Category Archives: sun and skin

Chemical peels: the modern day equivalent to Cleopatra’s beauty regimen

The quest for youth and beauty dates back to centuries ago when Cleopatra allegedly bathed in donkey milk (contains high amount of lactic acid which is an alpha hydroxy acid -AHA) to maintain a youthful clear skin. Cleopatra was not alone in this, the Greeks and French were also using sour milk (lactic acid) and fermented grapes (tartaric acid) for their skin.

Elisabeth Taylor as the beautiful Cleopatra

These ladies were not wrong in doing so! These centuries old beauty regimes have paved the way for modern anti ageing, and anti pigmentation beauty treatments.

So what does the 21st century beauty treatment look like?

The same concept of using sour milk etc to chemically exfoliate the upper dead layers of your skin is now being performed by dermatologists all over the world as an office based treatment called “chemical peel”.

There are various beauty treatment options available now, from creams, to LASER’s, to botox, fillers and chemical peels being one of them.

What is chemical peel?

Chemical peels are well controlled cosmetic procedures where a chemical with keratolytic property (able to exfoliate the skin cells -keratinocytes) is applied to the face with the aim of accelerating the natural exfoliation process wherein the superficial dead damaged skin is removed thereby improving the texture of skin, the appearance of fine wrinkles and decreases pigmentation.

In layman terms, chemical peels are cosmetic procedures that uses chemicals to peel off the dead layer of the skin.

The depth of such an effect will depend on the type of chemical used and the concentration of the substance ( eg. Glycolic acid- GA 10-30% is a very superficial peel i.e works in the upper epidermis while GA > 30-70% is a superficial peel effecting the lower epidermis and >70% is a medium peel reaching the dermis).

How does chemical peel work?

The skin has 3 layers : epidermis (uppermost) , dermis (middle) & sunbcutaneous fat (lowermost). The epidermis itself is divided into 4 layers (basal layer, stratum spinosum, stratum granulosum and the statum corneum.

The cells in our skin undergoes a process of multiplication and differentiation (change in shape, structure and biochemical composition) in which cells in the lowermost epidermis change their shape and composition as they move up to the uppermost layer and are eventually shed off.

This is called “skin cell turnover” which normally takes 28-40 days. This turnover is faster in babies and children and slows down with age.

As the cell turnover slows down, the dead skin cells in the uppermost layer of the skin do not get renewed but accumulates and gives the skin a dull, dry and aged appearance.

Ingredients such as alpha hydroxy acids (glycolic acid, lactic acid, mandelic acid etc) disrupts enzymes in the skin that hold the cells together. They can therefore cause the superficial layer of the skin to exfoliate and induce new cell replacement.

At higher concentration, these acids can penetrate deeper into the dermis and stimulate the fibroblast (cells that make collagen) to produce more collagen, elastin and substance that add structure to the skin (GAG’s) thus improves skin thickness and hydration.

Tricholoroacetic acid (TCA) works by causing destruction of the cells by protein denaturation. This then stimulates new wound healing.

Overall benefits that can be achieved with chemical peels

Improves skin texture
Can even out skin tone
Spot peels can be used to treated selected hyper-pigmented areas
Salicyclic peels are used as an adjunctive treatment for acne
Improves the appearance of aged skin.

Melasma after medium depth peel (Jessner’s solution) Image : Rooks textbook of dermatology

Acne scars after medium depth chemical peel. Image : Rooks textbook of dermatology

Procedure of a chemical peel

Chemical peels are not meant to work just on their own. One has to be motivated to follow a strict skin care plan for the maximum benefits from such a procedure.

A dermatologist will take a detailed history and clinical examination to assess if a patient is a good candidate for chemical peels.

A patient will be counselled on the skin care measures that needs to followed prior and after the procedure as well as about the expectations from this cosmetic procedure.

A process called “priming” which is done to thin out the epidermis so as the acids used in the chemical peel can penetrate the layers of the skin evenly. This step involves daily application of creams containing either retinoids/ azaelic acid/ kojic acid etc for at least 2-4 weeks prior the chemical peel procedure.

Sunscreens is an absolute must before and after the procedure.

A dermatologist may do a test peel behind the ear or other areas just to check if a patient is allergic to any of the ingredient or to assess for potential side effects.

Chemical peels are done in an office based setting once in a 3-4 weeks for 6-7 sessions depending on a patient’s response. The chosen acid is applied to the entire face or target area using a brush after degreasing the face. The peels are left for a certain contact time which is increased every session ( for eg, for the first session the contact time maybe 2 min which is then increased by a minute or two every successive session).

Post peel care

This step is just as important as the actual peel procedure.

