Prevention and Treatment of SunInduced Skin Damage

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Prevention and Treatment of Sun-Induced Skin Damage Nancy Kleiman, BSP, MBA Date of Revision: August 2014

Pathophysiology

The skin and its appendages (e.g., sweat glands, sebaceous glands and hair follicles) serve several important functions. They protect against minor injury, help control body temperature and water loss, prevent invasion by microorganisms, and prevent radiation damage from sun exposure. The skin is composed of three main layers: epidermis (which includes the stratum corneum), dermis and subcutaneous layer1 (Figure 1). Figure 1: The Skin

Ultraviolet Radiation

Ultraviolet light is divided into 3 categories: ultraviolet-A (UVA) (320–400 nm), ultraviolet-B (UVB) (290–320 nm) and ultraviolet-C (UVC) (270–290 nm).2 Longwave UVA radiation penetrates the dermis and subcutaneous fat. UVA is a less potent carcinogen than

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UVB or UVC, but is a significant contributor to skin cancer risk because more reaches the Earth than other types of ultraviolet (UV) radiation. UVA is present all day and can penetrate through clouds, windows and clothing. UVA radiation penetrates deep into the skin. There is a strong indication that UVA is responsible for phototoxicity, photoaging, immunosuppression, epidermal thickening, reduced skin barrier function and skin cancers.3 UVA is also responsible for reactions from photosensitizing drugs such as amiodarone, quinolones, sulfonamides, tetracycline and tricyclic antidepressants.4

UVB damages the stratum corneum and epidermal layers. It is the main cause of sunburn and plays a role in both skin cancer and photoaging.3 Acute exposure increases blood flow to the skin and activates inflammatory pathways, resulting in reddened skin and sunburn. However, even at doses too low to cause skin reddening, UVB can cause local and systemic immunosuppression, direct damage to DNA and other skin cell abnormalities that increase the risk of skin cancer.2 UVB is strongest between 10 a.m. and 4 p.m., at high altitudes, and is intensified by wind, humidity, high temperatures and reflective surfaces (e.g., water, sand, snow, concrete).2 UVC does not reach the surface of the Earth as it is filtered by the surrounding ozone layer.

The sun protection factor (SPF) of a sunscreen is determined by measuring the protection against UVB radiation. SPF is determined by measuring the lowest level of UV energy required to produce erythema with sunscreen divided by the lowest level of UV energy required to produce erythema without sunscreen (the length of time skin covered with sunscreen takes to burn as compared to the length of time skin not covered with sunscreen takes to burn).5 SPF is measured under ideal conditions and may not always be accurate as sunscreens are not always applied correctly.3 Standardization of SPF and UVA measurement is currently ongoing in many countries.5 The UV Index is provided by Environment Canada and predicts the strength of the sun's UV rays. Higher UV readings indicate a higher risk of sunburn as the rays are stronger. UV Indexes of 3 or more are reported daily.

Sun-induced Skin Damage

Sun-induced skin damage includes sunburn, photoaging, pigmentary changes, actinic keratosis and skin cancer. Sunburn is an inflammatory response of the skin to UV radiation. Sunburn is preventable and generally self-treatable. Refer to Burns, for assessment and treatment of burns. Photoaging refers to the effects of long-term exposure to the sun and is commonly referred to as “premature skin aging.”6 The effects can be seen many years before normal age-related changes are noted in non-sun-exposed areas. The difference between the signs of normal aging and photoaging can readily be seen by comparing non-sun-exposed areas of the body with skin on the face, arms and hands. Skin changes in photoaging differ from those in normal skin aging. In photoaged skin, changes in the stratum corneum and epidermal cells result in rough, coarse, dull-appearing skin with fine and deep wrinkles. In more advanced photoaging, deposition of abnormal elastic fibres, decreased collagen and pigment changes in the upper dermis result in deeply wrinkled, yellowish skin. Vascular changes in the dermis can cause telangiectasias and easy bruising. A change in the properties of water-retentive glycosaminoglycan contributes to the dry, rough, leathery appearance of photoaged skin.7 Pigmentary changes result from chronic exposure to UV radiation. Hypermelanosis is characterized by an increase in pigmentation, slowly progressing to irregular areas on the skin that range in colour from light to dark brown. It appears primarily on sun-exposed areas, particularly the face, and is commonly referred to as “age spots.”8 Actinic keratosis is a common sun-induced lesion caused by chronic exposure to sun and is particularly common in light-skinned individuals. Onset is typically after the age of 50 and is more common in males. It generally appears on the face, back of the hands, forearms and legs as a firm, scaling lesion with slight erythema. If left untreated, actinic keratosis can progress to squamous cell carcinoma. Prevention can be as simple as avoiding further exposure to the sun, wearing protective clothing and sunscreen.9 (See Photo, Actinic Keratosis) Photo 1: Actinic Keratosis

