Controversies Which Cloud Sunscreen

THE PROTECTIVE benefit of sunscreens from UV radiation, a known carcinogen, is well established. However, important questions still surround sunscreens and several key ingredients.

Regular sunscreen use has proved effective at reducing the development of both squamous cell cancers (SCC) and actinic keratoses. However, while there is no demonstrated benefit of regular sunscreen use in reducing the incidence of basal cell carcinoma (BCC) development, a trend toward reduced incidence of BCC tumors among sunscreen users has been observed.

Furthermore, current data has demonstrated that sunscreens do not increase the risk of melanoma, but clinical evidence for its protective benefits remains inconclusive. However a publication in the Journal of Clinical Oncology in 2010 featured a study from Australia in which the investigators showed a 50% reduction of melanoma in individuals who used sunscreens. One important limitation of all the available clinical and epidemiological evidence, however, is that most of the studies were conducted during the 1970s and 1980s when only sunscreens with low SPF and little to no UVA protection were available. Modern sunscreens have corrected these shortcomings. However, long-term studies using these newer sunscreens are not yet available. Moreover, it may take many years or decades to determine the potential protective effects of improved sunscreen formulations. Thus, it is reasonable to conclude that in conjunction with better education, future studies using these sunscreens in a corrective manner may demonstrate a preventive effect for BCC and melanoma.

What about vitamin D? Does sunscreen use impair vitamin D production? 
Considerable overlap exists between the UV absorption profiles of sunscreens and the action spectrum for vitamin D synthesis. In theory, correct usage of sunscreens should significantly reduce vitamin D levels. However, this is not the case in practice. In fact, several studies have demonstrated that sunscreens are rarely applied correctly, in the right dosages and with appropriate frequency.

Therefore, under real-world conditions, it is likely that the improper use of sunscreen and/or increased exposure time results in normal production of vitamin D among sunscreen users. It is important to note that the level of cutaneous vitamin D production from UVB exposure is also influenced by seasons, latitude, obesity level and age.

Hence, after considering all these factors, we dermatologists prefer dietary supplementation, instead of prolonged UV exposure, to maintain the sufficient levels of vitamin D.

Is oxybenzone safe?
Systemic absorption of oxybenzone after topical application in both humans and animals has garnered significant attention. It is important to note that systemic absorption did not result in clinically significant perturbations of hormonal homeostasis in humans.

In fact, acute toxicity has not been reported in any of the in vivo or human studies published to date. While more work remains to be performed in this area, the available evidence does not demonstrate biologically significant hormonal disruption with topical application of oxybenzone in humans.

Retinyl palmitate
Retinyl palmitate has found widespread use in cosmetic and sunscreen products during the past 20 years. Earlier this year, there was a flurry of media coverage discussing the photocarcinogenic potential of sunscreens containing retinyl palmitate.

It is important to understand that retinyl palmitate is the storage form of retinol (vitamin A), an essential and endogenous nutrient for human beings.  This compound is already present in our skin. All available evidence from in vitro and animal studies fails to demonstrate convincing evidence indicating that retinyl palmitate imparts an increased risk of skin cancer.

Although published data on the photocarcinogenic potential of retinyl palmitate in humans are lacking, evidence from 40 years of use in clinical medicine provide a powerful basis from which to question the notion that retinyl palmitate in sunscreen is photocarcinogenic. Clinically, retinoids are used by dermatologists in two major areas of therapy.

First, oral retinoids have been used with great success to prevent skin cancers in populations who are at high-risk, such as patients with xeroderma pigmentosum and immunosuppressed patients.

Second, dermatologists commonly prescribe topical retinoids in the management of skin disorders such as acne, psoriasis, photoaging, cutaneous T-cell lymphoma and a variety of other skin conditions. Among patients treated with topical or oral retinoids, no published data exists to date suggesting that these medications increase the risk of skin cancer.

Has the controversy surrounding nanoparticles heated up?

Nanoparticles exhibit different chemical, mechanical, electrical and optical properties than the standard-sized particles. Nano-scaled versions are postulated to also exhibit altered biological properties, which may have negative health implications. The recent integration of TiO2 and ZnO nanoparticles into sunscreens has raised interesting questions regarding the potential for dermal penetration, systemic absorption and subsequent toxicity. The increasing ubiquity of these nanocompounds in personal care and cosmetic products makes safety research especially relevant. Much concern has been voiced that the integration of nanomaterial technology into everyday formulations has outpaced the body of research evaluating their safety.

Currently, the FDA does not have regulations in place regarding the labeling of products containing nanoparticles of TiO2 and ZnO. Considerable data assessing the potential toxicity of these materials in sunscreens has been published to date, and studies were performed in controlled environments on healthy, undamaged skin. It has been established that the stratum corneum is an effective barrier preventing the entry of nano ZnO and TiO2 into deeper layers of the skin. Nonetheless, it remains to be determined whether a greater degree of penetration occurs through skin in conditions where the barrier function is damaged, or otherwise compromised. At the present time, however, the available data does not provide conclusive evidence demonstrating that damaged skin leads to increased penetration of nanoparticles.

Prognosis on the use of sunscreens and their role in preventing skin cancer
Sunscreens remain an effective tool in providing protection against the known carcinogenic effects of UV radiation. Sunscreens will continue to be a highly popular form of photoprotection in the foreseeable future.

As modern formulations of sunscreens grow increasingly more sophisticated, ongoing monitoring to assess both the safety and efficacy of these products is needed. Preferably, these assessments should be conducted under real-world conditions that reflect the actual behaviors of the general public.

Lastly, it is important to remember that sunscreen is only a part of the overall photoprotective strategy. We should also remind the public to avoid excessive UV exposure from the sun and wear hats and clothing for protection as well.

