Are sunscreens luxury products?

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Are sunscreens luxury products? Emmanuel Mahe´, MD,a,c Alain Beauchet, MD,b,c Marie-Florence de Maleissye, MD,c and Philippe Saiag, MD, PhDa,c Boulogne-Billancourt, France Background: The incidence of skin cancers is rapidly increasing in Western countries. One of the main sun-protection measures advocated is application of sunscreen. Some studies report a failure to comply with sunscreen application guidance. One explanation is their cost. Objective: To evaluate the true cost of sunscreen in two situations: a 4-member family spending 1 week at the beach and a transplant patient respecting all the sun protection recommendations. Methods: We performed an analysis of prices of sunscreens sold via Internet drugstores in Europe and North America. Standard sunscreen application recommendations were followed. We tested the recommended amount of sunscreen to be applied (ie, 2 mg/cm2). Results: Six hundred seven sunscreens from 17 drugstores in 7 countries were evaluated. Median price of sunscreen was $1.7 US per 10 grams. The price decreased with the size of the bottle. The median price for a family varied from $178.2 per week to $238.4 per week. The price decreased by 33% if the family wore UVprotective T-shirts and by 41% if large-volume bottles were used. The median price for a transplant patient varied from $245.3 per year to $292.3 per year. Limitations: Anti-UVA activity and topical properties were not evaluated. We tested the recommended amount (2 mg/cm2) rather than the amount actually used (1 mg/cm2). Conclusion: Under acute sun exposure conditions (a week at the beach), the cost of sun protection appears acceptable if sun protective clothing is worn and large-format bottles and low-cost sunscreens are used. Conversely, in a sun-sensitive population requiring year-round protection, the annual budget is relatively high and patients may require financial assistance to be compliant with sun protection guidelines. ( J Am Acad Dermatol 2011;65:e73-9.) Key words: cost; melanoma; nevus; prevention; skin carcinoma; sunscreen.

BACKGROUND The incidences of both melanoma and nonmelanoma skin cancers have been increasing in the Western world.1,2 Exposure to ultraviolet (UV) radiation is a key risk factor in skin carcinogenesis and one of the main targets of prevention campaigns. Recommended prevention measures include sun avoidance, sun-protective clothing, avoiding sun beds, and using sunscreens.3 Sun avoidance measures include staying out of the sun during peak hours and choosing to remain in the shade. Protective From the Departments of Dermatologya and Public Health,b Ambroise Pare´ University Hospital, University of Versailles-Saint Quentin en Yvelines, and Research Unit EA 4339 ‘‘Skin, cancer, and environment’’,c Ambroise Pare´ University Hospital, University of Versailles-Saint Quentin en Yvelines, Assistance Publique-Hoˆpitaux de Paris, Boulogne-Billancourt. Funding sources: None. Conflicts of interest: None declared. Accepted for publication June 30, 2010.

Abbreviations used: BSA: HP: MP: SPF: UV: VHP:

body surface area high protection medium protection sun protection factor ultraviolet very high protection

clothing refers to the use of UV-protective clothing, hat or cap and sunglasses. Children and teenagers in particular should not use sun beds and some Reprint requests: Emmanuel Mahe´, MD, Service de Dermatologie, Centre Hospitalier Universitaire Ambroise Pare´, 9 avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France. E-mail: [email protected]. Published online July 11, 2011. 0190-9622/$36.00 ª 2010 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2010.06.043