Cold compression using ice packs if there is any redness after the prcedure.

Strict sun protection using broad spectrum sunscreens.

Use mild cleansers or soap free cleansers for washing the face.

Use a moisturiser at least twice daily to help reduce the peeling of the skin.

Avoid facial waxing, threading, facials and skin bleaching procedures for at least 1 week after the procedure.

Avoid scratching, picking or peeling of the skin.

Complications

Chemical peels are not free form side effects, that’s why pre procedure counselling and right patient selection is very important.

The possible side effects are :

Persistent redness of skin
Post inflammatory hyper or hypo-pigmentation (i.e dark or light spots)
Scarring
Excessive peeling of skin
Scabbing
Allergic reactions.
Scabbing.

Chemical burns (left) and post inflammatory hyperpigmentation (right) as complications of chemical peel. Image : Rooks textbook of dermatology

Chemical peels are add on cosmetic procedures that can be used for various indications. The effects can be impressive when done by an experienced dermatologist and when a patient is compliant with the pre and post peel skin care.

Never try to attempt a self chemical peel at home with products that can be bought online because the side effects could be permanent if sub optimal products are used and with inexperienced hands.

Freckles or Sun spots?

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The beauty standards of this world fuelled by unrealistic expectations through social media has made the slightest blemishes on the skin an un-welcomed sight.

The world is more forgiving towards skin blemishes now, luxury brands are embracing models with vitiligo, freckles have made their way into instagram filters and I personally love seeing this change.

I’m hoping this post will help individuals understand why freckles occur and hopefully help one embrace them.

What are freckles?

Ephelides the medical term for freckles are small unform light brown pigmented areas (maucles) usually occurring on sun exposed skin such as the cheeks, bridge of nose or over the hands.

They are commonly seen in fair skinned individuals with red hair and blue eyes. Freckles can also occur in Asian and Indian skin type though with lesser prevalence.

In an Indian study of pigmentation disorders in Indian skin type, melasma was the commonest cause and freckles only contributed to ~7% of the study population.

Freckles usually start appearing in childhood & adolescence period.

What causes freckles?

Genetics plays a huge role, mutation of a gene encoding for melanocortin receptors have been found especially in red haired individuals. A positive family history of freckles is usually present.

UV radiation stimulates the melanocytes to produce more melanin (the pigment of our skin) and it also increases the transfer of the melanin to the keratinocytes (cells of the upper layers of our skin) and is responsible for the pigmenation.

Image source: http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%201/FG04_06.jpg

The number of melanocytes (specialised cells in the skin that makes the pigment melanin) are not increased but there is an increase activity of these melanocytes.

For an individual who is genetically predisposed, UVR (sun exposure) can cause the development of freckles

How to differentiate freckles from sun spots?

Freckles/ Ephelids

Freckles appear at early childhood (2-3 years) over the cheeks, nose or the hands.

They are light brown, 1-5 mm in size, round to oval, regular & well defined patches. Freckles are mostly uniform in size, colour and distribution.

They become darker on sun exposure and fade with strict sun protection. Hence they tend to be more prominent in summer and lighter in winter.

They may even fade with age.

Solar lentigens / Sun spots

Starts appearing in adulthood 20-30 years.

Light -dark brown patches on the sun exposed areas such as face, upper neck, hands. They are larger & more irregular than freckles.

Can occur both in light and dark coloured skin.

Caused by prolonged sun exposure over time.

They become darker with more sun exposure and do not fade in winter. They are persistent throughout life and no not fade with time. They may even increase in number with age.

When to worry about freckles?

A child with multiple freckles and a severe intolerance to sunlight

If the child develops severe sun burns even with minimal sun exposure, a detailed medical examination may be required to rule out genetic disorders such as xeroderma pigmentosa where the cells fail to repair the DNA damaged by UV radiation.

Are freckles harmful?

Freckles are completely harmless unless if its associated with the above mentioned condition.

How to fade freckles?

Freckles respond well to strict sun protection either in the form of sunscreens or physical protection.

I’ve mentioned in my previous blog posts on how to achieve a good level of sun protection.

Other form of treatments are topical creams such as hydroquinone or retinoids. However these tend to give an uneven result.

Chemical peels have shown good results, such as spot TCA or Phenol peels. In these procedures, a high strength alpha hydroxy acid (glycolic acid, mandelic acid etc) or caustic acid (TCA)are applied by a dermatologist using a toothpick or cotton buds to the freckles. These areas then forms a scab with falls off in 7-10 days and heals with a normal pigmented skin.

LASERS have been widely used successfully for fading the freckles as well.

