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Friday, July 12, 2024

The Problem With Sunscreen Isn’t Its Ingredients—It’s You

Ladies and gentlemen of the class of 2023: Wear sunscreen. Right?

Every year, as summer rears its head in the northern hemisphere, controversy stirs around the gloopy ivory cream. Spurious reasons not to wear it begin to surface: It stops you getting enough vitamin D from the sun; it actually increases your risk of developing cancer; you can find sunscreen particles in your brain cells 10 years after applying it.

The queen of dubious medical advice herself, Gwyneth Paltrow, decried the “really harsh chemicals in conventional sunscreen” in a video for Vogue, and says she doesn’t apply sunscreen “head to toe,” but only to the places “where the sun really hits”—a tiny smear on her nose and highpoints of her cheeks. (Goop’s team later said that the video was edited and that Paltrow does apply the sunscreen to her entire face.)

All existing research suggests that the benefits of sunscreen heavily outweigh any potential harms, yet distrust is on the rise—only 55 percent of Australian adults, one of the most sun-exposed populations on Earth, believe sunscreen is safe to use every day. That wariness meant last year, many turned to online recipes to create their own, wholly ineffective versions at home.

Distrust is far from being the only problem. Many people who use sunscreen don’t understand how it works—or even if they do, they often don’t use it properly. Science even has a hard time articulating just how effective sunscreen is. That’s a pretty big PR problem for what is essentially an anti-cancer intervention. And it needs fixing—because as the climate warms, much of the world’s population is increasingly going to need protecting from the sun.

Risk of Exposure

Skin cancer has long been one of the most prevalent cancers, and cases have been swelling over the past few decades. Less fatal varieties—such as basal and squamous cell skin cancers—make up the bulk of those cases. But what’s also seeing an uptick is melanoma, which is far more rare and also far more deadly. If trends continue as they are, cases of melanoma are expected to increase by 50 percent by 2040—and deaths by nearly 70 percent. The United Kingdom just reached an all-time high in melanoma cases.

A variety of reasons are behind the increase. It can partly be attributed to better screening and an aging population—age is a general risk factor for cancer. But researchers also point to other social behaviors, such as the advent of package holidays to sunny countries, where Brits turn to lobsters on the beaches of Benidorm. They also point the finger at the fairly recent—only about a century old—popularization of sunbathing and having a “healthy glow,” which can be traced back to photos taken of Coco Chanel after a leisurely cruise on the Mediterranean in the 1920s. “A golden tan,” she said, “is the index of chic.”

Alongside those factors, the concern is that a warming planet is likely to spur rising skin cancer rates. Hotter temperatures will mean people will naturally flock outdoors, for longer periods of time. And while the protective ozone layer is firmly on the mend since the phaseout of ozone-depleting aerosols in the 1980s, it’s not expected to fully recover until 2040. Much of the increase in melanoma cases will be concentrated in parts of the world with light-skinned populations, including Australia and New Zealand, North America, and Europe.

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That means that adopting sun-protective behaviors—sunscreen included—will be crucial in the coming years. But people are, for the most part, terrible at applying sunscreen. They wear about half as much as they should; they miss spots; they rub it in vigorously instead of gently, which can decrease the protection it offers—its sun protection factor, or SPF—by up to a fifth. (People also don’t really understand what SPF means; it’s not a measure of how long you can stay out in the sun. SPF basically just says how much the sunscreen blocks out UV rays. It’s calculated as the ratio of the amount of UV radiation needed to burn sunscreened skin relative to the amount needed to burn unprotected skin. That means that SPF 50 protects skin from 50 times the UV that would burn unprotected skin, SPF 30 against 30 times, and so on.)

Applying sunscreen can also encourage people to spend more time in the sun; a link has been found between sunburns and sunscreen use, because a sloppy application lends a false sense of security. One paper hypothesizes that the reason skin cancer incidence keeps rising can be attributed to people being so bad at putting on sunscreen.

The sun emits two kinds of ultraviolet radiation: UVA rays and UVB rays. It’s the latter that’s more closely associated with skin cancer. Sunscreen that protects against both—called broad-spectrum—is best, ideally with an SPF of at least 30. When the UV index (which measures the strength of the sun’s UV radiation) is 3 or above, you should apply 2 milligrams per square centimeter of skin—the equivalent of about half a teaspoon for the face and neck together, and a teaspoon each for your front, back, and each of your arms and legs. Apply this about 15 minutes before you head out into the sun, to give it time to dry and settle into your skin. You should reapply every two hours, or every hour if you’re swimming or sweating lots. Basically, put a lot on, very often.

