Based on her dermatology credentials, expertise, patient results and satisfaction, Dr. Jacquelyn Dosal has been selected as a “Top Doctor” on RealSelf.com. RealSelf.com is a patient education website and online community for anyone considering a dermatologic procedure. In order to be selected as a “Top Doctor,” the physician must be board-certified, highly rated by her patients, and active in educating patients. Less than 10% of Real Self doctors achieve this honor.
Dr. Jacquelyn Dosal is a practicing dermatologist in Miami, FL.
Summer is the time where I get alot of questions regarding sunscreens. It’s no wonder… the flood of information out there can be very confusing. I offer up a fairly comprehensive summary of what you need to know this summer to protect your skin. Here are some basics:
Considering that SPF was determined using experiments with 2 mg/cm2 of sunscreen, which is way more than anyone uses in real life (we generally use less than 1/3 of what we are supposed to), we are all getting less protection than we think. For that reason, I usually recommend an SPF of 30 or more (the sun laughs at less than SPF 30, especially here in Miami), one with the label “Broad Spectrum,” and to reapply every two hours. UVB rays cause sunburn and skin cancer, while UVA rays penetrate deeper into the skin, causing skin aging, cell damage, sun spots, and wrinkles by breaking down collagen and elastin. It is important to block both of them, and SPF only indicates the UVB protective power. “Broad Spectrum” indicates that the particular brand also blocks UVA. See this lovely infographic by Dr. Michelle Levy that illustrates how UVA and UVB damage the skin.
Why not use SPF 100?There is a miniscule incremental benefit in protection above SPF 50, so much that the FDA proposed banning the labeling of higher SPFs, as it can be misleading to the public. SPF 100 blocks 99% of harmful UVB rays, while properly applied SPF 50 blocks 98% of the same rays. Something about an SPF of 100 gives people a false sense of security, and they are more likely to improperly use it or expose themselves to the sun for longer. Additionally, there is some evidence that having the very high SPF makes it more difficult to chemically formulate a sunscreen with great UVA protection, which is just as (if not more) important as UVB.
Reapply! The most common reason for sunburn is missing an area of your body and forgetting to reapply every two hours.
There are so many sunscreens on the market, how do I know which one to use?
I classify my sunscreens by the type of use: everyday use, intense sun exposure (like going to the pool or beach), athletic use, and those for babies. Let’s start with babies:
Babies: Baby’s skin at less than 6 months of age hasn’t yet developed the same type of barrier protection as an adult. For that reason, the American Academy of Dermatology will generally recommend sun avoidance or sun protective clothing (look for clothes labeled with UPF- iPlay makes great ones). When sunscreen is needed, a physical sunscreen is best. Physical sunscreens bounce UV rays off the skin, as opposed to chemical sunscreens which are excellent at protecting the skin, but baby is more likely to be sensitive to these products (note: most sunscreens are chemical sunscreens). You can recognize a physical sunscreen because it only has one or two active ingredients: zinc oxide or titanium dioxide. These are some of my favorites: CeraVe Baby, Neutrogena Pure and Free Baby Sunscreen, Blue Lizzard Baby. (I don’t like the one made by the Honest company — I find it very hard to rub in and sticky).
Everyday Use: Yes, you should be wearing sunscreen every day!!! It’s not only to protect yourself from skin cancer, but if you want to look young, the MOST important intervention is sunscreen! See the difference between these twins, one who practiced sun protective measures, and the other who didn’t. The twin that protected herself from the sun looks at least ten years younger than her twin sister. Having a tan can be nice in the short term, but your skin will pay for it. By the time most people hit age 30, their skin can start to show their prior indiscretions! Time to embrace your inner Anne Hathaway. Pale is beautiful.
Athletic Use: This is a tough one. Intense exercise or very hot conditions cause you to sweat like it’s raining. Even water resistant sunscreens can be tough to keep on, and forget reapplying on that wet skin. I’m still in search for a good one, and would love to hear your comments/recommendations below! I would definitely recommend UPF moisture-wicking clothing for tennis, fishing, or other activities, as these actually keep you more cool than tank tops and have consistent sustainable sun protection.
