Skin cancer is the most commonly diagnosed cancer in the United States, with melanoma estimated to cause more than 80% of skin cancer deaths,1 and sunscreen is commonly recommended as a method to reduce the risk of skin cancer. The WHO International Agency for Research on Cancer classifies ultraviolet radiation, solar radiation, and indoor tanning as carcinogenic, with evidence linking these risk factors to melanoma and other skin cancers.2 For prevention of skin cancer, the United States Preventive Services Task Force recommends behavioral counseling (Grade B) for adolescents, young adults, and parents of young children regarding sun protective behaviors such as avoiding sun exposure and using sunscreen.3 The American Academy of Dermatology recommends using sunscreen every day one is outside, applying 15 minutes before going outdoors, reapplying every 2 hours or after swimming or sweating, and applying 2 mg/cm2 to achieve the sun protection factor (SPF) on the bottle (which is about 30 mL or 1 ounce for full body application).4
However, despite evidence that sunscreen reduces the risk of cancer (especially invasive melanoma5) and recommendations from multiple organizations promoting the use of sunscreen, the prevalence of sunscreen use is not high. A 2015 study using cross-sectional data found that only 14.3% of men and 29.9% of women regularly use sunscreen on both their face and other exposed areas.6 This study was only able to assess sunscreen use and was unable to assess whether participants were re-applying as recommended, but it appears as though prevalence of guideline-compliant sunscreen use is much lower, as a 2013 study of adults engaged in outdoor winter recreation found that only 4.4% were in full adherence to all sunscreen advice.7 The question then is: what are the barriers to sunscreen use, and how can we address them?
A survey of dermatology clinic patients’ sunscreen use found that the top three barriers to adequate sunscreen use were dislike of feel or appearance, time constraints, and cost.8 This is in line with other research regarding the use of sunscreen in practice. A study of participants in a skin cancer prevention trial found that the median quantity of sunscreen applied by participants was 0.79 mg/cm2, which is less than half the amount needed to get the SPF protection labeled on the bottle.9 Additionally, people frequently miss areas of exposed skin, with one study showing that participants missed a median of 20% of available body surface after sunscreen application.10 Two solutions that have been proposed include spending more time on sunscreen application and applying two layers. The rationale is that people have been shown to apply a constant amount of sunscreen per minute,11 and therefore increasing the amount of time spent on application will increase the amount of sunscreen used. Two applications of sunscreen have also been shown to reduce the amount of missed surface area.10 Unfortunately, both of these solutions may exacerbate barriers to sunscreen use. One can imagine that asking someone to apply more than twice the amount of sunscreen they typically would or to apply two layers of sunscreen would exacerbate both the dislike of feel/appearance and the time-consuming nature of sunscreen application. The barrier of cost is also significant: a 2014 study into the economic burden of sunscreen usage found that for the average man, ideal sunscreen use of SPF 30 sunscreens would cost around $236-$494 per year, depending on name-brand or generic-brand use, with prices increasing with increasing SPF.12 This is additionally supported by several surveys identifying higher socioeconomic status as being significantly associated with increased sunscreen use.8
Availability is also likely to affect people’s patterns of sunscreen use. As stated before, an adequate amount of sunscreen for one full body application has been cited as about 30 mL or 1 ounce, with an exponential decrease in sun protection as less sunscreen is applied.13 However, a simple search on Amazon for body sunscreen reveals that a majority of sunscreen bottles contain 3-8 ounces of product, with standard spray sunscreens containing around 5-5.5 ounces of product. That means that if one’s body were mostly exposed, one person would need to use up an entire bottle of sunscreen in one day if applying and re-applying as guidelines direct. Using an entire bottle in one day or over several days seems unrealistic. Additionally, sunscreen-containing cosmetics are likely to improve people’s use of photoprotection.14 However, a standard bottle of foundation is 30 mL, and recommendations for sunscreen use on the face and neck is about 1 teaspoon, or 5 mL of product. That means that for adequate photoprotection, one would use up one bottle of foundation in six days with once-daily applications, which again seems unlikely from an aesthetic, practical, or financial point of view. In this way, the market of available photoprotection products may give people inappropriate cues as to how they should be using sunscreen, and how much sunscreen is adequate.
Given all these barriers, what can be done to increase people’s use of sunscreen? First, when it comes to the cosmetic appeal (or lack thereof) of sunscreen, several advances have been made in the formulations of sunscreens. Older formulations of physical sunscreens used large-size particles, which caused an occlusive white film on the skin. This has been improved with newer nanotechnology methods that allow for smaller particles that form a more transparent film.15 Additionally, more aesthetically pleasing carriers for sunscreen ingredients are being used, such as oil-in-water emulsions that are thinner and less greasy than creams, or ethanol-based products that are fast-drying due to ethanol evaporation.16 However, these products can be more difficult to make, and therefore more expensive. When it comes to the practicality of using sunscreens, one intervention that has been shown to improve compliance is keeping photoprotection top of mind. A randomized controlled trial of electronic text-message reminders found that participants who received reminders had a mean daily adherence rate of 56.1% compared to 30.0% in those who did not receive text messages (p < 0.001).17 Another study found that instructing participants to place sunscreen (which they were given a 2-month supply of) in the same storage unit or location as their toothpaste increased overall sunscreen usage by 20% over a 6-week period.18 Additionally, consistent patient education is an intervention shown to have the potential to increase sunscreen usage, with a survey showing that dermatologists recommending sunscreen use was associated with a higher rate of sunscreen use (p < 0.001),8 and another survey showing that dermatologists only made sunscreen recommendations 58% of the time.19 It is also important for physicians to counsel patients on what proper sunscreen use consists of, as available products may give people inappropriate cues as to how to use their photoprotection products. Finally, increased awareness of other sun-protective behaviors, such as wearing protective clothing, is a solution that would serve to decrease many of the barriers listed here for adequate sunscreen use. By decreasing the amount of exposed skin, one would need less sunscreen for adequate protection. Additionally, by staying in the shade or indoors during times of day with high sun exposure, or by limiting activities like swimming that require more exposed skin and are more likely to wash off sunscreen, people can decrease their risk of skin cancer without needing to use as much. Indeed, given that the majority of barriers to appropriate sunscreen use appear to involve the amount required for adequate protection, it is clear that using sunscreen in conjunction with other sun-protective behaviors that reduce the amount of sunscreen required will make appropriate sunscreen use more acceptable and tolerable for patients.
