Sunscreen Product Performance and Other Determinants of

Sunscreen Product Performance and Other Determinants

of Consumer Preferences

Shuai Xu, MD, MSc; Michael Kwa, BA; Ashwin Agarwal, MD; Alfred Rademaker, PhD; Roopal V. Kundu, MD

IMPORTANCE

Sunscreen use is a modifiable behavior that can help reduce the risk for skin

cancer, prevent sunburns, mitigate photoaging, and treat photosensitive dermatoses. A

better understanding of consumer sunscreen preferences would inform dermatologists in

their own recommendations.

OBJECTIVE To determine the characteristics and the most commonly cited positive and

negative features of highly rated sunscreens described by consumers.

DESIGN, SETTING, AND PARTICIPANTS The top 1 percentile of sunscreen products on

Amazon.com as of December 2015 was selected according to average consumer review (ⱖ4

stars) and the highest number of consumer reviews. Descriptive data for each product were

collected from the product page and manufacturer claims. The top 5 “most helpful” reviews

(positive and critical) were analyzed and coded by a consensus qualitative coding scheme,

which included positive and negative descriptors in 6 major categories according to

consumer comments: affordability, cosmetic elegance, separate ratings, product ingredients,

product performance, and skin compatibility.

MAIN OUTCOMES AND MEASURES The Kruskal-Wallis test was performed to determine

whether characteristics of each product (eg, American Academy of Dermatology [AAD]

criteria, sun protection factor [SPF], or vehicle) could be used to predict price per ounce. The

number (percentage) of comments categorized by major themes and subthemes was

determined. Illustrative consumer comments were also collected.

RESULTS There were 6500 products categorized as sunscreens in the Amazon.com, online

catalog. Of the 65 products evaluated, the median price per ounce was $3.32 (range,

$0.68-$23.47). Of products, 40% (26 of 65) did not adhere to AAD guidelines (broad

spectrum, SPF ⱖ30, and water resistant) for sunscreens. Vehicles, AAD, and sunscreen type

predicted a higher price per ounce. Cosmetic elegance was the most cited positive feature

(198 of 325 [61%] comments) followed by product performance (146 of 325 [45%]

comments) and skin type compatibility (78 of 325 [24%] comments).

CONCLUSIONS AND RELEVANCE In this cohort of highly rated sunscreen products, a significant

proportion did not adhere to AAD guidelines, mostly attributable to a lack of water re sistance.

The most striking variation in this cohort was price, which varied by more than 3000%.

Dermatologists should balance the importance of cosmetic elegance, cost, and AAD

guidelines for sun protection in making their recommendations to consumers.

JAMA Dermatol. doi:10.1001/jamadermatol.2016.2344

Published online July 6, 2016.

Supplemental content at

jamadermatology.com

Author Affiliations: Department of

Dermatology, Northwestern

University, Feinberg School of

Medicine, Chicago, Illinois (Xu, Kwa,

Kundu); Duke University School of

Medicine, Durham, North Carolina

(Agarwal); Department of Preventive

Medicine, Northwestern University,

Feinberg School of Medicine,

Chicago, Illinois (Rademaker).

Corresponding Author: Shuai Xu,

MD, MSc, Department of

Dermatology, Northwestern

University, Feinberg School of

Medicine, 676 N St Clair St, Ste 1600,

Chicago, IL 60611 (stevexu

@northwestern.edu).

Research

Original Investigation

(Reprinted) E1

Downloaded From: http://archderm.jamanetwork.com/ by Shuai Xu on 07/06/2016

unscreen use is a modifiable behavior proven to reduce

the risk for skin cancers, prevent photoaging,reduce sun-

burns, and control photosensitive dermatoses. Despite

these results, sunscreen use remains persistently low for ado-

lescents and adults.

Insufficient sunscreen use is likely a mul-

tifactorial problem. Consumer preferences and recommenda-

tions likely drive sunscreen use but have not been well

investigated previously. Understanding these factors will help

health care professionals learn about meaningful patient con-

siderations regarding sunscreens to increase their sustained

use for preventive health.

In 2012, the market for sunscreens was expected to be-

come a $1 billion industry by 2016 with an expansive range of

marketed sunscreen products.

Of consumers, 73% buy beauty

and personal care products through Amazon.com, which to-

tals an estimated 9% of all sunscreen sales occurring with this

online retailer.

Previous work showed that online customer-

reported reviews of consumer products have a powerful ef-

fect on purchasing decisions.

Understanding the character-

istics of consumer reviews for highly consumer-rated

sunscreens would provide useful information for dermatolo-

gists to help inform their recommendations to patients.