Sprays: Personally, I love the convenience of sprays. However, it seems like people are more likely to under-apply or miss certain areas of their body, potentially leading to sunburn. There are also some questions about the possibility of inhaling the aerosolized chemicals, and we don’t yet know the dangers of this. I still use sprays sparingly when I need the convenience, but the jury is still out as to their proper role.
When should I be using a non-chemical (a.k.a. physical) sunscreen?
The majority of sunscreens on the market contain excellent scientifically developed chemicals that block a combination of UVB and UVA rays. For the vast majority of people, chemical sunscreens are perfect. In some cases, a physical blocker is preferred. For instance, in babies less than six months of age, I recommend a physical blocker for reasons stated above. There are 3 other scenarios where I prefer physical sunscreens: sensitive skin, rosacea, and melasma.
I know many people who tell me they are allergic to every sunscreen that they have tried. My bet is that they have not yet tried a purely physical sunscreen, as they can be difficult to find. While regular sunscreens have a fairly high rate of allergic contact dermatitis, physical blockers have almost no reactive potential. These are my favorites for non-facial use: Neutrogena Sensitive Skin, Neutrogena Pure and Free Baby Sunscreen, Blue Lizzard. See below for facial sunscreen recommendations.
Do you suffer from flushing, red pimple bumps, skin burning, and/or sensitivity to most products? Well then you might have rosacea, and I definitely prefer for you to wear a physical sunscreen. Rosacea and melasma (those brown patches on the face that come with sun or pregnancy) are very sensitive to heat, and chemical sunscreens produce an imperceptible amount of heat, potentially flaring the skin. In order to minimize anything that can exacerbate rosacea or melasma, I recommend a pure physical sunscreen for these heat sensitive conditions. Physical sunscreens bounce the UV rays off the skin, and are inactive on the skin. In both rosacea and melasma, sunscreen is mandatory. You will find with changing sunscreen alone, your skin may dramatically improve. These are my favorite physical sunscreens for daily facial use: La Roche Posay Anthelios Mineral SPF 50, Elta MD UV Physical SPF 41, SkinCeuticals UV Physical Defense, CeraVe SPF 50 Facial Sunscreen Lotion, Avene Mineral SPF 50. And don’t forget to reapply. For the sake of convenience, I like the following two products to help women reapply sun protection after they have applied their makeup. No one wants to put on a lotion sunscreen to a freshly painted (ahem, made-up) face. Use these products to layer on top of your pretty face throughout the day: Avene compact, Colorescience Sunforgettable Mineral Powder Brush.
In conclusion, don’t forget to practice other sun safe behaviors, such as wearing polarized sunglasses, protective clothing such as hats, UPF clothing, UPF scarves (see these great ones by Blox Sun), and seeking shade during peak hours of UV intensity, 10 am to — 4 pm.
I’d love to hear your thoughts and invite you to comment below!
Stay tuned for my take on the topic of Vitamin D and the Environmental Working Group’s rankings of sunscreens.
Photo credit: Shutterstock
Dr. Jacquelyn Dosal is a board-certified dermatologist practicing in Miami, FL. About Dr. Dosal: http://goo.gl/hbgqZW
Is my sunscreen going to kill me? Perform a search on sunscreen safety and some scary stuff shows up! Retinyl palmitate causes skin cancer. Oxybenzone causes estrogen-like effects on the body. I have seen these statements repeated over and over again all over social media and in real life. I recently heard from a patient, “I was using Neutrogena but then stopped because I heard it wasn’t so good for you.” How do we protect ourselves and our families from skin cancer without any nasty side effects?
I’d like to offer up my take — from a organic-loving, Whole-Foods-shopping, yoga-practicing, green-tea-drinking MD (dermatologist), with an eye for interpreting both media and science…
For those not able to read the whole post (we are all busy, I know!), here’s the quick summary of my findings. You can read on for more info too!