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Dr. P. Marazzi/Science Photo Library

Nonmelanoma Skin Cancer: Squamous cell carcinoma risk is related to chronic, cumulative lifetime sun exposure; therefore, people with visibly photoaged skin are at greater risk. Commonly found on the face, ears, neck, forearms, back of the hands and legs, it initially appears as an abnormal scaling or crusty lesion that may be raised and wart-like. The lesions may bleed or erode over time, leading to firm tumors.6 Basal cell carcinoma is related to sun exposure during childhood and adolescence and is commonly found on the face. It appears as small, dome-shaped lesions that may have a shiny surface (much like a pimple that does not heal) that slowly expand over time and develop central ulceration.9 Melanoma Skin Cancer: Malignant melanoma appears to be related to intense and intermittent sun exposure in childhood and adolescence. It is the rarest type of cancer, but is responsible for the majority of skin cancer deaths. Risk is increased in blond or red-headed individuals who have skin that tans poorly and burns easily, those with a large number of moles, chronic exposure to the sun or those with a past history of sunburns as a child. It appears as a flat brown or black spot (commonly in a mole or other dark spot) with irregular edges, that can grow larger if left untreated.9

Goals of Therapy

Prevent acute sun-induced skin damage (sunburn) Prevent phototoxic reactions from medications Provide relief of pain resulting from sunburn

Minimize the risk of infection in severe sunburns

Prevent long-term sun-induced skin damage (including photoaging and some types of skin cancer) Reduce the visible effects of photoaging on the skin

Patient Assessment

If the concern is sun-induced skin damage, determine if the goal is prevention (selection and use of sunscreens) or treatment. Figure 2 presents an assessment of patients requesting sun protection. Figure 3 presents an assessment of patients requesting treatment for non-acute sun-induced skin damage. Figure 2: Assessment of Patients Requesting Protection from Sun-induced Skin Damage

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If sun exposure is unavoidable despite these measures, a broad-spectrum SPF 30 sunscreen for babies can be applied to the small exposed areas (e.g., face, back of hands).10 Inorganic (physical) sunscreens containing zinc oxide and/or titanium dioxide are minimally absorbed and less likely to cause sensitization.11

a

Abbreviations: SPF = sun protection factor; UVA = ultraviolet-A; UVB = ultraviolet-B

Figure 3: Assessment of Patients Requesting Treatment for Non-acute Sun-induced Skin Damage

Prevention of Sun-induced Skin Damage Nonpharmacologic Therapy

There are many ways that the acute and chronic effects of sun exposure can be prevented. Avoiding direct sun exposure from 10 a.m. to 4 p.m. when UVB rays are strongest as well as when the UV Index is high decreases the risk of sunburn.2 A person should seek shade as much as possible while outside. Wearing protective clothing such

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as long-sleeved shirts, pants and gloves decreases exposure. Cotton or linen clothing that is tightly woven, loose fitting and lightweight provides some protection. Clothing that is wet, white or loosely woven provides very little protection (darker colours give better protection).2 Wide-brimmed hats of tightly woven fabric will protect the face, ears and parts of the neck from sun exposure, and long-term use will reduce the risk of skin cancers by 40%.2 Sunglasses should be worn to protect the eyes from sun damage. Children under the age of 6 months should be protected from the sun at all times by keeping them shaded and completely covered. Tanning salons should be avoided; the protection provided against environmental UV exposure (such as sunburn on tropical holidays) is minimal. Tanning bed use increases the risk of basal and squamous cell carcinoma12 as well as melanoma.13 The World Health Organization (WHO) recommends that no one under the age of 18 use tanning facilities. If used, time limits during the tanning session should be observed and protective eyewear should be worn at all times during the session. Those taking medications that may cause phototoxic reactions should use extra precautions when in the sun to prevent acute and chronic sun damage (see Table 1). a,14

