Following up from my post yesterday, I wanted to give a separate platform to the brilliant dermatologists that responded to my request for a comment on the Gwyneth/Vogue SPF situation.
I’m listing them in alphabetical order, via surnames. There is no hierarchy here. They are all fantastically qualified, brilliant people.
Aegean H. Chan, MD, FAAD
Board Certified Dermatologist & Dermatopathologist
Based in Santa Barbara, CA
Adjunct Professor in the Department of Dermatology at the Keck School of Medicine of the University of Southern California
Medical Training, Residency, & Fellowship: Albert Einstein College of Medicine/Montefiore Medical Center
Instagram: @draegeanchan
Website: Aegeanmd.com
The recommendation to apply sunscreen as a spot treatment based on your perception of where the sun hits your face is incredibly misinformed and dangerous. UV radiation affects any skin that is exposed to the sun and we know that UV radiation is the main driver for skin cancers, which predominantly occur on the head and neck. Skin cancer is not rare – data suggests that 1 in 5 people will develop some form of skin cancer in their lifetime. Exposure to UV radiation and skin cancer is preventable through the appropriate use of sunscreen and sun protection strategies, including sun avoidance and wearing sun-protective clothing.
To achieve the SPF rating on the bottle, enough sunscreen should be applied to achieve a density of two milligrams per centimeter squared of skin (2mg/cm2). This is approximately a quarter teaspoon for the face or two-finger lengths. It should also be reapplied after swimming, sweating, or after 2 hours.
Lastly, I want to reiterate that sunscreen, both organic and inorganic filters, is demonstrably safe. There is no such thing as clean sunscreen. There is no evidence of clinically significant hormone disruption in humans with the use of organic (chemical) sunscreen filters like oxybenzone. There is a lot of unfounded fear mongering around this issue, especially from the EWG.
The best sunscreen is the one you will actually use.
Dr Beibei Du-Harpur, Dermatology Registrar and Clinical Research Fellow
MRCP (Derm) MBBChir MA (Cantab) PGCert ClinEd
Based in London
Instagram: dermatology_demystified
The burden of skin cancers on NHS dermatology services cannot be underestimated.
Referrals and cases of skin cancer are increasing year-on-year, and this has led to dermatology services pivoting to expand their skin cancer services.
If you have struggled to see an NHS dermatologist for your acne, rosacea, eczema or non skin cancer related concern, this is a big reason why. There are not very many dermatologists in the UK per head, and an enormous amount of our time is now spent dealing with suspected skin cancer. It is true that non-melanoma skin cancers are less dangerous. However, squamous cell carcinoma can be deadly, and treatments of these skin cancers often involve facial surgery, resulting in permanent scars. Most of these skin cancers appear as skin ages, and those who have one skin cancer will usually continue to have more – leading to constant visits to the dermatologist for treatments. This is not how you want to spend your retirement.
Since the 70s, we have come to understand so much more about how dangerous ultraviolet (UV) radiation is, and how important it is to limit our exposure to promote longevity and health of the skin. However, sun seeking behaviours continue to be the norm, despite public health messages. We now know there is no such thing as a ‘healthy tan’ – it’s an oxymoron from a skin health perspective. Healthy skin is facilitated by sun protective behaviour. This includes: avoiding or limiting exposure to sun at high UV index, seeking shade, wearing sun protective clothing such as a wide-brimmed hat, and using broad-spectrum sunscreens. In the past year I have noticed a worrying trend of hesitancy over sunscreen use due to purported ‘toxic chemicals’. This is misinformation spread by commercial organisations. UV radiation is so harmful to skin that humans have evolved an entire DNA repair mechanism to address the damage it causes. The risk from sunscreen is unproven and when theoretical concerns have been raised, scientists at regulatory bodies have evaluated the risk and determined it to be irrelevant in real-world use settings. I have no doubt in safety of the products on our shelves, used according to instructions. On the other hand, the risk from UV is well-established scientifically. It is a grade I carcinogen.