Sunscreen won’t cause hormonal disruption — it would take 200 years of application to even reach questionable levels of exposure.
Sunscreen won’t cause skin cancer — the use of sunscreen is directly correlated to the prevention of skin cancer. Retinyl palmitate is an anti-oxidant that occurs naturally in the skin.
Nanosize sunscreens are safe for use, as they clump in real life, preventing them from being absorbed.
I’ve researched the issues of sunscreen safety personally, and WOW! It’s confusing and contradictory. I’ll at least say this— we always need to critically and scientifically analyze the sunscreen ingredients we use for both efficacy and safety. And just as important, let’s not perpetuate myths that are based on unsound science. If you are interested in sorting through the muddy waters of sunscreen information — read on!
Environmental Working Group’s Rankings of Sunscreens.
Most of the information about safety stems from the Environmental Working Group’s sunscreen rankings. The Environmental Working Group is a not-for-profit organization that searches to identify harmful chemicals in our environment. While I applaud the intentions of the EWG to find safe and environmentally responsible materials, we need to be fair and look at these issues seriously, and not just solely how presented by the EWG.
Do sunscreens cause hormonal disruption?
The EWG advises avoiding any products with oxybenzone (an excellent UVA and UVB blocker) as it may cause effects similar to estrogen. The concern comes from a study performed in rats, where the rats were fed supratherapeutic doses of sunscreen (let me say that again, the rats ATE sunscreen at megadoses), and the size of their uterus enlarged.
There is a monstrous difference between eating super high doses of sunscreen and applying it to your skin daily — and concluding that topical use in human sunscreen causes estrogenic effects is an unrealistic stretch. A study in 2011 in JAMA Dermatology showed that it would take 200 years of daily sunscreen application to reach the same amount of exposure as the rats in this study. To the author’s credit, their word-for-word conclusion in the abstract was: “Our findings indicate that UV screens should be tested for endocrine activity…” The authors do not say that the UV screens cause hormone activity in humans… they can’t. In order to substantiate their EWG’s claim, you would need to show hormone disruption in real live humans.
Luckily, such a study was performed. Human patients applied more than 3 times the real-life quantity of a high percentage oxybenzone sunscreen (10% oxybenzone, compared to the commercially available 6% oxybenzone) to their whole body daily for one week. Oxybenzone was in fact detected in the urine of the volunteers (as have some other sunscreen agents). Sound the alarm bells! — this is concerning. It indicates that there is some absorption from topical use (medications that are applied directly to the surface of the skin). However, the body quickly excreted it through the urine (which is a good thing). Much can be said about the fact that it was absorbed, but the take-home message was that the researchers were UNABLE to show a hormone disruption despite this absorption (again, this was at 3 times real-life dosage). There was no accumulation of the ingredients over time.
So we have a study in humans of real-life sunscreen use that shows no hormonal effect, or a study where rats ate sunscreen — which do you believe?
To be fair, when researching this blog post, I did come across an alarming number of lab and animal studies showing absorption of various sunscreen agents, with some experiments suggesting hormonal disruption. There were almost as many studies that showed no absorption nor hormone disruption. A good summary of those studies can be found here. But we have to look at what’s important… no human studies have shown hormonal disruption, and that is what counts.
Of note, it is important to mention that oxybenzone can cause allergic skin reaction in a fair percentage of people, so there should be some caution with its use.
And by the way, soy is weakly estrogenic. Where are the cries for banning or avoiding soy milk because of hormonal activity? There are many natural skin care products on the market containing soy, several of which I recommend and are excellent. A little perspective is important, and we need to remember that topical use is very different from ingestion.
Let’s move on to sunscreen and skin cancer.
Does my sunscreen increase my risk of skin cancer?
A few years ago there was media buzz about a toxicology study that suggested that retinal palmitate, a common inactive ingredient in sunscreens, may actually increase your risk for skin cancer by increasing oxidative damage, or reactive oxidative species (ROS). Oxidative damage is like rust on metal — it corrodes our body and makes us more prone to inflammation and cancer. Let’s dive into this deeper.
