International Journal of Research in Dermatology

Ghalla M et al. Int J Res Dermatol. 2022 Jan;8(1):168-174

http://www.ijord.com

DOI: https://dx.doi.org/10.18203/issn.2455-4529.IntJResDermatol20214928
Review Article

Expert consensus on the use of sunscreen agents: Indian perspective

Mansukh Ghalla1, Rasya Dixit2, K. Srinivasa Murthy3, Tina Priscilla Katta4*

1
Dermatree Skin and Hair Clinic, Mumbai, Maharashtra, India
2
Cosmetic Dermatology Clinic, Bangalore, Karnataka, India
3
Skin & Cosmetology Centre, Bangalore, Karnataka, India
4
Apollo Institute of Medical Sciences and Research, Jubilee Hills, Hyderabad, Telangana, India

Received: 15 June 2021

Accepted: 31 July 2021

*Correspondence:
Dr. Tina Priscilla Katta,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Sunscreens have been widely known to play an integral part in photoprotection. Both physical and chemical
sunscreens have been extensively used for prevention and management of several conditions induced by ultraviolet
rays such as sunburn, photoaging, skin cancer, and phototoxic reactions. Currently, sunscreens are available in
different formulations like creams, lotions, gels, sticks, and sprays. Forty experts in the field of clinical dermatology
participated in the expert group meetings organized via teleconference webinar to discuss definitions, diagnoses, and
management. Current evidence on the use of sunscreen agents along with clinical experience of experts was
discussed. The application of an adequate amount of sunscreen with an appropriate sun protection factor is
imperative, and must be in accordance to skin type and exposure pattern of an individual. As part of a complete sun
protection regimen, the judicious use of sunscreens must be combined with avoidance of midday sun exposure and
protective clothing. There is an undeniable need to improve public education and awareness regarding use of
sunscreens. This review article provides a consensus clinical viewpoint of expert dermatologists on effective use of
sunscreens to assist in clinical decision-making for healthcare professionals.

Keywords: Sunscreen, Sun protection factor, Photostability, Photoprotection

INTRODUCTION and photoaging, as well as for the management of

photodermatoses.3 Ideal sunscreens must have highly
Recurrent exposure of the skin to the sun could result in efficient filters against both UVB and UVA radiation.
short-term as well as long-term changes in the structure They must be photostable and must be available in
of the skin.1 In short term effects, repeated exposure formulations that are cosmetically acceptable.3 They
leads to erythema, whereas repeated exposure in the long should also be free of adverse effects.3 Consensus and
term could cause irreversible loss of skin elasticity and expert opinion on the use of sunscreens in the Indian
development of melanomas and non-melanomas.1 setting, and their benefits in photoprotection are lacking.
Photoprotective agents like sunblocks or sunscreens
prevent and reduce the damaging effects of ultraviolet Expert group meetings involving 40 dermatologists from
(UV) light.2 various cities across India were organized via
teleconference webinars in the month of September 2020.
The use of sunscreens for protection against damaging Current evidence on the use of sunscreen agents along
effects of sun rays has been on the rise since years.1 They with clinical experience of experts was discussed.
have been widely used for their photoprotective Numerous clinical insights were drawn from the focus
properties, including prevention of photocarcinogenesis group discussion based on the experts’ views. All the

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 Ghalla M et al. Int J Res Dermatol. 2022 Jan;8(1):168-174

opinions were collated in a consensus document, that was SPF = MED on protected skin/MED on unprotected
developed and finalized after approval from all experts. skin.2

