What doctors wish patients knew about summer skin safety

After a year of physical distancing and staying home to slow the spread of COVID-19, many people are eager to resume normal summer activities. As people flock to beaches and participate in other outdoor activities, it is important to take care of your skin because too much sun exposure can have detrimental effects such as sunburn, skin aging, eye damage and skin cancer.

To help, two AMA members took time to discuss what patients should know about summer skin safety. They are:

• Alexa B. Kimball, MD, a dermatologist, and CEO and president of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center.
• William L. Waller III, MD, a dermatologist at Hattiesburg Clinic Dermatology—South. Hattiesburg Clinic is a member of the AMA Health System Program.

Here are some summer skin safety tips they had to offer.  

While everyone knows about SPF, it is “actually a measure of just the UVB protection you get from the sunscreen. It doesn’t tell you anything about the UVA rays,” said Dr. Waller. “Yes, SPF is important, but you also need to make sure you can find product that says broad spectrum—that means that the UVA protection is equivalent to the UVB protection, which you’ll get from the SPF number.”

Choose a sunscreen that has an SPF of “30 or above for most kinds of activities for most people,” said Dr. Kimball. “If you're a particularly pale, you're going out for a long period of time or you're going to be in a reflective environment, like a ski slope or water, you may want to go higher—that's probably a good ground rule for folks in general.”

“With a 30 SPF, you get about 97% protection from UVB rays,” Dr. Waller said, noting that while they make higher SPFs, “the improvement is actually pretty marginal—you get about 98% protection with SPF 50 and 99% for 100 SPF.”

“Any sunscreen—whether SPF 30, 50 or 100—will wear off after about two hours,” explained Dr. Waller. “What people get in trouble with is they put on SPF 100 and think this will last me all day. It really doesn't—it is only marginally better than SPF 30, plus it still wears off in the same amount of time.”

That means “you'll still need to reapply every two hours or sooner if you get wet, you sweat or you wipe yourself with the towel, because a lot of times you're wiping off that sunscreen, even if it's water resistant,” he added.

“How often to reapply really depends on what you're doing. If you're out doing something athletic or where you might have some of it wash off either from sweat or water or whatever, you may want to apply every couple of hours,” said Dr. Kimball, adding that “if you've been in the pool for half an hour, even if it says waterproof, it may well be worth redoing when you get out.”

“Between the hours of around 10 to 4:00 p.m. is obviously when the sun's going to be the brightest and highest in the sky,” Dr. Waller said, adding that “you're looking at more UV radiation during those hours.”

“There's a little saying that says if your shadow is shorter than you are, then you need to think about finding shade because that means that the sun is usually in those points in the sky where it's the brightest,” he said.

“If you are concerned about the chemicals in sunscreens, use a mineral-based sunscreen,” said Dr. Waller. “These are products that have titanium dioxide or zinc oxide, and they’re actually minerals that sit on the surface of the skin and they’re not absorbed—they’re sunscreens that are usually a bit harder to rub in.

“When you apply them, they look pretty white or opaque because it’s actually a mineral that is that white color,” he added. “The other drawback to the mineral-only sunscreen is most of them offer less UVA protection.”

To determine whether there is UVA protection, “you want to start to look at the ingredients and the key ones are either titanium dioxide, zinc oxide or avobenzone,” said Dr. Kimball, adding “that’ll assure you have some UVA protection in there too.”

“The other thing that happens is that the zinc and titanium-based products tend to be less irritating to the skin if you have sensitive skin,” she explained.

“The most important thing is to have a sunscreen that you'll use,” said Dr. Kimball, adding that “sunscreens now come in foam, sprays, creams, sticks and anything you can imagine.

“If you find that there's a formula that makes you more likely to use it, then that's what you should go with,” she added.

It is important “to make sure you use enough sunscreen,” said Dr. Kimball, adding that “the recommendation is actually to cover your whole body you should use an ounce of sunscreen.

“Think of your classic sunscreen container, which is usually six to eight ounces. I guarantee you people are not using them just six to eight times,” she added. “As a visual, it’s a shot glass worth of sunscreen.”

For sprays, it is key to apply generously four to six inches away from your skin and rub it in. But do not spray directly on your face to avoid inhalation, explained Dr. Waller.

Another often overlooked sun-safety tip is to shake sunscreen before use.

“If it’s a lotion or an aerosol, the active ingredients can settle out,” said Dr. Waller, adding that “sometimes if you’re just taking off whatever’s on the top, it’s not always a good mix of ingredients.

“Especially if it’s been sitting around, it’s good to shake it up to get a good mix and the right concentration,” he added.

“A question I often get is, do I have to pay attention to expiration dates?” said Dr. Kimball. “The ingredients in sunscreens—the titanium and the zinc oxides—because of their formulas will probably last a little bit longer.

“But I would be careful about using sunscreens past their expiration dates because you might really see that their efficacy would drop,” she added. Fortunately, “they now crimp the expiration dates on the tubes so you can follow that carefully.”

“You still get UV through cloudy days. It’s especially tricky, for example, on a boat where you think it's not so sunny, but you're getting this double whammy through the clouds and then reflected back on the water,” explained Dr. Kimball, adding that “a fair amount of UV still gets through on a cloudy day.”

That is why it is important to protect your skin every time you’re outside, even in the winter while skiing, she said.