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countries have specific legislation concerning this. and Google.ca in English, Google.fr and Google.be in Sunscreens should only be used when other meaFrench, Google.de in German, Google.it in Italian, sures have failed. However, several studies have Google.es in Spanish, and Google.se in Swedish. The shown that using sunscreen could in fact increase Web sites on the first page (10 links) produced by the the incidence of melanoma and melanocytic nevus in search were analyzed. We included drugstores only. adults and children, respectively, probably through Companies selling their own sunscreens were failure to comply with sunscreen application recomexcluded. mendations.4-15 Melanocytic Selection of sunnevus is a tumor related to screens. All the sunscreens CAPSULE SUMMARY sun exposure in childhood. included in the study met the The link between sunscreen following requirements: (1) This study responds to a long-asked application and melanocytic sun protection factor (SPF) question in sunscreen sun prevention: tumor development remains of 15 or more, or labeled What is the true cost of sun protection controversial. Nonetheless, it ‘‘medium protection’’ (MP) with sunscreen? would appear that sunscreen (SPF 15-29.9), high protection Under occasional sun exposure application compliance is (HP) (SPF 30-59.9) or ‘‘very conditions (a week at the beach), the improved by explicit labeling high protection’’ (VHP) (SPF cost of sun protection is acceptable if and by providing free or low60 or more) as defined by the sun protective clothing is worn and large cost sunscreen.16,17 Under European Community29; (2) a format bottles and low cost sunscreens these conditions, sunscreens weight or volume of at least are used. could effectively protect the 30 g (1.06 oz) or 30 mL (1.01 fl user against sun-related skin oz); and (3) a stated price. We People at high risk of UV-induced skin tumors.17-20 did not take into account procancers may require financial assistance Sunscreen application motional offers. We systemati to be compliant with sun protection compliance issues include cally recorded these 3 paramguidelines. using inappropriate amounts eters (sun protection level, of sunscreen, frequency of weight/volume, and price). application, reapplication after swimming, missed We did not take note of the presentation (ie, cream, skin sites, and levels of sun protection ointment, spray) or such cosmetic claims as ‘‘hypoalprovided.5-9,21-24 The reasons cited for this lack of lergenic,’’ ‘‘water resistant,’’ ‘‘anti-ageing’’. compliance include the time it takes to apply sunPrice of sunscreens. When one sunscreen was screen, the complexity of the instructions printed on sold by two or more drugstores, we took into the bottle, cosmetic aspects (leaves a film, stings the account its mean price. The rate of exchange used eyes, smells unpleasant and makes the wearer feel for sunscreens sold in euro (V) or Swedish kroner hot and sweaty), as well as forgetting to apply it, and (SEK) was the official rate in the first days of August of course, cost.6,16,25 2009 (ie, 1 US$ = 0.7133 V = 7.2727 SEK). For the We evaluated the true cost of sunscreen use in analysis, the price was given for 10 g. Prices were Europe and North America under hypothetical acute evaluated according to country and continent and chronic conditions as follows: (1) a 4-member (Europe vs North America), weight (\100 g, 100family spending a week at the beach and using 199 g, $ 200 g) and to European-labeled category of sunscreen as their only sun protection measure, and sun protection (MP, HP, VHP). 2) a transplant patient at high risk of sun-induced Evaluation of body surface area to be skin cancer using sunscreen as recommended in the covered. Total body surface area (BSA) onto which current sun protection guidelines.26-28 sunscreen is to be applied was evaluated using Wallace’s rule of nines for adults, and its adaptation for children. The mean surface area was the ‘‘usual’’ METHODS BSA of 1.73 m2, with 1.62 m2 for women, and 1.8 m2 for Selection of drugstores by Web search men.30 For children, we evaluated the BSA using the We evaluated sunscreen prices on drugstore Web mathematical formula ‘‘BSA = (4 3 weight)/(weight 1 sites in 7 European countries (France, Belgium, United 90)’’ generally used by French pediatricians. Mean Kingdom, Germany, Spain, Italy, and Sweden) and weight of children was the weight given by the the United States and Canada. The search was standard growth curve for boys and girls. When performed in 6 languages—that is, English, French, we evaluated people wearing swimsuits or clothes, German, Italian, Spanish, and Swedish e with the key we considered that one palm was equivalent to 1% of word ‘‘buy sunscreen’’. We used the various local the BSA. versions of the search engine Google: Google.com d

