J AM ACAD DERMATOL
VOLUME 82, NUMBER 4
College of Medicine, Taipei Medical University,
Taiwan.c
Funding sources: None.
Conflicts of interest: None disclosed.
IRB approval status: Not applicable.
Reprints not available from the authors.
Correspondence to: Yu-Chen Huang, MD, Depart-
ment of Dermatology, Wan Fang Hospital, Taipei
Medical University, No. 111, Sec 3, Xinglong Rd,
Wenshan District, Taipei City 116, Taiwan
E-mail: dhist2002@yahoo.com.tw
REFERENCES
1. Thappa DM, Chiramel MJ. Evolving role of immunotherapy in
the treatment of refractory warts. Indian Dermatol Online J.
2016;7:364-370.
2. Liu PT, Stenger S, Li H, et al. Toll-like receptor triggering of a
vitamin D-mediated human antimicrobial response. Science.
2006;311:1770-1773.
3. Osborne JE, Hutchinson PE. Vitamin D and systemic cancer: is
this relevant to malignant melanoma? Br J Dermatol. 2002;147:
197-213.
4. Abou-Taleb DAE, Abou-Taleb HA, El-Badawy O, Ahmed AO,
Thabiet Hassan AE, Awad SM. Intralesional vitamin D3 versus
intralesional purified protein derivative in treatment of
multiple warts: a comparative clinical and immunological
study. Dermatol Ther. 2019;32(5):e13034.
https://doi.org/10.1016/j.jaad.2019.10.059
Evaluation of ‘‘reef safe’’ sunscreens:
Labeling and cost implications for
consumers
To the Editor: In 2013, an in vitro study at the
National Oceanic and Atmospheric Administration
(NOAA) identified benzophenone-2, a common
chemical in sunscreen, as toxic to corals.1 Since
then, several in vitro studies identified additional
ultraviolet filters as toxic to coral. The NOAA
currently cites 8 toxic sunscreen chemicals.2
Although these ex situ studies have been scruti-
nized for inaccurately reflecting reef conditions and
testing chemicals at unrealistically high concentra-
tions,3,4 they have received widespread publicity
leading to legislative and marketing changes. In
2019, Key West, Florida, followed Hawaii in
banning sunscreens containing oxybenzone and
octinoxate. Sunscreen brands have responded by
implementing ‘‘reef safe’’ labeling.
This study aimed to determine what proportion of
sunscreens labeled as ‘‘reef safe’’ met the legislative
ban and NOAA criteria. A secondary aim was to
determine whether ‘‘reef safe’’ sunscreens cost more
than regular sunscreens.
Research Letters 1015
We conducted an online search of the largest
online retailer, Amazon, in June 2019 to identify
the most popular sunscreens and included all
those with at least 150 reviews. We separated
these by whether they did and did not make
a claim to be ‘‘reef safe’’. We analyzed and
recorded the price-per-ounce cost and ingredients
of each product. Products with zinc oxide or
titanium dioxide were considered to contain
nanoparticles unless otherwise stated. Data were
analyzed using SPSS 25.0 software (IBM Corp,
Armonk, NY).
We evaluated 97 products, with 52 (54%) labeled
as ‘‘reef safe’’. The 52 products marketed as ‘‘reef
safe’’ were analyzed to determine whether the
labeling reflected NOAA and legislative criteria.
Fig 1 outlines the percentage of sunscreens labeled
as ‘‘reef safe’’ and the proportion of compliant
products. Table I lists the cost of each sunscreen
type.
Representative products were obtained from a
single distributor, and the number of reviews was
used as a proxy for popularity; both are limitations
of this study. Many labels failed to specify the
size of zinc or titanium dioxide particles.
We considered these as nanoparticles. This
could have caused underestimation of NOAA
compliance.
