Sjogren’s patients have two special risks related to sun exposure. Sun protection is key.
1. Sun exposure may flare Sjogren’s symptoms, especially in those who are SS-A positive. 2. Sjogren's patients have an increased risk of developing skin cancer. Sun exposure adds to this risk.
People with Sjogren’s disease (SjD), systemic lupus erythematosus (SLE), and scleroderma (SSc) have a 25% higher risk of developing non-melanoma skin cancers, which include basal cell or squamous cell skin cancer.
Patients who use immunosuppressive medications such as methotrexate for more than one year were found to have a 69% higher risk (215).
Hydroxychloroquine (aka Plaquenil) is an immune system modulator, not an immunosuppressant. While it mays cause sun sensitivity, it does not appear to increase skin cancer risk (216).
What do these numbers mean for individual risk? This example will help you think about your typical risk as a Sjogren's patient. It is based on U.S. data showing that overall,
Of 100 people in the general population, about 20 will develop skin cancer by age 70.
Of 100 with SjD, SLE, or SSc, about 25 will develop skin cancer by age 70
Of 100 with SjD, SLE, or SSc who have taken on immune suppressants for greater than one year, about 34 will develop skin cancer by age 70
The good news-
Sun protection reduces the risk of developing skin cancer.
Routine screening and excision of non-melanoma skin cancers usually cures them, especially if they are caught early. This is usually a minor procedure performed in an outpatient setting.
Sjogren's patients taking immune suppressing medications, especially those with a previous skin cancer diagnosis, should be monitored routinely. You can use the abstract of this article to discuss this with your clinician (215).
Being active and enjoying the outdoors is good for your physical and mental health. You can do that and protect your skin at the same time.
Does a suntan protect you from skin cancer?
No, tanning causes skin cancer. It is a myth that having a base tan will protect you from sun damage and skin cancer. For more information, see this page from the American Academy of Dermatology (AAD)
What about Vitamin D?
People with Sjogren's often have low levels of Vitamin D, even with adequate sun exposure. No one understands exactly why this is, but if do not have this problem, brief sun exposure at non-peak hours is usually produces adequate Vitamin D levels. Talk with your clinician about testing your Vitamin D level, and if it is low, ask about supplements. This is important because people with Sjogren's are at increased risk for osteoporosis. Vitamin D is important for bone mineralization and density.
What about people with darker skin tones?
"People of all colors, including those with brown and black skin, get skin cancer. Even if you never sunburn, you can get skin cancer. When skin cancer develops in people of color, it’s often in a late stage when diagnosed.” ~ AAD
Sun protection is key to reducing the risk for all types of skin cancer. Sunscreen is helpful, but not perfect. It should be used as an add-on to other sun protection strategies.
Sun protection strategies
Avoid midday sun; especially from 10 am to 3 pm. When possible, plan outdoor activities when the sun is low (early morning or evenings).
Choose shade whenever possible.
Wear sunglasses rather than apply sunscreen next to your eyes.
Cover up: hats, sun umbrellas, and sun protective clothing are key. Use a rash guard while swimming.
Use sunscreen, SPF 30 or more, on the places that you cannot cover. Don’t forget your neck, your ears, and your hands and feet.
More useful sun protection tips: The Sjogren’s Foundation The American Academy of Dermatology
Which sunscreen brands are best?
Instead of chemical sunscreens, choose mineral sunscreens that contain zinc oxide and/or titanium dioxide. Chemical sunscreens usually contain harmful ingredients such as oxybenzone and other chemicals that have endocrine-disrupting effects.
Do not assume that sunscreens marketed for babies are healthier options. These products are often the worst offenders.
Do not use spray sunscreens or loose powder sunscreens. These products can be inhaled deep into the lungs and cause irreversible damage.
Choose products labeled “fragrance-free”. Fragrances are not regulated by the FDA and often contain harmful chemicals. Sometimes a “fragrance-free” label can be misleading because of the lack of regulation.
Pay attention to skin or respiratory tract irritation. A few years ago, I tried Neutrogena “fragrance-free” sunscreen. I threw it away because I noticed a chemical smell and had problems with eye and throat irritation. It was later found to contain benzene, a known carcinogen, and pulled from the market. Do not assume that because a sunscreen is sold at the local pharmacy that it is safe. This is especially true in the U.S: the FDA only regulates the SPF part of the sunscreen, not the other ingredients. For more information, see the EWG guide to sunscreens.
Please note: I cannot endorse any particular product recommended by EWG, but this page is helpful for looking up your sunscreen brand.
~ Sarah Schafer, MD and Sjogren's patient