Ellen Yin, Class is a 3rd year medical student at NYU Grossman School of Medicine
Peer reviewed by Miriam Pomerantz, MD, associate professor, Dermatology, NYU Langone Health
Image courtesy of Wikimedia Commons, source: Use Sunscreen Spray? Avoid Open Flame (9196637400).jpg
- Henrikson NB, Morrison CC, Blasi PR, Nguyen M, Shibuya KC, Patnode CD. Behavioral counseling for skin cancer prevention: Evidence report and systematic review for the US Preventive Services Task Force. 2018;319(11):1143–1157. doi:10.1001/jama.2017.21630
- IARC monographs on the identification of carcinogenic hazards to humans. Lyon, France. WHO International Agency for Research on Cancer. https://monographs.iarc.frUpdated November 27, 2020. Accessed December 2, 2020.
- US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, et al. Behavioral counseling to prevent skin cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(11):1134-1142. doi:10.1001/jama.2018.1623
- American Academy of Dermatology. Sunscreen FAQs. AAD website. https://www.aad.org/public/everyday-care/sun-protection/sunscreen-patients/sunscreen-faqs. Accessed December 3, 2020.
- Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011;29(3):257–263. https://pubmed.ncbi.nlm.nih.gov/21135266/
- Holman DM, Berkowitz Z, Guy GP Jr, Hawkins NA, Saraiya M, Watson M. Patterns of sunscreen use on the face and other exposed skin among US adults. J Am Acad Dermatol. 2015;73(1):83–92. https://pubmed.ncbi.nlm.nih.gov/26002066/
- Buller DB, Andersen PA, Walkosz BJ, et al. Compliance with sunscreen advice in a survey of adults engaged in outdoor winter recreation at high-elevation ski areas. J Am Acad Dermatol. 2012;66(1):63-70. doi:10.1016/j.jaad.2010.11.044
- Weig EA, Tull R, Chung J, Brown-Joel ZO, Majee R, Ferguson NN. Assessing factors affecting sunscreen use and barriers to compliance: a cross-sectional survey-based study. J Dermatalog Treat. 2020;31(4):403-405. https://pubmed.ncbi.nlm.nih.gov/30889998/
- Neale R, Williams G, Green A. Application patterns among participants randomized to daily sunscreen use in a skin cancer prevention trial. Arch Dermatol. 2002;138(10):1319-1325. doi:10.1001/archderm.138.10.1319
- Heerfordt IM, Torsnes LR, Philipsen PA, Wulf HC. Sunscreen use optimized by two consecutive applications. PLoS One. 2018;13(3):e0193916. Published 2018 Mar 28. doi:10.1371/journal.pone.0193916
- Heerfordt IM, Torsnes LR, Philipsen PA, Wulf HC. Photoprotection by sunscreen depends on time spent on application. Photodermatol Photoimmunol Photomed. 2018;34(2):117-121. doi:10.1111/phpp.12373
- Johal R, Leo MS, Ma B, Sivamani RK. The economic burden of sunscreen usage. Dermatol Online J. 2014;20(6):13030/qt6vo352fw. https://pubmed.ncbi.nlm.nih.gov/24945639/
- Kim SM, Oh BH, Lee YW, Choe YB, Ahn KJ. The relation between the amount of sunscreen applied and the sun protection factor in Asian skin. J Am Acad Dermatol. 2010;62(2):218-222. doi:10.1016/j.jaad.2009.06.047
- Draelos ZD. The multifunctional value of sunscreen-containing cosmetics. Skin Therapy Lett. 2011;16(7):1-3. https://pubmed.ncbi.nlm.nih.gov/21833463/
- Wang SQ, Tooley IR. Photoprotection in the era of nanotechnology. Semin Cutan Med Surg. 2011;30(4):210-213. doi:10.1016/j.sder.2011.07.006
- Tanner PR. Sunscreen product formulation. Dermatol Clin. 2006;24(1):53-62. doi:10.1016/j.det.2005.09.002
- Armstrong AW, Watson AJ, Makredes M, Frangos JE, Kimball AB, Kvedar JC. Text-message reminders to improve sunscreen use: a randomized, controlled trial using electronic monitoring. Arch Dermatol. 2009;145(11):1230-1236. doi:10.1001/archdermatol.2009.269
- Wang SQ, Xu H, Dusza SW, Hu J, Stanfield J. Improving compliance of daily sunscreen application by changing accessibility. Photodermatol Photoimmunol Photomed. 2017;33(2):112-113. https://doi.org/10.1111/phpp.12292
- Winkelmann RR, Rigel DS. Assessing frequency and quality of US dermatologist sunscreen recommendations to their patients. J Am Acad Dermatol. 2015;72(3):557–558. https://pubmed.ncbi.nlm.nih.gov/25687313/