All the above procedures do come with certain side effects such as irritation, redness, pigmentation (especially in dark skinned individuals). Therefore always find a dermatologist experienced in this field to perform such procedures.

Recurrence of the freckles or sun spots can occur hence strict sun protection must be maintained even when the freckles have faded.

My advised is, start loving your sunscreen, use it judiciously for best results.
Try the other treatment options if you are very concerned about the freckles but in my opinion, every blemish, or scar or mole adds character to your face, learn to embrace it.

Melasma: the number one facial pigmentation

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As I was growing up I’ve seen my mum and most of my aunts trying in vain every remedy available for the pigmentation on their face

What is melasma?

Melasma also called cloasma is a common acquired hyperpigmentation disorder affecting mostly women in their reproductive age groups (~15-45 years) . It is the most common pigmentation disorder & is seen more commonly especially in individuals with darker skin type (FST IV-VI) affecting 9 -50% of the such high risk population . (Find out your skin type here)

What causes melasma?

Cause of melasma is multifactorial and factors such as UV radiation, elevated estrogen (female hormones) level work together to result in melasma in genetically predisposed individuals

Genetics: Certain genes are responsible for up regulating enzymes in the melanogenesis pathway (process of melanin production) which results in more melanin production.
UV Rays: Increase production of reactive oxygen species, which can then increase tyrosinase activity.
Hormones: Estrogen can up regulate enzymes (tyrosinase) and genes in the melanogenesis pathway, resulting in increase pigment production in genetically predisposed individulas.

How does it present?

Melasma presents with tan brown reticulate (lacy) pigmentation described in three distinct pattern on the face.

Centro facial pattern: Most common pattern affecting the forehead, nose, upper lip, chin and cheeks
Malar pattern : As seen in the below images affects the malar area (cheeks) of face
Mandibular pattern: Affects the jawline and chin, mostly seen in late onset melasma

Melasma in women can present for the first time in pregnancy and its referred to as “Mask of Pregnancy“. Treatment of which is more difficult because of the increase estrogen level in the body and as most medications used for pigmentation may not be safe during pregnancy.

The good news is that in some women, this mask of pregnancy is transient and will fade with time and proper management.

Can melasma occur in males?

Yes, melasma can occur in males as well. The male to female is ratio 1:9 i.e for every 9 females with melasma, 1 male individual also suffers from melasma. It has also been reported to have a higher prevalence in Indian males compared to Caucasian males.

Does melasma occur elsewhere besides the face?

Yes, rarely it can involve the neck, chest, the upper arms or forearms and it’s called “Extra facial melasma”

How is it diagnosed?

Most of the time a dermatologist can diagnose melasma by just examining it.

A wood’s lamp examination may be used to assess the dept of the pigmentation i.e if it is epidermal (superficial) or dermal (deep) pigmentation. Epidermal pigmentation respond to treatment better.

Occasionally a skin biopsy (examining of a skin sample under a microscope) may be required for a definitive diagnosis as all facial pigmentation is not melasma.

Treatment options

The hunt for the cure for melasma is still ongoing.

Though numerous treatment options are available now, there is still no “one product” that does it all.

The mainstay of treatment is avoiding the factors responsible for it as much as possible. Since one cannot change one’s genetic makeup, taking measures to avoid the modifiable factors (such strict sun protection) will help prevent its occurrence and reduce the appearance of an already developing melasma.

Its always good to know your personal risk of developing melasma so as you can actively prevent it from occurring in the future.

If melasma is highly prevalent in your ethnic group (for eg: melasma is highly prevalent in my hometown i.e Shillong, Northeast India) start taking preventive measures at the earliest. Its best to consult a dermatologist as early as possible at the start of the pigmentation rather than after a trail and error of using multiple self prescribed creams and remedies.

Shillong, though blessed with its hills, rivers, waterfalls and clouds, being at a higher altitude (1525 m above sea level) means it gets more UV rays than lower altitude areas and the cloud cover aids in scattering these UV rays. Understanding these facts will help individuals be more aware of the need of sun protection even in cloudy, pleasant days without the sun shining bright.

The first step to the treatment or prevention of melasma is strict sun protection. No creams, chemical peels or LASERS will effectively work if one is not complaint with this step

Ideal choice and method of a sunscreen application:

SPF of at least 30 (measure of UVB protection)
PA factor +++ (measure of UVA protection)
Gel formulation or matte finish for those with oily skin
Apply to both face and neck at least 20 mins prior to sun exposure and reapply every 2 hours especially when outdoors
Sunscreen application should be on all days even when the sky is cloudy or rainy
Use a sunscreen even when indoors (as glass cannot filter UVA light)

Other measures of sun protection include using a wide brim hat during your outing tot he beach or during any outdoor activity.