Table 1: Medications That May Cause Phototoxic Reactions Antimicrobials

Azole antifungals (itraconazole, voriconazole), ceftazidime, quinolones (ciprofloxacin, norfloxacin, ofloxacin), sulfonamides, tetracyclines (doxycycline, tetracycline), trimethoprim

Antineoplastics

Dacarbazine, EGF inhibitors (cetuximab, erlotinib, gefitinib, lapatinib, panitumumab), 5-fluorouracil, paclitaxel, vinblastine

Diuretics

Furosemide, hydrochlorothiazide

HMG-CoA Reductase Inhibitors

a b

NSAIDs

Diclofenac, ibuprofen, indomethacin, ketoprofen, naproxen, piroxicam, sulindac, tiaprofenic acid

Psychiatric Medications

Alprazolam, chlordiazepoxide, chlorpromazine, desipramine, fluphenazine, imipramine, perphenazine, prochlorperazine, trifluoperazine

Retinoids, systemic

Acitretin, alitretinoin, isotretinoin

Retinoids, topicalb

Adapalene, tazarotene, tretinoin

Others

Amiodarone, coal tar derivatives (topical), diltiazem, methoxsalen, quinidine, quinine, sulfites, tolbutamide, verteporfin

Radiation in the UVA range causes most drug-related phototoxic reactions. After continued use due to thinning of the stratum corneum.

Abbreviations: EGF = epidermal growth factor; NSAID = nonsteroidal anti-inflammatory drug

Pharmacologic Therapy

Sunscreens effectively reduce skin tanning and sunburn. Sunscreen use can also reduce photoaging and development of actinic keratosis, and promote regression of existing actinic keratosis.2 It is estimated that regular sunscreen use for the first 18 years could decrease the lifetime risk of skin cancer by about 80%.15 Daily sunscreen use for 4.5 years decreased the incidence of squamous cell cancer16 and reduced new primary melanomas by

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50% and invasive melanomas by 73%.17 Sunscreens are an adjunct only, and should be used to protect the skin rather than prolong the time that can be spent in the direct sun. The Canadian Dermatology Association recommends that sunscreens should:18 have an SPF of at least 30

be nonirritating, noncomedogenic and hypo-allergenic be minimally or nonperfumed

offer broad-spectrum UVA protection Sunscreens are combinations of several different active ingredients and may contain physical blockers as well as chemical sunscreens (see Table 2). Physical barriers such as titanium dioxide and zinc oxide reflect and scatter UV radiation while chemical agents absorb UV light. Physical barrier products currently available have been micronized to be more cosmetically appealing than older products.6 To ensure full effectiveness, sunscreens should be applied uniformly and liberally over the entire area of sun exposure, including lips, ears and tops of the feet. Sunscreen should be applied 15–30 minutes prior to exposure with re-application 15–30 minutes later to maximize protection.2 Sunscreens should also be re-applied after swimming, sweating or towelling off. It is recommended that 2 mg of sunscreen per cm2 of skin be applied to the body to ensure that the SPF protection claimed by the manufacturer is reached.9,19 An easier way to measure the appropriate amount of sunscreen is referred to as the “teaspoon rule.” It is recommended that a person apply ½–1 teaspoonful on the face and neck; 1–1.5 teaspoonfuls to arms, shoulders and torso and 2–2.5 teaspoonfuls to the legs and the tops of the feet.19 Many individuals do not apply enough sunscreen to attain the stated SPF of the product. Ensure that patients are aware of the proper application methods and that sunscreen should be reapplied after sweating or being in water. Lip balms should also be used on a regular basis in order to protect lips from the sun. Cutaneous synthesis upon exposure to sunlight is the primary source of vitamin D. In theory, 90% of the required vitamin D can be produced this way. In practice, the production of vitamin D is highly variable depending upon which area of skin is exposed to the sun and for how long, latitude, skin pigmentation, age, and season.20 Health Canada recommends oral vitamin D supplementation be taken during the winter months or year round in more northern communities as there is insufficient sunlight to produce enough vitamin D. For more information on vitamin D supplementation, see Nutritional Supplements. Debate continues as to the impact of the use of sunscreens on the production of vitamin D. Although vitamin D synthesis is dependent on UVB exposure, “real world” application of sunscreen by the general population may not actually be affecting vitamin D production significantly.20 The Institute of Medicine recommends the same daily intake of dietary vitamin D irrespective of sunscreen use, as its dietary reference intakes are based on an assumption of minimal sun exposure.21,22 Those individuals concerned that they may have low levels of vitamin D because of where they live or their limited exposure to sunlight may use oral supplements.20 Table 2: Sunscreen Ingredients

