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Are you also spending more time outside? For many, it’s a great time of year to be outdoors. Recently, I’ve been asked a few questions about sun safety in kids:

• What are the sun protection recommendations for babies?
• Do my non-White children need sunscreen?
• What about all those chemicals in sunscreen?

I’ll address all those questions today. First, we’ll review the standard recommendations from the American Academy of Pediatrics (AAP) and the American Academy of Dermatology (AAD). Then, I’ll go over some basic information about melanin (the reason for skin pigmentation), and why people with darker skin still need sun protection. I’ll also review some areas that need more research.

We’ll finish off with practical recommendations. I’ll share what we do in my own family.

Why Kids Need Sun Protection

UV radiation from the sun is linked to cancer in humans. Both the AAP and AAD recommend everyone protect themselves from too much sunlight. This applies to everyone, regardless of skin color. While sunlight has benefits like Vitamin D ( https://www.mayapeds.com/how-to-follow-vitamin-d-recommendations-for-kids/ ), excess can be harmful. Below are the standard suggestions to keep children safe from harmful sun exposure.

Recommendations for Sun Protection in Children

• Avoid being out in the sun between 10am and 4pm, when the radiation is strongest.
• When outside, wear sun protection on skin and eyes. This includes wide-brimmed hats, sleeves, and keeping legs covered when possible. It also means wearing sunglasses. For all exposed skin, use a broad spectrum sunscreen (SPF greater than 30). SPF stands for sun protection factor, a rating used on sunblock products.
• Choose the shade whenever possible.

This post focuses on skin protection, but I want to be clear that sunglasses are also important. Too much sunlight in the eyes can increase the risk of cataracts. It can also lead to other growths in the eye later in life (including cancers). Sunglasses should be labeled as blocking 99% or 100% UV light. They should fit well, ideally not letting in much light from the sides.

Additional Sun Safety Recommendations for Babies

The AAP recommends babies under age 6 months avoid all direct sunlight. A sunburn in a baby increases their future skin cancer risk. If time in the sun is unavoidable, they should cover up with hats, sunglasses and clothing. Use sunscreen on any uncovered part of their body (face or back of hands, for example) to prevent a sunburn. Later, we’ll discuss how I suggest choosing a sunscreen. 

What about melanin?

Melanin is a general term that covers pigments made by skin cells. There are several types of melanin. A person’s skin color depends on the type of melanin and how active the melanin-making cells are. Melanin itself protects against sunburn. It can have the equivalent of an SPF of 2-4. This depends on which study we refer to and how dark someone’s skin is. But also! Melanin itself has anti-skin cancer properties. More research is needed, but the available information is fascinating. Darker skin due to melanin can mean lower risk of some types of skin cancer (melanoma) in addition to the sun protection. 

We often refer to lowering the risk of melanoma when we talk about sun protection. White people are at much higher risk of developing melanoma than darker skinned people. 

Black people, people of Asian and Native American descent, as well as Hispanics can also get melanoma. It’s often detected at later stages, and commonly affects parts of the body not exposed to the sun. Statistically, though, melanoma is more common in fair-skinned people. There are also differences based on ethnicity. For example, White people have a higher risk of melanoma than Asians with fair skin. Survival rates of melanoma, however, are lower in the non-White population. (This likely means skin cancer prevention in the non-White population goes beyond sun protection. We need to learn more).

Does this mean kids with dark skin don’t need sun protection?

No. Everyone should still protect their skin and eyes from the sun. Sun damage is more than just melanoma risk. There are also other types of skin cancer. UV radiation also causes damage below the surface of the skin. Appearance (wrinkles!) is related to sun exposure as well.

The emerging and existing research reveals more information is needed about those with darker skin. I think it’s important to note here that medical research has a history of not including race or ethnicity in studies. I’m referring to the fact that much of today’s health information (in dermatology and elsewhere) is based on research in mostly fair-skinned people, or studies where race and ethnicity were not included. Fortunately, this is improving, especially in the United States. A lot of work remains to better understand skin of color.*

Below, we’ll discuss exactly how to protect ourselves from too much UV radiation.

Which sunscreen is best for kids?

We also need more research on sunscreen ingredients! Based on what information we do have, I’ve made choices in my own family despite FDA and AAD recommendations. The following is not a completely evidence-based recommendation.

But first, an explanation. 

There are two types of sunscreens, chemical and mineral-based.

What are chemical-based sunscreens?

The chemical-based sunscreens are popular partly because they blend into skin well. Many people find them more cosmetically appealing. However, as of February 2019, the FDA has listed many (12) ingredients in chemical sunscreens that need more research. The FDA does not say that they are definitely safe or unsafe to use. Oxybenzone is one of the most common ingredients. What do we know? Many of these chemicals are absorbed through skin. Many are found at higher-than-expected levels in blood and breastmilk. And, some of them may interfere with hormones. In animal studies, some of these chemicals affect the reproductive system. One small study showed a relationship between oxybenzone and lower testosterone levels in boys. According to the Environmental Working Group, there are other studies that show an association between oxybenzone and pregnancy outcomes. 