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Weight of sunscreen product. In both of our scenarios, we tested the recommended amount of sunscreen for efficiency: 2 mg/cm2.29 Sunscreen densities were not able to be evaluated, so we used water density (ie, 1 g = 1 mL) to homogenize weights of sunscreen products. Scenario 1. A family during a beach holiday. First, we looked at the hypothetical case of a family spending 4 hours at the beach during peak sunshine hours, every day for 1 week. We considered that children had to apply sunscreen 3 times during each 4-hour period owing to their sporting activity and swimming and parents, twice. Women were presumed to be wearing a bikini and men, standard swimming trunks. A second evaluation included sun-protective T-shirts for the whole family. The BSA onto which sunscreen was applied was evaluated for parents and children from 2 to 10 years of age (/2 years). Scenario 2: A transplant patient. We hypothesized that the transplant patient complied with standard sun protection recommendations, that is, wearing long sleeves, pants or long skirt, hat, VHP sunscreen, and sun avoidance during peak hours.3,27,28 In a usual sunny workweek, we postulated that the patient would have to apply sunscreen to the back of the hands, the neck, and face once a day; this increased to twice a day on weekends. Statistical analysis. The data were summarized by using descriptive statistics. Quantitative data were expressed as the median with minimum and maximum values (shown in brackets).

RESULTS Web sites and sunscreens Seventeen drugstores proposed 916 sunscreens. Thirteen stores in Europe proposed 689 sunscreens and the remaining 4 in North America, 229 sunscreens (Table I). We were unable to locate any drugstores in either Germany or the United Kingdom using this methodology. In the case of one American Web site (SkinStore), only the first 10 (of 55) pages found with search term ‘‘sunscreen’’ were taken into account. Of the 916 sunscreens identified, we found 607 different products (387 in Europe, and 220 in North America); the remaining products were duplicates (identical product, packaging, and volume) (Table II). These sunscreens are manufactured by more than 90 companies. Seventy companies offered at least two different sunscreens with a median of 4 (range, 250). La Roche Posay, Isdin, and Coppertone offer the largest variety of sunscreens (50, 45, and 44 different references, respectively).

Table I. Universal resource locators of drugstores analyzed for prices of sunscreens URLs

Europe Belgium www.colispharma.be www.newpharma.be www.parapost.eu France www.parapharmanet.com www.parasolder.com www.paratamtam.com pharmacie-conseil. parapharmacie-du-marche.fr Italy www.easyfarma.it www.pagineprezzi.i Spain www.farmacia.es www.farmaciadelprado.com www.farmacia-morlan.com Sweden www4.apoteket.se North America Canada www.abconlinepharmacy.com www.globaldrugsdirect.com United States www.overstockdrugstore.com www.skinstore.com

No. of sunscreens

13 56 70 22 64 115 38

51 71 65 62 44 16

23 22 102 82*

*For the SkinStore Web site, we only took into account the first 10 (of 55) pages found with search term ‘‘sunscreen’’.

Of the 607 sunscreens, 28% provided MP (SPF 1529.9), 46% HP (SPF 30-59.9), and 26% VHP (SPF 60 or more) (see Table II). These proportions were 31%, 37%, and 32%, respectively in Europe and 23%, 61%, and 15%, respectively, in North America. Volume was less than 100 grams for 38% of the sunscreens available, 100-199 grams for 39%, and 200 grams and more for 23%. Price of sunscreens Irrespective of sun protection level and volume, the median price of sunscreen was 1.7 US$/10 grams (1.8 US$ in Europe and 1.2 US$ in North America) with a minimum of 0.1 US$/10 grams in Europe and North America, and a maximum of 21.5 US$/10 grams in Europe and 44.8 US$/10 grams in North America. The highest median price was found in Italy (2.3 US$/10 g) and the lowest in Canada (1.1 US$/10 g). In Europe, the price increased with the level of sun protection provided, whereas in North America, it decreased. Mean prices consistently decreased as the packaging volume rose (see Table II) irrespective of the protection factor (data not shown).

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Table II. Price of sunscreens

All Protection* Moderate High Very high Weight (g) 30-99 100-199 $ 200 Europe Country Belgium France Italy Spain Sweden Protection* Moderate High Very high Weight (g) 30-99 100-199 $ 200 North America Country Canada United States Protection Moderate High Very high Weight (g) 30-99 100-199 $ 200

No. of sunscreens

Price (US$)/10 grams, median (range)

607

1.7 (0.1-44.8)

170 279 158

1.7 (0.1-20.2) 1.5 (0.1-20.2) 2.0 (0.4-9.8)

229 238 139 387

3.7 1.5 1.0 1.8

(0.9-44.8) (0.4-4.2) (0.1-6.4) (0.4-21.5)

