When I moved to Singapore twelve years ago, I didn't realize, coming from Canada, how much more I would be exposing myself to the sun. Aside from wearing more short sleeved clothing because of the hot weather, I also spend a lot more time outdoors: at the pool, doing exercise and just walking to and from shops and public transportation. A little bit every day accumulates and *gasp!* I am starting to notice the signs of sun damage.
As a mom of young kids, I'm also very concerned about how much sun exposure my little munchkins are getting, as they also spend a significant amount of their time outdoors. So I tapped on our friend, Dr. Shanna Ng, Singapore Ministry of Health-accredited dermatologist, and had a chat with her to really get to the bottom of what we need to do to protect ourselves and our family from the ravages of the sun.
We discuss the importance of vitamin D and how to get enough, the best methods of sun protection including sunscreen ratings (psst: higher SPF numbers are not necessarily better!), how to treat sun damaged skin to look younger and the big C - how to look out for skin cancer in adults and children.
Watch the video below for Dr. Shanna's expert advice (and scroll down for a text version of the interview).
Our Interview with Dr. Shanna
So, why is sun protection so important?
Sun protection is important to prevent most importantly, skin cancer, and also of course something everyone is concerned about, which is skin aging.
Protecting ourselves from the sun is important, but so is getting enough vitamin D. So, how do we balance these two important factors?
In regards to vitamin D, now we know a lot more about what it contributes to our bodies. Sun exposure is certainly required to convert cholesterol to vitamin D3, and then this is later converted in the liver and then in the kidneys to an active form of vitamin D known as calcitriol. Calcitriol is important for maintaining not only our bone health, but now we know that it also helps to maintain our mental health, which is very important now. It also benefits our immune system, our colon, and also possibly even prevent diabetes and high blood pressure.
When you compare us to what our hunter and gatherer predecessors used to do, which was go out in the sun all the time, they used to get a lot of vitamin D naturally. Nowadays we can easily obtain vitamin D through fortified foods, such as fortified juices and cereals, and also through fish like salmon and tuna. If you're a vegetarian, you can also get vitamin D from vegetables, such as spinach, kale and even soybeans.
So then how much sun exposure do we really need to maintain a good level of vitamin D?
So that's a question that a lot of people have been trying to answer. The truth is that it's hard to determine because the research studies have all been very heterogeneous, which means there is no uniformity. Because there are so many variable factors, such as skin colour, a person's lifestyle, dietary habits and also country of residence. There was a study done in the UK, which of course is in a different part of the world from us and also has different seasons and different of skin types. But the study actually showed that we only need around nine minutes of lunchtime sun exposure for someone who is fair-skinned, and around 25 minutes of lunchtime exposure for someone with darker skin, to get adequate amounts of vitamin D.
One point of great importance to note is that the studies have also shown that application of sunscreen doesn't actually reduce our vitamin D levels, and doesn’t contribute to vitamin D deficiency. So sunscreen is still extremely important, and there's no downside to using sunscreen from that aspect.
Since we're talking about sunscreen now, what's the best way to actually protect our skin from the sun. Is it sunscreen, or should we be using like physical barriers, like clothing and hats?
When you have kids, it's often quite difficult to reapply the sunscreen or even remember to use or bring along our sunscreen, since there's so much else to pack along in our bags! When the kids are having fun in the water, it's so hard to like hold them back and reapply the sunscreen again. Therefore the most important thing actually is avoidance of the sun, especially from 10:00 AM to 2:00 PM. So you can always choose your water activity or any form of sports before that or after that timing. If need be, you can always plan your activities in the shade.
Secondly, of course, if one has to, or one enjoys a lot of activities out in the sun, then do use sun protective clothing where the fabric is tightly woven, and those that have a UV protection factor that filters out the sun. If possible, always have on a broad-brimmed hat to protect the face, the ears, and the scalp, which often gets forgotten. If you do water spots, consider rash guards for additional protection. If you see me out on the beach, you would see this short little lady wearing a broad brimmed hat, and I will be covered from head to toe literally – all the way down to my wrists and ankles. That’s me in the sun!
So, what's the difference between UVA and UVB rays? And what should we look for when we're looking for a sunscreen?
