Journal of Clinical and Aesthetic Dermatology • Hot Topics in Skin Health May 2023 • MEETING HIGHLIGHTS

The American Academy of Dermatology (AAD) held its 2023 Annual Meeting on March 17–21, 2023. The meeting provided researchers, physicians, and members of the industry with the opportunity to share and learn about the latest research in dermatology. Speaker and poster sessions presented data from cutting-edge research on multiple dermatological topics, including sun protection. Clinical evaluations of skin health across different populations, as well as discussions of sun protective behaviors and knowledge on sunscreens, were presented. Summaries of key sessions and abstracts are included here.

Photoprotection is essential in all individuals to combat the effects of ultraviolet (UV) light exposure. UV-induced erythema, pigment darkening, tanning, photoaging, and photocarcinogenesis impact every skin color, but people experience these effects in various ways.

Visible light (VL) is of particular concern to people of color, as it induces persistent pigmentation in skin phototypes III–VI, but not lighter skin tones. As such, people of color should use a broad-spectrum, tinted sunscreen that protects against both UV light and VL.

VL exposure increases reactive oxygen species (ROS) generation and results in the release of proinflammatory cytokines and matrix metallicproteases and the activation of epidermal growth factor receptor pathways in keratinocytes. VL-induced ROS and reactive nitrogen species damage the skin barrier, thus causing hyperpigmentation, photoaging, and melasma.

Perception of photoprotective modalities is important to understainding photoprotective behaviors. In one study of over 2,000 Black individuals in California, only 31 percent reported always using at least one form of photoprotection, most commonly sunglasses. Research has shown that, compared to other racial groups, Black individuals have lower rates of sunscreen use. One study found that Black and Hispanic individuals used sunscreen to prevent conditions such as postinflammatory hyperpigmentation (PIH), vitiligo, and melasma, and not necessarily to prevent skin cancer.

There are various photoprotective modalities to utilize, aside from sunscreen. Wearing a hat with a diameter of at least 7.5cm (or, even better, 10–12cm) that has thick material and weaving can provide SPF seven for the nose, three for the cheeks, five for the neck, and two for the chin. Tightly woven, dark sun-protective clothing made of wool or polyester can reduce UV radiation transmission; beware of cheap brands that break down after one wash, though. Sunglasses that are wrap-around or have side shields with tinted lenses offer great protection against UVA and UVB. Window glass in cars and residential buildings can provide minimal protection as well. Staying in the shade can offer great photoprotection, providing SPF 4 to 50 depending on the density of the foliage.

One study showed that 47 percent of Hispanic individuals rarely or never used sunscreen, and 60 percent rarely or never wore sun-protective clothing. Research on Puerto Rican individuals showed that only 21 percent often or always wore sunscreen, and 38 percent sought shade; interestingly, those who spoke mostly or only English were more likely to use sunscreen, while those who spoke only or mostly Spanish were more likely to stay in the shade. While you cannot make vast generalizations with these findings, it is important to consider which photoprotective modalities individuals prefer in order to encourage positive photoprotective behaviors.

Sunscreen use is also low among Asian patients, with one study from the Southern US reporting that 71 percent of Asian individuals rarely or never use sunscreen, and 67 percent rarely or never seek shade. Another study from California showed that Asian individuals raised in the US engaged in more deliberate sunbathing behaviors than those raised in Asia.

Data on Native American individuals is lacking, but one small study found that only about 10 percent of respondents used sunscreen, despite 87 percent having had a sunburn at least once. The most common reason for not using sunscreen was not liking the feeling of it, followed by forgetting to use it.

A Wake Forest study from 2012 showed that dyschromia was one of the top 10 diagnoses in Black patients at the dermatologist. Some of the most common pigmentary disorders among these patients included vitiligo, melasma, and PIH. Looking at treatments prescribed to patients, sunscreen was much less commonly utilized than other therapies. Dyschromia was also reported as one of the top concerns for Hispanic patients, but not White or Asian patients, although that does not mean these patients do not experience dyschromia.

