Sun-safe practices in different pediatric patients

According to the American Academy of Dermatology (AAD), “It only takes 1 blistering sunburn during childhood or adolescence to nearly double a person’s risk of developing melanoma, the deadliest form of skin cancer, later in life.”¹ Caregivers and parents should feel empowered to protect their children with sun-safe practices that include sunscreen, sun-protective clothing, and sun-safe activities. Sun-safe practices should begin at an early age to foster long-term habits of sun safety and should be maintained beyond the summer season.

Methods for sunscreen application

Ages 6 months and older

Babies older than 6 months should be dressed in sun-protective clothing and accessories, such as wide-brimmed hats.² Additionally, they should have generally recognized as safe and effective (GRASE) sunscreen applied to their faces and other exposed skin areas, such as the feet.³ In sunscreens, the FDA identifies only zinc oxide and titanium dioxide as GRASE ingredients. Non-GRASE ingredients include substances such as para-aminobenzoic acid (PABA). Other ingredients, including oxybenzone, ensulizole, avobenzone, and padimate, require further testing. A comprehensive list of these ingredients can be found on the FDA website under the Sunscreen Innovation Act.⁴

Neurodivergent patients

Neurodivergent children with sensory challenges may require additional assistance in applying sunscreen. It is as important for neurodivergent children to practice safe sun habits as it is for neurotypical children. A recent article published by Australian dermatologists discusses barriers to sun protection and provides tactics to support the sunscreen application process, emphasizing elements of signposting, independence, and collaboration.⁵ Techniques such as positive reinforcement and taking turns are also recommended. Sun-safe clothing is an additional protective measure that should always be included in sun safety practices.⁶

Frequency

Sunscreen reapplication should occur at 2-hour intervals, and for water-resistant sunscreen, reapplication should be done every 40 to 80 minutes. Sunscreen should be first applied 30 minutes prior to going outdoors.⁷

Expiration

Sunscreen expiration dates are typically within a 3-year period and can be found on product labels. Visible signs of expired sunscreen include changes in consistency. Sunscreen left in hot environments will undergo an expedited expiration process.⁸

Sunscreen forms and efficacy

Sunscreens are available in various forms, including sprays, gels, and creams. Sunscreen sprays are often considered the least effective, as a significant portion of the product may be carried away by the wind. Gels are lightweight and have higher skin absorption, making them suitable for children with oily or acne-prone skin. Sunscreen creams may be recommended for children with dry skin, as they offer moisturizing and emollient properties that can help hydrate the skin.⁹

Unraveling sunscreen language

The AAD provides definitions and explanations for common terms used in sunscreen labels, as follows:

• Broad spectrum refers to UV-A and UV-B coverage. UV-A and UV-B rays affect skin differently, as UV-A rays penetrate the skin deeper than UV-B rays. UV-A is most related to skin aging and skin cancer, while UV-B rays are associated with skin burns and skin cancer.¹⁰

• Sun protection factor (SPF) refers to a sunscreen’s protection against UV-B rays. An SPF of 30 blocks 97% of UV-B rays, while an SPF of 50 blocks 98% of UV-B rays. SPF can also be interpreted as allowing 1 out of every 30 rays to reach the skin for SPF 30 and 1 out of every 50 rays for SPF 50.¹¹

• Water-resistant sunscreens are effective for 40 minutes in the water rather than being washed off immediately. Water-resistant sunscreens require reapplication every 40 minutes when in contact with water.

• Waterproof sunscreen does not exist. The AAD explains that water and sweat wash sunscreen from our skin, and the FDA prohibits manufacturers from labeling their products as waterproof^.12

• Mineral sunscreens, also known as physical sunscreens, block the sun’s rays by reflecting them off the skin. They are more likely to cause a white cast and are preferred for sensitive skin. Zinc oxide and titanium oxide are ingredients in these sunscreens and considered GRASE.

• Chemical sunscreens absorb the sun’s rays and are less likely to leave a white cast. The following active ingredients are found in chemical sunscreens: oxybenzone, avobenzone, octisalate, octocrylene, homosalate, and octinoxate. They require additional study by the FDA before they will be considered GRASE.