14,23,24

For product selection, consult Compendium of Products for Minor Ailments. Skin Care Products: Sunscreens. Class

Wavelength

Anthranilates

UVB (weak)

meradimate (menthyl anthranilate, menthyl-2-aminobenzoate)

UVA (incomplete protection, 300–340 nm)

Benefits

Comments Allergic reactions are rare.

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For product selection, consult Compendium of Products for Minor Ailments. Skin Care Products: Sunscreens. Class

Wavelength

Benefits

Comments

Benzimidazoles

UVB

Well tolerated.

Water soluble. Allergic reactions are rare.

May advertise broadspectrum UVB/UVA protection, since cover most of UVB plus lower-mid UVA range.

Some skin sensitization (oxybenzone may cause allergic reactions). Must be combined with titanium dioxide and/or zinc oxide for stability.

ensulizole (2-phenylbenzimidazole5-sulfonic acid, PBSA, Eusolex 232, Parsol HS)

(minimal UVA)

290–320 nm

Benzophenones

UVB

oxybenzone (benzophenone-3, Escalol 567, Eusolex 4360)

260–380 nm depending on chemical

dioxybenzone (benzophenone-8)

sulisobenzone (benzophenone-4, 2-hydroxy-4-methoxybenzone-5-sulfonic acid)

Photostable.

Lower UVA

Benzotriazoles

UVB

Characteristics of organic and inorganic filters.

Allergic reactions are rare.

Benzylidene Camphor Derivatives

UVB

Photostable.

Water soluble.

terephthalylidene dicamphor sulfonic acid (ecamsule, Mexoryl SX)

UVB

Good photostability.

Easily removed through perspiration or swimming (need to be combined with products that do not wash off). Allergic reactions are rare.

Cinnamates

UVB

octinoxate (octyl methoxycinnamate, 2-ethylhexylmethoxycinnamate, EMC, OMC, Escalol 557, Parsol MCX)

280–320 nm

Photostabilize dibenzoylmethanes (avobenzone).

Easily removed by abrasion, perspiration or swimming (need to be combined with products that do not wash off). Allergic reactions are rare.

bisoctrizole (methylene bis-benzotriazolyltetramethylbutylphenol, Tinosorb M)

enzacamene (4-methylbenzylidene camphor, MBC, Eusolex 6300, Parsol 5000)

cinoxate (2-ethoxyethyl p-methoxycinnamate)

octocrylene (2-ethylhexyl-2-cyano3,3-diphenylacrylate, OCR, Eusolex)

UVA (broad spectrum, maximum absorption 360 nm) Maximum absorption at 300 nm UVA (broad spectrum, maximum absorption 345 nm)

May have some UVA

Octocrylene: some coverage in low UVA range which allows products to claim UVB/UVA protection.

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For product selection, consult Compendium of Products for Minor Ailments. Skin Care Products: Sunscreens. Class

Wavelength

Benefits

Comments

Dibenzoylmethanes

UVA (broad spectrum, 320–400 nm)

Better UVA protection than benzophenones and Mexoryl SX.

60% decrease in efficacy after 1 h of exposure to the sun (combined with Mexoryl to enhance photostability). May cause allergic reactions/contact dermatitis.

Hydroxybenzotriazoles

UVB

Photostable.

Allergic reactions are rare.

Hydroxyphenyltriazines

UVB

Included in products to improve the photostability of sunscreens containing avobenzone.

Para-aminobenzoic Acid (PABA) esters

UVB

Resistant to water and sweating and adhere well to skin even after swimming.

avobenzone (t-butylmethoxydibenzoylmethane, Eusolex 9020, Parsol 1789)

drometriazole trisiloxane (silatriazole, Mexoryl XL)

bemotrizinol (anizotriazine, bis-ethylhexyloxyphenolmethoxyphenyl triazine. Tinosorb S)

padimate O (octyl dimethyl PABA)

UVA (broad spectrum, 320–360 nm) UVA (broad spectrum, maximum absorption 343 nm) 260–320 nm

Photo unstable.