It is important to be aware that sunscreen work because they contain chemicals (inorganic, or organic) with the ability to absorb dangerous wavelengths of energy. It is a product (in the USA, it is considered a drug) with a dose; 2mg of product for each cm2 skin, to achieve the sun protection factor (SPF) stated on the bottle; this is related to the testing standards. Therefore, there is a relationship between its absorptive power and the amount applied. Inadequate application means significant reduction in protective factor. Furthermore, research has shown that people apply woefully inadequate quantities of sunscreen (even when they know they are being assessed on their application!). Studies have also shown that sun-seeking behaviours are incredibly ingrained; they even persist despite a melanoma diagnosis. There is also data suggesting that high SPF sunscreens are used to facilitate sun-seeking behaviour, which, taking into account that true SPF on skin is nowhere near what it is on the bottle due to inadequate application, extremely dangerous.
Time after time, patients report tanning and burning despite using sunscreen – this is because it is being used incorrectly, or as part of a sun seeking behaviour pattern. Our public health message is clear: use sunscreen liberally, as part of sun protective behaviour.
We, and patients who see us, could seriously do without large platforms contradicting our message and misleading the public.
Dr Dennis Gross, M.D., F.A.A.D
Board Certified Dermatologist & Dermatologic Surgeon
Based in Manhattan, New York
Instagram: Dr Gross: @dennisgrossmd
Instagram: Dr Dennis Gross Skincare: @drdennisgross
Clinic website: www.dennisgrossmd.com
Brand website: drdennisgross.com
As a practicing dermatologist and former skin cancer researcher, sunscreen education is very important to me. It is imperative for consumers to understand that for sunscreen to protect us from skin cancer and photoaging, it must be BOTH properly applied and used in adequate amounts on the entire skin surface.
This means applying a thorough coating of sunscreen thick enough to block out the sun. The recommended amount is 2mg/cm2 which means you should apply your sunscreen generously and diligently enough to coat the entire surface area of exposed skin. Do not “skip” ANY part of the skin surface – that is what creates vulnerable, unprotected skin.
I have evidence that this is good advice. In my practice, I see patients with alarming rates of skin cancer in areas where they “ missed” applying sunscreen. This is especially common in ears and upper forehead near the hairline. Getting a little bit of sunscreen in your hair is the least of your worries. Wearing a hat is a great way to add extra protection. Even your scalp can burn!
The bottom line is wear your sunscreen and your technique does matter! Be smart and disciplined. Your skin will be healthier for it!
Ranella Hirsch, M.D., F.A.A.D.
Past-President, American Society of Cosmetic Dermatology and Aesthetic Surgery
Based in Cambridge, MA, USA
Instagram: @ranellamd
Instagram: @atollaskinlab
Clinic website: www.skincaredoctors.com/dr-hirsch
Skin cancer is THE most common cancer in the United States and Worldwide.
-1 in 5 Americans will develop skin cancer in their lifetime.
-More than two people die of skin cancer in the US every hour.
-Having 5 or more sunburns doubles your risk for melanoma.
While these may just sound like scary statistics to you, to your board-certified dermatologist, they are the facts of sun life. Unprotected exposure to the sun’s ultraviolet rays remains the most preventable risk factor for skin cancer, particularly melanoma, the deadliest form. Anyone can get skin cancer, irrespective of age, gender, or race. It is for this reason that dermatologists worldwide recommend sunscreen as a powerfully proven tool in the fight against skin cancer.
Most people don’t apply enough sunscreen. To achieve a product’s Sun Protection Factor (SPF, which protects against the sun’s UVB radiation) as labeled on a bottle of sunscreen, you need to use approximately two milligrams of sunscreen per square centimeter of skin.
In practice, this means applying the equivalent of a shot glass (two tablespoons) of sunscreen to the exposed areas of the face and body.
References:
Boo YC. Emerging Strategies to Protect the Skin from Ultraviolet Rays Using Plant-Derived Materials. Antioxidants (Basel). 2020 Jul 18;9(7):637.