A proportion of the ‘‘reef safe’’elabeled
sunscreens do not meet legislative (4%) or NOAA
(48%) criteria. In theory, the label should
help consumers select safe products. However, the
current United States Food and Drug Administration
sunscreen labeling regulation lacks a formal ‘‘reef
safe’’ definition, allowing companies to meet
standards of ‘‘truthful and non-misleading’’ labeling
without providing evidence.5 Clearly, defining ‘‘reef
safe’’ could resolve this issue.
Our study suggests ‘‘reef safe’’ sunscreen—
whether defined by label, legislative standards, or
NOAA criteria—may be more expensive than regular
sunscreen. This substantiates concerns that sun-
screen bans may create an increased economic
burden that disproportionately affects individuals
of lower socioeconomic status.
Although efforts to preserve reefs and improve
sunscreen safety should not be ignored, the existing
literature provides insufficient evidence to conclude
that these sunscreen ingredients threaten reef
safety.4 Future research efforts should clarify the
impact of these sunscreen ingredients under
authentic reef conditions and sunscreen concentra-
tions. In the meantime, it is important for legislators
to consider the public health impact of sunscreen
bans.
1016 Research Letters J AM ACAD DERMATOL
APRIL 2020

Fig 1. The ‘‘reef safe’’ label is an unregulated term commonly used in sunscreen marketing. The
term has no strict definition. aHawaii and the Florida Keys have issued legislative bans on the use
of oxybenzone and octinoxate-containing sunscreen. bThe National Oceanic and Atmospheric
Administration (NOAA) proposes more stringent criteria for ‘‘reef safe’’ sunscreen, citing 8
sunscreen chemicals as toxic to coral: oxybenzone and octinoxate, octocrylene, benzophenone-
1, benzophenone-8, octyl-dimethyle para-aminobenzoic acid (OD-PABA), 4-methylbenzylidene
camphor, 3-benzylidene camphor, nano-titanium dioxide, and nano-zinc oxide. Sunscreens were
considered to be nano-sized unless otherwise stated on package labeling.

Table I. Cost of sunscreen according to labeling and compliance with various ‘‘reef safe’’ standards
Product type No. Average cost (95% CI) in dollars/oz P value
Products labeled as ‘‘reef safe’’ 52 3.84 (3.07-4.61) .027
Products not labeled as ‘‘reef safe’’ 45 2.61 (1.83-3.38)
Products free of oxybenzone and octinoxate 66 3.94 (3.20-4.68) \.001
Products contain oxybenzone and/or octinoxate 31 1.83 (1.43-2.24)
Products meet NOAA criteria 28 4.55 (3.96-5.13) \.001
Products do not meet NOAA criteria 69 2.75 (2.04-3.46)

CI, Confidence interval; NOAA, The National Oceanic and Atmospheric Administration.

John Tsatalis, BA, Brandon Burroway, MBA, and
Fleta Bray, MD
From the Dr. Phillip Frost Department of Derma-
tology and Cutaneous Surgery, University of Miami
Miller School of Medicine, Miami, Florida.
Authors Tsatalis and Burroway
equally and are cofirst authors.
Funding sources: None.
Conflicts of interest: None disclosed.
IRB approval status: IRB approval was not required
for this study.
Reprints not available from the authors.
Correspondence to: Fleta Bray, MD, Dr. Phillip
Frost Department of Dermatology and Cuta-
contributed neous Surgery, University of Miami Miller School
of Medicine, 1600 NW 10th Ave, RMSB, Room
2023-A, Miami, FL 33136
E-mail: fleta.bray@jhsmiami.org
J AM ACAD DERMATOL
VOLUME 82, NUMBER 4
REFERENCES
1. Downs CA, Kramarsky-Winter E, Fauth JE, et al. Toxicological
effects of the sunscreen UV filter, benzophenone-2, on
planulae and in vitro cells of the coral, Stylophora pistillata.
Ecotoxicology. 2014;23(2):175-191.
2. National Ocean Service, National Oceanic and Atmospheric
Administration (NOAA). Skincare Chemicals and Coral Reefs.
Available at: https://oceanservice.noaa.gov/news/sunscreen-
corals.html. Accessed August 13, 2019.
