If you’re worried about sun damage, read on for advice from top dermatologists Y. Claire Chang, MD, Dendy Engelman, dermatologic surgeon at MDCS, and Dr. Melissa Kanchanapoomi Levin, a NYC-board certified dermatologist and founder of EntièreDermatology, who addressed some of your biggest skincare concerns, late summer edition:
We seem to all be smarter about sunscreen yet so many more people seem to be complaining about sun damage; what gives?
Dr. Chang: With increased education and awareness of the harms of sun exposure, we are fortunately moving away from the age of baby oil, light reflectors, and tanning beds, and towards the age of increased sunscreen use. However, skin cancers and photodamage in the form of brown spots and wrinkles are still common complaints in my dermatology practice. In addition, the American Academy of Dermatology reports skin cancer is the most common cancer in the U.S. with about one in five Americans developing skin cancer in their lifetime. With increased awareness and use of sunscreens, why is there still such a high prevalence of photodamage? There are likely multiple reasons.
First, many patients I see are aware of the importance of sun protection but are not educated on proper application of sunscreen. There are currently numerous sunscreens out on the market. I recommend broad-spectrum sunscreens with SPF 30 or greater for daily use. I also emphasize the importance of reapplication every 2-3 hours. I educate my patients on applying a thick enough layer of sunscreen to cover all exposed skin. According to the American Academy of Dermatology, average adults need about 1 ounce to fully cover their body. There are many new make-ups on the market that claim SPF of 30 or greater. However, most people do not apply a thick enough layer to get the full protection needed. I recommend my patients apply a base sunscreen before applying their make-up to get adequate protection.
Second, photodamage can take many years, sometimes decades, to appear. Sun exposure causes DNA damage in keratinocytes, increases oxidative damage to skin cells, increases melanin production to cause pigmentation, and breaks down collagen. Photodamage presents with brown spots, blood vessels, fine lines, wrinkles, and skin sagging. Because sun damage is cumulative, it is important to start sun protection early and continue daily sunscreen use.
Third, the ozone layer has become depleted due to global warming and environmental factors for many years, allowing more UV radiation to reach the ground surface. This has allowed for more UV-related skin damage.
Dr. Engelman: People think sunscreen is a protective bubble that won’t allow for any sun at all to penetrate. Couple that with inadequate reapplication techniques and lack of sun safety behaviors (avoiding peak hours of 10am-2pm, seeking shade whenever in bright light, etc.) and sun damage will continue to occur. We must remember that anytime the skin changes color from sun exposure (tans), damage has occurred. This predisposes us to skin cancer and signs of accelerated aging- fine lines, wrinkles, sun spots…
Dr. Levin: It’s true that people are much better at putting sunscreen than before but as a dermatologist, I still see sunburns and suntans on a regular basis. Most people are not applying enough sunscreen which is why unintended tanning and sunburns occur even with sunscreen application. Most adults need about 1 ounce to cover their body or 1 tablespoon for the face and neck alone. Sunscreen also needs to be re-applied every 40 to 80 minutes or even more frequently after swimming, heavy sweating, or toweling off to ensure adequate protection.
What are some of the ingredients to look for when shopping for products to repair sun damage?
Dr. Engelman: Look for products that contain the below:
—Physical blockers like zinc oxide / titanium dioxide
—Newer sunscreens contain an enzyme called phyotolyase that actually repairs DNA damage.
—Retinoids/retinols like Elizabeth Arden Retinol Ceramide Capsules for beginners and move on to Adapalene or Rx retinoids
Prescription imiquimod is used to treat superficial basal cell carcinoma; Fluorouracil cream (5-FU) used to treat actinic or solar keratoses (scaly or crusted lesions [skin areas] caused by years of too much exposure to sunlight). Fluorouracil cream and topical solution are also used to treat a type of skin cancer called superficial basal cell carcinoma if usual types of treatment cannot be used. Fluorouracil is in a class of medications called antimetabolites. It works by killing fast-growing cells such as the abnormal cells in actinic keratoses and basal cell carcinoma.
Dr. Levin: The most important part of reversing or halting future sun damage is focusing on protection and prevention. This basically means protection from primarily sun damaging UV rays but also from environmental stressors. Overexposure to the sun’s damaging radiation can lead to uneven pigmentation, thickened skin, wrinkles, and loss of volume.
Without a doubt, sunscreen is imperative in order to maintain protection from sun damage. Not only is applying sunscreen every day (not just in summer months) necessary, but also reapplication is key. We used to only focus on sunscreen but now we understand antioxidants are also important in order to neutralize free radicals forms from UV radiation, infrared radiation, and environmental stressors. In the past recent years, there is a new wave of skin care products with DNA repair enzymes, which are thought to repair DNA damage from the sun.
Keeping the skin barrier healthy and well-hydrated are not to be ignored either. Continued use to good moisturizers and cleansers keeps the skin texture and appearance healthy. Besides sunscreen and antioxidants, retinoids are key in terms of exfoliating the skin, collagen re-modeling, and treating discoloration. Most of the clinical studies for brown spots and collagen production have been performed with Tretinoin (Retin-A) but any retinoid such as Differin and Tazorac can also be effective. My favorite over the counter retinoid is Differin Gel and retinol is Skin Better AlphaRet, which combines vitamin C as well as a retinoid-strength retinol. Other acids such as alpha hydroxy acid and glycolic acid are effective chemical exfoliators. Over the counter ingredients such as kojic acid and azelaic acid can be used to lighten brown spots and blotchy discoloration.
Can it actually be accomplished with products?
Dr. Engelman: Oftentimes topical products — whether over the counter or prescription — are all we need to reverse sun damage. For more severe cases, in-office procedures like photodynamic therapy, intense pulsed light or fractionated CO2 may be required.
How do you know if the damage is too significant?
Dr. Engelman: If you are getting precancerous or cancerous lesions on the skin, over-the-counter repair products are likely inadequate to reverse the degree of damage and prescription or in-office procedures may be needed.
What’s the best treatment for every age?
Dr. Engelman: Most treatments are catered to the degree of damage and one’s skin type, not their age per se. that said…a basic guideline would be, antioxidants and sunscreen starting in 20s and carried out for a lifetime. Retinoids in the 30s. IPL in the 40s, PDT/imiquimod/5-FU in the 50s, fraxel in the 60s.
Dr. Levin: I don’t look at sun damage particularly by age but what I see on the skin based on your sun exposure, genetics, lifestyle, etc.
What are some non-invasive derm techniques that permanently remove or fade the look of sun damage?
Dr. Levin: There are a number of in-office non-invasive procedures that dermatologists perform to reverse sun damage. Resurfacing laser treatments like Halo and Fraxel Dual remain the workhorse for not only treating wrinkles, discoloration, freckles, scars, but they also turn over the skin to create new skin cells which are healthier. Light based therapies like intense pulsed light (IPL) or broadband light (BBL) – this is an in office procedure that not only treats discoloration (both red and brown spots) but it can also stimulate the production of important proteins such as collagen and elastic as well as repair DNA.
Microneedling can also be coupled with topical treatments such as vitamin C, trichloroacetic acid, platelet rich plasma (PRP), which helps not only stimulate collagen, treat discoloration, but also smooth out wrinkles. Chemical peels are useful by removing the upper layers of dead skin cells as well as interfering with the production of pigment depending on the active ingredient used such as glycolic, mandelic, salicylic acid, lactic acid, trichloroacetic acid, etc.
Image credit: Deposit Photos