Shades of Protection: Navigating Sunscreen Challenges for Skin of Colour

Original Article: Photoprotection for people with skin of colour: needs and strategies

What are the key takeaways of this article?

Individuals with skin of colour have increased eumelanin-to-pheomelanin ratio, more mature (i.e., stage IV) melanosomes, and greater amounts of melanin in the upper layers of the epidermis. Compared to lighter skin tones, they also exhibit better protection against ultraviolet radiation (UVR) damage, have more efficient DNA repair, and demonstrate enhanced skin barrier function. Despite these inherent protective mechanisms, individuals with skin of colour remain susceptible to photodamage and pigmentary disorders. Photoprotection measures, including sunscreen use, are crucial yet underutilized among this population. Therefore, this review explores the distinct characteristics of skin of colour with regards to photocarcinogenesis, photoaging, and pigmentary disorders, thereby highlighting the need for enhanced photoprotection among this population.

Krutmann et al. report that skin cancer accounts for approximately 40% of all neoplasms in individuals with light skin but only 1–4% in those with darker skin tones. As such, the role of photoprotection in reducing photocarcinogenesis in individuals with skin of colour remains controversial. Photoprotection may not significantly alter the risk of carcinogenesis in these individuals, as their skin cancers are often detected on non-sun-exposed sites, such as acral lentiginous melanoma on the sole and mucosal melanoma. Nevertheless, while skin cancer is less frequent in people with skin of colour, outcomes are poorer in these individuals. For example, African Americans are four times more likely to be diagnosed with advanced-stage melanoma and can have a two- to threefold higher risk of mortality than patients with light skin overall. Ultimately, delayed diagnoses and poorer outcomes are more frequent in pigmented skin compared to lighter skin tones.

The paper also reviewed photoaging and pigmentary disorders among populations with skin of colour. Photoaging typically results from chronic UVR exposure, presenting as wrinkles, elastosis, uneven pigmentation, and pigment spots. Individuals with light skin exhibit significantly more wrinkles, laxity, and overall photodamage compared to those with dark skin tones. Conversely, individuals with darker skin tones typically develop clinically apparent signs of photoaging later in life, usually in their fifth and sixth decades. They commonly present with hyperpigmentation, uneven skin tone, and deeper pores. Moreover, those with skin of colour are more prone to developing pigmentation disorders such as melasma and postinflammatory hyperpigmentation (PIH). A large survey of new dermatological outpatients found that the rate of PIH was seven-fold higher in patients with darker-toned skin than in those with lighter skin. Common causes of PIH in patients with skin of colour include acne vulgaris, atopic dermatitis, and impetigo.

Interestingly, multiple studies have shown that patients with skin of colour are less likely to adhere to photoprotective recommendations and healthcare providers are less likely to prescribe them sunscreen products. A large study (n > 18,000) from 25 countries confirmed that light skin tone was associated with more frequent use of photoprotective measures. This can be explained by a lack of public education on this subject, limited representation of skin of colour in medical student resources, economic factors, and prevalent myths such as the belief that individuals with darker skins do not get sunburns. A recent survey (n = 151) performed among African Americans revealed that only 5% had discussed how to prevent or treat photoaging with a physician and over 40% would have liked more information on sun protection. In an anonymous survey of dermatologists (n = 77), more than half answered that they counsel patients with skin of colour less on sunscreen use than patients with light skin and that they never, rarely, or only sometimes take patients’ skin phototype into account when prescribing sunscreen.

In summary, this review by Krutmann et al. highlights that despite inherent protective mechanisms, individuals with skin of colour remain vulnerable to pigmentary disorders and photodamage and thus should be properly assessed to avoid late diagnoses. Tailored approaches, such as broad-spectrum sunscreen and oral supplements, show promise in mitigating these risks and improving skin health. Moreover, the authors suggest addressing disparities in photoprotection engagement and access to suitable products as well as enhanced public education and physician guidance to promote photoprotection against photodamage. Further research is needed to develop effective strategies tailored to the unique needs of individuals with skin of colour.

Publication Date: April 1st, 2024

Reference: Krutmann J, Piquero-Casals J, Morgado-Carrasco D, Granger C, Trullàs C, Passeron T, et al. Photoprotection for people with skin of colour: needs and strategies. British Journal of Dermatology. 2023 Feb 10;188(2):168–75.

Summary By: Megan Lowe