Sunscreen, vitamin D and skin of colour

Letter

It is encouraging to see the issue of sun protection brought to prominence for Australian clinicians in the October 2025 issue of Australian Prescriber.¹ However, the sunscreen advice needs to be clarified.

Cancer Council Australia recommends sunscreen use in 2 contexts:

• routinely on all days when the ultraviolet index is forecast to reach 3 or more, providing protection during incidental exposure
• when undertaking planned outdoor activities, as part of a broader suite of protective measures.²

Morriss and Scardamaglia advise that Australians should use sunscreen in both contexts, irrespective of skin type.¹ However, since UV-induced skin cancer is rare in people with Fitzpatrick skin types 5 (brown skin) and 6 (dark brown or black skin), and vitamin D deficiency is common, a group of leading medical and public health practitioners concluded that for people with these skin types the benefits of applying sunscreen routinely do not outweigh the risks, costs and potential impact on the environment (e.g. packaging, transport, ecosystems).³ Sun protection (including sunscreen) is, however, advised for all people, irrespective of skin type, during extended outdoor exposures. These recommendations have been endorsed by Cancer Council Australia, the Australasian College of Dermatologists, and the Royal Australian College of General Practitioners.

Morriss and Scardamaglia also state that sunscreen does not cause vitamin D deficiency. A recent randomised controlled trial (the Sun-D Trial) of daily sunscreen application for 1 year found that, while the difference in 25-hydroxyvitamin D concentration was small (compared with discretionary use), daily sunscreen use increased the risk of vitamin D deficiency by 33% by the end of the study period (winter), with a similar increase across all 4 eastern Australian states.⁴ Clinicians need to be aware of this finding, and advise their patients about vitamin D supplementation accordingly.

Rachel E Neale
Senior Group Leader, QIMR Berghofer, Brisbane
Adjunct professor, School of Public Health, The University of Queensland, Brisbane

David C Whiteman
Distinguished Scientist, QIMR Berghofer, Brisbane
Adjunct professor, School of Public Health, The University of Queensland, Brisbane

Conflicts of interest: Rachel Neale and David Whiteman were co-authors of position statements titled 'Balancing the risks and benefits of sun exposure' (2024) and 'When to apply sunscreen: a consensus statement for Australia and New Zealand' (2019). They have received grants from the National Health and Medical Research Council for studies related to the epidemiology of skin cancer and the effect of sunscreen on vitamin D. David Whiteman is Chair of the Expert Advisory Committee for the Roadmap for a National Targeted Skin Cancer Screening Program, an Australian Government initiative.

 

References

1. Morriss S, Scardamaglia L. Sun protection: a practical guide for health professionals. Australian Prescriber 2025;48:173-8.
2. Cancer Council Australia. Be SunSmart. 2025. [cited 2025 Nov 10]
3. Neale RE, Beedle V, Ebeling PR, Elliott T, Francis D, Girgis CM, et al. Balancing the risks and benefits of sun exposure: A revised position statement for Australian adults. Aust N Z J Public Health 2024;48:100117.
4. Tran V, Duarte Romero BL, Andersen H, Clarke M, Collins LG, Dawson T, et al. Effect of daily sunscreen application on vitamin D: findings from the open-label randomized controlled Sun-D Trial. Br J Dermatol 2025;193:1128-37.

 

Authors' response

Samuel Morriss and Laura Scardamaglia, the authors of the article, comment:

We thank Professors Neale and Whiteman for their thoughtful comments regarding our article on sun protection.¹ Their letter highlights the importance of ongoing dialogue about photoprotection in Australia's diverse population.

While we acknowledge that ultraviolet (UV)-induced skin cancer is less common in individuals with darker skin types, the recommendation to limit routine sunscreen use in these groups overlooks the significant morbidity associated with UV and visible light exposure in people with skin of colour.² UVA and visible light are now recognised as key contributors to hyperpigmentary disorders such as melasma, post-inflammatory hyperpigmentation (e.g. in people with acne), and acquired dermal macular hyperpigmentation.³ These conditions are more common in people with skin of colour and have a substantial impact on quality of life.^4,5 These findings underpin our recommendation for daily use of broad-spectrum sunscreens, ideally tinted formulations that provide visible light protection.