Compres E, Holzem K, Ibler E, Bierman JA, Rademaker AW, Kundu RV. A Brief Dermatology Curriculum in Skin Cancer Detection and Prevention to Improve Medical Student Knowledge and Confidence. MedEdPORTAL. 2020 Dec 29;16:11049.
De Castro-Maqueda G, Gutierrez-Manzanedo JV, Lagares-Franco C, de Troya-Martin M. Sun Exposure during Water Sports: Do Elite Athletes Adequately Protect Their Skin against Skin Cancer? Int J Environ Res Public Health. 2021 Jan 19;18(2):800.
Merhi S, Salameh P, Kaplan P, Banerjee S, Lajnef M, Dumont ELP, Ezzedine K. An Ecological Study Indicates the Importance of Ultraviolet A Protection in Sunscreens. Acta Derm Venereol. 2021 Mar 18.
Nguyen THT, Tran BX, Nguyen SH, Latkin CA, Nguyen CT, Nguyen SH, Pham HQ, Ho CSH, Ho RCM, Oh JK. Attitudes about and practices for skin cancer prevention among patients with dermatological issues in Hanoi, Vietnam: a cross-sectional study. Environ Health Prev Med. 2020 Aug 1;25(1):35.
Raimondi S, Suppa M, Gandini S. Melanoma Epidemiology and Sun Exposure. Acta Derm Venereol. 2020 Jun 3;100(11):adv00136.
Sultana N. Sun Awareness and Sun Protection Practices. Clin Cosmet Investig Dermatol. 2020 Sep 29;13:717-730.
Shereene Idriss, MD, FAAD
Board Certified Dermatologist and Clinical Instructor at Mount Sinai Hospital
Instagram: @shereeneidriss
Clinic website: www.unionderm.com/dr-shereene-idriss
There she goes again… but this time she hit too close to home. In a video that took no longer than it took for Ms Paltrow to assimilate her medical knowledge, she managed to insult the whole medical field of dermatology, along with decades of scientifically backed medical research… but more infuriatingly, she does so while endangering the lives of millions of people whom she somehow manages to have an influence over.
When it comes to medicine, and protecting your skin, the dose ultimately makes the poison… but sadly in Ms Paltrow’s case, the lack thereof has left her (and the millions of those who hold on to her every word) susceptible to the poisonous and potentially life-threatening effects of the sun.
Dr. David R Jack, BSc (Hons) MBChB MRCSEd MBCAM
Based in London
Instagram: @drdavidjack
Clinic website: www.drdavidjackclinic.com
In my opinion, the most important step in anyone’s skincare routine should be the use of a broad spectrum SPF. Exposure to UV light is inevitable and is the number one extrinsic cause of ageing, pigmentation changes and most importantly, all types of skin cancer.
The use of daily SPF is important year round (not just summer time) as UVA levels tend to be at similar levels throughout the year and can even penetrate through glass.
SPF should include a broad spectrum UV filter to cover both UVA and UVB light; the type of SPF used, whether it be mineral based (inorganic) or chemical (organic filters) is largely irrelevant (in my opinion) – it is the level of protection that matters (denoted by the SPF number and Star/PA rating).
It is irresponsible on the part of any celebrity or mainstream media channel to discourage the use of SPF and to demonise certain ingredients without firm clinical and/or scientific evidence. This is particularly significant given the level of supportive evidence for the use of sunscreens in prevention of skin cancers, as well as the scale of the years of skin cancer prevention campaigns over the past 3 decades.
Dr Justine Kluk, MBChB FRCP (UK) (Dermatology)
Consultant Dermatologist
Based in London
Instagram: @drjustinekluk
Clinic website: www.drjustinekluk.com
It is a well established, scientifically verified fact that too much ultraviolet radiation from the sun damages the DNA in your cells and can cause skin cancer.
Skin cancer kills people. It leaves disfiguring scars. It ruins lives. It is often avoidable.
In the United Kingdom, where I live, Cancer Research UK estimates that almost 9 in 10 cases of melanoma could be prevented by taking consistent measures to reduce ultraviolet exposure. Skin damage doesn’t just happen on holiday or in hot, sunny places. It doesn’t only happen on your nose or cheeks. Getting sunburnt just once every 2 years can triple your risk of melanoma.