Photodermatoses in skin of color is another important area of concern. Lupus, chronic actinic dermatitis, and dermatomyositis are all more common in Black patients, compared to non-Hispanic White patients, with the latter being four times more likely to occur in Black individuals.

Those with lighter skin tones should always use a broad-spectrum sunscreen with an SPF of at least 30. Those with darker skin could use SPF 15, due to their lower risk of skin cancer, but SPF 30 is still the safer bet. Tinted sunscreens are crucial in all individuals with skin of color to protect against VL-induced damage, and physical photoprotective modalities are also useful.

Based on session by Amy McMichael, MD, titled “Photoprotection in Skin of Color People.”

Demonstrating the whitening effect of mineral sunscreens across multicultural skin tones. White cast of mineral sunscreens is a crucial consideration among consumers, but this effect varies based on formulation, amount and method of application, and skin tone. Here, Shyr et al evaluated the whitening effect of five mineral sunscreens, with one chemical sunscreen as a control, on multicultural skin tones. Ninety-six female participants, divided into groups based on light (n=32), medium (n=31), and dark skin tones (n=33), completed the study. Whitening was measured by image analysis and participant forced ranking. Under controlled application (2mg/cm2), there was a consistent correlation between image analysis, consumer perception of whitening, and likeability of sunscreen. Regardless of participant skin tone, whiter sunscreen was associated with greater dislike of the sunscreen. All mineral sunscreens had a whitening effect on darker skin tones, with a 2.95-fold increased whitening effect on dark skin tone, compared to light skin tone. Regardless of sunscreen chosen, discretionary application to the face resulted in minimal whitening. For all five mineral sunscreens, there was a significant reduction in whitening effect between controlled and discretionary application. The overall facial application density was 0.93mg/ cm2, with a lower density observed with mineral sunscreen use (0.84mg/cm2), compared to chemical sunscreen use (1.1mg/cm2). These results suggest that consumers, particularly those with darker skin tones, might apply less sunscreen to compensate for negative aesthetic effects, which could result in less sun protection.

Guide to tinted sunscreens for skin of color. Unlike nontinted sunscreens, tinted sunscreens protect against both ultraviolet (UV) light and visible light (VL), both of which can contribute to hyperpigmentation disorders, such as melasma and postinflammatory hyperpigmentation (PIH). Thus, use of tinted sunscreens for photoprotection is particularly important in individuals with skin of color. Tinted sunscreens include iron oxide and pigmentary titanium dioxide, which block VL and UVA1 and provide color to the sunscreen; the tint of the sunscreen depends on the ratio of these two components. Multiple studies have demonstrated that tinted sunscreens provide greater protection from VL-induced pigmentation and hyperpigmentation, compared to nontinted sunscreens. Individuals with skin of color should use a broad-spectrum sunscreen (UVA and UVB protection, plus VL 400–465nm) with a sun protection factor (SPF) of 30 or higher. In addition to iron oxides and pigmentary titanium dioxide, individuals should consider sunscreens containing antioxidants, anti-inflammatory ingredients, or immunomodulators to improve therapeutic action; emollient- or humectant-containing compounds to prevent pigmentation; and depigmenting agents. When selecting a tinted sunscreen, skin tone and undertone should be considered to pick the most accurate shade.