Methods

The keyword s unsc reens was searched in the broader cat-

egory of “Beauty and Skin Care” products on the US internet

retailer Amazon.com. From the results, we determined the top

1 percentile of sunscreen products according to the average con-

sumer review (≥4 stars) and the number of consumer reviews

(>150 reviews) (eTable in the Supplement). Descriptive data

for each product, including SPF strength, price, and active in-

gredients, were also collected. Sunscreen products marketed

for the face, body, and children were included. Tanning lo-

tions and oral sun protection capsules were excluded.For prod-

ucts with multiple-size options, the product with the highest

number of reviews was included in the analysis and coded as

1 entry. The Kruskal-Wallis test was used to associate a prod-

uct’s descriptive characteristics with price per ounce.

For each sunscreen product, the content of the top 5 most

helpful positive and critical comments as voted by consum-

ers (325 total comments) was analyzed. Reviewer character-

istics, such as skin type, age, and prior dermatological condi-

tions, were not consistently available on the Amazon.com

platform. Three of us (S.X., M.K., and A.A.) developed, com-

pared, and reconciled a single, standard qualitative coding

scheme. Two of us (M.K. and A.A.) coded consumer-reported

comments for positive and negative descriptors with major cat-

egories, including affordability, cosmetic elegance, separate

ratings, product ingredients, product performance, and skin

compatibility. For each major category, subthemes were also

coded. Cosmetic elegance was defined as any feature associ-

ated with skin sensation on application, color, or scent. Prod-

uct performance included SPF and real-world effectiveness in

preventing sunburn, and product ingredients focused on the

sunscreen’s active and inactive ingredients. Skin compatibil-

ity reflected how the product performed in association with

skin conditions cited by reviewers. Comments may have mul-

tiple subcodes for a given major category (eg, a product was

noted to be nongreasy and have a pleasant scent). Of entries,

20% (65 comments) were coded by one of us (S.X.) to ensure

internal validity as previously reported.

5,6

This study was

deemed exempt by the institutional review board at North-

western University.

Results

There were 6500 products categorized as sunscreens in the

Amazon.com, online catalog. The top 65 products were se-

lected first by ratings (≥4 stars). This group was then ranked

by the number of consumer reviews (a surrogate for popular-

ity) to finalize the cohort. Our calculations revealed that the

top 1 percentile of Amazon.com sunscreen products acquired

more than 24 400 customer reviews as of December 2015. The

median review rating was 4.5 of 5 stars with a median of 288

customer reviews (range, 178-1792 reviews) per product. Price

per ounce was highly variable. The median price per ounce was

$3.32 (range, $0.68-$23.47). The median SPF was 35 (range,

4-110), with 89% (58 of 65) of products being 30 or higher.

Sunscreens with an active chemical ingredient were most

common (40%; 26 of 65) followed by physical sunscreens

(32%; 21 of 65) and a combination of chemical and physical sun-

screens (25%; 16 of 65). Of products, 92% (60 of 65) had a broad-

spectrum claim and 62% (40 of 65) were labeled as water or

sweat resistant. For vehicles, creams were the most common

(49%; 32 of 65) followed by lotions (29%; 19 of 65) and sprays

(11%; 7 of 65). Nearly all products (88%; 57 of 65) had addi-

tional claims associated with being sensitive skin compat-

ible, preservative-free, natural and/or organic, noncomedo-

genic, or animal safe. Of the highest rated sunscreen products

on Amazon.com, 40% (26 of 65) did not adhere to AAD crite-

ria (SPF ≥30, broad-spectrum claim, and water and/or sweat

resistance). Sunscreens that adhered to AAD criteria or had wa-

ter resistance were associated with higher cost (P < .001, Krus-

kal-Wallis test). Physical sunscreens were more expensive than

chemical sunscreens (P = .001). From highest to lowest cost,

creams were more expensive than lotions (P < .001), whereas

Key Points

Question What are the characteristics and features of sunscreens

that consumers rate favorably?

Findings In this analysis of the top 1 percentile of sunscreen

products on an online retailer, consumers preferred sunscreen

products predominately for their cosmetic elegance followed by

product performance. The cohort had a wide range of prices

($0.68-$23.47 per ounce), with 40% (26 of 65) of highly rated

products not adhering to the American Academy of Dermatology’s

recommended criteria for sunscreens, mostly owing to a lack of

water and/or sweat resistance.

Meaning Dermatologists should balance the importance of

cosmetic elegance, cost, and adequate sun protection in making

their recommendations to consumers.