Covering up with clothing, wearing a hat and sunglasses, and applying a thick, even layer of sunscreen to exposed skin are simple, affordable and evidence-based actions that we can all take to reduce our risk of cancer. To encourage fear and mistrust about effective methods of cancer prevention is at best irresponsible and at worst utterly dangerous.
Dr Zainab Laftah BSc MBChB MRCP MRCP(Derm) PCME
Consultant Dermatologist
Based in London and Surrey
Instagram: @drzainab.dermatology
Professional profile: hcahealthcare.co.uk/hca/specialist/dr_dr_zainab_laftah
More than 100,000 NEW cases of skin cancer are diagnosed every year in the UK of which extensive sun exposure is the cause with 4 out of 5 could have been prevented if safe sun exposure had been practiced. The risk is real and as Dermatologists we see it every day in our clinics.
Now for the basic science part – Ultraviolet B rays are shorter wavelengths with higher energy. They penetrate the skin easily and damage the DNA in the outer layer of the skin. With excess exposure these skin cells are unable to repair this damage and this can lead to skin cancers developing, in particular BCCs and Melanomas. The take home message is it is never too late to start practicing safe sun exposure so reach for that sunscreen!
Unfortunately, the sun does not differentiate which part of the face it is going to cause damage to and whilst the nose is at risk because it sticks out of the face, the sun can and does penetrate all exposed skin. I have seen thousands of skin cancers on the forehead, chin, lower cheeks, ears, scalp and neck to name a few. Your sunscreen’s purpose is to protect your skin from the harmful rays of the sun – please do not use it as a highlighter!
For an average adult’s face, neck and ears, half a teaspoon (equivalent to 2.5ml) and for the whole body 6 full teaspoons is recommended. If in doubt apply more – remember it is all about protecting your skin! Also do not forget to apply sunscreen on often neglected areas which include around the eyes, the back of the neck, ears and tops of feet.
Dr Davin S. Lim
Consultant Dermatologist
Based in Australia
Instagram: www.instagram.com/drdavinlim
Clinic website: www.cutis.com.au
I don’t watch celebrity skin care videos, however Caroline Hirons sent me a late-night text to check this one out. As painful as it was to watch I managed to get through Gwyneth Paltrow’s 11 min 57 sec Everyday Skincare and Wellness guide video on Vogue.
The eye masks were banal enough, I ignored the comments on toxic antifreeze in skincare (she’s referring to propylene glycol), however her sunscreen routine really shocked me. Gwyneth adds ‘‘I am not a head to toe slatherer of sunscreen…I’d like to put it on my nose & where the sun really hits…’’ She then demonstrates how she dabs a few drops to the areas described.
I don’t have a problem with the product. Unsun SPF 30 is a good physical sunscreen. I do, however, have a problem with the probable SPF given her application guide. Firstly, sunscreen should be to the face, neck, & chest. Evident by her marked photo-damage, especially to the décolletage, Gwyneth clearly practices what she preaches.
Let’s do some quick math. An SPF of 30 is determined by the protection it gives when sunscreen is applied at 2.0 mg/cm2, or 3 to 5mls.
Her ‘dab on’ application realistically translates to a 1/10 of the recommended amount, meaning using the ‘GP method of sunscreen application’, one is getting an actual SPF of 3. Dermatologists recommend a minimum SPF of 30, most of us recommend 50+, further reinforcing the need for correct application technique & amount. Sunscreen remains the foundation of skin care both in the context of aesthetics and importantly the prevention of skin cancers.
Sure, this is her own routine, her own option, I am cool with that. The problem is that celebrities have a powerful impact on viewers and followers and they should be mindful of their own views, especially when it comes to the importance of sunscreen. GP has the power to influence a tremendous amount of her followers, and with the correct message of sunscreen application she has the potential to save a few hundred lives. Use this influence for the greater good.
