How many times have dermatologists advised patients to use sunscreen? This may be better off left as a rhetorical question, as photoprotection is such an integral part of basic skin care. While it can help reduce premature aging and play a role in correcting dyschromia, among other applications, sunscreen is best known by patients and consumers as a method to preventing sunburn and skin cancer.1 However, access can create problems with use, potentially compounding issues with proper application and adding to the increasing incidence of skin cancers across the country.2
Tiffany J. Libby, MD, FAAD, director of Mohs micrographic and dermatologic surgery and assistant professor of dermatology at the department of dermatology, Warren Alpert Medical School, Brown University in Providence, RI; Julia A. Siegel, MD, a dermatology resident physician at Brown; and colleagues3 recently proposed defining sunscreen products as medical necessities by the Transportation Security Administration (TSA). In other settings, sunscreen is considered a medication, such as day cares and schools, where parents are required to have a note allowing sunscreen application to their children. Given this fact and sunscreen’s multifaceted medical use, the classification seems logical to dermatologists—but getting
others on board with the concept is more of an uphill battle.
Travel Changes
Because of the increasing costs to air travel, passengers are opting to use free or low-cost options such as personal items and carry-on luggage. The TSA limits the amount of liquids in these bags by the “3-1-1 rule,” or 3.4 oz (100 mL) or smaller containers that fit into one quart-sized resealable bag. The current TSA-approved size of 3.4 oz gives carry-on travelers enough product for approximately 2.4 applications, noted Drs Libby and Siegel. After just about 4 hours, 48 minutes, of outdoor activity, travelers would need another source of sunscreen and will have to make an often expensive purchase shortly after arriving at their destination. This may also lead to wasted product upon return flights, as passengers may not be able to bring their semi-used full-size containers through TSA checkpoints.
“The idea was born two years ago when I was traveling to a tropical island and was told I could not bring six travel-sized sunscreens in my carry-on luggage. I was only permitted to bring two that fit in the same quart sized bag per the TSA 3-1-1 rule,” said Dr Siegel. “Upon arrival to my destination, I was faced with extremely high sunscreen prices and, even as a dermatology resident, elected to buy the bare minimum. I wore protective clothing and tried to seek shade, but I still found myself with sunburns.”
“Because inadequate access to sunscreen can lead to severe sunburns and subsequent skin cancers, we decided to make this push as an important public health initiative,” Dr Siegel added. “And, as my coauthor, Josh Yudkin, MA, MPH, wrote, ‘we have a professional and moral responsibility to remove barriers and empower people to take charge of their health and engage in preventive behavior.’”
Full-size sunscreens in carry-on bags would encourage sun safety among travelers. Shared decision-making models of care highlight that patient preferences may also influence adherence to therapy, thus full-size sunscreens would help patients who desire specific brands or formulations that are not readily available at their destination. Patients with sensitive skin may even need certain products or are restricted in what they can use due to allergic contact dermatitis.
“If our patients could bring adequate amounts of their desired sunscreens on vacation, they would be more likely to use them as directed throughout the duration of their trip, potentially lowering their risk of skin cancer,” said Dr Libby. “In addition, labeling sunscreen as medically necessary, and highlighting its ability to prevent skin cancer, will promote awareness of the importance of sun protection within the general population.”
Currently, the TSA accepts contact lens solution, insulin, baby formula, breast milk, liquid vitamins, and other liquid medications as medical items in containers larger than 3.4 oz. On April 7, 2021, the TSA website was updated to include sunscreen as a medically necessary item, allowing passengers to carry sunscreen containers larger than 3.4 oz through security checkpoints in personal items or carry-on luggage.4 The change would also mean travelers would need to declare sunscreen to the TSA at security checkpoints, just like any other medical item.
Drs Siegel and Libby shared their excitement in seeing the TSA willing to work with dermatologists to consider sunscreen as a medically necessary liquid and allow full-size bottles in carry-on luggage as appropriate. However, 5 days later on April 12, 2021, the TSA released a follow-up statement, clarifying that the previous update was erroneously released:
Our website incorrectly reported that sunscreen containers larger than 3.4 oz. were allowed in carry-on bags, if medically necessary. That error has been corrected. Travelers still need to ensure liquids, gels and aerosols in carry-on bags meet the 3-1-1 requirements and are no larger than 3.4 ounces. TSA advises passengers who need larger quantities of sunscreen, or other liquids, gels and aerosols, to add them to checked baggage for use at their destination.5
Travelers and dermatologists alike might see this as a defeat, but Drs Siegel and Libby stressed that the change may just take more time. “This is an important long-term initiative, and we hope to continue working with the TSA to promote sun protection while also respecting the restrictions that are important for the safety of travelers.”