Avoid the peak hours of the day such as between 12 noon -2 pm when the sun is directly above the earth.

Seek shade whenever possible

Treatment to reduce pigmentation

Now that we’ve had sun protection covered, you will need to seek expert opinion (dermatologist) for further management as there are many active ingredients available for treating pigmentation and not everything is suitable for everyone.

If you are on medications such as oral contraceptive pills containing estrogen or drugs for seizures such as phenytoin which could be the potential cause of the melasma, then its best to speak to your treating physician for a possible changeover of the medications.

What are the treatment options available?

To understand how the treatments work, we first need to have an overview of how melanin (pigment responsible for our skin, hair, eyes colour) is formed.

Melanogenesis i.e process of melanin formation in melanocytes (cells for melanin production). The 3 main types of melanin are eumelanin brown, eumelanin black & phaeomelanin (yellow red). Humans have all 3 types but the ratio of each type of melanin is different in different ethnic group. For eg more pheomelanin is present in red heads with pale fair skin, more of brown eumelanin is seen in blondes and more of eumelanin black is seen in brown-black skin type with black hair.

Topical medications for melasma

Various options are availabe in the form or creams, ointments or serums and the choice will differ from patient to patient.

Topicals required long term and consistent use for the best results.

Not every option will work for everyone

Some of the active ingredients that are use to reduce pigmentation are enumerated in the tables below:

There are numerous options for the treatment of melasma, and the choice will depend with every patient.
For best results, sun protection, strict compliance and abundance of patience is required as improvement can only be appreciated after months of consistent skin care routine.

Oral medications for melasma

Trenexamic acid – An anti fibrinolytic drug that prevents the breakdown of protein (fibrin) present in blood clots. Therefore it is traditionally used to treat bleeding disorders.

It has been shown to be effective for the treatment of melasma in low doses. It has been show to produce results in 3 months but relapse rates are high and melasma recurs within 3 months of discontinuation of the drug.

Side effects are nausea, vomiting & serious side effects such as heart attacks, blood clots in veins of legs, renal injury (kidney problems) could potentially occur in individuals at risk.

Chemical peels

Dermatological procedure where acids of higher strength is used such as glycolic acid, salicylic acid, trichloroacetic acid etc are applied to the face or pigmented area by a dermatologist for a short contact time.

The procedure is done every 3-4 weeks for 5-6 sessions depending on the patient’s response.

Second line treatment for those not responding to topicals alone.

Expensive and requires an experienced hand.

LASER for melasma

Various types of LASER are available for the treatment of melasma.

LASER treatment can be tricky especially in individual’s with darker skin type as the risk of pigmentation is higher. LASER are usually reserved for resistant cases not responding to the above mentioned treatment options.

LASER are not one time treatment. Creams and sunscreens will still be required to maintain the result and prevent recurrence.

LASER treatment are expensive but may be worth it when done by experienced hand.

There is still no cure for melasma.
Seek guidance from a dermatologist as the appearance of the pigmentation can be improved with either depigmenting creams & sunscreens or a combination of treatment especially when the treatment is started early.

Prickly heat : Another nuisance of the summers

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Summer is here is various parts of India!!! Its hot, its humid, we’re sweating and for the unlucky few, the skin is actually itching and pricking.

Stay ahead of the summer…

Miliaria also called “prickly heat”, “sweat rash”, “heat rash” “ñiang shit” (in my mother tongue) is a common dermatological condition occurring mostly in hot, humid summers. Infants ( <1 year) are more susceptible as their sweat glands have not well developed.

But this does not mean adults are spared, it can occur in adults as well, both males and females

So how and why does it occur?

Miliaria is caused due to blockage of the sweat glands ( eccrine glands) which may be due to excessive colonisation of a bacteria in our skin ( don’t worry its mostly the bacteria which normally resides in our skin. Yes! we have bacteria and yeast, a small little world living in out skin :p).

Sometimes these sweat glands can be occluded by debris (i.e dirt)

Sweating is therefore a risk factor, and activities or febrile illness (infection/medical conditions that causes fever) that could increase sweating are high risk factors for developing miliaria.

Source : https://www.ncbi.nlm.nih.gov/books/NBK537176/

Levels of occlusion of the sweat duct and its resulting clinical presentation

Sometimes the duct ruptures causing inflammation around the area, seen clinically as red bumps, itching, pricking sensation.

How does it present?

Occlusion of these sweat glands result in sweat not being able to leave the surface of the skin, & instead gets pushed back into the different layers of the skin forming small sweat filled lesions.

