Sunscreen: Have the Derms Been Lying? 

“Apply generously and evenly to exposed skin 20 minutes before sun exposure. Reapply at frequent intervals after perspiring, swimming or towel drying”: these are the directions for sunscreen use at the back of my tube. The dermatological community wholly believes they’re our best defense against skin cancer.

Sunscreen can limit and  even block cancer caused by UV rays. However, in a world where whiteness is the default for medicine and science, how relevant are some of these findings for black people? Do they do more harm than good? What does the science say?

There are multiple types of skin cancer and not all are UV exposure related. 98% of cases are types known as basal and squamous cell carcinomas that are considered so minor they aren’t even tracked in cancer registries. Melanoma accounts for less than 2% of cases, but about 7,000 deaths.1 It’s predicted to increase in the population in coming years.

 

Enter dermatologist extraordinaire Adewole Adamson, M.D. In 2019, he published an opinion piece in The Washington Post debunking the recommendation that sunscreen use in black people can reduce melanoma risk. His reason? “There exists no study that demonstrates sunscreen reduces skin cancer risk in black people. Period.”2

When he was fresh off the M.D boat, Adamson trained his eye on melanoma and quickly saw that something was odd, and initially, his interest had nothing to do with race. “For me, it all started with a simple figure,” he says. “Melanoma incidence has gone up sixfold, and mortality has stayed flat. That never quite made sense. That was the beginning of the rabbit hole.”3

The reason for the rise in melanoma cases has remained mysterious. The sun hasn’t changed. Sunscreen use has improved. The ozone layer has been healing for years.4 Yet public health messages promoting sunscreen recommendations for dark skin people are at odds with the available evidence.

Acral lentiginous melanoma (ALM) is a type of melanoma common in black people that often shows up in places where UV exposure is minimal like palms or soles of the feet.5 Bob Marley famously passed away due to an untreated case of ALM on one of his big toes. So why all the fuss with marketing if skin cancer from sun exposure isn’t that risky for black folk?

Well, as any good sleuth would tell you… follow the money. Fortune Business Insights says that the global sun care market size was $13.03 billion in 2019 and is projected to reach $16.84 billion by 2027. That’s a lot of digits. The business of dermatology is increasingly dominated by profit-oriented practices boosted by increasing the number of procedures performed in-house and maximizing the use of physician’s assistants, who come cheaper than doctors.6 While there is no risk for over-testing, doctors could face a lawsuit if they dismiss a patient who is at risk of developing melanoma, further encouraging testing which is costly.

Dermatologists feel it’s taken so long to get people to use sunscreen, so they’re extremely hesitant to go public with recommendations about relaxing sunscreen use. However, there’s harm in a decision like this. “Making that link makes patients feel like they are the reason they got melanoma,” says Adamson “It’s almost like victim-blaming.”7

Most studies of malignant melanoma largely include Caucasian populations, in part because of higher incidence in lighter-skinned individuals.8 This lack of prioritisation of other racial populations means that misinformations can easily spread. Skin conditions look different on various skin tones. Applying a standard across the board and ignoring the nuances in various illnesses can mean the difference between life or death.

In the U.S., melanoma is 20 to 30 times more common among whites compared to blacks. In contrast, melanoma is reportedly rare among black Africans. Studies in Nigeria, Togo and South Africa identified only 15, 63 and 185 cases respectively over periods of 11, 20 and 15 years. According to the World Health Organisation (WHO), acral lentiginous melanoma (ALM) is considered the most common subtype among Africans.9

The time has come for more nuanced recommendations. If your concerns so far have been cosmetic such as ageing or sunburns then glob on the sunscreen but do not mistake this practice for preventing cancer. Regular checking is the only way to save yourself. The earlier it’s detected, the earlier it can be treated. Plus in a world where doctors are using social media to educate, keeping an ear to the ground never hurt.

Footnotes
  1. Rowan Jacobsen, “There’s No Proof Sunscreen Prevents Cancer in Black People. Why Do Doctors Keep Pushing It?,” Mother Jones, September 1, 2021, https://www.motherjones.com/politics/2021/09/theres-no-proof-sunscreen-prevents-cancer-in-black-people-why-do-doctors-keep-pushing-it/.
  2. Adewole S. Adamson, “Perspective | in Rare Occasions, Dark-Skinned People Can Get Skin Cancer. But Sunscreens Won’t Help.,” Washington Post, May 26, 2019, https://www.washingtonpost.com/national/health-science/in-rare-occasions-dark-skinned-people-can-get-skin-cancer-but-sunscreens-wont-help/2019/05/24/539daf8c-7b0d-11e9-8bb7-0fc796cf2ec0_story.html.
  3. Jacobsen 2021)
  4. Helena Horton, “‘Larger than Usual’: This Year’s Ozone Layer Hole Bigger than Antarctica,” the Guardian, September 15, 2021, https://www.theguardian.com/environment/2021/sep/16/larger-than-usual-ozone-layer-hole-bigger-than-antarctica.
  5. Maurice Mulenga et al., “Epidemiological and Histopathological Profile of Malignant Melanoma in Malawi,” BMC Clinical Pathology 19, no. 1 (April 2, 2019), https://doi.org/10.1186/s12907-019-0087-6.
  6.  (Jacobsen 2021)
  7. Ibid
  8. (Mulenga et al. 2019)
  9. Ibid