Consumer Behavior, Sunscreens, and Tools for Photoprotection: Comparison
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Please note this is a comparison between Version 2 by Lindsay Dong and Version 1 by Elisabete Pereira Santos.

Sunscreens and photoprotection tools along with consumer habits and behaviors, can mitigate the skin damage caused by excessive solar radiation. For example, protecting oneself in the shade, avoiding inadequate sun exposure at times of higher incidence of UVB radiation (between 10:00 a.m. and 4:00 p.m.), wearing clothes with sun protection factors, applying sunscreens at the correct amounts and intervals, and wearing glasses with anti-UVA and UVB lenses are effective measures for protecting an individual.

  • solar radiation
  • photoaging
  • skin cancer
  • prevention

1. Introduction

Excessive solar radiation without adequate skin protection, among several other factors, can aggravate skin aging, the formation of burns (erythema), and the development of different types of skin cancer. However, the use of effective sunscreens and different tools for photoprotection, in addition to healthy habits, can provide satisfactory results in the mitigation, prevention, and combating of these physiological changes observed in the skin. Notably, among these changes, skin cancer is a global public health problem [1,2][1][2].
The skin is the most extensive organ of the human body and is constantly exposed to solar radiation, regardless of aesthetic, professional, leisure, or daily habits [3]. However, the habit of exposing the whole body to the sun in order to tan has been adopted, as tanned skin is interpreted as a sign of beauty and health for many people, especially young women [4].
In fact, tanning, through melanin synthesis, is a natural response of the skin to the cumulative deleterious effects of ultraviolet radiation (UVR). The immediate response to UVR boils down to inflammation and tanning, while prolonged exposure leads to photoaging, which is characterized by premature skin ageing, the appearance of wrinkles, skin dryness, sagging, lines of expression and the formation of spots. In addition, photocarcinogenesis, which is another of the consequences of excess UV radiation on human skin, directly induces changes in DNA, which causes mutations and leads to cancer [6][5]. 

2. Sunscreens and Photoprotection Tools

2.1. Solar Radiation and Ultraviolet Index

Solar radiation, especially UVR, is recognized as the main physical exogenous source responsible for the increasing incidence of skin cancer worldwide [7][6]. However, UV rays are responsible for some beneficial effects, such as the synthesis of vitamin D3 (cholecalciferol), fungicidal and bactericidal activity, and a feeling of well-being. The harmful effects on individuals, in short and medium terms, include water loss and dryness of the skin, causing an opaque aspect, loss of elasticity and collagen, edema, scaling, spots, and sunburns of different degrees. Chronic solar exposure of the skin to UVR leads to a variety of adverse effects, such as decreased immunity [8][7], wrinkling, basal cell and squamous cell carcinoma, malignant melanoma, elastosis, and irregular pigmentation, which culminate in photoaging. In the search for solutions, the scientific community has expanded the research and development into the production of sunscreens with broad-spectrum protection against solar radiation [9][8]. The radiation emitted by the sun is non-ionizing radiation, which can be defined as UVR at a wavelength (λ) (100–400 nm), VL (400–750 nm) and infrared radiation (IRR) (750–2000 nm). UVRs are subdivided into UVA (320–400 nm), which is responsible for the induction of free radicals and premature skin ageing; UVB (280–315 nm), which is responsible for sunburn and is also known as erythematogenous radiation; and UVC (100–280 nm), which directly affects cellular DNA. UVI is an important parameter that can increase the level of public awareness against the risks of excessive UVR exposure and alert people to the need for preventive and remedial measures. The UVI is a measure of the intensity of solar UVR incident on the Earth’s surface. The higher the UVI, the greater the risk of damage and the onset of skin cancer. This index can be checked daily as a part of the weather forecast around the world. The elements of the UVI are the season, time of day, ozone layer, clouds and haze, altitude (in general, for every 1000 m increase in altitude, the UVR flux increases by approximately 10%), latitude, pollution, and the reflection from surfaces such as sand and snow [13][9]. UVI can and should be used as an important tool in combating the damage caused by inadequate sun exposure, especially against skin cancer.