Depending on where the blockage occurs, the presentation can be different clinically.

Miliaria crystallina

Miliaria crystallina : Sweat filled blisters with “Dew drops” appearance
See the resemblance?

Blockage occurs at the superficial part of the skin (epidermis). Presents with these asymptomatic (no itching /pain/burning sensation) clear fluid filled lesions (vesicles) over normal looking skin.They are referred to as “dew drops” .
The fluid collected is actually sweat!!

2. Miliaria rubra

Most common form, presents with multiple red raised lesions (papules). (“Rubra”= Red in Latin). Individuals also experience an uncomfortable pricking/itching sensation in their skin. Pustules (pus filled lesion) may also be present and its referred to “miliaria pustulosa”.

3. Miliaria profunda

Least common form. Mostly seen in individuals who suffer from repeated episodes of miliaria rubra. Seen as large deeper lesions either skin colored or red. May be itchy.

Is this condition dangerous?

Apart from being a nuisance, miliaria normally resolves once the factors causing the sweating is removed.

In very rare occasions when the involvement is extensive or in infants with poorly developed sweat glands, it can be threatening.

Normally, sweating is a defence mechanism to increasing body temperatures, which cools the body down as the sweat evaporates from our skin. As the sweat glands are blocked this process is not able to take place and individuals may then be at risk of hyperthermia.

Signs to look out for:

Fever, muscle cramps, headache, fainting, increase heart rate, dizziness.

How to prevent and treat it?

As the condition is cause by heat and sweating, the main measures are to reduce exposure to such environmental conditions as much as possible.

General measures

Staying indoors in air conditioned , well aerated rooms/offices.
Avoid strenuous exercise which is a potential risk factor.
Wear loose fitting, cotton clothing
Avoid tight fitting clothing ( jeans, jeggings, treggings and all the likes) , un-necessary bandaging as friction can lead of excess distension of the sweat duct causing its rupture.
Avoid wrapping your baby in layers of clothing.
Take frequent showers with cool water and mild pH balanced soaps (such as dove, or other syndet soaps) to help remove debris from the skin. You do not need to use a soap for every bath you take in a day, using a soap once a day is adequate.
Cool compressed with a damp towel helps calms the skin
If you don’t have the luxury of travelling in air conditioned cars/buses, try carrying a face towel with you which you can damp with cold water for regular compressions on your face, chest, neck etc.
Change clothes such as gym wear, uniforms and hop into a cold shower immediately once the activity is over.
Avoid use of occlusive moisturisers/ointments.

Specific treatment options

Powders/Sprays formulated with menthol (for cooling and anti-itch action), anti-bacterial (boric acid), anti-septic (zinc oxide) are easily available in the market. Note that, without the general cooling measures mentioned above, this form of treatment would not be effective on its own.
Seek a dermatologist opinion if the rash gets too uncomfortable, as a course of mild steroid to help reduce the inflammation my be required. ( I stress on the term “mild steroid” as there are various classes of steroids with various potency and we do not want you to be given the wrong form of such creams/ointments as they do come with their own set of complications)
A course of antibiotic cream may be needed if pustules are present and extensive.

Heat rash usually subsides spontaneously even without treatment if the above general cooling measures are followed and treatment is usually un necessary.

Miliaria crystallina, usually subsides within 24 hours of removal of the predisposing factors. And the good news is that miliaria heal without scarring.

featured image: Photo by Hans Reniers on Unsplash

Controversies regarding sunscreens

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This is in continuation the my “All About Sunscreens” post. There are a few controversies relating sunscreens that we are worth mentioning.

1. Does regular use of sunscreens causes deficiency of Vitamin D?

SUNLIGHT IS REQUIRED FOR OUR BODY TO PRODUCE VITAMIN D

Multiple studies have shown that consumers do not use the adequate recommended amount of sunscreen on a daily basis to prevent vitamin D synthesis in our body. Vitamin D can also be obtained from our diet and many fortified food products such as milk fortified with Vitamin D which can compensate for the lack of Vitamin D synthesis via sunlight.

UVB is responsible for Vitamin D synthesis. Adequate amount of Vitamin D can be produced in our body in just under 15 mins of sun exposure to the mid day sun. This process can take longer for darker skinned individuals since they have a natural protection against the sun. Regular daily use of even adequate amount of sunscreens does not lead to Vitamin D deficiency as there are always some parts of our body that are always left unprotected such as our feet or neck or even hands through which UVB can penetrate and initiate the process of vitamin D production in our skin. A recent study showed that:

Regular daily use of adequate amount of sunscreens with high SPF (SPF 50) even in Indian patients with (FST III ,IV) did not cause any vitamin D deficiency in these individuals.