Research Original Investigation Consumer Evaluations of Commercial Sunscreen

E2 JAMA Dermatology Published online July 6, 2016 (Reprinted) jamadermatology.com

Downloaded From: http://archderm.jamanetwork.com/ by Shuai Xu on 07/06/2016

lotions, as a category, were more expensive than sprays

(P = .005). We provide a list of highly rated consumer sun-

screens by the top 10 lowest-cost products and the top 10 most-

reviewed products (Table 1 and Table 2); the full cohort is de-

scribed in the eTable in the Supplement.

In analyzing the top-voted comments for each product, sev-

eral consonant themes emerged. First, cosmetic elegance was

the most cited positive feature associated with sunscreen prod-

ucts (61%; 198 of 325) followed by product performance (45%;

146 of 325). Skin compatibility (24%; 78 of 325) and product

ingredients (17%; 55 of 325) were cited less commonly as posi-

tive features. A few consumer reviews cite separate ratings

(12%; 39 of 325) and price (9%; 29 of 325) as positive features.

Second, when negative features were cited, patients mostly

Table 2. Top 10 Lowest-Cost, Highly Rated Sunscreens According to Amazon.com

No. Product Price per

Ounce, $

Reviews,

No.

Rating

(1-5)

Type

SPF Broad

Spectrum

Water

Resistance

Vehicle Additional

Claims

AAD

Criteria

1 NO-AD Sunscreen Lotion SPF 45 0.68 193 4.3 Chemical 45 Yes 80min Lotion No Yes

2 NO-AD Sport Sunscreen Lotion SPF 50 0.72 179 4.6 Chemical 50 Yes 80min Lotion Yes Yes

3 Banana Boat Sunscreen Sport Family Size

Broad Spectrum Sun Care Sunscreen Lotion, SPF

0.83 259 4.5 Chemical 50+ Yes 80min Lotion Yes Yes

4 Australian Gold SPF 30 Spray Gel with Bronzer 0.90 254 4.6 Chemical 30 Yes 80min Spray Yes Yes

5 Banana Boat Sunscreen Sport Performance Quik

Dri Broad Spectrum Sun Care Sunscreen Spray

1.02 178 4.2 Chemical 30 Yes 80min Spray Yes Yes

6 Banana Boat Sunscreen Sport Performance

Coolzone Broad Spectrum Sun Care Sunscreen

Spray

1.23 474 4.3 Chemical 50+ Yes Yes Spray No Yes

7 Hawaiian Tropic Sunscreen Silk Hydration SPF

1.33 1078 4.6 Chemical 30 Yes 80min Lotion Yes Yes

8 Babyganics Mineral-Based Baby Sunscreen

Lotion, SPF 50

1.33 407 4.3 Combination50+ Yes 80min Lotion Yes Yes

9 Zinc oxide powder 1.35 182 4.9 Physical NL NL No Powder No No

10 L'Oreal Paris Sublime Sun Advanced Sunscreen

SPF 30 Crystal Clear Mist

1.41 279 4.4 Chemical 45 Yes Yes Spray Yes Yes

Abbreviations: AAD, American Academy of Dermatology; NL, not listed;

SPF, Sun Protection Factor.

Data adapted from number of reviews ranked by number of ratings and lowest

price per ounce.

Statistically significant at P =.05.

Nearly all products (88%; 57 of 65) had additional claims associated with

being sensitive skin compatible, preservative-free, noncomedogenic, or

animal safe.

Table 1. Top 10 Most-Reviewed, Highly Rated Sunscreens According to Amazon.com

No. Product

Reviews,

No.

Rating

(1-5)