A Hot Mess

But a bunch of people just … don’t use it. A survey by a British skin cancer charity found that about a third of survey respondents rarely or never used sunscreen. One reason is cost: A tenth didn’t wear sunscreen due to the price. “There is an equity problem,” Rachel Neale, a cancer epidemiologist at the QIMR Berghofer Medical Research Institute in Australia, says. Some countries have started to address this: Starting this summer, the Netherlands will provide free sunscreen at schools, festivals, parks, sports venues, and open public spaces. Florida has trialed the same thing. The deputy chair at the UK’s Primary Care Dermatology Society told The Guardian that in an ideal world, sunscreen would be given out for free.

But a mushrooming reason behind poor uptake is fear over harms. The anti-sunscreen movement has gained traction, spreading fear over just how safe sunscreen actually is, and whether you’d be better off frying in the sun.

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Sunscreens are usually delineated into two camps: chemical and physical (also called mineral). Michelle Wong, who runs the beauty blog and YouTube channel Lab Muffin Beauty Science and has a PhD in medicinal chemistry, doesn’t love this distinction: A better classification would be organic and inorganic.

Chemical, or organic, sunscreens, which have been particularly villainized in recent years, are often criticized for their harsh-sounding, impossible-to-pronounce ingredients: words like homosalate, octocrylene, octinoxate, octisalate. Mineral sunscreens, on the other hand—better described as inorganic—only feature two main ingredients: zinc oxide and titanium dioxide. “There are a lot of organizations that are quite pseudoscientific, and they tend to always fear-monger about sunscreen ingredients. And a lot of it is simply because the names sound scary,” she says.

It means that mineral sunscreens are often held up as the “cleaner” option, when there’s no good evidence that either is harmful. It doesn’t help that even trusted organizations perpetuate misinformation about the distinction between the two; Wong points to the sunscreen FAQs on the website of the American Academy of Dermatology (AAD). These tell the reader that chemical sunscreens work by absorbing UV, whereas physical or mineral sunscreens work by reflecting UV—a common misconception. Both types absorb UV.

When this was flagged with the AAD, president Terrence A. Cronin Jr said that its guidance would be updated to say that mineral sunscreen “protects you by reflecting the sun’s rays and sometimes also absorbing them.”

It also didn’t help that in 2019, the US Food and Drug Administration, which regulates sunscreen as an over-the-counter drug in the US (it’s regulated as a cosmetic in Europe) set out to “bring sunscreens up to date with the latest science.” This involved publishing a study that garnered a lot of coverage (including in WIRED) suggesting that sunscreen ingredients soak into your bloodstream. Sounds scary, right? But the conclusion of the small paper was that people should not refrain from wearing sunscreen, because whether absorbing ingredients poses any health risks is still not clear.

Oxybenzone has been pegged as the baddest egg of them all. Not only has it been linked with causing cancer, but it’s also been villainized for messing with coral when sunscreen washes off in the sea. The EU recently lowered the legal limit of oxybenzone in body products from 6 percent to 2.2 percent, but that number comes with a massive margin of safety built in, and is based on applying it all over your body, every single day—something very few people do.

And whether sunscreen actually harms coral reefs is contentious. While reef-safe sunscreen has become a thing, and places like Hawaii have banned certain sunscreens, what the world’s coral is really threatened by is warming oceans. “Based on the current evidence, I don’t think oxybenzone is much of a concern for our health or for coral,” says Wong. “For most of us, it’s just not that much of a concern.” (One caveat is that Wong agrees it’s probably best not to put sunscreen on babies under six months, due to the permeability of their skin.)

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The other common worry is whether sunscreen inhibits vitamin D absorption—a contention popularized by a polarizing article in Outside magazine in 2018 (the publication’s most popular piece to date). This is not something to worry about. Even if we put enough on, which most people don’t, sunscreen will never block all sun exposure, which means a little UV will always get through. Even in a gloomy country like the UK, people only need to sit in the sun for 10 minutes in the middle of the day between April and September to stave off vitamin D deficiency for the rest of the year, says Neale.