139 239 122 171 14

1.9 1.6 2.6 1.7 1.3

(0.6-7.2) (0.4-7.0) (0.9-20.2) (0.6-21.5) (0.8-4.8)

120 143 124

1.5 (0.4-20.2) 1.7 (0.6-20.2) 2.2 (0.7-7.2)

146 146 94 220

3.6 1.7 1.0 1.2

46 184

1.5 (0.1-44.8) 1.1 (0.9-5.6)

51 135 34

2.2 (0.1-44.8) 1.0 (0.1-17.5) 1.2 (0.4-9.8)

83 91 46

4.2 (0.9-44.8) 0.8 (0.4-4.2) 0.4 (0.1-1.2)

(1.1-20.2) (0.9-2.7) (0.4-6.4) (0.1-44.8)

*Moderate, high, and very high sun protection levels include sunscreens with SPF 15-29.9, 30-59.9, and 60 or higher, respectively, as recommended by the European Community.29

Scenario 1: A family at the beach during a seaside holiday In the first scenario, a family went to the beach every day for a week, 4 hours daily, during peak hours (Table III). At a rate of two applications per exposure to the sun, sufficient sunscreen was required to cover 20.7 m2 per week for the father and 17.9 m2 for the mother. For the children (3 applications of sunscreen per 4-hour session), adequate coverage for 7.3 m2 (2-year old girl) to 16.4 m2 (10year-old girl or boy) per week was required. During a 1-week beach holiday, a family with two 2-year-old girls therefore required sufficient sunscreen to cover

Table III. Scenario 1: A family at the beach during a seaside holiday* Body surface area (m2) Requiring sunscreen

Father Mother Girl (age) 2 years 4 years 6 years 8 years 10 years Boy (age) 2 years 4 years 6 years 8 years 10 years

Total

1 time

1 week

Sunscreen price (US$)/ week, median (range)y

1.8 1.62

1.48 1.28

20.72 17.92

69.2 (5.2-1856.3) 60.0 (4.5-1605.4)

0.45 0.57 0.70 0.84 1

0.35 0.44 0.55 0.66 0.78

7.35 9.24 11.55 13.86 16.38

24.5 30.8 38.5 46.2 54.6

(1.8-658.5) (2.4-827.8) (2.9-1034.7) (3.5-1241.7) (4.1-1467.4)

0.47 0.57 0.73 0.89 1

0.37 0.44 0.57 0.69 0.78

7.77 9.24 11.97 14.49 16.38

25.9 30.8 39.9 48.3 54.6

(2.0-696.1) (2.4-827.8) (3.1-1072.4) (3.6-1298.1) (4.1-1467.4)

*We hypothesized that during each session on the beach, adults applied sunscreen twice and children, three times. y 20 g/m2 corresponds to recommended practices.

53.3 m2 of skin, with the area of skin increasing to 71.4 m2 for a family with two 10-year-old children. The median cost for a family with two young girls, irrespective of the volume of the bottle and the level of sun protection, was 178.2 US$ per week (minimum/maximum: 13.3-4778.7 US$/wk) for about 1.0 L of sunscreen. The median cost for the family with two 10-year-old children was 238.4 US$ per week (minimum-maximum: 17.9-6396.5 US$/wk) for about 1.5 liters of sunscreen. When UV protective tee shirts were worn, the BSA to cover decreased by 35%, 32%, and 33% for the father, mother, and children, respectively. The total cost for the family therefore dropped by approximately one third (33.2%). Buying large-format bottles reduced the price by 41%. When combined, these measures brought about a 58% decrease in the total cost of sun protection. Scenario 2: A transplant patient In our second hypothetical case, a transplant patient followed sun protection recommendations. Sunscreen was therefore only used for exposed areas of skin (hand, neck, and face) for short periods of time. The patient used VHP sunscreens. The median cost of covering 1.2 to 1.4 m2 per week was 4.7 to 5.6 US$ per week (minimum-maximum: 1.1-28.0 US$/wk) (Table IV). Year-round (52.2 weeks) application of sunscreen in a sunny country represented a median annual budget of 245.3 to 292.3 US$.