2. Are chemicals used in sunscreens killing our coral reefs?

Few articles were published claiming that chemicals used in sunscreens were toxic to coral reefs and caused bleaching of the reefs. Based on these reports, many beaches in Hawaii and in Florida banned the public use of sunscreens at their beaches. This however was unjustified and potentially risky, exposing beach goers to the increase risks of sunburns and skin cancers.

Several other articles followed debunking this controversy. They highlighted that the earlier reports on the toxic effect of sunscreens on coral reefs were based on experimental studies in laboratories where the reefs placed in plastic bags and were exposed to higher amounts of the chemicals than that present in sunscreen products. This caused bleaching of the reefs. It was then pointed out that the results of these experiments did not translate to real life. The amount of chemicals dispersing from human’s skin into sea water was barely detectable. Since longterm,detailed, well studied scientific evidence regarding this claim is not available yet, banning sunscreens which could prevent skin cancers is unjustified.

It is more important to stress on the fact that rising water temperatures as a result of global warming is more responsible for destroying our coral reefs than sunscreens.

3. Chemical sunscreens are absorbed systemically (into our blood stream) at high concentration. Should we be concerned?

A study published in the Journal of American Association (JAMA) in May 2019 shed new light on the systemic absorption of topically applied sunscreens. The study concluded that active ingredients used in chemical sunscreens such as avobenzone, oxybenzone, octocrylene, ecamsule were all absorbed systemically (into the blood stream) after topical application at significant concentration ( >0.5 ng/ml). According to the Food and Drug Administration (FDA) any ingredient which is absorbed into the system at such concentrations needs further evaluation into the safety and significance of such ingredients in our body. It also means that manufacturers of over the counter sunscreens must produce scientific data on the absorption and safety profile of their sunscreens.

The study concluded that, consumers must not neglect the use of sunscreens that can prevent various types of skin cancers based on this results, since the presence of such chemicals in our blood does not necessarily mean they are toxic or harmful.

For those concerned about this can always opt for mineral (physical) sunscreens.

4. Sunscreens used by adults are not safe for kids?

The incidence of skin cancers are increasing over the years and a unprotected sun exposure during childhood further increases the risks of such cancers in adulthood. Therefore sun protection is especially valuable for children, as it not only decreases the chances of sunburns but also decreases the risks of skin cancers in adulthood.

Regular use of sunscreen during childhood has been estimated to reduce lifetime skin cancer risk by up to 80%

There is no actual difference between sunscreens marketed for adults and for children, nor is it more harmful for children to be using sunscreens formulated for adults. Children are known to have more delicate skin and can be sensitised to various components in the sunscreen products, therefore most sunscreens marketed exclusively for children have less components (fragrance and paraben free) and are mostly mineral based containing zinc or titanium oxide which does not result in sensitisation and allergic reactions.

It is important to note that, the FDA does not approve the use of sunscreens in children less than 6 months of age. Physical sun protection such as wide brim hats, using strollers with proper shade, long sleeves clothing and avoiding exposing babies to sunlight between 10-16:00 hours is the recommended sun protection measures for such age groups.

My personal advice is, if your child is not allergic to any components of the sunscreen and is above 6 months of age, there is no reason to buy a separate sunscreen marketed exclusively for kids.

If you have heard or more controversies regarding sunscreens and want me to discuss about it, drop in a comment below.

All about sunscreens

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Sunscreens are the number one skin care product every dermatologist swears by. In the Western countries, where the incidence of sunburns and skin cancers are high among Caucasians, sunscreen is life saving. In a country like India, where the individual’s skin type (FST IV and V) predisposes them to pigmentation disorders (melasma, post inflammatory hyperpigmentation -PIH), sunscreens are the first armour to fight against pigmentation.

Lets recap a little on solar radiation, so as to understand what exactly a sunscreen does.

UVA– 98-99% of the solar radiation reaching the earth’s surface. UVA is the spectrum of UV radiation that can penetrate the dermis and is responsible for immediate tanning, photoaging, pigmentary disorders, photodermatoses such as polymorphous light eruption etc

UVB– 1-2% of UVR reaching the earth’s surface. UVB is highly energetic but does not penetrate beyond the epidermis (superficial layer of skin) and is responsible for sunburns, skin cancers and delayed tanning. UVB is also required for Vitamin D synthesis in our body.

UVC– filtered out by the ozone layer and does not reach the earth’s surface.

How sunscreens work?