A literature search was performed using the databases Sunscreen products are also graded based on the
PubMed and Google Scholar. Relevant articles were photoprotection factor of UVA (PFA) value. 2 The method
identified using the keywords sunscreen, sun protection of testing PFA has been described as the amount of
factor, photostability, and photoprotection. After product to be applied, dose of radiation, and radiation
screening, 49 suitable articles were identified and collated field.2
as evidence-based literature on the use of sunscreens to
support the experts’ views and suggestions. PFA = Minimal persistent pigment darkening (MPPD) of
protected skin/MPPD of unprotected skin.2
AN OVERVIEW ON SUNSCREENS
If the PFA is ≥and <4, the protection level is low and is
Sunscreens have been well established and documented labelled as PA+.2 If the PFA is ≥4 and <8, the protection
as effective photoprotective agents for preventing adverse level is moderate and is labelled as PA++.2 If the PFA is
outcomes of exposure to sunlight.3 UVA imposes the risk ≥8 or more, the protection level is high and is labelled as
of skin aging, dryness, dermatological photosensitivity, PA+++.2
and skin cancer, whereas UVB can directly damage
DNA, leading to mutation and cancer.4 Sunscreens play a Critical wavelength
critical role in reducing the incidence of human skin
disorders induced by UV rays. 4 Critical wavelength is defined as the wavelength below
which 90% of the UV absorbency of a sunscreen as
Classification of sunscreens measured in the band region 290-400 nm occurs.7
Sunscreens offering chiefly UVB protection would have
Sunscreens are categorized as topical or systemic agents. 4 a critical wavelength >320 nm, while those providing
Topical agents are further classified as having inorganic both UVB and UVA protection would have critical
or organic UV filters, based on specific mechanisms of wavelengths between 320 and 400 nm.8 The Food and
action upon exposure to sunlight (Figure 1).4 Organic Drug Administration (FDA) necessitates that sunscreen
sunscreens (chemical sunscreens) comprise of UVA and products must have a mean critical wavelength of
UVB blockers.5 UVB filters absorb the entire spectrum of ≥370 nm to be labeled as providing “broad spectrum”
UVB radiation (290 to 320 nm), whereas UVA filters UVA and UVB protection.8 A broad-spectrum sunscreen
cover UVA I (340 to 400 nm) or UVA II (320 to 340 nm) can be defined as a sunscreen with critical wavelength
radiation.5 Broad-spectrum sunscreens absorb UV >370 nm and PFA >4.9.
radiation from both the UVA and UVB spectra, thereby
covering the entire spectrum (290-400 nm).1,5 Boots star rating system

Inorganic blockers protect the skin from direct contact An in vitro measurement of the ratio of a product’s UVA
with sunlight by reflecting or scattering UV radiation (320-400 nm) absorbance over its UVB (290-320 nm)
over a broad spectrum.4 Hybrid UV filters are constituted absorbance is used to calculate its Boots star rating.9 A
of organic components mixed with inorganic components higher boots star rating is seen with products having
at the molecular or nanoscale level.4 The combination better UVA absorbance.9
enables creation of ideal materials with a large spectrum,
high chemical, electrochemical and optical transparency; Common indications for using sunscreen in clinical
as well as magnetic and electronic properties.4 Lastly, practice
systemic sunscreens are absorbed into the body and
accumulate in the skin affording protection from UV The common indications for using sunscreens in
rays.1 dermatology are prevention and management of
conditions like sunburn, freckling, discoloration,
SPF and PFA values photoaging, skin cancer, phototoxic/photoallergic
reactions, photosensitivity diseases, polymorphic light
The efficacy of a sunscreen is usually expressed in terms eruption (PMLE), solar urticaria, chronic actinic
of the sun protection factor (SPF).6 It is defined as the dermatitis, persistent light reaction, lupus erythematosus,
UV energy needed for producing a minimal erythema xeroderma pigmentosum, albinism, photo-aggravated
dose (MED) on protected skin, divided by the UV energy dermatoses, and post-inflammatory hyperpigmentation
needed for producing a MED on unprotected skin. 6 MED (PIH).9
is described as the lowest time interval or dosage of UV
light irradiation necessary for producing a minimal, RECOMMENDED SPF FOR SUNSCREENS
perceptible erythema on unprotected skin.6 The higher the
SPF, higher is the protection offered by a sunscreen The grading system for SPF ranges from low to high
against sunburns.6 (low: SPF 2-15; medium: SPF 15-30; high: SPF 30-50,

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 Ghalla M et al. Int J Res Dermatol. 2022 Jan;8(1):168-174

and highest: SPF >50).1 Sunscreens with an SPF of ≥30 even when applied in inadequate amounts.10 Individuals
that include photostable UVA filters are generally ideal.2 practicing outdoor sports like swimming and hiking
Using sunscreens with SPF >30 during the summer and experience considerably higher exposure to UV radiation
on sunny days is recommended.1 Consumers typically exceeding recommended exposure limits, and are at a
apply sunscreens unevenly and in amounts lesser than higher risk of skin cancer.11 Athletes exposed to UV
recommended, thus decreasing the actual SPF.10 High- radiation must be encouraged to use broad-spectrum,
SPF sunscreens might offer more adequate protection water-resistant sunscreen of at least SPF 30-50.12

Figure 1: Classification of sunscreen agents (Adapted from Ngoc et al Cosmetics. 2019;6(4):64).