Vitamin D: Are You Getting Enough?

There has been a lot of recent research on vitamin D. Some has focused on its known benefits, notably its crucial role in working with calcium to keep bones strong. But many studies have looked at its potential to reduce the risk of everything from some common cancers and multiple sclerosis to diabetes, hypertension, and age-related muscle weakness. The research is promising.

Much of this research has linked the potential benefits to high blood levels of vitamin D—levels higher than most Americans and Canadians have. Thus, some prominent researchers recommend that people have their blood levels of D measured so that, if necessary, they can take enough supplemental D to get their levels into the "desirable" range. Some doctors have started testing many of their patients. Should you be tested? First, some basics about this special vitamin.

D basics

Vitamin D is unique in that your skin manufactures it just by being exposed to sun. The amount made depends on the time of day, season, how far north you live, skin pigmentation (darker skin makes less D), how much of your body is exposed to the sun, and your age (older people produce less D from sun exposure). Because D is fat soluble, the body can store it for the days or even months when you don’t get any sun or consume any D.

Few foods supply vitamin D. Milk is fortified with D and is the major dietary source, with 100 IU (international units) per cup. Some soy milks, orange juice, margarines, and breakfast cereals are also fortified. Fatty fish, such as salmon, tuna, and sardines, are naturally rich in D. But it’s hard to get adequate D from food alone. Thus, supplements are often necessary (see below).

Many people are deficient in vitamin D, especially those who are over 60, live at northern latitudes, have darker skin, or are rarely outdoors. In the northern U.S. and in Canada, blood levels drop markedly in the winter, when days are shorter, the sun is weaker, and we wear more clothes and spend less time outside. Many young people also have low blood levels of D, according to some recent studies. Obesity is associated with reduced blood levels.

The case for testing

A recent meta-analysis in Archives of Internal Medicine of 18 studies found that people taking D supplements (usually 400 to 800 IU a day) had a 7% reduction in total mortality rates. In an accompanying editorial, Dr. Edward Giovannucci of Harvard concluded: "Given the high probability of benefit for at least some of the many conditions that have been associated with vitamin D deficiency, and the low likelihood of harm, it seems prudent that physicians measure serum 25-hydroxyvitamin D in their patients." That’s the form of D in the blood measured by the preferred test.

Among those advocating routine vitamin D testing is Dr. Bruce Hollis of the Medical University of South Carolina, who has been doing vitamin D research for 30 years. "Everyone needs to know his or her level of 25-hydroxyvitamin D," says Dr. Hollis, because of its potentially protective effect against chronic diseases. The amount of D in a multivitamin (usually 400 IU) and/or from exposing your face and arms to the sun for short periods may not be enough to reach desirable blood levels. An intake of even 800 to 1,000 IU a day won’t be enough for some people, he says. The body’s ability to make and utilize D varies from person to person. That’s why testing can be important.

Blood levels: what’s desirable

Most experts now agree that blood levels of at least 30 to 40 ng/ml (nanograms per milliliter of blood) of 25-hydroxyvitamin D are desirable. It’s often hard to achieve such levels via current recommended intakes of D (see box at left) and a little sun exposure. Many people, especially those over 60 and during the winter, have levels of 20 ng/ml or below. There is some debate, however, about what the optimal blood levels are. Dr. Hollis believes that 50 to 60 ng/ml is a better goal.

Exposing your arms and legs or your full body to the midday sun without sunscreen (and not in winter in the northern half of the U.S. or in Canada) can produce high blood levels of D, but can cause skin cancer. That leaves supplements as the best option, unless you know your blood level is in the desirable range.

Practical matters

If you ask for the blood test for vitamin D, your doctor may well say it isn’t necessary. It costs about $100, and insurance may not pay for it unless you have osteoporosis or another condition potentially related to vitamin D deficiency. And if the test shows low D levels and you start taking higher doses of D, you should repeat the test to make sure you’re getting into the desirable range. Keep in mind, too, that blood levels of D vary markedly by season—with the lowest readings in late winter and early spring. A result of 25 ng/ml may be okay for late winter, for instance, but is low for late summer.

Bottom line: It’s too early to recommend vitamin D testing for everyone. The large, long-term clinical studies that would justify routine screening have not yet been done. But talk to your doctor about testing, especially if you are over 60, for instance, or have low bone density. In any case, consider taking 800 to 1,000 IU of supplemental D a day. For most people, that should raise blood levels to the desirable range (above 30 ng/ml) or at least close to it.

How much D to take

The official recommended daily intakes for vitamin D, devised by the Institute of Medicine, are 200 IU (international units) for people 50 and younger, 400 IU for those 51 to 70, and 600 IU for those 71 and older. Most people don’t consume that much D, unless they drink lots of milk and/or take a multivitamin. However, many researchers believe those guidelines are too low, and that a better goal for everyone, especially those over 60 and/or with darker skin, is 800 to 1,000 IU a day. Some people with low blood levels of D may need even higher intakes to reach the desirable range.

Thus, fifteen leading nutrition experts last year urged the Institute of Medicine to increase its recommended intakes of D. Meanwhile, the Canadian Cancer Society now advises all Canadian adults to take 1,000 IU of D a day during fall and winter, and older and darker-skinned people to take this much year round. That is good advice for most Americans as well.

The official "Upper Limit" for D, set many years ago, is 2,000 IU a day. It’s possible to get that much, or more, if you consume milk, other fortified foods, and fatty fish, and also take a multivitamin and combined calcium/D supplement. However, a review article in theAmerican Journal of Clinical Nutrition last January concluded that D is not toxic up to 10,000 IU a day. We don’t recommend that much, but you needn’t worry if you get somewhat more than 2,000 IU.