3. International Coral Reef Initiative. Action plan of the Interna-
tional Coral Reef Initiative (ICRI) Secretariat (2016-2018).
Available at: https://www.icriforum.org/icri-secretariat/
current. Accessed August 13, 2019.
4. Lim JW. Update on photoprotection: what dermatologists need
to know. Dermatol World Am Acad Dermatol; 2019. Available at:
https://aadmeetingnews.org/2019-summer-meeting-dailies/up-
date-on-photoprotection-what-dermatologists-need-to-know/.
Accessed August 13, 2019.
5. Center for Drug Evaluation and Research. Labeling and
Effectiveness Testing: Sunscreen Drug Products for
Over-The-Counter Human Use—Small Entity Compliance Guide.
Rockville, MD: U.S. Food & Drug Administration; 2012.
Accessed August 13, 2019.
https://doi.org/10.1016/j.jaad.2019.11.001
Altmetric analysis of biotin in
scholarly outputs after the biotin
Food and Drug Administration
warning
To the Editor: Biotin is an essential cofactor for
metabolic pathways in humans. Supplementation is
rarely required because adequate levels are
consumed in average Western diets.1 A United States
Food and Drug Administration (FDA) notice in
November 2017 warned that biotin supplementation
can interfere with laboratory tests and lead to
misdiagnosis, inappropriate patient management,
and death.2
There is limited evidence that biotin improves
dermatologic conditions, but it is still commonly
self-prescribed by patients or recommended by
physicians.1 A survey-based study revealed that
supplementation was highly prevalent among
outpatient dermatology patients despite this
warning.3 Therefore, our objectives were to analyze
Table I. Number and percentage of articles citing biotin risk (laboratory interference, missed diagnoses) and
the Food and Drug Administration (FDA) warning from November 28, 2017, to August 24, 2019*
Biotin articles
Variable No.
All articles 119
Top 10 Altmetric Attention Score articles 10
Top 10 impact factor journals 13
No., Number.
*Data sourced from Altmetric.com.
Research Letters 1017
the literature and media focus on biotin after the FDA
warning.
Altmetric (Altmetric, London, United Kingdom),
a tool that measures the degree of online
attention surrounding scientific research, and
therefore its public dissemination, was used to
find biotin-related articles (search term ‘‘biotin’’)
after the FDA warning (November 28, 2017-August
25, 2019). Only articles in English were chosen
for inclusion, exclusion criteria were other
languages, book chapters, news stories, and
data sets. These articles were analyzed for mentions
of risk and the FDA warning and media attention
reach.
The Altmetric search resulted in 119 biotin articles
during the study period; of these, 25 of 119 (21%)
cited biotin associated risks, and only 6 (5%)
mentioned the FDA warning (Table I). For the top
10 impact factor journals in this group, only 2
articles mentioned the FDA warning and 4 cited
biotin risks. Of the top 10 articles with the highest
Altmetric Attention Score, 4 mentioned risk and 2
cited the FDA warning (Fig 1). For reference,
the highest Altmetric score of 88 corresponds to
only 17 tweets, 11 news stories, 1 blog, and
1 Google1 post. Of the 25 articles citing biotin risk,
9 (36%) had scores of #2; these articles accounted
for only a few tweets.
Our study demonstrates that although scholarly
work regarding biotin is well represented in the
literature after the November 2017 FDA warning,
only a minority of articles mentioned biotin risks
and even fewer mentioned the FDA warning.
Furthermore, those that cited risks/warnings were
generally not published in high-impact journals and
did not receive a high Altmetric score.
Despite limited evidence that biotin supplemen-
tation improves dermatologic conditions,1 a survey-
based study reported that 66% of dermatologists
recommended supplementation.4 Furthermore, of
the top 1% of most reviewed biotin products on
Amazon (November 2018), none listed the FDA
warning on the label, and most of the reviews stated
Articles citing biotin risk Articles citing FDA warning
No. Percent No. Percent
25 21 6 5
4 40 2 20
4 31 2 15