Price

per

Ounce,

$ Type

SPF

Broad

Spectrum

Water

Resistance

Vehicle

Additional

Claims

AAD

Criteria

1 EltaMD UV Clear SPF 46 1792 4.4 13.38 Combination 46 Yes No Cream Yes No

2 Hawaiian Tropic Sunscreen

Silk Hydration SPF 30

1078 4.6 1.33 Chemical 30 Yes 80min Lotion Yes Yes

3 Blue Lizard Australian

Sunscreen, Sensitive SPF 30+

812 4.5 3.41 Physical 30 Yes No Cream Yes No

4 SPF 30 daily oil-free face

moisturizer

786 4.7 5.98 Chemical 30 Yes No Cream Yes No

5 Neutrogena Age Shield Face

Lotion Sunscreen SPF 110

740 4.4 3.73 Chemical 110 Yes 80min Lotion Yes Yes

6 EltaMD UV Physical SPF 41 715 4.7 6.57 Physical 41 Yes 40min Lotion Yes Yes

7 Neutrogena Ultra Sheer

Dry-Touch Sunscreen, SPF 55

693 4.6 2.26 Chemical 55 Yes 80min Cream Yes Yes

8 Neutrogena Sunscreen Ultra

Sheer Stick SPF 70

647 4.6 5.91 Chemical 70 Yes 80min Roll-on Yes Yes

9 Neutrogena Oil Free Moisture

SPF 35

635 4.5 2.76 Chemical 35 Yes No Roll-on Yes No

10 Eucerin Daily Protection

Moisturizing Face Lotion

631 4.3 1.76 Physical 30 Yes No Lotion Yes No

Abbreviations: AAD, American Academy of Dermatology; SPF, sun protection

factor.

Data adapted from number of reviews ranked by number of ratings and lowest

price per ounce.

Statistically significant at P =.05.

Nearly all products (88%; 57 of 65) had additional claims associated with

being sensitive skin compatible, preservative-free, noncomedogenic, or

animal safe. In total, the top 1 percentile of sunscreens categorized by

Amazon.com have received more than 24 400 customer reviews. The AAD

criteria for preferred sunscreens were adhered to if the product had an SPF

rating of 30 or greater, a broad-spectrum protection claim, and water

resistance. Of the highest-rated sunscreen products on Amazon.com, 40%

(26 of 65) did not adhere to AAD recommendations, the primary reason being

a lack of water or sweat resistance (73%; 19 of 26). The median customer

rating was 4.5, with a median of 288 customer reviews. The median price per

ounce was $3.32 with a wide range ($0.68-$23.47).

Consumer Evaluations of Commercial Sunscreen Original Investigation Research

jamadermatology.com (Reprinted) JAMA Dermatology Published online July 6, 2016 E3

Downloaded From: http://archderm.jamanetwork.com/ by Shuai Xu on 07/06/2016

noted cosmetic elegance concerns (22%; 72 of 325). Product

performance (11%; 36 of 325), product ingredients (10%; 33 of

325), and expense (9%; 29 of 325) were comparable as nega-

tively cited features. Only a few reviewers cited skin compat-

ibility concerns, formulation changes, and separate ratings as

negative features.

An analysis of the subthemes confirmed more specific de-

terminants of consumer preferences with sunscreens. Catego-

rized in cosmetic elegance, the subthemes of “rubs in well” and

“positive tactile skin feel” were most commonly cited. Third,

product residue and thickness were the most common nega-

tive cosmetic features. Regarding product performance, con-

sumers frequently cited “effectiveness” and “did not

sunburn” as positive features. For skin compatibility, sun-

screens that did not cause acne were most commonly cited as

a positive feature (13%; 42 of 325), and for ingredients, zinc ox-

ide and natural and/or organic ingredients were cited specifi-

cally as positive features (10%; 33 of 325). Separate rankings

were cited by 12% (39 of 325) of top comments. Of those rank-

ings, the Environmental Working Group’s ranking was the most

cited followed by “dermatologist recommended” and Con-

sumer Reports. Finally, affordability and high cost were not

commonly cited as positive or negativeconcerns (9%; 29 of 325)

(Table 3).

Discussion

For our cohort, cosmetic elegance was the most commonly

cited positive feature. Qualitative research with consumers pro-

vides insight into the consumer attitude when it comes to sun-

screens. Prior research has shown that people apply more prod-

uct when it spreads easily. Increased use means producing

photoprotection that more closely reflects the expected pho-

toprotection or SPF.

7,8

Our qualitative analysis provides em-

pirical evidence of this as well. In cosmetic elegance, consum-

ers frequently cited the subtheme of rubs in well. Our results

clarify features identified by previously published studies in-

dicating consumer preference for sunscreens that specifi-

cally did not leave residues and were not greasy.

For product effectiveness, the sunscreen SPF was not fre-

quently cited as a positive feature, which may be associated

with a lack of consumer understanding of SPF

or preselec-

tion of high SPF products. Real-world product performance,

such as “effective” and “did not sunburn,” were how consum-

ers described product effectiveness, which makes the results

difficult to interpret because variables such as UV index, ex-

posure time, amount of sunscreen applied, and consumer skin

type are not clearly specified. However, most of our cohort in-

clude sunscreens with an SPF of 30 or greater (89%; 58 of 65),

which should have provided adequate protection with proper

use. The emphasis on effectiveness, even among this high SPF

cohort, could reflect patient misunderstanding of the differ-

ence between expected and produced photoprotection.