Can cause skin irritation and photosensitivity reactions. Can stain clothing.

Rarely included in products because of sensitivity issues (contact dermatitis). Avoid in those sensitive to sulfonamides, thiazides and sulfonylureas. Physical Blocks titanium dioxide zinc oxide

(inorganic filters)

UVB, UVA (full spectrum)

290–400 nm

Can be used by all ages (infants >6 months).

Less risk of sensitization than chemical sunscreens. Photostable.

Reflect and scatter UV and visible light.

Titanium should not be used on children under 6 months or applied to open wounds. May cause or worsen acne by clogging skin pores.

Clear formulations of

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For product selection, consult Compendium of Products for Minor Ailments. Skin Care Products: Sunscreens. Class

Wavelength

Benefits

Comments

micronized particles are cosmetically more appealing. Salicylates

homosalate (homomenthyl salicylate, HMS)

octisalate (octyl salicylate, 2-ethylhexyl salicylate, Escalol 587)

UVB only (weak)

260–320 nm

Skin irritation is rare.

Very stable; included in other products to improve stability.

Easily removed by abrasion, perspiration or swimming.

triethanolamine salicylate (trolamine salicylate)

Chemical Tanning Agents: Sunless tanning products contain dihydroxyacetone (DHA), a dye which colours the skin when applied topically to produce an artificial tan. The colour change is temporary, lasting several days, and must be reapplied every few days to maintain an even colour. Tanning agents have a very low SPF (3–4) value unless marketed in combination with sunscreen products. Dihydroxyacetone is considered nontoxic and is regulated as a cosmetic rather than as a drug.25

Treatment of Sun-induced Skin Damage Nonpharmacologic Therapy

Treatment of sunburns, both minor and severe, includes relieving the discomfort caused by the burn. Application of cool tap water compresses will relieve some pain associated with minor sunburn. Patients should avoid further exposure to the sun to prevent further burning, which could lead to an increase in the severity of the sunburn. If further exposure to the sun cannot be avoided, the individual should wear protective clothing, apply a sunscreen and limit the amount of time in the sun during peak times (10 a.m. to 4 p.m.).

Pharmacologic Therapy

For product selection, consult Compendium of Products for Minor Ailments. Analgesic Products: Internal Analgesics and Antipyretics and Skin Care Products: First Aid.

Sunburns Skin protectants such as petrolatum and hydrophilic ointments provide symptomatic relief of minor sunburns and redness. These products protect the area from irritation caused by friction from clothing as well as moisturize and rehydrate the skin. Bath and baby oils have minimal effect and peanut and corn oil have no effect.26 Analgesics are used short term to relieve the pain and mild inflammation caused by sunburn. They should be taken either just before exposure or immediately after exposure as inflammation generally occurs within the first 24 hours. Nonprescription anti-inflammatory agents such as ibuprofen, naproxen sodium or acetylsalicylic acid (ASA) are recommended. Acetaminophen can also be used for pain relief if a person cannot tolerate

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ibuprofen, naproxen sodium or ASA.26 Topical aloe vera has traditionally been promoted for its wound-healing ability. A systematic review found that there is inconclusive evidence to determine whether aloe vera gel or dressings improve outcomes in acute wounds including burns.27 The amount of active ingredient in aloe vera products varies according to growing conditions, age of the plant, harvesting and extraction methods used.28 Some patients may experience burning sensation, contact dermatitis or mild itching with topical use. For information on prescription therapy, see Sunburn.