The association of parental status with increased sunburn prevalence and sunburn-related activities in females. In this study, Shuja et al conducted a survey to assess sunburn incidence and sunburnrelated behaviors among mothers of young children living in the United States (US). The online survey was conducted from August 25 to September 5, 2020, and participants provided information on sunburn experience from January to August 2020. A total of 3,409 individuals of diverse racial/ethnic backgrounds aged between 18 to 50 years completed the survey, with an oversampling of female participants with children under 12 years of age. All Fitzpatrick skin types were represented in the survey. Overall, mothers of young children were significantly more likely to get a sunburn than other female individuals, with a sunburn prevalence of 37.3 and 22.9 percent, respectively. Black and Hispanic mothers of young children were more than twice as likely to have had a sunburn than other female respondents of the same race/ethnicity, with a sunburn prevalence of 15.3 and 35.8 percent for Black and Hispanic mothers, respectively, and 4.7 and 20.2 percent for other Black and Hispanic female respondents, respectively. White mothers also had a significantly higher sunburn prevalence than other White female respondents (43.1% vs. 29.4%). When divided into subgroups by age, mothers of young children had a higher sunburn prevalence across all subgroups than other female respondents. Being in or near water was the most commonly reported activity during most recent sunburn for both female (59.0%) and male respondents (44.1%). Compared to other White female individuals, White mothers of young children were significantly more likely to experience a sunburn during activities in or near water.

Analysis of utilization of sunprotective behavior among national SPOT Skin Cancer® program screenees from 2018 to 2019. Gao et al evaluated the relationship between demographic factors and sun-protective behaviors in 116,569 attendees of the AAD’s SPOT Skin Cancer® screening from 2018 to 2019. Screenees were largely White (86.3%), female (61.8%), at least 30 years of age (88.6%), and had a college education (69.6%). Less sun-protective behaviors were associated with lower income and male sex. Compared to White screenees, Hispanic, Asian, and Black screenees were significantly more likely to rarely or never practice sun-protective behaviors. Residents of the Northeastern US were significantly more likely to practice sun protective behaviors, compared to residents of the Midwestern and Southern US. Individuals whose highest attained education level was elementary school, high school, or college more frequently reported less sun-protective behaviors than those with a graduate degree.

A study on the impact of visual, audio media usage on patients of color; understanding the need and usage of sunscreen. Healthcare literacy on sun damage and protection in skin of color needs to be improved. As such, Fowler-Canty et al surveyed patients of color at a university dermatology clinic to determine the use of audiovisual media in improving healthcare literacy among this population. Participants, aged between 20 and 80 years, watched a 2.5-minute video of an African American healthcare professional, who discussed UVrelated skin damage, how to avoid skin damage due to sun exposure, and benefits of sunscreen use. Participants completed pre- and post-video surveys assessing their knowledge. Forty-one individuals participated, 43.9 percent of whom were people of color and 31.7 percent of whom were Hispanic/Latino. After watching the video, all participants indicated they understood the importance of wearing sunscreen to protect against sun damage, compared to 68 percent prior to watching the video. Understanding of the benefits of sunscreen use increased significantly in Black/African American participants after watching the video. Overall, 71 percent of participants indicated they planned to wear sunscreen every day after watching the video, compared to 24 percent who wore sunscreen every day prior to viewing the video.

Influence of gender, race, and psychiatric disorders on sun protective behavior and outcomes: a population-based study. Here, Shan et al aimed to assess the association of various demographic factors with sun-protective behaviors. Data from adults who participated in the National Health Interview Survey (NHIS) 2020 were included for analysis. Significantly more female than male participants wore sunscreen (24.72% vs. 10.91%). White individuals wore sunscreen most often, whereas Black individuals wore sunscreen the least. Sunburn incidence and history of melanoma were highest in White individuals, with a prevalence of 25.61 and 3.38 percent, respectively. Sunscreen use was higher and sunburn prevalence lower among the general population, compared to individuals with anxiety, depression, and dementia. Furthermore, incidence of melanoma was increased in individuals with dementia.

A social media analysis of sunburn-related videos on TikTok. Here, Siva et al evaluated TikTok videos claiming to be informational about sunburn, as well as their sources. The top 100 videos under “#sunburn” were analyzed. Two independent reviewers assessed the quality of the videos. The hashtag had about 1.2 billion views; the top 100 videos had over 454 million plays and were shared over 1.4 million times. The majority of videos came from laypersons (n=88), with only 12 videos from healthcare professionals, seven of whom were dermatologists. Of the 37 videos discussing sunscreen, only five noted the importance of using SPF 30 or higher and only seven recommended reapplication. Twenty-seven videos discussed sunburn aftercare, with 18 mentioning aloe vera application. Only six videos noted that sunburn increased the risk of melanoma.

