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The Efficacy and Safety of Sunscreen Use for the Prevention of Skin Cancer

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The Efficacy and Safety of Sunscreen Use for the Prevention of Skin Cancer REVIEW CPD The efficacy and safety of sunscreen use for the prevention of skin cancer Megan Sander MD, Michael Sander DMD, Toni Burbidge MD, Jennifer Beecker MD n Cite as: CMAJ 2020 December 14;192:E1802-8. doi: 10.1503/cmaj.201085 n Canada, more than 80 000 cases of skin cancer are diagnosed every year.1 Because exposure to ultraviolet radiation is esti- KEY POINTS mated to be associated with 80%–90% of skin cancers, the use • Several well-conducted randomized controlled trials with long Iof sunscreen — which blocks ultraviolet radiation — is promoted as follow-up showed that sunscreen use reduces the risk of an important means of preventing skin cancers,2,3 as well as sun- squamous cell and melanoma skin cancers. burn and skin photoaging (see definitions in Appendix 1, available • Commercial sunscreens protect against the skin-damaging at www.cmaj.ca/lookup/doi/10.1503/cmaj.201085/tab-related effects of ultraviolet radiation through either chemical or -content). Use of sunscreen has been shown to reduce the inci- physical ingredients. dence of both melanoma and nonmelanoma skin cancers.4,5 Both • The Canadian Dermatology Association recommends the use of the Canadian Dermatology Association and the American Academy an adequate dose of a broad-spectrum sunscreen with a sun protection factor of at least 30 for most children and adults, as of Dermatology recommend the use of sunscreen for the preven- part of a comprehensive photoprotection strategy. tion of skin cancer.6,7 Yet, since the development of the first com- • Emerging evidence suggests that some chemical sunscreen mercial sunscreen in 1928, questions regarding the safety and effi- ingredients are systemically absorbed, but the clinical cacy of sunscreen have been raised, and more recently, the impact importance of this remains unclear; further research is required of sunscreens on the environment has become a cause for concern. to establish whether this results in harm. We summarize evidence related to the effectiveness and harms of • Ultraviolet filters found within chemical sunscreens may be sunscreen to help physicians counsel their patients (Box 1). harmful to the environment. How do sunscreens work? high-intensity ultraviolet radiation, resulting in excitation to higher Sunscreens contain chemical (organic) or physical (inorganic) energy states. When these molecules return to their ground states, compounds that act to block ultraviolet radiation, which is light the result is conversion of the absorbed energy into lower-energy with wavelengths shorter than visible light (subdivided into ultra- wavelengths, such as infrared radiation (i.e., heat).8 violet A [UVA]1, UVA2, ultraviolet B [UVB] and ultraviolet C [UVC]), Physical sunscreen filters, such as titanium dioxide and zinc as shown in Figure 1. Generally, the shorter the wavelength, the oxide, reflect or refract ultraviolet radiation away from the skin; greater the potential for light radiation to cause biological dam- however, experimental studies have shown that when particle age. Sunscreen filters are active against UVA1, UVA2 and UVB radi- sizes are very small, as in micronized sunscreens, the mechanism ation. Chemical filters, such as oxybenzone, avobenzone, octo- of action is similar to that of chemical filters. More specifically, crylene and ecamsule, are aromatic compounds that absorb micronized zinc oxide and titanium dioxide behave as semicon- ductor metals, which absorb ultraviolet light throughout most of the electromagnetic spectrum.9 The sunscreen ingredients that Box 1: Evidence used in this review are currently approved by Health Canada are listed in Table 1.10 We conducted a targeted search of MEDLINE using a combination of the search terms “sunscreen,” “skin cancer,” “melanoma,” What is the effectiveness of sunscreens in “squamous cell carcinoma,” “basal cell carcinoma,” “photoaging,” preventing photoaging and skin cancer? “safety” and “environment” to identify studies published from 1984 to 2020. We particularly sought randomized controlled trials, Evidence from observational studies,11 a large randomized con- systematic reviews and meta-analyses relevant to this article’s 12 clinical questions. We also identified relevant review articles, basic trolled trial (RCT) and smaller, nonrandomized experimental 13–15 science publications and institutional guidelines. We studies support the effectiveness of sunscreens in preventing supplemented our search with literature from our own collections. the signs of photoaging, including wrinkles, telangiectasia and pig- mentary alterations induced by ultraviolet radiation.11–15 Despite E1802 CMAJ | DECEMBER 14, 2020 | VOLUME 192 | ISSUE 50 © 2020 Joule Inc. or its licensors Visible light Ultraviolet light UVA UVB UVC UVA1: 300–400 nm 280–315 nm 100–280 nm REVIEW UVA2: 315–340 nm • Accounts for • Accounts for 5% of • Accounts for less 95% of UVR UVR that reaches than 1% of UVR that reaches the Earth’s surface that reaches the the Earth’s with varied Earth’s surface surface with intensity that • Not absorbed fairly constant peaks around deeply into the intensity over midday skin the course of • Partially absorbed • Absorbed by the the day by the ozone and atmosphere and • Penetrates the clouds, does not ozone layer ozone, clouds, penetrate window • Germicidal and window glass glass • Not absorbed as • Penetrates deeply into the human skin skin as UVA more deeply • Primarily • Responsible for responsible for photoaging and tanning and carcinogenesis, burning, less so less so tanning photoaging and Epidermis and burning carcinogenesis Dermis Figure 1: Schematic representation of the electromagnetic spectrum of light, emphasizing ultraviolet radiation (UVR) frequencies and their effect on human skin. Generally, the shorter the wavelength of radiation, the greater the potential for biological damage. Note: UVA = ultraviolet A, UVB = ultraviolet B, UVC = ultraviolet C. Sunscreen filters are active against UVA1, UVA2 and UVB radiation. the challenges of studying skin cancer, owing to its multifactorial arrest signs of skin aging caused by photodamage.12 Another large pathogenesis and long lead time, the following evidence supports Australian RCT showed a significantly reduced rate of development the use of sunscreen in the prevention of skin cancer. of actinic keratoses (a precursor to squamous cell carcinoma) Experimental studies from the 1980s and 1990s showed that among participants randomized to regular use of sunscreen, com- sunscreens protect against cell damage consistent with carcinogen- pared with controls who used a nonactive base cream over 1 sum- esis in animal models.16,17 A well-conducted community-based 4.5- mer season (rate ratio 0.62, 95% CI 0.54 to –0.71).19 year RCT of 1621 adult Australians, with follow-up for more than a In organ transplant recipients, a population at high risk of decade, found a 40% lower incidence of squamous cell carcinomas morbidity and death from skin cancer, a prospective single-centre among participants randomized to recommended daily sunscreen study of 120 matched patients showed that the use of sun protec- compared with participants assigned to use sunscreen on a discre- tion factor (SPF) 50 sunscreen over 24 months reduced the devel- tionary basis (rate ratio 0.61, 95% confidence interval [CI] 0.46 to opment of actinic keratoses, squamous cell carcinomas and, to a 0.81).4,18 However, the incidence of basal cell carcinomas was not lesser extent, basal cell carcinomas.20 Recent meta-analyses have significantly reduced, possibly owing to the protracted pathogen- not supported the findings of these RCTs, finding no significant esis of basal cell carcinomas.18 Almost 15 years after the completion effectiveness of sunscreen for preventing either melanoma or of the study, participants who used sunscreen daily throughout the nonmelanoma skin cancers.21,22 However, these meta-analyses 4.5-year study period showed a significantly reduced risk of invasive included studies with retrospective designs with methodological melanoma (hazard ratio [HR] 0.27, 95% CI 0.08 to –0.97), although inconsistencies among studies, and 1 included studies that used very few invasive melanomas were noted, given the long lead time only UVB filters (rather than broad-spectrum sunscreens).21 Over- for this type of tumour.5 A predefined subgroup analysis in this trial all, the highest-quality evidence available suggests that sun- confirmed that regular use of sunscreen over a 4.5-year period can screens do prevent skin cancer. CMAJ | DECEMBER 14, 2020 | VOLUME 192 | ISSUE 50 E1803 Who should use sunscreen? shown that sunscreens with an SPF of 100 are superior to sunscreens with an SPF of 50 for preventing sunburns under actual use condi- The American Academy of Dermatology recommends regular sun- tions, in both a beach setting25 and a high-altitude skiing setting.26 screen use with an SPF of 30 or higher for people of all skin types,23 Health Canada does not recommend the use of sunscreen for although skin cancers are far more prevalent in White individuals children younger than 6 months because of the theoretical risk of than people with darker skin.24 There have been no studies to increased absorption of sunscreen ingredients as a result of assess the effectiveness of regular sunscreen use in reducing the higher body surface-to-volume ratios and thinner epidermis.27 REVIEW risk of skin cancers among people who are not White. The mainstays of sun safety in infants include sun avoidance and For children older than 6 months, as well as adults,
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