In certain conditions, higher SPF might be essential. For improvement.14 For people living at high altitudes and
instance, patients with cutaneous lupus erythematosus having prolonged exposure to UV radiation, liberal use of
(CLE) must apply adequate amounts of sunscreen with broad-spectrum sunscreen with SPF>30, at least 20 min
SPF of ≥50, half an hour prior to expected exposure. 13 before going out in the sun, should be the norm. 17
Evidence also suggests that individuals with existing PIH
using a sunscreen with SPF 60 exhibited greater RECOMMENDED AMOUNT OF SUNSCREEN
improvements in overall skin lightening and number of FOR APPLICATION AND REAPPLICATION
macules, compared with individuals using sunscreen with
SPF 30.14 Sunscreen use can improve outcomes in PIH, A sunscreen must be applied properly to all sun exposed
and sunscreens with higher SPF might be more areas at a concentration of 2 mg/cm2. It must be allowed
effective.14 In photosensitive patients, an optimal to dry completely before sun exposure. 2 The teaspoon
sunscreen would have an SPF of no less than 50.15 For rule of applying sunscreen as proposed by Schneider et al
people of color, broad-spectrum sunscreens with SPF states that 33 mL would be applied to the entire body if 3
≥30, especially, those containing inorganic filters are mL (slightly more than half a teaspoon) was applied to
better suited.16 A study by Lakhdar et al established the each arm and to the face and neck and if 6 mL (slightly
efficacy of regular application of a broad-spectrum SPF more than a teaspoon) was applied to each leg, to the
50+ sunscreen by pregnant women.14 Only 2.7% new chest and abdomen, and to the back.18 Described in a
cases of melasma were seen versus 53% cases observed simpler way, sunscreen can be applied to each of the 11
in a previous study performed by the same investigators body areas (rule of nines) at a dose of 2 mg/cm2 if two
under similar conditions.14 Additionally, 8 of 12 strips of sunscreen are squeezed out on to both the index
participants with preexisting melasma saw marked and middle fingers from the palmar crease to the

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fingertips.19 The application of “two fingers” of sunscreens has been established, and superior efficacy of
sunscreen will ensure that users are protected according products comprising both compared to those containing
to their expectations. either organic or inorganic sunscreens has been
demonstrated.1
Evidence suggests that for indoor workers who apply
adequate amount of sunscreen once in the morning, WATER-RESISTANT ATTRIBUTE IN A
reapplication might not be needed.21 SUNSCREEN