For skin compatibility, most products claimed additional

product features in addition to sun protection, including safe

for sensitive skin, preservative-free, or noncomedogenic. Pa-

tients should be counseled that these labels are marketing

mechanisms instead of performance standards such as SPF

regulated by the US Food and Drug Administration, although

these factors may have equal importance to patients and should

be discussed to promote products that satisfy both areas. Prod-

uct ingredients and separate ratings were less commonly cited

features. Physical sunscreen ingredients (zinc and titanium ox-

ide) were more likely to be cited as positive features, whereas

nanoparticles (6 comments) were the most commonly cited

negative feature regarding product ingredients. Active

ingredients zinc oxide and titanium dioxide, particularly mi-

cronized versions, offer superior UV-A protection and

photostability.

A small, noticeable amount of detailed comments cited the

Environmental Working Group ratings (22 comments) for pur-

chasing decisions surrounding product safety. Environmen-

tal Working Group was cited more often than dermatologist

recommended (18 comments) regarding positive product fea-

tures. This group describes itself as a nonpartisan, nonprofit

organization and determines its sunscreen rankings accord-

ing to manufacturer and toxicology databases without sec-

ondary verification of product performance.

Negative cos-

metic elegance was the most frequently cited feature followed

by product performance and skin compatibility. This study is

limited to highly rated products, making interpretation of the

negative comments more difficult to generalize.

Analogous to Consumer Reports’ review of sunscreens,

our cohort also had a wide range of prices with a difference be-

tween the least and most expensive products ($0.68-$23.47

per ounce). Cost is an important consideration, especially for

those with an increased risk of developing skin cancer, such

as patients who underwent an organ transplant for whom regu-

lar photoprotection is recommended. For these patients, the

cost of daily sunscreen use can range from $249 to $292 per

year. If used daily for 1 week, sunscreen cost for a family of 4

can range from $178 to $238.

Although expense was not fre-

quently cited as a negative feature, previous studies showed

that expensive sunscreens may compel patients to use less.

15,16

Dermatologists are often asked by patients to recommend

sunscreen products.

Health care professionals should incor-

porate cost-conscious recommendations of sunscreens for

patients, particularly in skin cancer prevention.

The AAD has published guidelines recommending sun-

screen products that have an SPF of 30 or higher, broad-

spectrum coverage, and water and sweat resistance.

A sig-

nificant proportion (29%; 19 of 65) in our cohort of highly rated

sunscreens did not adhere to AAD guidelines solely owing to

a lack of water or sweat resistance claims. Because many prod-

ucts in our cohort were comarketed as moisturizers or daily

beauty products, water-resistant products would not be a criti-

cal feature. Consumers may choose a non–water-resistant sun-

screen product with more favorable cosmetic elegance. Be-

cause water exposure reduces the efficacy of sunscreens when

a person is sweating or immersed in water, water-resistant

products are often reserved for use in water-related activities

or sports with profuse sweating. Previous studies showed that

two-thirds of sunscreen products are advertised as cosmetics

(38%; 25 of 65) or moisturizers (26%; 17 of 65), whereas a mi-

nority were advertised as a stand-alone sunscreen (19%; 12 of

Research Original Investigation Consumer Evaluations of Commercial Sunscreen

E4 JAMA Dermatology Published online July 6, 2016 (Reprinted) jamadermatology.com

Downloaded From: http://archderm.jamanetwork.com/ by Shuai Xu on 07/06/2016

Table 3. Positive and Negative Themes Identified by Consumer Comments for Highly Rated Sunscreens

a,b

Positive Coding Themes Negative Coding Themes

Major Theme Subtheme Exemplary Quote

No. (%) of

Comments Major Theme Subtheme Exemplary Quote

No. (%) of

Comments

Cosmetic

elegance

198 (61) Cosmetic

elegance

72 (22)

Absorbs well “You feel it there for

about 5 min and then it

absorbs very well”

124 (38) Skin residue “It left a white

residue all over

my face”

26 (8)

Tactile skin feel “Doesn't leave my skin

feeling oily, just smooth”

107 (33) Too thick “This cream was

way too thick

and impossible

to rub in”

23 (7)

Not greasy “Goes on easily with no

greasiness”

75 (23) Greasy “The biggest

drawback with

the American

formula is

GREASE”

20 (6)

Moisturizing “It leaves my skin feeling

moisturized and

protected”

46 (14) Bad smell “It absolutely

reeks”

20 (6)

Nice smell “Love the barely-there

fragrance”

42 (13) Bad skin feel 13 (4)