Photoaging Tretinoin in prescription formulations improves photoaging symptoms after several weeks of treatment. Continued treatment over the next 6–12 months results in skin that is smoother and less sallow. Fine and coarse wrinkles are reduced, and pigment is less mottled.5 Nonprescription products containing retinol have limited efficacy because the skin is only able to convert small amounts of retinol to retinoic acid. Nonprescription products containing vitamin A do not contain sufficient concentrations of retinoids to effectively treat photoaging and are likely added for their moisturizing properties.29 Antioxidants have been studied to determine if they are able to prevent or reverse the signs of photoaging. Topical Vitamin C can prevent redness from UV exposure and significantly decrease wrinkling.6 Topical coenzyme Q10 (ubiquinone) which is found in the epidermis and dermis layers significantly reduces wrinkles.6 A number of antioxidants that may reverse the signs of photoaging are being investigated: soy isoflavones, green tea polyphenols, lutein and carotenoids.6 Chemical peels contain alpha-hydroxy acid (AHA), salicylic acid, trichloroacetic acid and phenol. Chemical peels work by regeneration and re-epithelialization of the epidermis and dermis. Glycolic acid improves skin texture, reduces wrinkles and decreases the number of actinic keratoses.6 Botulinum toxin A does not reverse photodamage but appears to rejuvenate the skin by relaxing the underlying musculature. The effects of treatment typically last 3 months.6

Pigmentary Changes Hypermelanosis can be treated with hydroquinone, which helps to reduce visibility and degree of pigmentation. Hydroquinone does not affect the upper layer of the skin but interacts with melanin production in the lower layers of the epidermis. Skin improves over 3 weeks to 3 months. Recurrence is prevented by limiting sun exposure and using a sunscreen, particularly on areas that have been treated.5 Skin irritation, redness and allergic or contact dermatitis have been reported. Sun exposure can exacerbate the pregnancy-associated skin-darkening condition chloasma (melasma). This may lead women to consider treatment with hydroquinone. Hydroquinone is significantly absorbed when applied topically,30 and evidence of its safe use in pregnancy is limited.31 Use of hydroquinone should be minimized during pregnancy.32 No information is available on the excretion of hydroquinone into breast milk, and it should be avoided while breastfeeding.33,34,35

Monitoring Therapy for Sun-induced Skin Damage

Table 3 provides a plan for monitoring therapy for sun-induced skin damage. Table 3: Monitoring Therapy for Sun-induced Skin Damage Symptom

Monitoring

End Point

Actions

Early

Monitor for changes in

Skin feels softer,

Prevention is the most effective

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Symptom

Monitoring

End Point

Actions

photodamage

skin appearance (rough, dry skin with surface or deep wrinkles).

smoother, fine wrinkles less apparent.

treatment (continual use of sunscreens with SPF 30 or more).

(fine wrinkles, dry skin)

Sunburn

Monitor regularly for signs of mottling or pigment changes (“liver” spots or “age” spots). Monitor for 24–48 h after unprotected sun exposure for worsening or improvement of burn. Monitor pain 24–48 h.

Monitor for 7 days for signs of infection (particularly if blistered).

Actinic keratosis

Monitor regularly for dry, scaly lesions on chronically sun-exposed areas (particularly age 50 and up). Monitor closely for signs of change (size, shape or colour).

Skin does not show signs of pigment change.

Sunburn lessens or disappears after 48 h. Pain relief is accomplished with nonprescription treatment.

No signs of infection after 48 h.

No signs of actinic keratosis, e.g., firm scaling lesion with slight erythema.

Tretinoins, chemical peels and antioxidants may reverse or improve signs. Refer to physician if self-management results are inadequate for patient.

Cool compresses to relieve pain. Nonprescription pain relief (acetaminophen, ibuprofen). Skin protectants such as petrolatum to protect and moisturize. Avoid further exposure.

Refer to physician if signs of infection within 7 days. Avoid chronic exposure to sun.

Refer to physician for further investigation if changes in the area (rule out squamous cell carcinoma, basal cell carcinoma or melanomas). Wear sunscreens regularly and cover area to protect from further sun exposure.

Suggested Readings

Antoniou C, Kosmadaki M, Stratigos AJ et al. Sunscreens–what's important to know. J Eur Acad Dermatol Venereol 2008;22:1110-8. Government of Canada. Sunscreens. It's your health. Available from: healthycanadians.gc.ca/healthsante/environment-environnement/sun-soleil/screen-ecrans-eng.php. Lautenschlager S, Wulf HC, Pittelkow MR. Photoprotection. Lancet 2007;370:528-37. Ramirez R, Schneider J. Practical guide to sun protection. Surg Clin North Am 2003;83:97-107.