Dr Anjali Mahto, Consultant Dermatologist & British Skin Foundation spokesperson
MBBCh BSc FRCP
Based in London
Instagram: @anjalimahto
Clinic website: www.cadoganclinic.com/dr-anjali-mahto
British Skin Foundation website: www.britishskinfoundation.org.uk
Ultraviolet radiation from the sun is a well-recognised causative factor for both the development of skin cancer as well as photo-ageing of the skin. Using a regular sunscreen as part of one’s daily skincare routine can have both medical and cosmetic benefits for the skin. When choosing a sunscreen, it is important to go for a broad-spectrum product which offers protection against both UVA and UVB radiation, which has a SPF of at least 30-50. Newer sunscreen technologies also incorporate antioxidants which can reduce damage by harmful molecules known as free radicals generated by other wavelengths of light as well as environmental pollution. For darker skin tones with concerns about pigmentation, using an iron oxide containing sunscreen can be of benefit to block the effects of visible light.
It is always better to use a separate daily sunscreen for the face rather than a product containing SPF in either a moisturiser or foundation. This is partly because SPF is only a marker of UVB protection, and the other wavelengths of light are also able to damage the skin. Secondly, most of us tend to under apply our products so we are unlikely to be getting the factor otherwise stated on the bottle
Most standard sunscreens in the laboratory are tested for their protection at 2mg/cm2 and “real-life” studies show we tend to apply roughly half this amount and more like 0.75mg-1mg/cm2 thickness.
Consultant Dermatologist & Honorary Senior Lecturer
Dr Cristina Psomadakis, MBChB, MSt (Oxon), BA, BSc, MSc in Skin Ageing & Aesthetics (in progress)
Dermatology Registrar in the NHS
Based in London
Instagram: @dr.somaskin
Numerous research studies throughout the years have demonstrated the importance of sunscreen in preventing both skin cancer and accelerated skin ageing.
Skin cancer is the most common cancer in the United States (5.4million cases annually) and the U.K. (152,000) and the fifth most common cancer globally. Exposure to UV radiation, aka sunlight, is thought to play a role in up to 90% of skin cancers. Skin cancer rates have more than doubled in the past decade – this is thought to be because they appear late in life, in a generation that were the first to really take up global travel and sunbathing without protection, and doctors have become much better at detecting them.
There are roughly two groups of skin cancers, melanoma cancers and non melanoma skin cancers (basal cell cancers and squamous cell cancers). Research over the years has showed that sunscreen is particularly beneficial in preventing sunburn, pre-cancerous lesions, squamous cell skin cancers and to a lesser extent melanoma, and even less so basal cell cancers. We also know that having multiple blistering sunburns increases your risk of skin cancer, and sunscreen helps prevent sunburns.
It can be really hard to prove sunscreen works in preventing skin cancers, because these cancers take years to develop and studying people’s sunscreen use along other habits over long periods of time is not an easy feat. However, we have some great data from long studies, particularly a famous one in Australia that followed up people over 15 years.
The US Federal Drug Administration recommends that sunscreen is applied at 2mg/cm2 and this is the amount required to get the SPF protection listed on a sunscreen label. Research shows that people use much less than this, usually by more than half the recommended amount. Advising 2mg/cm2 is impractical to calculate, so as an easy rough guide we say two to three fingers on the face, neck and ears. Obviously people’s faces and fingers come in a variety of sizes, but this is a great way to ensure pretty good coverage.
The safest advice for preventing skin cancer and skin ageing is to combine sunscreen with avoidance of direct sun, by seeking shade or wearing protective hats and clothing.
It also important not to trivialise the impact UV exposure has on skin ageing. This is not purely a cosmetic issue but fundamentally impacts the integrity of the skin, wound healing and susceptibility to infections. These issues actually amount to a tremendous healthcare burden and significant morbidity for patients.
References
https://www.cancer.net/cancer-types/skin-cancer-non-melanoma/statistics
https://www.who.int/news-room/fact-sheets/detail/cancer
https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/non-melanoma-skin-cancer#heading-Zero
Califf RM, Shinkai K. Filling in the evidence about sunscreen. Jama. 2019 Jun 4;321(21):2077-9.