Tint or matte

finish

“This went on very

smoothly and easily and

left my skin with a gently

matte finish”

23 (7) Too white 7 (2)

Makeup

compatible

“It is moisturizing, so I

can use it as a base for

my makeup”

23 (7) Staining 3 (1)

No smell 13 (4) Bad color 3 (1)

Exfoliative 7 (2) Drying 3 (1)

Antiaging 3 (1) Too dark 1 (0.3)

Performance 146 (45) Makeup

incompatible

1 (0.3)

Effective “Thin yet highly potent

even with such a small

amount”

117 (36) Performance 36 (11)

Did not sunburn “I was able to stay out at

my children's soccer

games for the entire

afternoon with no

sunburn”

49 (15) Not effective 13 (4)

Water and/or

sweat proof

“I was pleased to find it

remained on for around

90 min worth of direct

sunlight and sweating”

29 (9) Sunburned 13 (4)

High SPF “I’m absolutely obsessed

with this SPF”

23 (7) Packaging

problem

10 (3)

Broad spectrum “It has the

broad-spectrum rating

from the FDA that means

it protects from the UVA

and UVB”

16 (5) Not water and/or

sweat proof

10 (3)

Obtainability of

tan

13 (4) Low SPF 3 (1)

Skin

compatibility

78 (24) Product

ingredients

33 (10)

Acne prone “Works great with my

acne prone skin”

42 (13) Unsafe

ingredients

10 (3)

Sensitive skin 13 (4) Nanoparticles 7 (2)

Safe for kids 10 (3) Retinyl palmitate 3 (1)

No eye stinging 7 (2) Avobenzone 3 (1)

Oily skin 7 (2) Parabens 3 (1)

Darker skin 7 (2) Oxybenzone 3 (1)

Rosacea 3 (1) Homosalate 3 (1)

No skin reaction 3 (1) Octinoxate 1 (0.3)

Melasma 3 (1) Expensive “At nearly $20 a

tube, it isn't

cheap”

29 (9)

(continued)

Consumer Evaluations of Commercial Sunscreen Original Investigation Research

jamadermatology.com (Reprinted) JAMA Dermatology Published online July 6, 2016 E5

Downloaded From: http://archderm.jamanetwork.com/ by Shuai Xu on 07/06/2016

65).

These findings may cause consumer confusion regard-

ing what makes up an adequate sunscreen product. A small but

significant proportion (11%; 7 of 65) of the cohort had an SPF of

less than 30. Physicians should educate consumers on these key

considerations. Nine of 10 of the least costly sunscreen prod-

ucts in the cohort did adhere to AAD guidelines.

There are several important limitations in this study. Al-

though these data sources represent 9% of all sunscreen sales,

the generalizability may be limited because of the lack of re-

viewer demographic information. Another limitation of this

study was the use of higher-rated product reviews as a surro-

gate for product popularity. Researchin product marketing sug-

gests that online review measurements, specifically volume

and valence, directly influence product sales.

19-21

Of our co-

hort, 46% (30 of 65) was also in Amazon.com’s top 100 best

sellers list in the sun protection category. We believe that our

cohort mitigates the volatility that exists with best seller lists,

which are updated hourly. This frequent updating may change

the exact product name and review number of sunscreens. Fur-

ther work comparing our cohort’s representation with the cata-

log of other major online retailers would provide further in-

sight. Finally, a limitation of using the AAD guidelines is that

consumers who use sunscreen daily and do not engage in

sweat-producing activities or water sports may appropriately

choose not to use water-resistant sunscreens.

Although our data showed that dermatologist recommen-

dations were not a significantly cited positive feature, derma-

tologists are the most likely physicians (86%) to recommend

sunscreen use in all outpatient visits where sunscreen use is

mentioned.

Frequently, patients with skin concerns ask for

nonprescription product recommendations from dermatolo-

gists. Dermatologists should be aware of the implications of

their recommendations, particularly regarding cost and con-

sumer preferences. With recent legislation allowing the US Food

Table 3. Positive and Negative Themes Identified by Consumer Comments for Highly Rated Sunscreens

a,b

(continued)

Positive Coding Themes Negative Coding Themes

Major Theme Subtheme Exemplary Quote

No. (%) of

Comments Major Theme Subtheme Exemplary Quote

No. (%) of

Comments

Eczema 3 (1) Skin tolerance 26 (8)

Product

ingredients

55 (17) Skin reaction “Like another

reviewer, I, too,

had an allergic

reaction with

itching”

20 (6)

Natural and/or

organic

ingredients

“Made [. . .] with

[. . .] certified ‘organic’

ingredients”