References 1. Bond CA. Skin disorders. In: Koda-Kimble MA, Young LY, eds. Applied therapeutics: the clinical use of drugs. Vancouver: Applied Therapeutics; 1992. p. 64-1-6. 2. Kullavanijaya P, Lim HW. Photoprotection. J Am Acad Dermatol 2005;52:937-58. 3. Wondrak GT, Jacobson MK, Jacobson EL. Endogenous UVA-photosensitizers: mediators of skin photodamage and novel targets for skin photoprotection. Photochem Photobiol Sci 2006;5:215-37.

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4. Fourtanier A, Moyal D, Seite S. Sunscreens containing the broad-spectrum UVA absorber, Mexoryl SX, prevent the cutaneous detrimental effects of UV exposure: a review of clinical study results. Photodermatol Photoimmunol Photomed 2008;24:164-74. 5. Osterwalder U, Herzog B. Sun protection factors: worldwide confusion. Br J Dermatol 2009;161:13-24. 6. Rabe JH, Mamelak AJ, McElgunn PJ et al. Photoaging: mechanisms and repair. J Am Acad Dermatol 2006;55:1-19. 7. Lawrence N. New and emerging treatments for photoaging. Dermatol Clin 2000;18:99-112. 8. Cayce KA, McMichael AJ, Feldman SR. Hyperpigmentation: an overview of the common afflictions. Dermatol Nurs 2004;16:401-6, 413-6. 9. MacKie RM. Long-term health risk to the skin of ultraviolet radiation. Prog Biophys Mol Biol 2006;92:92-6. 10. Environment Canada. Sun protection for babies. Available from: www.ec.gc.ca/uv/default.asp?lang=En& n=2B3B8766-1. Accessed August 7, 2014. 11. Paller AS, Hawk JL, Honig P et al. New insights about infant and toddler skin: implications for sun protection. Pediatrics 2011;128:92-102. 12. Wehner MR, Shive ML, Chren MM et al. Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis. BMJ 2012;345:e5909. 13. Boniol M, Autier P, Boyle P et al. Cutaneous melanoma aFteaspoonttributable to sunbed use: systematic review and meta-analysis. BMJ 2012;345:e4757. 14. Guenther L. Sunburn. In: CTC 7. 7th ed. Ottawa: Canadian Pharmacists Association; 2014. 15. Stern RS, Weinstein MC, Baker SG. Risk reduction for nonmelanoma skin cancer with childhood sunscreen use. Arch Dermatol 1986;122:537-45. 16. Green A, Williams G, Neale R et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet 1999;354:723-9. 17. Green AC, Williams GM, Logan V et al. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol 2011;29:257-63. 18. Canadian Dermatology Association. Available from: www.dermatology.ca. Accessed August 7, 2014. 19. Ramirez R, Schneider J. Practical guide to sun protection. Surg Clin North Am 2003;83:97-107. 20. Norval M, Wulf HC. Does chronic sunscreen use reduce vitamin D production to insufficient levels? Br J Dermatol 2009;161:732-6. 21. Ross AC, Taylor CL et al. DRI Dietary Reference Intakes for calcium and vitamin D. Washington: Institute of Medicine of the National Academies; 2010. Available from: www.iom.edu/Reports/2010/Dietary-ReferenceIntakes-for-Calcium-and-Vitamin-D.aspx. Accessed August 7, 2014. 22. Shahriari M, Kerr PE, Slade K et al. Vitamin D and the skin. Clin Dermatol 2010;28:663-8. 23. Antoniou C, Kosmadaki M, Stratigos AJ et al. Sunscreens–what's important to know. J Eur Acad Dermatol Venereol 2008;22:1110-8. 24. Lautenschlager S, Wulf HC, Pittelkow MR. Photoprotection. Lancet 2007;370:528-37. 25. Fu JM, Dusza SW, Halpern AC. Sunless tanning. J Am Acad Dermatol 2004;50:706-13. 26. Han A, Maibach HI. Management of acute sunburn. Am J Clin Dermatol 2004;5:39-47. 27. Dat AD, Poon F, Pham KB et al. Aloe vera for treating acute and chronic wounds. Cochrane Database Syst Rev 2012;2:CD008762. 28. Maenthaisong R, Chaiyakunapruk N, Niruntraporn S et al. The efficacy of aloe vera used for burn wound healing: a systematic review. Burns 2007;33:713-8. 29. Draelos ZD. Therapeutic moisturizers. Dermatol Clin 2000;18:597-607. 30. Wester RC, Melendres J, Hui X et al. Human in vivo and in vitro hydroquinone topical bioavailability, metabolism, and disposition. J Toxicol Environ Health A 1998;54:301-17. 31. Mahé A, Perret JL, Ly F et al. The cosmetic use of skin-lightening products during pregnancy in Dakar, Senegal: a common and potentially hazardous practice. Trans R Soc Trop Med Hyg 2007;101:183-7. 32. Bozzo P, Chua-Gocheco A, Einarson A. Safety of skin care products during pregnancy. Available from: www.motherisk.org/prof/updatesDetail.jsp?content_id=946. Accessed August 7, 2014. 33. Drugs and Lactation Database (LactMed). Bethesda: U.S. National Library of Medicine. Available from: toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Accessed August 7, 2014. 34. Hale TW. Medications and mothers' milk: a manual of lactational pharmacology. 15th ed. Amarillo: Hale