Retinyl palmitate is an interchangeable form of retinol that is present naturally in our skin, and this should already be a clue that it’s not dangerous. Retinyl palmitate is not just in sunscreens; is approved by the FDA for use in prescription and over the counter medications, as well as a food additive in dairy products and cereals. It was selected for testing due to its prevalent use in common agents, not for any concerns of safety up to that point.
Once again, we have to look at the details of the study that created the buzz. It was never published in a peer-reviewed journal (the standard for medical literature — data needs to be vetted by people in-the-know), and was not performed in humans (also a huge red flag). It was performed in hairless mice, known to have an already increased risk of skin cancer, and these mice were burned with and without retinyl palmitate (RP). The studies showed the production of oxidative damage and increased risk of malignancy. However, these studies take RP out of human context, which is a very complex interactive antioxidant system. According to Dr. Steven Wang, the lead investigator in the study, “when a sunscreen with retinyl palmitate is applied to the skin, a number of antioxidants work together to alleviate the risk of free radical formation seen in these in vitro experiments. If studied on its own — outside of this environment — its antioxidant properties can rapidly be exhausted, allowing the production of oxygen radicals. In these non-human studies, retinyl palmitate was the only compound studied — making the biological relevance of these findings to humans unclear.” Even the lead investigator is not ready to recommend avoiding retinyl palmitate.
The final and probably most convincing evidence of the safety of retinyl palmitate comes from real life use in humans. We often use the family of retinoids (of which retinyl palmitate is a member), as a pill for the prevention of skin cancers in those most at risk (immunosuppressed organ transplant patients). We also have decades of experience using retinoids in acne medications; and topical retinoids are one of the best anti-aging creams on the market — I personally use one (Retin-A) every night. Undeniable humanresearch shows it can reverse oxidative damage and signs of aging, keeping the skin healthy and youthful.
If you are interested in more, I encourage you to read this summary by the Journal of the American Academy of Dermatology detailing the properties of retinyl palmitate and discussing its safety.
What are nano particles, and are they safe?
Nanoparticles are molecules that have been divided into nanometers (one billionth of a meter). By making the molecules small, it makes sunscreens more cosmetically acceptable and elegant, thus making it more attractive for people to use (i.e. not thick, sticky, or opaque like the old sunscreens found on lifeguards’ noses).
Concerns arose that these molecules might be small enough to penetrate through the skin into the bloodstream. Time and time again, human studies have shown that these particles are unable to penetrate through the skin because, in nature, these nanoparticles aggregate into clumps that are too large to penetrate the skin. There was also some thought that these ingredients could increase reactive oxidative species (ROS). We now know that this is meaningless if tested outside of the complex human antioxidative system. With this in mind, we should all embrace these new technologies that makes sunscreens less opaque, pastey, and more consumer friendly!
Be Cautious of Media Sound Bites
The EWG extrapolates data (usually from animal studies, not humans), and uses scare tactics to make us feel like we are hurting our children if we use certain products. What I don’t like is that they ignore actual sound studies that show safety in humans. Their sound bites are alarming and catchy for headlines. I’ve actually seen website titles citing the EWG reading: “The Most Dangerous Sunscreens For Kids (And They’re Probably Hiding in Your Beach Bag).” Talk about mommy guilt!
I love this story which explains why we need to critically interpret how the media presents headlines: Chocolate Causes Weight Loss!
Background: A scientist wanted to show just how easy it was to convince the media to pick up a poorly designed faux scientific experiment that was catchy for headlines. It was a completely fake, but intriguing idea — eating chocolate can help loose weight. It turns out, it was really easy to get experienced journalists to pick up the headline! Read here: I Fooled Millions into Thinking Chocolate Helps Weight Loss. A critical eye is really needed in these days of rapid information sharing.
What does this all mean?
I don’t agree with the EWG rankings. Many of the poorly ranking sunscreens are very reputable and excellent brands. You can’t take the data from one animal or lab study and ignore other science and human experiments that are in disagreement. That’s not how science works. That’s the reason why thousands of drugs that work in animals never get to the market — because animal studies and in vitro studies often don’t translate into efficacy in the complex environment of the human body.