There are two types of sunscreen :

Physical or inorganic sunscreens

They contain titanium dioxide, zinc oxide, iron oxide, or calamine, and functions by forming a coat on the skin that reflects, scatter or absorb the UVR. Physical sunscreens are ideal for patients with sensitive skin as the ingredients do not interact with the proteins and lipids in the skin, and they can protect against both UVA and UVB radiation but they bear the disadvantage of leaving a white cast on the skin. The newer physical sunscreens are relatively more expensive as well.

Micronised & ultrafine particles of zinc or titanuim oxide are generally considered more acceptable cosmetically. Multiple positive reviews on elta MD and LRP physical sunscreen, consumers remarked that these sunscreens do not leave white cast and blends easily.

Neutrogena and kiehl’s have mixed reviews. They seems to be well suited for fair skin individuals and not very aesthetically pleasing to individuals with darker skin tone.

Chemical or organic sunscreen

Most sunscreens available in the market are chemical sunscreens. They contain ingredients that can absorb UVR and converts it to heat energy which then dissipates into the environment. They do not leave a white cast on the skin and hence considered more cosmetically acceptable.

Chemical sunscreens are most commonly found in the market. Bioderma photoderm max has a combination of both physical and chemical sunscreen and no white cast on application.

Active ingredients in chemical sunscreens

It is not uncommon to find a mixture of both physical and chemical sunscreen as well. The disadvantage of a chemical sunscreen is that the active ingredients can react with components in the skin such as proteins and lipids which then may result in wanted production of reactive oxygen species causing irritation to the skin. Susceptible individuals may be sensitized to these components in the sunscreen which will manifest as contact allergic dermatitis (red, itchy skin). For this reason physical sunscreens are preferred for patients with sensitive skin.

What does SPF and PA factor mean?

SPF stands for sunburn protection factor which is a measure of protection against UVB induced sunburn. Sunscreen which only mentions SPF means they only provide protection against UVB and not UVA ( the spectrum which is responsible for pigmentation, photoaging). The grading of SPF is as follows:

Low: SPF 2 – 15
Medium: SPF 15 – 30
High: SPF 30 – 50
Highest: SPF >50

An SPF of 15 blocks 93% and an SPF of 30 blocks 95% of the UVB radiation. Note that double the SPF does not mean double the protection. Sunscreens with higher SPF contains more active ingredients which may make the product less pleasing to use to some individuals.

PA factor measures the protection against UVA. It measures the Persistent pigment darkening (PPD) or tanning after UVA exposure.

PA + : some protection from UVA
PA ++: moderate protection
PA +++: best protection
PA ++++: highest protection : rare to find this in products

How to use a sunscreen?

A given sunburn protection factor in a sunscreen can be obtained only when the right amount of sunscreen is used. Studies use 2mg/cm2 when testing for SPF in a sunscreen, however in reality we tend to use a lesser amount which will then result in a lower SPF than what is labelled in the sunscreen. Therefore dermatologist recommend a higher SPF (SPF>30) to help compensate for the inadequate application.

Dermatologist use the “teaspoon rule” to determine the correct amount of sunscreen needed.

3 mL (slightly more than half a teaspoon)- 3 mL for each arm and 3 mL for the face and neck
6 mL (slightly more than a teaspoon)- 6 mL for each leg, 6 mL of the chest and 6 mL for the back

Apply a sunscreen at least 20 mins prior to outdoor exposure so as the ingredients can form a uniform layer on the skin. It is also ideal to wait 20 mins before putting on clothes otherwise a significant amount of sunscreen will be wiped away during the contact with clothing. The best way to do this is to apply a sunscreen right after a shower or washing your face in the morning and not wait until its time you get dressed for work.

When to re-apply a sunscreen?

We are all familiar with the golden rule of “re-application of sunscreens” which states that a sunscreen must be re-applied every 2 hours as physical activities like touching your face, sweating, friction from contact with sand at the beach can remove some amount of sunscreen from your skin. Reapplication is also recommended after activities in water.

So does this rule apply to modern water-resistant sunscreens which can bind effectively to the skin and retains its said SPF even after 40-80 mins immersion in water?? Recent studies have shown that reapplication helps compensate for the under application of sunscreens. Reapplication after 20 mins also provides better protection against sunburn than delayed reapplication i.e after 2 hours. Therefore early reapplication of a sunscreen is preferred, ideally within the first hour of the first application.

Gentle application is better for sunscreens with gel, or creams consistency. Rubbing it immediately on the skin is recommended for spray sunscreens.

Always search for a broad spectrum sunscreen (UVA & UVB protection) and a water resistant sunscreen.

White cast of physical sunscreens.

The white cast blends with the skin in 30-40 secs of gentle rubbing.

Aesthetics of chemical sunscreens

No white cast, no excuse. Wear sunscreen.