33 (10) Burning on

application

10 (3)

Zinc oxide “The active ingredients

are Zinc Oxide and

Titanium Dioxide, which

are high quality minerals

for broad spectrum UVA

and UVB skin protection”

33 (10) Burns eyes 7 (2)

Safe for children 10 (3) Formulation

change

“I was

disappointed

when I tried their

new facial

sunscreen

formulation”

7 (2)

Avobenzone 3 (1) Separate ratings 3 (1)

Titanium dioxide 3 (1) EWG 3 (1)

Physical sunscreen 3 (1)

Separate ratings 39 (12)

EWG “I ordered this product

after doing some

research on the EWG’s

online database of the

least harmful sunblocks”

23 (7)

Dermatologist

recommended

“Was recommended to

me by my dermatologist

who is a specialist in skin

cancer”

20 (6)

Consumer Reports 3(1)

Affordable “It's the best sunblock

product on the market at

a reasonable price”

29 (9)

Abbreviations: EWG, Environmental Working Group; FDA, US Food and Drug

Administration.

There were 65 sunscreen products in the cohor t.

The qualitative coding of the top 5 most helpful comments (positive and

critical) voted by consumers for each product in the entire cohort is

summarized. As expected, positive features were much more likely to be cited

than negative features. The features were similar in themes but opposite in

valence. Cosmetic elegance was the most cited positive and negative feature

followed by product performance, skin compatibility, and product ingredients.

When investigating specific subthemes, consumers most commonly cited how

the product absorbed as a positive and negative feature. Exemplary quotes

were only included for all features cited with more than 5% (<3) of the total

comments assessed.

Research Original Investigation Consumer Evaluations of Commercial Sunscreen

E6 JAMA Dermatology Published online July 6, 2016 (Reprinted) jamadermatology.com

Downloaded From: http://archderm.jamanetwork.com/ by Shuai Xu on 07/06/2016

and Drug Administration to rapidly advance the approval of

additional sunscreens, consumers and dermatologists will have

more product options to consider soon.

Although sun-

screen products available in Europe have better UV absorp-

tion performance, there is limited empirical evidence that

this leads to lower skin carcinogenesis in clinical practice.

Ultimately, dermatologists must remain informed of the

continued evolution of sunscreen products and consumer pref-

erences to improve use.

Conclusions

There is wide variability in price, SPF protection, and prod-

uct claims among commercially available sunscreens. Con-

sumer comments show that cosmetic elegance is the most

important positive feature, followed by product perfor-

mance. Dermatologists should counsel patients that sun-

screen products come with numerous marketing claims and

varying cosmetic applicability, all of which must be balanced

with adequate photoprotection. In addition, consumers should

be advised to select a product with broad-spectrum cover-

age, an SPF of 30 or higher, and water and/or sweat resistance

in the setting of water activities or high ambient tempera-

tures. Our list provides dermatologists, other health care pro-

fessionals, and patients with a cohort of sunscreen products

organized by consumer preference, ranked by price or rating,

and detailed information regarding how those products ad-

hered to sunscreen performance standards together with their

consumer reviews.

ARTICLE INFORMATION

Accepted for Publication: May 27, 2016.

Published Online: July 6, 2016.

doi:10.1001/jamadermatol.2016.2344.

Author Contributions: Drs Xu and Kundu had full

access to all of the data in the study and take

responsibility for the integrity of the data and the

accuracy of the data analysis.

Study concept and design: Xu, Agarwal, Kundu.

Acquisition, analysis, or interpretation of data: All

authors.

Drafting of the manuscript: Xu, Kwa.

Critical revision of the manuscript for important

intellectual content: Xu, Agarwal, Rademaker,

Kundu.

Statistical analysis: Rademaker.

Administrative, technical, or material support: Xu,

Kwa, Agarwal, Kundu.

Study supervision: Xu, Kundu.

Conflict of Interest Disclosure s: None reported.

REFERENCES

1. Buller DB, Cokkinides V, Hall HI, et al. Prevalence

of sunburn, sun protection, and indoor tanning

behaviors among Americans: review from national

surveys and case studies of 3 states. J Am Acad

Dermatol. 2011;65(5)(suppl 1):S114-S123.

2. Innovation and insight in sun protection. Paper

presented at: Incosmetics; April 18, 2012;

Barcelona, Spain.

3. Ben-Shabat H, Gada K. Beauty and the

e-commerce beast: 2014 edition. ATKearney. https:

//www.atkearney.com/consumer-products-retail

/beauty-and-the-e-commerce-beast. Accessed

June 9, 2016.