While in general, I’m in favor of the organic movement, real foods, and responsible farming practices, I often laugh when I see websites recommending chemical-free everything, including sunscreens. Chemicalsarein everything, and there is no such thing as a purely chemical-free susncreen. Of course, live in moderation — extreme use of any susbtance can lead to some bad effects, but to say that normal day-to-day use of products causes the same effect seen with extreme use or oral ingestion doesn’t make any sense.
As this EXCELLENT video describes, the dose is the poison, not the chemical itself. Almost any substance, including natural or beneficial substances, can be toxic under certain conditions, such as high temperatures, pH, concentrations, or when in the presence of other chemicals. Even too much Vitamin C can be lethal to skin cells at certain doses. The age-old mantra still holds true — everything in moderation.
Let’s thank the EWG for their laudable efforts in keeping us safe, but ask them not to demonize valuable products when the science shows otherwise. I completely agree that more testing needs to be done on household and cosmetic ingredients, but I wish they were a little more unbiased when it came to promotion of their agenda. And the media perpetuates these news snippets with negligible investigation into the validity of the EWG claims. It serves our society poorly.
Feel good about protecting your family — and apply that sunscreen this summer!
Hayden CG, Roberts MS, Benson HAE. Systemic absorption after topical sunscreen. The Lancet. 1997;350:863–4.
Janjua NR, Mogensen B, Andersson AM, et al. Systemic absorption of the sunscreens benzophenone-3, octyl-methoxycinnamate, and 3-(4-methyl-benzylidene) camphor after whole-body topical application and reproductive hormone levels in humans. J Invest Dermatol. 2004 Jul;123(1):57–61.
I’m feeling quite grateful today in many ways. I just had lunch with an old friend from my medical training. She’s always been a lovely person, but today, I was reminded how truly beautiful she is inside and out.
Nancy, at 32, is a two-time breast cancer survivor in addition to having lost her mother at a young age due to breast cancer. She recently underwent a total mastectomy with reconstruction, and the aftermath left it difficult for her to exercise due to removal of muscles in her back used for her reconstruction. In turn, she gained about 25 pounds after her surgery. The pain of losing her mother to cancer, then getting diagnosed herself, along with a recurrence and painful surgery are enough for anyone to give up. But not Nancy, she always keeps a smile on her face and tries to look at the bright side — her attitude is inspirational.
Today at lunch, we talked for a while. She was disappointed at her weight but motivated to lose the pounds. She splurged on a personal trainer and reported it has been “life-changing” for her since it’s helped her get out some energy and internal frustration.
While her physical recovery has been taxing, there were two other aspects of her journey that I couldn’t help but appreciate: (1) her struggle to accept her surgical scars, and (2) her lifelong battle with acne. Both may be easily overlooked or tossed aside as unimportant, but with the skin being my passion, I knew that it was more important to her than she let on.
Nancy told me that she has finally started actively dating, but hadn’t found the right person yet. Part of her hesitation to be more pro-active about her dating life originates from self-consciousness about her surgical scars. While easy to feel comforted about your appearance when in a relationship with a loving partner, it is harder to flaunt surgical scars when developing a new relationship.
I never truly appreciated how difficult the breast cancer journey can be for a single woman until talking with her.
Nancy admitted that things were looking pretty good after the reconstruction, but the scars were still notable. I happily informed her that the world of scar therapy has immensely advanced, and laser treatment of scars has really been miraculous. Below I show one of the scars I treated that resulted from a skin cancer surgery. Nancy was so happy and hopeful once I let her know her options.
Creating hope for people is one of the best things I can do as a physician and friend.