Van Der Pols JC, Williams GM, Pandeya N, Logan V, Green AC. Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use. Cancer Epidemiology and Prevention Biomarkers. 2006 Dec 1;15(12):2546-8.
Sander M, Sander M, Burbidge T, Beecker J. The efficacy and safety of sunscreen use for the prevention of skin cancer. CMAJ. 2020 Dec 14;192(50):E1802-8.
Dennis LK, Beane Freeman LE, VanBeek MJ. Sunscreen use and the risk for melanoma: a quantitative review. Annals of internal medicine. 2003 Dec 16;139(12):966-78.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123459/
Dr Mary Sommerlad, BSc., MBBS, MRCP (Derm), DCH (RCPCH)
Consultant Dermatologist
Based in London
Instagram: drmarysommerlad
Clinic website: www.drmarysommerlad.com
In order for sunscreen to be effective it must be evenly spread over exposed skin at a thickness of approximately 2mg/cm2 which in real life equates to about a 1/2 teaspoon on the face and 1 teaspoon for each arm, for each leg, for the chest and for the back. Inadequate use of sunscreen means inadequate sun protection leading to increase skin cancer risk. Every year, thousands of people die because of skin cancer. Publications like Vogue, which are highly regarded with a huge loyal following should hold celebrity skin care routines to account: if a practice clearly flies in the face medical professional advice this needs to be obviously highlighted (no pun intended) so that viewers know and are well informed. Misinformation flourishes when people peddling unsound practice are given platforms without a balancing view or as a minimum a fact check. This legitimises the misinformation leading members of the public not to question harmful practices.
A “clean” product gives us no indication on how effective, safe and sustainable a product is. Rather than promoting clean beauty, beauty and skincare platforms like Vogue should champion sustainable, low irritation/ low allergy, safe and effective evidence based skincare.
People will always be attracted to alternative skincare but it’s important that platforms fact check and highlight problematic recommendations in order to safeguard the viewer to ensure they are well informed.
Dr. Wassim J. Taktouk, MBBS MRCGP DipDerm BCAM
Based in London
Instagram: drwassimtaktouk
Clinic Instagram: taktoukclinic
Clinic website: www.drwassimtaktouk.com
Using SPF on limited areas of the face rather than all over the face is incredibly ineffective when it comes to protecting the face from premature ageing from exposure to UVA and UVB. Using SPF in limited areas such as the cheekbones and nose in order to use the sun as a way of creating ‘long lasting’ highlights and contours though tanning is, in my professional opinion, incredibly irresponsible and disappointing.
I always tell my patients that a high SPF should be used daily, through all seasons, and a 10p size portion of product should cover the entire face, including the ears, and another 10p measure of SPF brought down over the neck, chest and hands to prevent future damage.
My role as a cosmetic doctor may be to turn back the clock, but it is also my responsibility to talk about prevention.
Dr Emma Wedgeworth MA MBBS(Hons) FRCP UK (Derm)
Consultant Dermatologist
Based in London
Instagram: @dremwedgeworth
Clinic website: drsambunting.com/dr-emma-wedgeworth
As a Dermatologist who devotes their career to promoting healthy skin, I find this type of celebrity skincare advice incredibly frustrating and downright concerning.
Firstly, there is no evidence that sunscreen, chemical or otherwise, is toxic to humans and plenty of evidence that sunscreen prevents skin cancer.
Secondly, sunscreen cannot just be applied to areas that we perceive are most exposed to sun.
I see facial sun damage on a daily basis and it certainly doesn’t limit itself to just the nose or the cheekbones. Our entire face is at risk of sun damage. Sunscreen needs to be used all over exposed skin.
For the face, we need to use at least 2.5ml or 2 finger lengths to achieve the protection level labelled on the bottle. I would strongly advise against applying sunscreen in the way that was demonstrated in this video.
Furthermore, I would urge people to look to skin experts when seeking advice, rather than celebrities.
Huge thanks to the brilliant doctors who took the time to respond to my call. I am so grateful.