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Publishing; 2012. 35. Ferreira E, Martin B, Morin C. Grossesse et allaitement: guide thérapeutique. 2nd ed. Montréal: CHU SainteJustine; 2013.

Skin Damage from the Sun — What You Need to Know

Sunlight causes damage to the skin that can be seen right away, such as redness or sunburn. It also causes damage that can't be seen right away, even when the skin does not change colour. This damage can show up many years later as skin cancer, or as signs of aging, especially on the face (such as wrinkles, dryness, dullness, yellowing or an uneven skin color).

What can you do to prevent skin damage from the sun?

Here are some suggestions to help prevent immediate skin damage (such as sunburn) and delayed effects of sun exposure (such as wrinkles and skin cancer):

Avoid direct exposure to the sun from 10 a.m. to 4 p.m. when the sun's rays are the strongest. Staying in the shade when outside offers some protection but caution should still be exercised as sunlight also goes through leafy trees and umbrellas and is reflected from surfaces outside the shaded area.

Protect the skin from sun damage or burning by wearing clothing that covers areas exposed to the sun (broadbrimmed hat, sunglasses, long-sleeved shirt and long pants). Cotton or linen clothing that is tightly woven, loose fitting and lightweight will provide some protection. Clothing that is wet, white or loosely woven provide very little protection. Avoid tanning lamps and sun lamps as they use UVA radiation and are not considered safe to use on a regular basis (exceptions are for medical use such as patients with psoriasis). They increase risk of having wrinkles and skin cancer. Do not stay in the sun for long periods of time to get a tan. Tanning increases the risk of skin damage, including wrinkles. A tan does not offer protection from further sun damage. Avoid sun exposure in infants less than 6 months of age as they are very vulnerable to sunburn. Infants should be kept in a well shaded area and covered with clothing that will offer complete protection from the sun. Sunscreens have not been proven safe in infants less than 6 months of age. It is recommended that a sunscreen be applied particularly if out in the sun for long periods of time. Sunscreens should also be applied during cloudy weather as sun is still able to penetrate through clouds. Sunscreens should be worn while boating, as the sun reflects off the water, increasing sun exposure. Sunscreens with an SPF of 30 or more will help to protect the skin from sun induced skin damage and the possibility of permanent skin damage or cancer later in life.

Correct application of sunscreens

Sunscreens can help protect skin but do not completely prevent skin damage from sunlight. These tips will help to get the most benefit from sunscreen:

Apply a sufficient thickness to offer protection as a thin application will not offer the SPF value indicated on the product. Sunscreens should be applied 30 minutes before exposure and re-applied 15–30 minutes later to maximize protection and ensure enough has been applied to the body. Sunscreens should be applied to all exposed areas, ensuring that the ears, nose, lips, back of the neck and hairline are covered as well. Sunscreens should be applied to the skin 15–30 minutes before going into the water to allow it time to get absorbed. Sunscreens should be reapplied after swimming, towelling off or sweating to prevent burning. Sunscreens should be reapplied every 2 hours to ensure that the skin is constantly protected.

To get the full effect of the labelled sun protection factor (SPF) it must be applied correctly and the correct quantity (approximately 30 mL to cover the entire body). An average-size adult should use at least the following amounts: ½–1 teaspoonful on the face and neck

1–1½ teaspoonfuls to arms, shoulders and torso

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2–2½ teaspoonfuls to the legs and the tops of the feet. CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-03-2016 02:22 PM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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