http://dx.doi.org/10.1016/S0140-6736(07)60638-2)
  7. Prescriber's Letter 14(8): 2007 PATIENT HANDOUT: Staying Safe In The Sun Update on Sunscreens: UVA Protection Detail-Document#: 230806 (subscription needed) http://www.prescribersletter.com
  8. Gordon LG et al Regular sunscreen use is a cost-effective approach to skin cancer prevention in subtropical settings. J Invest Dermatol 2009 Dec; 129:2766. PMID: 19536149 - King SC and Chen S. Analyzing the cost of preventing nonmelanoma skin cancer. J Invest Dermatol 2009 Dec; 129:2745. PMID: 19901945
  9. Green AC et al. Reduced melanoma after regular sunscreen use: Randomized trial follow-up. J Clin Oncol 2011 Jan 20; 29:257. PMID: 21135266 - Gimotty PA and Glanz K. Sunscreen and melanoma: What is the evidence? J Clin Oncol 2011 Jan 20; 29:249. PMID: 21135278
  10. FDA PRESS RELEASE: June 14, 2011 FDA Announces Changes to Better Inform Consumers About Sunscreen http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm258940.htm
  11. Prescriber's Letter 18(8): 2011 Sunscreens COMMENTARY: New Requirements for OTC Sunscreen Products PATIENT HANDOUT: Staying Safe in the Sun PATIENT HANDOUT SPANISH VERSION: Medidas de seguridad para evitar danos causados por la exposicion al sol Detail-Document#: 270808 (subscription needed) http://www.prescribersletter.com
  12. Hughes MCB et al Sunscreen and Prevention of Skin Aging: A Randomized Trial. Ann Intern Med. 2013;158(11):781-790 PMID: 23732711 http://annals.org/article.aspx?articleid=1691733
  13. Akamine KL et al Trends in Sunscreen Recommendation Among US Physicians. JAMA Dermatol. Published online September 04, 2013. PMID: 24005847 http://archderm.jamanetwork.com/article.aspx?articleid=1735118
  14. Heurung AR et al. Adverse reactions to sunscreen agents: epidemiology, responsible irritants and allergens, clinical characteristics, and management. Dermatitis 2014 Nov/Dec; 25:289 PMID: 25384223
  15. Holman DM et al. Patterns of sunscreen use on the face and other exposed skin among US adults. J Am Acad Dermatol 2015 Jul; 73:83 PMID: 26002066 http://www.jaad.org/article/S0190-9622%2815%2901352-3/abstract
  16. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.
  17. Ou-Yang H, Jiang LI, Meyer K et al Sun Protection by Beach Umbrella vs Sunscreen With a High Sun Protection Factor. A Randomized Clinical Trial. JAMA Dermatol. Published online January 18, 2017. PMID: 28114650 http://jamanetwork.com/journals/jamadermatology/fullarticle/2597893
  18. FDA News Release. Feb 21, 2019 FDA advances new proposed regulation to make sure that sunscreens are safe and effective. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm631736.htm
  19. FDA. Nov 26, 2014 Sunscreen Innovation Act (SIA) https://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/ucm434782.htm
  20. Matta MK, Zusterzeel R, Pilli NR et al Effect of Sunscreen Application Under Maximal Use Conditions on Plasma Concentration of Sunscreen Active Ingredients. A Randomized Clinical Trial. JAMA. Published online May 6, 2019 PMID: 31058986 https://jamanetwork.com/journals/jama/fullarticle/2733085 - Califf RM, Shinkai K Filling in the Evidence About Sunscreen JAMA. Published online May 6, 2019 PMID: 31058950 https://jamanetwork.com/journals/jama/fullarticle/2733084
  21. Matta MK, Florian J,Zusterzeel R et al Effect of Sunscreen Application on Plasma Concentration of Sunscreen Active Ingredients. A Randomized Clinical Trial. JAMA. 2020;323(3):256-267. PMID: 31961417 https://jamanetwork.com/journals/jama/article-abstract/2759002 - Adamson AS, Shinkai K Systemic Absorption of Sunscreen. Balancing Benefits With Unknown Harms. JAMA. 2020;323(3):223-224 PMID: 31961400 https://jamanetwork.com/journals/jama/article-abstract/2758982
  22. Koenig D Many Sunscreens Have High Levels of a Carcinogen, Pharmacy Tells FDA. Medscape - May 28, 2021. https://www.medscape.com/viewarticle/952106 - Schwartz F J&J Recalls Aveeno, Neutrogena Spray Sunscreens. Wall Street Journal. July 14, 2021 https://www.wsj.com/articles/j-j-recalls-aveeno-neutrogena-spray-sunscreens-11626303616