Guidelines for selecting an appropriate sunscreen for children

The proper sunscreen for your child’s protection should meet the following criteria:

1. They should have SPF 30 or higher.

2. They should provide protection against UV-A and UV-B rays.¹³ Additional information on UV-A and UV-B blockers is included below.¹⁴

3. They should be water-resistant.

4. They should contain GRASE ingredients established by the FDA.

UV-A filters

• Benzophenones: These are broad-spectrum blockers, showing a greater affinity for UV-B absorption and limited absorption of UV-A II. Some derivatives in this category have been known to induce various forms of dermatitis reactions.

• Ecamsule: This compounddemonstrates photostability, water resistance, and low systemic absorption.

• Avobenzones: These are considered broad-spectrum blockers effective against UV-A I. However, they are limited by photoinstability, losing 50% to 90% of efficacy after 1 hour of UV exposure.

• Anthranilates: Thesefunction as weak blockers of both UV-B and UV-A rays.

UV-B filters

· Octocrylene: This compoundcan enhance SPF when combined with other UV absorbers. It is considered safe and is less likely to cause irritation.¹⁵

• Ensulizole: This compoundfilters only UV-B rays and is water-soluble. It is commonly used in cosmetics.

• Aminobenzoates: These arehighly effective UV-B absorbers with no UV-A absorption. They are associated with PABA, which often causes dermatitis.

• Padimate O: This compound isgenerally considered safe, being a PABA derivative with effective UV-B protection. However, further testing is required by the FDA before inclusion in the GRASE category.

Irritants and allergies

Certain sunscreen ingredients can trigger reactions in individuals with sensitive skin. It is recommended to avoid products containing ingredients that have previously irritated your child’s skin. However, if a caregiver suspects a potential reaction based on past experiences, patch testing offers a safe method to prevent more severe reactions.¹⁶

Patch testing involves applying a small amount of the product to the skin on the forearm and monitoring for any reaction over a 48-hour period. Signs of a reaction may include swelling, hives, scaling, pain, or blistering.¹⁷ If your child displays any of these symptoms, it is important to notify their primary care physician, dermatologist, or allergist for further evaluation and guidance.

Recent studies have identified common allergens in sunscreens, including added fragrances, cinnamates, dibenzoylmethanes, and benzophenones like benzeophenone-3 and oxybenzone.¹⁸ Allergic reactions are more likely to be triggered by inactive ingredients than by active ones. However, individuals with autoimmune conditions may react to both inactive and active ingredients, making physical sunscreens preferable over chemical ones in such cases. Additionally, research indicates that all SPF 100 sunscreens utilize chemical blockers, highlighting the importance of consulting a dermatologist when choosing a suitable sunscreen for your child’s skin condition.¹⁹

Caregivers can discuss 4 types of reactions, also referred to as forms of dermatitis or eczema, with their child’s health care provider to gain a better understanding of their child’s condition. These include contact dermatitis, irritant contact dermatitis, allergic contact dermatitis, and photocontact dermatitis. It is worth noting that sunscreens rarely cause photocontact dermatitis.²⁰

Sunscreen guidelines and management for pediatric age groups of all skin types

Infants (ages 0-6 months)

Sunscreen should not be used on infants under 6 months of age due to their inability to metabolize sunscreen ingredients. Sun safety for infants includes using lightweight sun-protective clothing with Ultraviolet Protection Factor; wide-brimmed hats; and, if tolerated, sunglasses with UV-A/UV-B protection. It is also essential to keep infants hydrated and out of the sun between 10 am and 4 pm. Further protective measures, such as UV window films or shades, which filter UV radiation, should be implemented. Protecting infants from exposure to UV radiation is crucial in reducing their risk of cataracts and retinal damage, which often occurs before the age of 18.²¹

Babies (ages 6-12 months)

Sunscreen is safe to use in babies above 6 months of age. A baby’s sunscreen should include broad-spectrum protection against both UV-A and UV-B rays, have SPF 30 or higher, include GRASE ingredients, and avoid fragrances. Patch testing is recommended to minimize the risk of a reaction.²²

Once an appropriate sunscreen has been selected for your baby, apply the sunscreen 30 minutes before sun exposure and reapply every 2 hours. If water-resistant sunscreen is used, reapplication must be done every 40 to 80 minutes due to its limited efficacy in water. Apply sunscreen to all exposed skin surfaces, including the face, ears, neck, hands, and feet. Use lightweight sun-protective clothing, wide-brimmed hats, and umbrellas to keep your baby safe.²³