You’re So Vain

But something paradoxical is happening to our attitude to sunscreen. While anti-sunscreen influencing is rising, so are sales. As the skincare industry has boomed, it’s glommed onto promoting sunscreen use—not especially as an anti-cancer measure, but rather as an anti-aging measure. People on TikTok brag about being mistaken for being underage due to their religious sunscreen application.

Setting aside the problematic, ageism-embedding nature of this trend, the experts I spoke to for this article thought this could be an imperfect means to a less-cancerous end. “People are vain,” says Wong. Especially for the young, for whom cancer may seem like an abstract concept that only affects older people, hammering home the appearance-based benefits of sunscreen use may be more effective than focusing solely on the health benefits; research has shown that concerns about wrinkles can be a motivating factor to quit smoking—the same could work to motivate sunscreen use. “People are more concerned about their image,” agrees Neale. “Sunscreen being the best anti-aging agent that we’ve got is something that the public health messaging, I think, should push harder.”

Particularly so, as that messaging really needs strengthening. Because while we do know that sunscreen prevents cancer, the evidence of this isn’t as sturdy as it could be. The first and most cited human trial to provide evidence that sunscreen use reduces the incidence of melanoma was a randomized trial conducted in 2011 in Australia. It followed 1,600 people living in the state of Queensland for five years; half were instructed to apply sunscreen every day to their head and arms, the other half could use sunscreen if they wanted to and as they pleased (most applied it once or twice a week at most, or not at all).

After a 15-year follow up, twice as many people in the control group had developed melanoma than in the sunscreen-intervention group. The study was, at last, proof that sunscreen use prevents cancer. To strengthen this argument, we’d ideally run more randomized control trials, considered the gold standard in research, but they’re difficult to run for sunscreen because skin cancer takes so long to turn up. “I’m very pro-sunscreen, but I also think that we like to promote it without recognizing that we do have some evidence gaps,” says Neale.

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One area where the research is sorely lacking is who exactly needs to wear sunscreen. Advice from medical bodies commonly espouses that sun exposure can damage all skin types. While skin cancer is far more prevalent among white people, it is usually more deadly for Black people, because it’s diagnosed later down the line. In recent years, public health bodies and the media began to spread the message that everyone needs to wear sunscreen to protect against skin cancer, regardless of skin color. But there have never been any studies that have looked at whether sunscreen reduces melanoma risk for Black people. In fact, whether sun exposure causes melanoma in Black populations “has never been shown,” says Adewole Adamson, a dermatologist and assistant professor of internal medicine at the University of Texas.

Adamson accepts that the absence of evidence is not evidence of absence—but enough research has been done to disqualify a link between sun exposure and skin cancer in Black people, and that sunscreen having any benefit for Black people can be effectively ruled out by default, he says. Such research also hasn’t been done for other non-white populations. (The issue is still a matter of contention, as the level of disagreement in a recent piece on the question in The Washington Post illustrates.)

Today, we know that sunscreen does prevent cancer for light-skinned populations. But we also know that sunscreen is no panacea. It’s typically the third listed line of defense of sun protection, after seeking shade and avoiding sun exposure at peak times—but it’s usually the one people make their first. Wong recommends a Swiss cheese model approach; each method has their imperfections (or holes like Swiss cheese), but layering them together will give you a good, even layer of protection. Even just wearing a bit more coverage makes a big difference: “Most clothes do a much better job than sunscreen,” says Neale.

The fallibility of sunscreen is something that a country like Australia—uniquely vulnerable to the harms of the big fireball in the sky—has long understood. It first launched its famous Slip, Slop, Slap campaign 40 years ago, which recommends you slip on a shirt, slop on sunscreen, and slap on a hat. (It’s since been updated to Slip, Slop, Slap, Seek, Slide: you should also seek shade and slide on sunglasses.) Most crucially, it instilled the idea in Australians that sunscreen alone was not enough. The rest of us would do well to mimic this attitude and sit our sunscreen-lathered bums in the shade.

Updated 7-14-2023 5:30 am ET: The amount of sunscreen to apply per square centimeter of skin was corrected. 

Updated 7-20-2023 8:00 am ET: The American Academy of Dermatology’s decision to update its guidance was added.

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