The second topic seems trivial compared to Nancy’s breast cancer journey, but it was definitely noticeable! Nancy had clear skin! Still battling with her acne in her 30s, she finally decided to proceed with Accutane (isotretinoin) — with unbelievable results. Instead of being distracted by deep cystic pimples, my eye instead focused on her beautiful smile, which is just so radiant and representative of her personality. As I examined her face, I was proud of my specialty of Dermatology, and I was proud of the often-vilified medication’s (Accutane) ability to remove self-consciousness from people who may be hiding their skin and face. No more cover up needed. It is truly one of the most powerful tools I have in giving people back their self-confidence. There is no reason to suffer from scarring acne when a miraculous cure exists for those who truly suffer. (That’s right, I didn’t say “dangerous,” I said “miraculous.” More on that later.)
I share Nancy’s story because she has truly inspired me. She keeps my troubles and worries in perspective — she reminds me to be grateful.
I’m grateful for my health, family, and healthy skin. I’m grateful for my job as a dermatologist, a job that I love. I’m grateful for the chance to give others clear skin. I’m one of the few doctors that people actually like to see… I don’t make people take diabetes or blood pressure medication. People are usually motivated to use my prescribed treatments to improve their skin. It is the only organ system we can see with our eyes, and thus the benefits are often both somatic (of the body) and psychological. I love what I do, and I’m so happy to share it with others.
I was so refreshed and happy to see Nancy. Life’s a journey, not a destination, and Nancy is still on her journey for health, love, and fitness. On her way, she found clear skin, hope for her scars, and the best attitude one could ask for!
Dr. Jackie Dosal is a board-certified dermatologist in Miami, FL. About Dr. Dosal: http://goo.gl/hbgqZW
I diagnosed two melanomas last week. My partner diagnosed another one the same week. Three melanoms in one week!!! Much to your surprise, here was the order of the most dangerous:
#1 most deadly case last week — melanoma on the bottom of the foot.
#2 most deadly case last week — melanoma on the lower leg.
#3 most deadly case last week — melanoma on the face.
Now, most of this has to do with how advanced the melanoma was when it presented, but there is an important lesson here. Alot of people will poo-poo a dark or unusual lesion on the lower body, since they don’t feel like the lower body gets alot of sun exposure.
Melanoma can happen ANYWHERE! The most common location for women to develop melanoma is the legs (as illustrated above — patients #1 and #2 were women).
I’ve said it before:
If your dermatologist doesn’t make you #getnaked, find another one.
When you come to me for a full body skin examination, I check everywhere (unless you absolutely decline, I will respect your privacy!). But seriously, your dermatologist should be checking in between your toes, looking through your scalp, and checking where the sun doesn’t shine! I used to have a teacher in dermatology residency that would drill into us that if we weren’t checking the buttocks, we had not finished our full body exam. It was a little embarassing when she asked in front of the patient, but the point was well taken. Bob Marley died of melanoma on his foot.
In truth, some melanomas are not sun induced (how would sun get to the bottom of your foot?), and these melanomas are more similar to other cancers that happen spontaneously. Therefore, everyone should come in for an annual skin exam, even people with dark skin.
I also strongly urge all of you to take a look at your skin regularly. Take a hand mirror and look ALL around before you get in the shower. Look at your spouse’s and your children’s skin. Become a “skin checker.”
What should I be looking for?
Dermatologists will often talk about the ABCDE method of detecting of melanoma. This is a great tool to help identify potentially suspicious lesions. Each letter corresponds to a characteristic of a mole that may signal an issue:
A stands for asymmetry — if a mole is asymmetrical. One half is not like the other half. B stands for border — if the edges are ragged, not smooth. C stands for color — if there are more than 1 or 2 colors present. D stands for diameter — if it is more than >6 mm or the size of a pencil eraser. E stands for evolution — if any mole is changing.
If you feel that any of your moles have met these criteria, don’t panic, but please do see your dermatologist for a professional evaluation.
As an aside, you should never feel funny going to the dermatologist to check any spot on your skin. The spot in question may be benign, but just being in the office may help identify other problem areas. More often than not, the worrisome spot is fine, but I may subsequently locate an inconspicious lesion that is a problem (potentially a skin cancer). This was the case in patient #3.
90% of melanomas are curable if caught early. Take care of yourself and your family — #getnaked and check your skin!