Skin cancer risk factors, screening, and sun protection among the United States Hispanic population. Comparing sun protection and skin cancer-related factors and screenings among Hispanic individuals of various origin and non-Hispanic individuals, Yang et al found that severe sunburn with blister prevalence over the past year was more common among non-Hispanic individuals (8.8%) than Hispanic individuals of any origin, ranging from 2.5 percent for Dominican individuals to 6.6 percent for Cuban individuals. Severe sunburn with peeling was also more common in non-Hispanic individuals (23.6%) than Hispanic individuals of any origin (range: 7.7–21%). Compared to non-Hispanic individuals, Hispanic individuals of all origins, were more likely to seek shade. Rates of total body skin exam (TBSE), sunburn, and indoor tanning in the past year were lower in Hispanic individuals of all origins than in non-Hispanic individuals. Mexican individuals were more likely to wear long-sleeves shirts, long pants, and hats and less likely to receive a TBSE than other Hispanic individuals.

Effects of demographic variables on sun-protective behaviors using the NHANES database from 2005– 2020. Analyzing data from 19,797 individuals who completed the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008, 2011 to 2014, and 2017 to 2020, Kumar et al determined that there was no correlation between income status or education level and likelihood of seeking sun-protective behaviors. Additionally, shade-seeking behaviors did not differ based on income status or education level. Across all cohorts, those with an income status over three times the poverty line were signi cantly more likely to wear sunscreen than individuals below the poverty line. College students were likelier than those not yet in high school to wear sunscreen in all three cohorts. However, in the 2017 to 2020 cohort, college students were less likely to wear long-sleeved shirts than those not yet in high school.

A study of factors affecting sunprotective behavior change after surgical treatment of keratinocyte carcinoma. Here, Marani et al aimed to determine how sun-protective behaviors changed following Mohs micrographic surgery (MMS) for nonmelanoma skin cancer. Twenty-two patients were surveyed immediately before and three months after MMS. On average, the likelihood of practicing sun-protective behaviors and perception of skin cancer risk increased among patients following MMS. The largest behavioral change from pre- to post-MMS among patients was increased sunscreen use (3.09 vs. 3.73), followed by the increase in seeking shade (3.45 vs. 3.77). There was an insignificant positive correlation between lower Fitzpatrick skin type, living with a spouse or children, and larger household and increased sun-protective behaviors post-MMS.

Outdoor activities and sunburn among urban and rural families in a Western region of the US: Implications for skin cancer prevention

Comparing sun protection and outdoor activities among parent-child dyads in rural (n=41) and urban (n=56) areas, Wu et al observed that sunscreen use was higher among those in urban areas than rural areas. Wearing long pants or skirts was higher among children in rural areas than those in urban areas. Unintentional tanning was higher among adults in rural areas, while intentional outdoor tanning was higher among adults in urban areas. Farm work, sports, and yard work were more common among rural than urban residents.

Source: Wu YP, Parsons B, Jo Y. Outdoor activities and sunburn among urban and rural families in a Western region of the US: Implications for skin cancer prevention. Prev Med Rep. 2022;29:101914.

Additional information: Marson JW, Litchman GH, Rigel DS. The magnitude of increased United States melanoma incidence attributable to ground-level ultraviolet radiation intensity trends. J Am Acad Dermatol. 2021;84(6):1734–1735.

References: 1Pfahlberg A, Kölmel KF, Gefeller O. Timing of excessive ultraviolet radiation and melanoma: epidemiology does not support the existence of a critical period of high susceptibility to solar ultraviolet radiationinduced melanoma. Br J Dermatol. 2001;144:3:471–475. 2Lew RA, Sober AJ, Cook N, et al. Sun exposure habits in patients with cutaneous melanoma: a case study. J Dermatol Surg Onc. 1983;12:981–986.