Scientific evidence of the effectiveness of sunscreens for melasma in Indian patients.

A recently published study in the Indian journal of dermatology which studied the efficacy of two different sunscreens on skin pigmentation. A total of 230 patients were recruited in the study. One group was given a sunscreen with an SPF of 50 with PA +++ and the other group a sunscreen of SPF 19 and PA +++. At the end of 12 weeks of twice daily usage, a significant improvement in the form of decrease density of pigmentation and better radiance was noted in both groups. The conclusion is that:

Regular use of a sunscreen with high UVA protection (PA+++) highly effective in improving the skin radiance and in decreasing the skin pigmentation.

So my advised is always look for a sunscreen with PA+++ if you have pigmentation issues, and if you are also prone to sunburns, then get one with an SPF of at least 30.

Hope this was helpful. And stay tune to my next posts on “Controversies regarding sunscreens”.

Do we need to fear the sun?

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There is nothing like a bright sunny summer day to lighten up your mood. The sun is an essential component in the process of vitamin D synthesis in our skin, required for normal development and functioning of the bones. Yet exposure to the sun is not without any consequences.

Before talking about the risks associated with sun exposure, let’s have a look at the general principles of ultraviolet radiation (UVR) for a better understanding of what we will be discussing next.

The sun emits UVR which is of three different forms depending on the wavelength: UVA, UVB and UVC.

fig. the longer the wavelength of the UVR the deeper the penetration.

Although UVA is less harmful than UVB in its ability to cause cancers, the high amount of UVA that reaches the earth’s atmosphere and the ability of UVA to penetrate deeper into the skin makes protection against UVA it as important as protection against UVB.

How our skin protects us against the harmful UVR?

Besides the ozone layer which absorbs the harmful UVR and preventing it from reaching the earth’s surface, our skin also plays an important role in protecting our body against the UVR.

Our skin acts an effective barrier preventing the penetration of the UVR beyond the dermis (deeper layer of skin) and into the internal organs. Our skin is also equipped with various defence mechanisms such as enzymes and antioxidants which help repair the damage to the cells produced by UV exposure.

But in the process of protecting us from the UVR, certain light absorbing substances (called chromophore) undergoes a photo-chemical reaction that results in damage to the skin cells which results in sunburn, allergic reactions to the sun and if the body fails to repair the damage, the mutations can lead to skin cancers. Therefore the skins bears the maximum detrimental effect of the sun.

So, do we need to fear the sun?

My answer is “YES”, especially if you’re person with Fitzpatrick skin type I-II, who have the maximum risk of UV induced skin cancers (see the previous blog post: “Do you know your skin type?“). Sun protection in these individuals is necessary from a very young age as risk of melanoma (a malignant cancer of the skin) is more with intense intermittent sun exposure from a very young age.

Sun protection is also necessary to prevent early signs of ageing and for individuals with pigmentation disorders or individuals with photodermatosis ( skin diseases caused solely due to the body’s abnormal response to the UVR) or genetic disorders such as xeroderma pigmentosa (inherited disease caused by a mutation that affects the ability of the body to repair the DNA damage produced by the sun).

That being said, fearing the sun does not mean you live under a rock and never see the sunlight again. As I did mention we need the sun for Vitamin D synthesis, and a few minutes of sun exposure two times a week is adequate for this normal process to occur. My advice is for you to understand when and where the danger lies and how to minimise it.

When and where is the sun’s UVR the maximum?

Areas near the equator receives maximum UVR.

fig. the red band represents where earth receives maximum UVR.

Higher the altitude more the UVR (Shimla, Jammu and Kashmir etc), even though these places are relatively colder, sun protection is still a must due to the shorter UVR path.

The time of the day when the sun is directly overhead i.e around noon time (9am- 3pm) is the time when sun protection has to be at its maximum. Early morning and late afternoon sun’s rays are directed at an angle to the earth’s surface and are mostly absorbed.

What if it is cloudy outside?

Clouds can reduce (though not by a great amount) the UVR reaching the earth but in days with scattered clouds, the UVR may even be more as most of the radiation are scattered. So my fellow Meghalayians (people hailing from a state in India call Meghalaya), you still need that sunscreen even if you live in a state whose name literally translates to the “Abode of clouds”

Abode of the Clouds (CC BY 2.0: Rajesh Dutta)

And what if its snowing outside?

Snow and sand, sea, are a good reflector of UVR which can double the risk of UV exposure.

In future posts we will explore the ways of proper sun protections. In the meantime remember that packing a sunscreen for your skiing trip at the Alps is as important as packing your sunscreen for a day at the beach.