The difference between the two is that UVA actually has a longer wavelength. So UVA is responsible for the immediate skin tanning that we may see, which then also leads to skin damage, and of course skin aging. This is as opposed to UVB, which has a shorter wavelength, and this actually causes the redness that we get from being under the sun. With this redness, there is delayed skin burns and delayed tanning. So, the difference between the two is that actually a large part of our sun exposure is actually due to UVA - 95% of our sun UV rays are UVA, and only 5% are UVB. And most importantly, UVA rays pass through our glass windows, while UVB rays are blocked by glass windows. Even on an overcast day, you still get UVA rays that come through, in fact, more UVA than UVB.
Typically when we look for sunscreen, we always look for the highest numbers. But the thing is that by the time the SPF reaches about 30, then the protection beyond that actually starts to plateau. For example, with an SPF of 30, you're actually blocking out 97% of the sun rays. When it increases to SPF of 50, then you actually block out about 98% of our sun rays. One won’t really get much more added protection from any SPF beyond 50. If you go to other countries you might see SPF 120, for example. But the truth is that it won’t give you much more protection. So an SPF sunscreen over SPF 30 will be good enough to protect 97%. With SPF of 50, about 98% of our sun rays will not reach our skin. If you go beyond that it you might even get a false sense of security.
And of course, the SPF factor only tells us the protection against UVB. And remember what I said earlier on, that actually 95% of our UV rays are UVA. So to protect ourselves against UVA rays, we look for the plus sign after the SPF number. So, the highest plus number would be four plus (++++).
As we all want to look younger, what are the signs of sun damage and what are the best ways to treat it?
Certainly we all want to look younger, and sun damaged skin definitely makes us look older than our actual age. With a lot of sun exposure, in early stages, you may first notice sunspots. These are brown spots on the cheeks or other sun exposed areas of your body such as your forearms, wrists and legs. Then you will also notice that your skin starts to get quite rough and dry easily. Further down the timeline, one may notice more obvious blood vessels around the sun exposed areas of the face, even the chest, and on the ears as well. There’s also loss of elasticity. So you'll see more wrinkles that are usually deeper than what you should see for your actual age.
In terms of the treatment, there are many treatments available. There are over the counter treatments and post prescription treatments that come in the form of applications, lasers, and of course injectables as well. In terms of topical applications, there are retinoids, vitamin C and hyaluronic acid. For topical retinoids, they are over the counter options or prescription options. With hyaluronic acid, you can find them in application topicals or even an injectable, such as skin booster injections. And then the last thing would be lasers. Lasers are done for maintenance, perhaps once every two to six months, just to maintain both pigmentation and blood vessels that form under the skin. And it helps with fine lines and open pores as well.
Now let's talk about the big C word, skin cancer. Are some people really more susceptible to it, based on skin tone or ethnicity? What should we look out for and how do we know when we need to seek professional help?
The big C word is very important to look out for. If one is fairer or of a lighter skin type and burns or tans more easily then that puts that person at higher risk of skin cancer. The sun exposure is accumulative; the frequency and the number of hours of sun exposure leads to a form of skin cancer known as basal cell carcinoma and also squamous cell carcinoma. Whereas the intermittence of sun burns that one gets would increase the risk of melanoma.
If one actually has pre-existing moles or develop multiple moles and has a positive family history, have certain genetic conditions, or if the immune system is suppressed any reason, such as due to an underlying medical condition or certain medications, then this would put that person at a higher risk of developing skin cancer.
One should hopefully have somebody to become familiar with their moles in certain areas where self-surveillance is difficult, such as on the back or on the scalp. A partner who will be able to monitor that periodically for you and get familiar with how it looks would be most helpful. We frequently see a husband or wife that actually tells their partner to come in for a skin check if they noticed something started to change, so having a reliable partner would be actually very important. Otherwise, you can certainly survey and get familiar with your own moles. If they change in any size, shape, colour, they become itchy or they bleed then do see a doctor early. The most formal way to assess them, of course would be to see your dermatologist. But nowadays a lot of information is very widely available online; you can check out the American Academy of Dermatology or British Association of Dermatology for patient information. Pay attention to the ABCDE’s of melanoma:
Do pay attention to any change and see your doctor earlier, the earlier the better. But because my subspecialty is in children. So, I must make a mention that in children, the mole tends to be quite different. So, the ABCD is modified in children:
Skin cancer is less common in children, but depending on one's family history, one's skin type, whether there's any underlying genetic condition or sometimes long-term medications, like if they've had a transplant and they are on immunosuppressants to prevent transplant rejection, then that would of course increase on that child's risk of developing skin cancer.
BMedSci (Melb), MBBS (Melb), MRCP (UK), FAMS (S’pore)
August Society Founder & Creative Director