Toddlers to school-aged children

The use of sunscreen and sun-protective clothing is important for school-aged children. Some schools may allow for the reapplication of sunscreen throughout the day. However, additional protective measures include ensuring your child’s play area has adequate shading and areas to cool off. If your child has a skin condition that requires the reapplication of sunscreen throughout the day, a doctor’s note may be necessary to ensure your child’s health and safety at school.²⁴

Tweens (ages 9-12 years)

There has been a growing interest among tweens in skin care and the establishment of a skin care routine, which necessitates appropriate guidance. Academic institutions such as Kaiser Permanente have outlined components of an age-appropriate skin care regimen for tweens, which typically include a gentle moisturizer, broad-spectrum sunscreen with SPF 30 to 50, and a mild cleanser. Tweens are advised to refrain from using retinols or acids unless specifically recommended by their physicians.²⁵

Teenagers (ages 13-19 years)

As tweens transition into their teenage years, their skin may undergo changes, including concerns such as acne and hyperpigmentation. Skin types become relevant in this age group, ranging from dry and oily to combination skin. A teenager’s skin type influences the type of sunscreen recommended. Gel sunscreens are lightweight and may be best for oily skin, while cream sunscreens, containing emollients, may be more suitable for dry skin.²⁶

Teenagers dealing with acne may be undergoing certain treatments, emphasizing the need for appropriate sunscreen use to prevent complications. This includes individuals taking oral antibiotics, using retinols, or undergoing isotretinoin treatment.²⁷ Older teenagers using advanced treatments such as laser hair removal may also need to incorporate sunscreen as a fundamental component of their skin care routine.

Skin care routines at this age may be as simple as using a gentle cleanser, moisturizer, and sunscreen. Teenagers should also consider using a lip balm with sunscreen to protect their lips. Those who wear makeup should not rely solely on the integrated sunscreen in foundations and concealers, as sunscreen is most effective when applied directly to the skin.²⁸ Teenagers should apply sunscreen in the morning after washing their faces. The recommended order of skin care items is as follows: gentle face wash, sunscreen, moisturizer, and then makeup.²⁹ For teenagers using vitamin C serums, apply the serum before sunscreen.

Click here for more from the May issue of Contemporary Pediatrics.

References:

1. 10 surprising facts about indoor tanning. American Academy of Dermatology Association. Updated April 26, 2023. Accessed April 5, 2024. https://www.aad.org/public/diseases/skin-cancer/surprising-facts-about-indoor-tanning

2. Infant sun protection: how parents can keep their baby safe. American Academy of Dermatology Association. 2023. Accessed April 5, 2024. https://www.aad.org/public/diseases/skin-cancer/prevent/sun-babies

3. Generally recognized as safe (GRAS) notification program. FDA. January 31, 2024. Accessed April 5, 2024. https://www.fda.gov/animal-veterinary/animal-food-feeds/generally-recognized-safe-gras-notification-program

4. Center for Drug Evaluation and Research. Sunscreen Innovation Act: Section 586C(c) Advisory Committee Process: Guidance for Industry. FDA; 2016. FDA-2015-D-3990. Accessed April 5, 2024. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/sunscreen-innovation-act-section-586cc-advisory-committee-process

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17. Garg V, Brod B, Gaspari AA. Patch testing: uses, systems, risks/benefits, and its role in managing the patient with contact dermatitis. Clin Dermatol. 2021;39(4):580-590. doi:10.1016/j.clindermatol.2021.03.005

18. Heurung AR, Raju SI, Warshaw EM. Adverse reactions to sunscreen agents: epidemiology, responsible irritants and allergens, clinical characteristics, and management. Dermatitis. 2014;25(6):289-326. doi:10.1097/DER.0000000000000079

19. Keyes E, Werth VP, Brod B. Potential allergenicity of commonly sold high SPF broad spectrum sunscreens in the United States; from the perspective of patients with autoimmune skin disease. Int J Womens Dermatol. 2019;5(4):227-232. doi:10.1016/j.ijwd.2019.05.006

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