2.2. Skin Cancer, Photoaging, the Importance of Sunscreen Use, and Tools for Photoprotection

To better understand the relevance of skin cancer worldwide, 1.20 million (non-melanoma) and 325,000 (melanomas) new patients were registered in 2020 [14][10]. In Brazil, melanoma corresponded to approximately 30% of all cancers diagnosed in humans, and each year, the National Cancer Institute (INCA) registers approximately 185.000 new patients with non-melanoma skin cancers. Among the external physical causes, the main one is excessive exposure to the sun without protection. The early detection of skin cancer is key to therapeutic success, and the earlier it is detected, the better the treatment effectiveness [15][11].

2.3. Sunscreens

Sunscreens have crossed traditional boundaries of literal use; that is, they are present in countless cosmetic products. Previously, sunscreens were restricted to synthetic sunscreens for the protection of the skin before sun exposure; in contrast, at present, sunscreens are present in different products for daily use, including personal skin and hair care products. Recently, Stiefel and Schwack [19][12] highlighted that sunscreens with a higher sun protection factor (SPF) could offer better protection capacity; on the other hand, they would also encourage the user to spend more time in the sun.

2.4. Sustainable Sunscreens: Eco-Friendly and Not Tested on Animals

The spectrum UV, VL and IRR affect biological systems. The most studied sunscreens are those against the adverse effects of UVR; however, with the discovery of the harmful effects on coral reefs and the endocrinological effects on mammals, new sunscreens have been developed [26,27][13][14]. Concerns regarding environmental preservation and animal care have impacted the cosmetics sector, which has resulted in the worldwide trend of sustainable products that are ecologically correct and free of animal cruelty. Many sunscreens available in the market are not aligned with the Sustainable Development Goals (SDGs) of the United Nations (UN) [28][15]. Synthetic substances are used as sunscreens that have been withdrawn from the market for their proven toxicity and pose a real danger to the health of its users. In the 1960s, dermatologists began treating patients who were allergic to PABA, which proved to be photolabile; this led to its withdrawal from the market and, at the same time, the current labeling of many sunscreens as “PABA-free” [18][16]. Wang et al. [29][17] demonstrated that the different sunscreens tested offered adequate UVA protection according to US Food and Drug Administration guidelines for broad-spectrum status, but nearly half of the sunscreens tested did not pass the established standards in the European Union. This is inappropriate in terms of effectiveness and safety for the user. Additionally, cinoxate is no longer used to protect against UVB radiation, and due to the high levels of oxybenzone found in breast milk, in tumors, and the bleaching of coral reefs, these two filters have been banned in the United States of America (USA) state of Hawaii. Many preparations on the market are labeled oxybenzone, octinoxate, and avobenzone free [30,31][18][19]. In addition to polluting the environment, chemicals in rivers and oceans and the trophic chain in marine environments can act as endocrine disruptors according to the Environmental Protection Agency (EPA) of the USA [32][20]. Scientific studies have linked various synthetic filters to problems with coral reproduction and bleaching, which weaken them and, over time, lead to their death. These synthetic filters are released from the skin as people dive, swim, and surf in the sea [27][14]. Owing to these issues, European legislation recommends toxicity testing for substances that are poorly soluble and poorly degradable in water. In addition to being ecologically friendly, consumers seek sunscreens that are not tested on animals. Since 2013, such appeals have led to a ban on the use of animals for safety testing in cosmetics [33][21]. In general, consumer preference for sustainable and animal cruelty-free products directs the cosmetic industry to develop sunscreens that are effective and safe for humans but, most importantly, environmentally friendly [34][22].