4. Mudambi S, Schuff D. What makes a helpful

online review? a study of customer reviews on

Amazon.com. Manage Inf Syst Q. 2010;34(1):185-

200.

5. Xu S, Kesselheim AS. Medical innovation then

and now: perspectives of innovators responsible for

transformative drugs. J Law Med Ethics. 2014;42

(4):564-575.

6. Kesselheim AS, Xu S, Avorn J. Clinicians’

contributions to the development of coronary

artery stents: a qualitative study of transformative

device innovation. PLoS One. 2014;9(2):e88664.

7. Pissavini M, Diffey B, Marguerie S, Carayol T,

Doucet O. Predicting the efficacy of sunscreens in

vivo veritas. IntJCosmetSci. 2012;34(1):44-48.

8. Pissavini M, Doucet O, Diffey B. A novel proposal

for labelling sunscreens based on compliance and

performance. Int J Cosmet Sci. 2013;35(5):510-514.

9. Solky BA, Phillips PK, Christenson LJ, Weaver AL,

Roenigk RK, Otley CC. Patient preferences for facial

sunscreens: a split-face, randomized, blinded trial.

J Am Acad Dermatol. 2007;57(1):67-72.

10. Kong BY, Sheu SL, Kundu RV. Assessment of

consumer knowledge of new sunscreen labels.

JAMA Dermatol. 2015;151(9):1028-1030.

11. Wang SQ, Balagula Y, O sterwalder U.

Photoprotection: a review of the current and future

technologies. Dermatol Ther. 2010;23(1):31-47.

12. Andrews D, Gray S, Leiba N, et al. EWG’s

methodology for assessing sunscreens. http://www

.ewg.org/2015sunscreen/report/methodology/.

Published 2015. Accessed January 4, 2016.

13. Consumer Reports. Best Sunscreens 2015. http:

//www.consumerreports.org/cro/sunscreens.htm.

Published 2015. Accessed December 5, 2015.

. Mahé E, Beauchet A, de Maleissye MF, Saiag P.

Are sunscreens luxury products? J Am Acad Dermatol.

2011;65(3):e73-e79.

15. Wysong A, Gladstone H, Kim D, Lingala B,

Copeland J, Tang JY. Sunscreen use in NCAA

collegiate athletes: identifying targets for

intervention and barriers to use. Prev Med. 2012;55

(5):493-496.

16. Banks BA, Silverman RA, Schwartz RH,

Tunnessen W W Jr. Attitudes of teenagers toward

sun exposure and sunscreen use. Pediatrics.1992;

89(1):40-42.

17. Cosmetic Corner: dermatologists weigh in on

facial sunscreens. Cutis. http://www.cutis.com

/specialty-focus/sunscreens/article/cosmetic

-corner-dermatologists-weigh-in-on-facial

-sunscreens

/70d0e91c228325d309b08cec10be86ef.html.

Accessed February 20, 2016.

18. Lee ET, O’Riordan D, Swetter SM, Demierre MF,

Brooks K, Geller AC. Sun care advertising in popular

U.S. magazines. Am J Health Promot. 2006;20(5):

349-352.

19. Dellarocas C, Zhang X, Awad NF. Exploring the

value of online product reviews in forecasting sales:

the case of motion pictures. J Interact Market.

2007;21(4):23-45.

20. Duan W, Gu B, Whinston A. The dynamics of

online word-of-mouth and product sales—an

empirical investigation of the movie industry.

J Retailing. 2008;84(2):233-242.

21. Forman C, Ghose A, Wiesenfeld B. Examining

the relationship between reviews and sales: the

role of reviewer identity disclosure in electronic

markets. InfSystRes. 2008;19(3):291-313.

22. Akamine KL, Gustafson CJ, Davis SA, Levender

MM, Feldman SR. Trends in sunscreen

recommendation among US physicians. JAMA

Dermatol. 2014;150(1):51-55.

23. US Food and Drug Administration. Sunscreen

Innovation Act. 2013-2014. 113th Congress. Pub L

No. 113-195, S.2141. https://www.congress.gov/bill

/113th-congress/senate-bill/2141/. Accessed June

14, 2016.

24. Diffey B. New sunscreens and the

precautionary principle. JAMA Dermatol. 2016;152

(5):511-512.

Consumer Evaluations of Commercial Sunscreen Original Investigation Research

jamadermatology.com (Reprinted) JAMA Dermatology Published online July 6, 2016 E7

Downloaded From: http://archderm.jamanetwork.com/ by Shuai Xu on 07/06/2016