Patients/conditions and preference of sunscreens A water-resistant sunscreen is one which maintains the
label SPF value after two sequential immersions in water
Sunscreens are commonly available in various for 20 min (total 40 min). A very water-resistant
formulations like creams, lotions, gels, ointments, pastes, sunscreen is one which maintains the label SPF value
oils, sticks, and sprays.2 Choosing the most adequate after four sequential immersions in water for 20 min
galenic form of a sunscreen must be based on the (total 80 min).9 Water-resistant sunscreens must be
characteristics of the patient concerning manner of use applied in conditions in which there is substantial
and area of application.22 Cream-based or stick-based sweating, water immersion, increased skin friction via
sunscreens are primarily favorable for children from 6 physical contact, or contact with sand.27
months to 2 years of age.22 Gel-based or spray sunscreens
are preferred in patients with oily skin and acne.2 Gel- PHOTOSTABILITY OF SUNSCREENS
based sunscreens are less greasy compared to oil-based
sunscreens, but are more easily removed by sweat or Sunscreens are formulated to attain maximum efficacy
water.23 Spray formulations are convenient, but are often that incorporates measures to support and promote
difficult to apply evenly and might leave a film. 23 photostability because all organic UV filters might
potentially photodegrade.28 Evidence depicts a reduction
Novel sunscreens with microfine particles have been in SPF of 38% and 41% after 4 hours and of 55% and
established to be efficacious and safe in acne and 58% after 8 hours of application of organic and inorganic
rosacea.2 Sprays are good for protecting the scalp. 23 sunscreens, respectively, in participants who over the
Evidence suggests that applying a lipstick sunscreen course of eight hours performed physical activities, were
helps in increasing lip hydration.24 Additionally, then exposed to a hot environment, and finally bathed. 2
cosmetics like foundation makeup, help provide an Hence, it is obligatory to apply the adequate and
everyday protection with SPF ranging from 4 to 30. 23 recommended amount of sunscreen to derive the claimed
Currently, sunscreens with variable SPF are incorporated benefit.2
in moisturizers, providing additional sun protection.25
Cinnamates, titanium dioxide, and zinc oxide have USE OF SUNSCREENS FOR SPECIFIC PATIENT
replaced the toxic para-aminobenzoic acid (PABA) GROUPS AND CONDITIONS
agents.25
Infants and children
PHYSICAL AND CHEMICAL SUNSCREENS
Application of sunscreens should be a part of an overall
Chemical sunscreens absorb high-energy UV rays, sun protection strategy that includes avoidance of
whereas physical sunscreens reflect or scatter light.2 exposure to midday sun and use of protective clothing. 29
Physical sunscreens contain zinc oxide and titanium Oil-based emulsions containing inorganic filters seem to
dioxide.5 Chemical sunscreens like octisalate and be the safest sunscreens for children.29 However, certain
avobenzone provide better aesthetics upon application, organic filters need to be added to achieve an SPF of
and are therefore more widely accepted.1 However, they 50.29 Oxybenzone and octocrylene must be avoided in
have the potential for systemic absorption, subsequent sunscreens for children.29 Regular use of sunscreens
sensitivity, and untoward effects.1 during childhood and adolescence could also significantly
diminish lifetime risk of skin cancer.30 The use of
On the other hand, physical sunscreens are relatively sunscreens is not recommended for infants younger than
inert, safe, stable, and non-irritating.26 They have 6 months.9
minimum potential for allergic sensitization, have high
photostability, and are specifically beneficial for patients Preventing skin damage/aging/wrinkles in the elderly
with sensitive skin, who cannot tolerate chemical
sunscreens.1,26 Metal oxides deliver photoprotection to Photoprotection inclusive of sunscreens helps to prevent
patients with visible light and UVA photosensitivity like skin aging including wrinkles, sagging skin, or age
those with porphyria, drug photoallergy, and PMLE. 26 spots.31 Sunscreens permeate through the skin and absorb
Nevertheless, their reflective properties might cause UVA rays before they can reach and damage the dermal
excessive shine and a whitish aspect, restraining their layer.31
exclusive use due to low cosmetic acceptance.1
Interestingly, the synergy between organic and inorganic

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 Ghalla M et al. Int J Res Dermatol. 2022 Jan;8(1):168-174

Sunburns and photodermatoses Conventional treatment of melasma includes elimination