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Table IV. Scenario 2: A transplant patient following sunscreen application recommendations (VHP sunscreen on sun-exposed areas: back of hands, neck, and face)* Body surface area (m2) Requiring sunscreen

Men Women

Sunscreen price (US$), median (range)y

Total

1 time

1 week

Per week

Per year

1.8 1.62

0.13 0.11

1.43 1.21

5.6 (1.3-28.0) 4.7 (1.1-23.7)

292.3 (67.9-1461.6) 245.3 (57.4-1237.1)

*We hypothesized that during each session on the beach, adults applied sunscreen twice and children, three times. y 20 g/m2 corresponds to recommended practices.

DISCUSSION In this study, we evaluated the cost of using sunscreen, with the recommended amount to be applied to the skin (ie, 2 mg/cm2) in two typical scenarios: (1) brief and intensive exposure to the sun, disregarding sun-protective measures other than sunscreen application; this is the typical behavior pattern of holiday-makers in a sunny climate in most countries,8,31 and 2) and long-term sun exposure in transplant patients, who must respect strict sun protection measures.26,27 In both scenarios, we postulated that people used sunscreen according to current recommendations.3,27,28 This evaluation is important for 3 main reasons. (1) one of the reasons put forward for the failure to use sunscreens is their cost6,16,18,25; (2) in some populations (ie, xeroderma pigmentosum, transplant patients)32-34; long-term sun protection is necessary to prevent rapid development of skin tumors. In these populations, sunscreens can be viewed as a long-term treatment and giving patients access to free or at least low cost treatments should improve compliance. In 2009 in France, the French Health Authority issued an overriding decision supporting reimbursement of sunscreen to patients with xeroderma pigmentosum.35 It is to be hoped that this exceptional decision will be extended to other highly sun-sensitive populations in France and other countries; (3) finally, irrespective of population and type of exposure, the use of sunscreen to prevent long-term events is perceived as problematic (ie, the sunscreens are too oily, they leave a film).25 These parameters do not encourage users to apply adequate amounts of sunscreen. Cost should therefore not be seen as a deterrent. When a family on a beach holiday applies the sunscreen adequately, the median price may seem quite high ([178 US$/wk). In fact, the cost of sun protection can be significantly reduced by buying large bottles and selecting cheaper brands. Following ‘‘basic sun protection messages’’ such as using protective T-shirts36 could also have a major impact on cost. Therefore the role played by cost of sunscreen in poor compliance is probably overestimated.

In our second scenario, in which sun-sensitive patients closely follow sun prevention recommendations, the weekly cost appears acceptable (median: 6 US$/wk). However, in this population, prevention must be continued all year round in sunny countries, for several years. The median annual cost of treatment therefore ranges from 245 to 292 US$. Helping these patients to cover the cost of treatment could enhance compliance.16 There are a few limitations in this study: we did not evaluate protectiveness of sunscreen against UVA37 or the cosmetic, hypoallergenic and waterproof properties of sunscreens, all of which can have an impact on price and compliance.25 Doubts may be cast on some of our theories: the 1.73 m2 BSA is probably less than the true BSA in 2009; our swimsuit coverage was less extensive (bikini and traditional trunks), which increased the BSA to be protected30; the number of applications is also debatable. Nevertheless, this evaluation with generally accepted methods (ie, BSA, Wallace’s rule of nine, median price of a large range of sunscreen in several countries) provides quite a realistic estimation of the cost of sunscreen protection. Finally, we tested the recommended amount of sunscreen to be applied (ie, 2 mg/cm2).29 This recommendation overestimates the amount of sunscreen usually applied whatever the topical properties of the sunscreen selected. Several studies have shown that consumers apply much less sunscreen, usually an average of 0.5 to 1.5 mg/cm2. This may differ greatly on different parts of the body.7,9,21-23,28 If this is the case, obviously the cost of sunscreen is reduced by 50%; however, if only 50% of the recommended amount of sunscreen is used, effective sun protection is less than what is stated on the label. This problem has been known for several years, and it is now suggested that the standard layer thickness of sunscreens, used by standardization authorities to evaluate the SPF, should be reviewed to reflect real conditions of use. As an example, the German DIN 67502 method proposes a smaller amount (0.75 mg/cm2) of sunscreen to determine the UVA protection performance (UVA balance) of