Support for Sunscreen
Clinical experience and research support the need for increased sunscreen access. Keratinocyte carcinomas are the most common types of cancer in the United States, and it is not uncommon for dermatologists to diagnose nonmelanoma skin cancers multiple times per day. Over the past decade, the annual diagnosis of new invasive melanoma increased by 44%.2 Research from 2016 found that just a 5% increase in sunscreen use per year over 10 years would translate to a 10% reduction in melanomas (approximately 230,000 melanomas),6 building upon previous studies showing the reduced risks of cutaneous malignancies and sunburn with sunscreen use.7-11
Not only could increased sunscreen use at a population level prevent new skin tumors and melanoma deaths, it may reduce health care costs overall.12 Over the 5-year period
between 2007 to 2011, skin cancer treatment cost an average $8.1 billion annually, and this number is only expected to rise as the incidence of skin cancers increases with time.13,14
Drs Siegel and Libby added that their team is now partnering with the American Academy of Dermatology on the initiative, signaling broader support for the change. “We would appreciate any support or ideas from our dermatology community to help us make this a reality. Please feel free to reach out with any questions or comment,” they added.
Pushing for cultural changes, including the TSA recognizing sunscreen as a medical item, could go a long way in dermatology’s fight against skin cancer.
References
1. Holman DM, Ragan KR, Julian AK, Perna FM. The context of sunburn among U.S. adults: common activities and sun protection behaviors. Am J Prev Med. 2021;60(5):e213-e220. doi:10.1016/j.amepre.2020.12.011
2. Cancer Facts & Figures 2021. American Cancer Society; 2021. Accessed May 5, 2021. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf
3. Siegel JA, Yudkin JS, Craker K, Hwang A, Libby TJ. Uncapping the bottle: a proposal to allow full-sized sunscreens in carry-on luggage to promote sun protection and prevent skin cancer. J Am Acad Dermatol. 2021;84(4):1206-1207. doi:10.1016/j.jaad.2020.10.066
4. Dall'Asen N. Nope, the TSA will not allow full-size sunscreen in carry-on bags. Self. April 14, 2021. Accessed May 5, 2021. https://www.self.com/story/tsa-full-size-sunscreen
5. Statement regarding sunscreen in carry-on bags. Press release. Transportation Security Administration; April 12, 2021. Accessed May 5, 2021. https://www.tsa.gov/news/press/statements/2021/04/12/statement-regarding-sunscreen-carry-bags
6. Olsen CM, Wilson LF, Green AC, Biswas N, Loyalka J, Whiteman DC. How many melanomas might be prevented if more people applied sunscreen regularly?. Br J Dermatol. 2018;178(1):140-147. doi:10.1111/bjd.16079
7. Green A, Williams G, Neale R, et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet. 1999;354(9180):723-729. doi:10.1016/S0140-6736(98)12168-2.
8. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011;29(3):257-263. doi:10.1200/JCO.2010.28.7078
9. Olsen CM, Wilson LF, Green AC, et al. Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use. Aust NZ J Public Health. 2015;39(5):471-476. doi:10.1111/1753-6405.12470
10. van der Pols J, Williams GM, Pandeya N, Logan V, Green AC. Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use. Cancer Epidemiol Biomarkers Prev. 2006;15(12):2546-2548. doi:10.1158/1055-9965.EPI-06-0352
11. Wu S, Cho E, Li WQ, Winstock MA, Han J, Qureshi AA. History of severe sunburn and risk of skin cancer among women and men in 2 prospective cohort studies. Am J Epidemiol. 2016;183(9):824-833. doi:10.1093/aje/kwv282
12. Gordon L, Olsen C, Whiteman DC, Elliott TM, Janda M, Green A. Prevention versus early detection for long-term control of melanoma and keratinocyte carcinomas: a cost-effectiveness modelling study. BMJ Open. 2020;10(2):e034388. doi:10.1136/bmjopen-2019-034388
13. Guy GP Jr, Machlin SR, Ekwueme DU, Yabroff KR. Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med. 2015;48(2):183-187. doi:10.1016/j.amepre.2014.08.036
14. Guy GP Jr, Thomas CC, Thompson T, Watson M, Massetti GM, Richardson LC; Centers for Disease Control and Prevention. Vital signs: melanoma incidence and mortality trends and projections - United States, 1982-2030. MMWR Morb Mortal Wkly Rep. 2015;64(21):591-596.