of any possible causal factors coupled with use of a
Sunscreens are most useful in sunburn prevention.7 Broad sunscreen and depigmenting agents like hydroquinone,
spectrum UVB/UVA protection and regular application kojic acid, and azelaic acid.41
in sufficient amounts are necessary.7 Topical application
of broad-spectrum sunscreens with SPF>30 is usually the POST-PROCEDURAL USE OF SUNSCREENS
appropriate choice for adequate photoprotection in
photodermatoses like PMLE, and phototoxic After application of chemical peels, patients must use a
dermatitis.32,33 broad-spectrum sunscreen on a daily basis to limit PIH
development.42 Sun protection creams with a minimum
Furthermore, corticosteroids, nonsteroidal anti- SPF of 50 are beneficial in such cases.43 Patients
inflammatory drugs, antioxidants, and antihistamines undergoing procedures like laser-based therapies that can
have been evaluated for enabling the reduced production induce PIH, are often advised to apply sunscreen
or diminishing the effects of various mediators in a regularly for several weeks before the procedure and to
sunburn reaction.34 Numerous topical treatments like avoid sun exposure.14 It has also been observed that
emollients, cool compresses, and topical anesthetics have broad-spectrum sunscreens with anti-inflammatory agents
been recommended for symptomatic treatment of starting on the first day after ablative fractional skin
sunburn.34 resurfacing can reduce PIH after laser treatment at 1-
week postoperatively.44
Melasma and post-inflammatory hyperpigmentation
USE OF SUNSCREEN WHILE WORKING
A broad-spectrum sunscreen covering UVA, UVB, and INDOORS
visible light could play an adjuvant role in therapy for
melasma and PIH by preventing exacerbations of People who work indoors can still be exposed to UV
hyperpigmentation and improving appearance of these radiation from light bulbs or from working next to
pigmentary disorders.14 Tinted sunscreens that provide windows.21 Such people could apply adequate sunscreen
photoprotection against visible light could be beneficial once in the morning.21 Reapplication of sunscreen may
for patients with melasma or visible light-induced not be required.21 Constant exposure to heat and light
photodermatoses.35 while cooking can also aggravate chances of sensitive
skin and pigmentation.37 Hence, a sunscreen is
APPLICATION OF SUNSCREEN FOR recommended indoors in such cases.37
DIFFERENT SKIN TYPES
VITAMIN D AND SUNSCREEN
A sunscreen combined with a moisturizer is an important
recommendation for patients with acne.36 It is advisable Broad-spectrum sunscreens are unlikely to compromise
for such patients to avoid inorganic filters, on account of vitamin D status in healthy people.45 Vitamin D screening
their dense and oily consistency.22 Physical sunscreen must be carried out for those at risk of hypovitaminosis,
formulations are usually less oily and might be suitable in like patients with photosensitivity disorders, who need
patients with oily and acne-prone skin.26 They are also rigorous photoprotection.45 Screening and
useful in cases of sensitive skin and intolerance to supplementation is advised for such individuals.45
chemical sunscreens.26 Moreover, gel-based formulations
or matte-finish sunscreens could be preferred for NEED FOR SUNSCREEN EDUCATION IN INDIA
sensitive skin.37 An Indian study by Sarkar et al
established that regular usage of sunscreens with A study by Agarwal SB et al showed that consciousness
moderate SPF and high PA+++ values may offer efficient about sunscreen was low among Indians.46 Awareness
protection against pigmentation irregularities, and about protective spectrum of sunscreens, correct method
enhance the overall skin radiance in Indians with of application, and clearing misconceptions need to be
Fitzpatrick phototypes IV and V. the primary focus.46 A comprehensive effort for
improving patient education with respect to various
COMBINATION OF SUNSCREENS WITH aspects like primary prevention of skin cancer and
DEPIGMENTING AGENTS photodamage must be implemented.47

The cornerstone of hyperpigmentation therapy is use of CONCLUSION

broad-spectrum sunscreens. Avobenzone absorbs light in
the UVA range, but is unstable.39 Its stability is increased Photoprotection with the use of sunscreens essentially
by combining it with oxybenzone.39 Many cosmeceuticals protects the skin from various deleterious effects of UV
have physical sunscreens in the same formulation for rays and prevents further grave consequences like
additional benefits.39 PABA or PABA-free UVB sunburns and cancer. Application and reapplication of the
sunscreens with a waterproof claim and SPF of at least 15 adequate amount of sunscreen are essential for achieving
are protective against UVB-induced hyperpigmentation.40 maximum benefits of photoprotection. In spite of various

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 Ghalla M et al. Int J Res Dermatol. 2022 Jan;8(1):168-174

developments in photoprotection, further studies on the 13. Okon LG, Werth VP. Cutaneous lupus
use of sunscreens specifically in the Indian population are erythematosus: diagnosis and treatment. Best Pract
required. Res Clin Rheumatol. 2013;27:391-404.
14. Fatima S, Braunberger T, Mohammad TF, Kohli I,
ACKNOWLEDGEMENTS Hamzavi IH. The role of sunscreen in melasma and
postinflammatory hyperpigmentation. Indian J
The authors thank Scientimed Solutions Pvt. Ltd. for Dermatol. 2020;65:5-10.
assisting in manuscript development. 15. Keyes E, Werth VP, Brod B. Potential allergenicity
of commonly sold high SPF broad spectrum
Funding: No funding sources sunscreens in the United States; from the
Conflict of interest: None declared perspective of patients with autoimmune skin
Ethical approval: Not required disease. Int J Womens Dermatol. 2019;5:227-32.
16. Kumari P, Suvirya S, Verma P, Pathania S, Shukla
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International Journal of Research in Dermatology | January-February 2022 | Vol 8 | Issue 1 Page 174