Relationships and associations do not mean direct cause, however. And the research overall really is limited. Until there is more information, the FDA has not recommended removing them from currently available products or limiting their use. 

For what it’s worth, many of these same chemicals harm marine life, especially the reproductive systems of fish and other sea animals. (This is why some beach resorts request visitors avoid using certain sunscreens). 

What are the mineral-based sunscreens?

Mineral-based sunscreens include zinc oxide and/or titanium dioxide. Not much seems to be absorbed or found in the blood. They often appear white-ish in color when applied. These sunscreens are ‘generally recognized as safe,” by the FDA, and work by directly blocking UV radiation. 

Choosing the Best Sun Protection for Kids

First, even though we need more research overall, there is no question that sun protection prevents some types of skin cancer. The best sun protection is clothing, hats, and sunglasses. Sunscreen is for the remaining exposed body parts. 

When it comes to sunscreen for my kids, I’ve chosen to use only mineral-based sunscreens when possible. Even though we don’t have complete information about the chemical-based sunscreens, I’ve made this decision for my family. This is especially because there is an easily available and safer alternative. We also wear brimmed hats and long sleeved shirts (i.e. rash guards) when outside. Ideally, we’d also always wear long pants and sunglasses.

In this situation, we can make a choice while awaiting official recommendations. I thrive on evidence-based medicine and decision-making. However, sometimes we can also draw conclusions until research catches up. (I’m reminded of research on plastic as another example. There were concerns long before official statements came out).

I encourage others to also prioritize whatever sun protection works for them.

November 2021 update: A recent study showed that zinc oxide combined with some different chemical-based sunscreens can be toxic in sunlight. It was a study in zebra fish, so there’s still a lot to learn about what happens in humans. However, until we know more, we can be careful not to mix (or layer) zinc oxide with chemical sunscreens.

Summary

Everyone needs sun protection to lower risks of several types of cancer as well as other skin damage. Choose covering first with clothing. I also suggest families decide if mineral-based sunscreens are the best choice for them. We need to advocate for more research to include people with skin of color. We also need more research on chemical exposures and possible hormone-disrupters in sunscreen.

Importantly, we should all continue to spend time outside! Information here today is just to help everyone enjoy the outdoors more safely.

*In dermatology, skin can be scaled using the Fitzpatrick skin classification, ranging from1 to 6, based on how easily skin sunburns. “Skin of color” usually includes those in the 4-6 range. See https://dermnetnz.org/topics/skin-phototype/ for details and a chart.

Addendum: In this post, I use the term “Hispanic” as opposed to “Latino” because “Hispanic” is used in the paper I reference. There are differences between the terms, and I want to maintain as much accuracy as possible.

References

Garnett, E., Townsend, J., Steele, B., & Watson, M. (2016). Characteristics, rates, and trends of melanoma incidence among Hispanics in the USA. Cancer causes & control : CCC, 27(5), 647–659. https://doi.org/10.1007/s10552-016-0738-1

Dawes, S. M., Tsai, S., Gittleman, H., Barnholtz-Sloan, J. S., & Bordeaux, J. S. (2016). Racial disparities in melanoma survival. Journal of the American Academy of Dermatology, 75(5), 983–991. https://doi.org/10.1016/j.jaad.2016.06.006

Irvin Painter, N. (2020 July 22) Why ‘White’ should be capitalized, too. Washington Post. Retrieved from: https://www.washingtonpost.com/opinions/2020/07/22/why-white-should-be-capitalized/

Brenner, M., & Hearing, V. J. (2008). The protective role of melanin against UV damage in human skin. Photochemistry and photobiology, 84(3), 539–549. https://doi.org/10.1111/j.1751-1097.2007.00226.x

McFarling, U.L. (2020 July 21). Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color . Stat. Retrieved from https://www.statnews.com/2020/07/21/dermatology-faces-reckoning-lack-of-darker-skin-in-textbooks-journals-harms-patients-of-color/

The Environmental Working Group. The Trouble with ingredients in sunscreens. https://www.ewg.org/sunscreen/report/the-trouble-with-sunscreen-chemicals/#:~:text=The%20most%20common%20sunscreens%20contain,oxide%20and%2For%20titanium%20dioxide

Brown, J. (2019 July 22) Sunscreen: What science says about ingredient safety. BBC Future. Retrieved from https://www.bbc.com/future/article/20190722-sunscreen-safe-or-toxic

Hippo Education. (2020 December). Race in Medicine: Skin of Color. Peds RAP

The American Academy of Dermatology, via www.aad.org

The American Academy of Pediatrics, via healthychildren.org

Buster, K. J., Stevens, E. I., & Elmets, C. A. (2012). Dermatologic health disparities. Dermatologic clinics, 30(1), 53–viii. https://doi.org/10.1016/j.det.2011.08.002