The misconception that darker skin is inherently protected against all types of photodamage contributes to lower engagement in photoprotective behaviours.^4,6 Although the incidence of skin cancer is lower in people with skin of colour, cases are more frequently diagnosed at advanced stages, leading to 2- to 3-fold higher mortality rates compared with those with lighter skin.⁴ This pattern is also observed among Australian Aboriginal and Torres Strait Islander people, further highlighting the need for inclusive and tailored public health messaging.⁷

The suggestion that sunscreen use increases the risk of vitamin D deficiency remains contentious. Most evidence shows minimal impact on serum 25-hydroxyvitamin D concentrations.^8,9 A recent meta-analysis of prospective observational trials reported a mean difference of 2 nanograms/mL (5 nanomoles/L) between sunscreen users and non-users.⁹ The Sun-D randomised controlled trial reported a mean difference of 5.2 nanomoles/L in vitamin D concentrations in routine sunscreen users (when UV index was forecast to be 3 or more) compared with discretionary users.¹⁰ Importantly, most studies (including the Sun-D trial) have lacked representation of people with skin of colour, underscoring the need for further research in this population. Screening for vitamin D deficiency in regular users of sunscreen is a matter of clinical judgement. A 2019 international consensus statement suggested that routine sunscreen use does not compromise vitamin D synthesis, and that testing for vitamin D deficiency should be reserved for at-risk patients.¹¹

Given the well-established harms of sunlight exposure and the uncertain significance of modest vitamin D reductions, public health recommendations should prioritise photoprotection for all skin types.

Conflicts of interest: none declared

 

References 2

1. Morriss S, Scardamaglia L. Sun protection: a practical guide for health professionals. Australian Prescriber 2025;48:173-8.
2. Gupta AK, Bharadwaj M, Mehrotra R. Skin Cancer Concerns in People of Color: Risk Factors and Prevention. Asian Pac J Cancer Prev 2016;17:5257-64.
3. Mun SJ, Lee V, Gupta M. Sunscreens in pigmentary disorders: time to revise the message. Photochem Photobiol Sci 2025;24:215-25.
4. Krutmann J, Piquero-Casals J, Morgado-Carrasco D, Granger C, Trullas C, Passeron T, et al. Photoprotection for people with skin of colour: needs and strategies. Br J Dermatol 2023;188:168-75.
5. Lim HW, Zhang C, Taylor M, Dlova NC, Conceicao K, Jablonski N, et al. International Expert Consensus on Knowledge Gaps in Care for Dermatologic Disorders in Skin of Color. Int J Dermatol 2025.
6. King A, Sabbah SG, Bose R, Heath CR, Silverberg NB. Photoprotection in Skin of Color: A Scoping Review of Barriers, Behaviors, and Pediatric Considerations. Pediatr Dermatol 2025;42:933-8.
7. Slape DR, Saunderson RB, Tatian AH, Forstner DF, Estall VJ. Cutaneous malignancies in Indigenous Peoples of urban Sydney. J Med Imaging Radiat Oncol 2019;63:244-9.
8. Neale RE, Khan SR, Lucas RM, Waterhouse M, Whiteman DC, Olsen CM. The effect of sunscreen on vitamin D: a review. Br J Dermatol 2019;181:907-15.
9. Gatta E, Cappelli C. Sunscreen and 25-Hydroxyvitamin D Levels: Friends or Foes? A Systematic Review and Meta-Analysis. Endocr Pract 2025;31:839-48.
10. Tran V, Duarte Romero BL, Andersen H, Clarke M, Collins LG, Dawson T, et al. Effect of daily sunscreen application on vitamin D: findings from the open-label randomized controlled Sun-D Trial. Br J Dermatol 2025;193:1128-37.
11. Passeron T, Bouillon R, Callender V, Cestari T, Diepgen TL, Green AC, et al. Sunscreen photoprotection and vitamin D status. Br J Dermatol 2019;181:916-31.

 

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