2.5. Effectiveness of Sunscreen Products

The efficacy of sunscreen is the quality or property that produces a greater or lesser photoprotective effect in relation to the formation of erythema. Moreover, its efficacy depends on its incorporation into appropriate vehicles, as their hydrophilic, lipophilic, emollient, pH, and stability properties at elevated temperatures influence the SPF. Several standardized methods are available for determining the SPF of a product against UVR. The ISO 24444:2019 SPF measurement method is considered the gold standard, although it is complex, time-consuming, and expensive. The classic division of SPF measurement is based on methods such as in vivo, in vitro and in silico; in addition to the UVR load to which the skin is exposed. The ISO/AWI 23675 Cosmetics method, approved by Cosmetics Europe (CE), compares in vivo results with in vitro results. The “Fused method” is an unofficial name for a combination of different in vitro transmittance methods. The in silico methods, the most popular for generating realistic results, include the Sunscreen Simulator (BASF) and the Sunscreen Optimizer (DSM). The Hybrid Diffuse Reflectance Spectroscopy (HDRS or H-DRS) is based on non-invasive diffuse reflectance spectroscopy (DRS); in this case, UVA protection is directly evaluated in vivo using in vitro data, this hybrid method is also called UVA measurement sunscreen efficacy by diffuse reflectance spectroscopy, or ISO/AWT 23698 [36][23]. SPF evaluation uses the erythematous response of the skin formed by the exposure to UVB radiation, the intensity of which is proportional to the dose received [37][24]. According the position statement by Krutmann et al., (2020), there are three important points to be considered when measuring the SPF of a photoprotective preparation, such as: SPF determination methodologies should evolve to predict sunscreen efficacy in real life conditions in a more reliable manner; for SPF determination alternative endpoints, other than erythema, reflecting both acute and chronic damage should be considered; and photoprotection needs to include protection against wavelengths beyond UV [38][25]. 

3. Skin Phototypes

Thomas B. Fitzpatrick, an American dermatologist and professor at Harvard Medical School, classified skin phototypes between I and VI based on the amount and type of melanin produced in the body. Fitzpatrick’s classification, the most widely accepted method for determining skin phototypes, continues to be used as an international reference [42][26]. The coloration of human skin phototypes varies according to the proportion and type of epidermal melanin and is classified into two types: pheomelanin and eumelanin. People with lighter skin tones tend to possess a greater amount of pheomelanin, while people with darker skin tones tend to possess predominantly eumelanin. The types of melanin differ from each other in several factors, including their ability to act as an intrinsic filter against UVR. In general, eumelanin performs better in this function, absorbing 50–75% of UVR, in addition to eliminating the free radicals formed in the skin. On the other hand, pheomelanin does not act as effectively against UVR and may be an endogenous photosensitizer [43][27]. The main function performed by the SC is to ensure cutaneous homeostasis and provide a protective barrier for the organism [40][28]. The human skin reacts in different ways to UVR according to the Fitzpatrick classification. Some skin phototypes, typically III, IV, V, and VI, tend to tan more easily, whereas other skin phototypes, such as I and II, fail to tan, regardless of the duration of sun exposure. According to Lim et al. [44][29], following Fitzpatrick’s classification of phototypes, the autscholars highlighted that visible light (VL) causes burning (erythema) in light-skinned people and induces pigmentary changes in dark-skinned individuals, being an important factor in triggering dermatological diseases. Such events can be explained by the predominant type of melanin in each skin phototype. For example, pheomelanin, a less effective intrinsic UV filter, does not eliminate the reactive oxygen species (ROS) formed during sun exposure, which, in turn, cause epidermal damage, leading to redness and burns. In addition, ROS generation can damage DNA, culminating in long-term carcinogenesis [45][30].

4. Ethnicity and Sunscreen Habits

Despite the geographical, economic, and socio-cultural aspects, people of different ethnicities are subject to the effects of UVR exposure and respond in an individual way, regardless of their skin phototype. However, each person has photoprotection needs that require specific attention from dermatologists [48][31]. For example, even today, there are individuals of African descent with phototypes IV, V, and VI who are unaware of the need to use sunscreens because they do not feel the negative effects of UVR [49][32]. Part of this belief may be associated with a reduced susceptibility to erythema and skin cancer, and explained by the intrinsic SPF of darker skin, which resembles SPF 15 sunscreens [50,51][33][34]. However, the skin of colored populations also experiences photoaging, pigmentary disorders, and skin cancer, and their diagnoses tend to occur late and at an advanced stage, with a more severe prognosis [52][35].