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sunscreens.38 Therefore worldwide standardization and recommendations for smaller amounts of sunscreen are required to evaluate sunscreen SPF. In conclusion, the price of adequate sun protection during acute exposure appears acceptable if 3 basic rules are followed, that is, respect of ‘‘basic sun protection messages’’, buying large bottles and choosing a sunscreen from the lower end of the price range. Although the weekly cost of sun protection is low in a sun-sensitive population requiring long-term protection, the annual cost is obviously substantially higher; patients may require financial assistance to be compliant with sun protection guidelines. We thank Sara Newbery for her help. REFERENCES 1. Thompson JF, Scolyer RA, Kefford RF. Cutaneous melanoma. Lancet 2005;365:687-701. 2. Alam M, Ratner D. Cutaneous squamous-cell carcinoma. N Engl J Med 2001;344:975-83. 3. Lautenschlager S, Wulf HC, Pittelkow MR. Photoprotection. Lancet 2007;370:528-37. 4. Neale R, Williams G, Green A. Application patterns among participants randomized to daily sunscreen use in a skin cancer prevention trial. Arch Dermatol 2002;138:1319-25. 5. Dobbinson S, Wakefield M, Hill D, Girgis A, Aitken JF, Beckmann K, et al. Prevalence and determinants of Australian adolescents’ and adults’ weekend sun protection and sunburn, summer 2003-2004. J Am Acad Dermatol 2008;59:602-14. 6. Mahe´ E, Morelon E, Fermanian J, Lechaton S, Pruvost C, Ducasse MF, et al. Renal-transplant recipients and sun protection. Transplantation 2004;78:741-4. 7. Reich A, Harupa M, Bury M, Chrzaszcz J, Starczewska A. Application of sunscreen preparations: a need to change the regulations. Photodermatol Photoimmunol Photomed 2009;25:242-4. 8. Wright MW, Wright ST, Wagner RF. Mechanisms of sunscreen failure. J Am Acad Dermatol 2001;44:781-4. 9. Autier P, Boniol M, Severi G, Dore´ JF. Quantity of sunscreen used by European students. Br J Dermatol 2001;144:288-91. 10. Dennis LK, Beane Freeman LE, VanBeek MJ. Sunscreen use and the risk for melanoma: a quantitative review. Ann Intern Med 2003;139:966-78. 11. Huncharek M, Kupelnick B. Use of topical sunscreens and the risk of malignant melanoma: a meta-analysis of 9067 patients from 11 case-control studies. Am J Public Health 2002;92: 1173-7. 12. Gorham ED, Mohr SB, Garland CF, Chaplin G, Garland FC. Do sunscreens increase risk of melanoma in populations residing at higher latitudes? Ann Epidemiol 2007;17:956-63. 13. Oliveria SA, Satagopan JM, Geller AC, Dusza SW, Weinstock MA, Berwick M, et al. Study of Nevi in Children (SONIC): baseline findings and predictors of nevus count. Am J Epidemiol 2009;169:41-53. 14. Rodvall Y, Wahlgren C, Ulle´n H, Wiklund K. Common melanocytic nevi in 7-year-old schoolchildren residing at different latitudes in Sweden. Cancer Epidemiol Biomarkers Prev 2007;16:122-7. 15. Bauer J, Bu¨ttner P, Wiecker TS, Luther H, Garbe C. Effect of sunscreen and clothing on the number of melanocytic nevi in 1,812 German children attending day care. Am J Epidemiol 2005;161:620-7.

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www.who.int/uv/publications/en/GlobalUVI.pdf. Accessed Nov 20, 2009 37. Cadet J, Sage E, Douki T. Ultraviolet radiation-mediated damage to cellular DNA. Mutat Res 2005;571:3-17. 38. DIN 67502: Charakterisierung der UVA-Schutzwirkung von dermalen Sonnenschutzmitteln durch Transmissionsmessungen unter Beru¨cksichtigung des Lichtschutzfaktors, ICS 71.100.70. Berlin: Deutsches Institut fu¨r Normung; 2005.