“Skin cancer can develop on the lips and be quite aggressive,” said Dr. Waller. “To protect your lips, select a lip balm that includes sunscreen and be sure to use it year-round.”

“There's lots of lip balm sunscreens, so it’s not a bad idea if you're going to be out for a long period of time,” said Dr. Kimball. “Interestingly, a lot of lipsticks contain zinc oxide as an ingredient, so even if they don't say that they're protective, they may have some sort of protection for women who are wearing lipstick.”

Reapply lip protection “even more frequently” than sunscreen on the rest of your body “because it’s not going to stay on as well,” she said.

“A lot of my patients who have outdoor jobs have a hard time reapplying every two hours, so I usually recommend protective clothing and hats, especially with the broad brim,” said Dr. Waller. “You want a hat that covers the ears and the neck. They also make a lot of clothing now that has this UV shield or protective UPF,” which means ultraviolet protection factor.

“The nice thing about these materials is they're synthetic and they're very lightweight … and these are nice because they reflect the sun, but they also keep it cool because they're lighter weight fabrics,” he said. “It's always good to have multiple layers of protection, so not only shirts and hats, but also wearing the sunscreen as well.”

There are “approved sunscreens down to the age of 6 months,” said Dr. Waller. “Before 6 months, use protective clothing and try to avoid sun exposure, but after that point it appears that sunscreens are safe to use on kids.”

“For younger kids in general, the pediatricians don't recommend using sunscreen under 6 months old, so you want to use hats and other things,” echoed Dr. Kimball. “The good news is the fashion trends have changed a little bit. For a while no one wore protective gear while swimming, but now we’re seeing parents and kids wearing it.

“If you just think about the challenges of getting sunscreen on kids, when they’ve got a fabric covering, you don’t have to worry about it to the same extent,” she added. “It’s about making that fashionable and fun for them."

“People with darker natural pigments are going to be less likely to burn, but that doesn't mean that they are immune to the effects of the UV radiation because it's still hitting their skin,” said Dr. Kimball. “Darker skin types also are susceptible to skin cancers and sometimes they're harder to detect because we don't expect to see them as frequently.”

Additionally, skin cancer on darker skin tones “look and present a little bit differently, so we do recommend photoprotective measures for darker skin types in general that are similar to other skin types,” she added.

“People feel like sunburns are temporary—you get one and you peel and then you're good to go,” said Dr. Waller. But “one thing that research has shown over the years is that the more burns you get, especially when you're young, the more damage that you're going to see later in life.”

Sunburn is permanent. The redness and the peeling will go away but the sun damage that you get is lifelong,” he explained. “In fact, one study showed that if you burned five times when you were younger, it doubles your chance for melanoma when you're older.”

“The sunburn may take hours or up to a day to really get to its height, so if you see that you've got a burn and you're still in the sun, you’ve got to get out of the sun exposed area immediately because you're only seeing the tip of how bad it could be,” said Dr. Kimball. Once you’re sunburned, “all those cooling techniques that are intuitive like taking a wet cloth and letting it just sit on the skin and evaporate off to get a cooling effect can be helpful.”

“Depending on how bad of a sunburn you get would tell you what you do to treat it,” said Dr. Waller. “If it's some kind of a first degree or minor sunburn, you can use aloe vera or lotions, and you can take Tylenol for pain and Benadryl for itching.

“If it gets to more of a blistering or a second-degree sunburn, you have to start worrying about infection,” he added. But with “third degree burns, you're getting to the point where, depending on how extensive it is, you might even have to go into a burn unit to control infections and to prevent dehydration because you actually can lose a lot of fluids through your skin if the barrier is compromised.”

“You're already getting sun damage when your skin tans—that is a result of your body trying to protect itself,” said Dr. Waller, adding that “you're already shooting yourself in the foot before you even have a chance to get outside.”

“What the tan tells you is that there have been lower levels of UV and that your skin’s protective melanin producing cells have started to do that, but you’ve accumulated some damage in that process,” said Dr. Kimball. “It’s not as severe or acute, but they wouldn’t be turning on it they weren’t responding to that UV radiation.”

“The photo aging part is a similar process as skin cancer, but you're essentially breaking down some of the tissues that make the skin look fair and healthy in the collagen,” she said. “You're also causing areas of pigmentation marks, which make people look older.”

“Window glass is pretty good about blocking UVB rays, but it does not block UVA very well, so you’ve got to be careful” said Dr. Waller. “Even if you're in the car and the windows are up, you're still getting some damage, especially from UVA, and those are the rays that will cause skin aging.

“You don't necessarily get sunburned, but it'll damage the skin and cause premature aging,” he added, emphasizing that “even if you're in the car, it's good to use sunscreen if you're in a window with sun coming through.”

“If you're good with your sunscreen application, reapplying after you're in the water and especially if you're seeking shade during the brightest times of the day, I don't think there's necessarily a limit to the total time you could spend outdoors,” said Dr. Waller. “It's just being responsible while you're on the beach or by the pool doing the things you need to do to protect your skin.”

“People should be outside, do activities and be healthy, but what we encourage is to be as protective as you can,” said Dr. Kimball. “You're never going to be 100%, but with a combination of things like not being at the height of the sun, making sure you've got protective gear with you and using your sunscreen, you should get out there and live your life and have fun.”