Other ethnic groups require special attention regarding photoprotection and exposure to UVR. After researchers investigated the prevalence of sunscreen use among different racial and ethnic groups, it was observed that the sunscreen habits of Asian descendants have been inadequately explored. Understanding how Asians behave during sun exposure is essential, because while part of the Asian population uses cosmetics that reduce melanogenesis in order to obtain lighter skin tones, another part of the population suffers from late diagnoses of skin cancer [53,54][36][37].

5. Photoprotection in Specific Populations

The adoption of the appropriate measures against sun exposure should start at the earliest age to allow individuals to develop good habits early in life and maintain them throughout life. The photoprotection of infants and children, especially those up to three years old, requires extra care because their skin has a thinner epidermis and stratum corneum, and UVR penetrates more deeply, causing photodamage and immunosuppression, regardless of skin phototype [50][33]. Due to the characteristics of the skin of children, dermatologists suggest that photoprotectors containing inorganic particulate filters, such as zinc oxide and titanium dioxide, be used as other photoprotectors may contain sunscreens considered allergens [61][38]. In addition, the exposure of children and infants to radiation may be a risk factor for the development of skin cancer in the long term. Sun exposure precautions are necessary during other phases of human life, such as pregnancy. During this period, the woman’s body, including the skin, undergoes several changes. Skin changes occur mainly due to an increase in hormones, resulting in increased skin sensitivity, worsening of pre-existing conditions, and the emergence of new dermatoses, such as melasma and hyperpigmentation [64][39]. Sun exposure should be carefully monitored, and sunscreen use is essential to protect the skin during this phase. However, dermatologists should be consulted for the choice of the most adequate sunscreen, as clinical research has shown that certain synthetic sunscreens can pose risks to pregnant women and fetuses. 

6. Consumer Behavior

6.1. Skin Damage Caused by Artificial Tanning

Currently, the standard of beauty includes tanned skin, and the search for socially accepted skin tones has become a goal for many people, especially for western people [67][40]. The use of tanning beds has been a way to achieve this standard, especially by young, non-Hispanic, and white women who seek to obtain a skin tone associated with health that is visually more pleasant than their baseline tone [68][41]. A tanning chamber emerged in the 1970s, and as its use was popularized, concerns have arisen about this practice. Several clinical investigations have highlighted the relationship between this type of artificial tanning and malignant skin changes, such as the development of skin cancer. Compared to sunbathing, artificial sources of ultraviolet (UV) light continue to be mistakenly advertised as safe; in reality these artificial UV lights can provide greater harm as the lamps emit both UVA and UVB rays and can be used continuously at high intensity, different from solar radiation, which can vary according to different factors, such as the season of the year and the time of day [69][42]. 

6.2. Photoprotection Behavior of Adolescents and Young People

In adolescence, intentional tanning and excessive sun exposure occur more frequently, posing a greater risk of skin damage and cancer development [74][43]. In a recent clinical trial with adolescents, the investigators observed that young people recognized the damage caused by UVR, but a minority used sunscreen daily. Even those who used sun-protection products daily applied insufficient amounts for promoting adequate photoprotection.

7. Consumer Preferences in the Choice of Sunscreen Products

Although the benefits of sunscreen use are well known, encouraging the population to use such products involves issues beyond counseling about the damage that excessive sun exposure can cause to individuals. Consumer preferences are essential for establishing habits related to sunscreens. Xu et al., (2016) investigated public preferences regarding the choice of sunscreens by searching the keyword “sunscreens” on the website of the American retailer “Amazon.com”, and the positive aspects considered were cosmetic elegance, product performance, and compatibility with skin phototype. On the other hand, the negative points that led consumers to discard the choice of sunscreens involved cosmetic elegance and the price of the product [76][44]. During a sunscreen use study, consumers evaluated the fast absorption, ease of application, transparent finish, no glare, no white spots, non-sticky or greasy sensory, sweat and water resistance, no eye burning, and keeping the skin hydrated and soft as important properties. In addition, consumers seek sustainable products that do not negatively impact the environment, but can withstand different climatic conditions, such as humidity, environmental pollution, and temperature [77,78][45][46]. Finally, considering consumer preferences allows dermatologists to make personalized recommendations that ensure photoprotection effectiveness and provide a pleasant experience to the consumer, making them loyal to the habit of protecting themselves [17,79][47][48].

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