Examining Indoor Tanning
Tanning has become, for many teenagers, a very important part of the high school experience. With a society that equates tanned skin with health and beauty, some teens between the ages of 14 and 18 seek out indoor tanning facilities year-round: before dances, prom, graduation, athletic matches and other events that are important on the teenage social calendar.
However, with growing awareness of the link between melanoma and indoor tanning beds — especially among youth — many local and state governments are taking steps to protect vulnerable populations from additional risks of developing the disease. The US National Library of Medicine has published several studies in recent years examining the link between UV exposure and melanoma, including a 2010 study that found melanoma risk was pronounced among users of UVB-enhanced and UVA-emitting devices.1 Risk of melanoma increased with use, with those using the devices over the longest periods of time developing the greatest risk, regardless of the age at which use began.1
In April of this year, the Mayo Clinic published a study that observed an 8-fold increase in the incidence of melanoma among young women and a 4-fold increase among young men between 1970 and 2009.2 This increase is due to the higher use of indoor tanning beds by young women than by young men, according to the results of another similar study by Mayo Clinic researchers.3
Recent Legislation Restricting Indoor Tanning for Minors
With the growing concern over the link between indoor tanning and melanoma and the potential impact on youth, many state and local governments have begun to enact regulations and restrictions to prohibit minors from using indoor tanning facilities. According to the National Conference of State Legislatures, a bi-partisan organization that works to promote policy and effectiveness between states, many state governments began drafting new restrictive legislation after the release of recommendations against indoor tanning from the International Agency for Research on Cancer (IARC). The IARC, a subsidiary of the World Health Organization, recommended restricting access to indoor tanning facilities by minors as a way to reduce the risk of melanoma.4
California, New York and Vermont currently ban minors under the age of 18 from using indoor tanning services, regardless of parental consent. In the current legislative cycle, similar bans are being considered in more states, and some state governments are debating requiring parental consent or physician oversight for minors between the ages of 14 and 18. In all, 31 states have some form of regulation in process that address the use of indoor UV tanning beds by minors. Some local governments have taken state regulations farther, which is the case with Howard County, MD. While minors may use UV tanning beds and facilities with parental consent in the state of Maryland, the county became the first local jurisdiction to ban indoor tanning for all minors. Similar local restrictions are in place in Chicago and Springfield, IL.
According to the American Academy of Dermatology (AAD), indoor tanning is associated with a 75% increase in the risk of melanoma, and rates of the disease are increasing faster in young women (15-29 years old) than in young men of the same age group. The Academy also attributes this to the fact that young women are more likely than young men to use indoor tanning beds, estimating nearly 70% of tanning salon patrons are Caucasian females age 29 or younger. In the studies referenced by the AAD, individuals who have been exposed to UV radiation from indoor tanning may be at an elevated risk of developing melanoma, with risk increasing along with level of usage. The AAD also reported in a recent survey of adolescent tanning bed users that 58% reported burns due to frequent exposure to the tanning beds and lamps, another risk factor of developing melanoma later in life.
With this evidence, the AAD has taken a strong position on indoor tanning. This position is prominently displayed on the organization’s website: “The American Academy of Dermatology Association (AADA) opposes indoor tanning and supports a ban on the production and sale of indoor tanning equipment for non-medical purposes.”5
The Dermatologist’s Role in the Indoor Tanning Debate
So, as dermatologists, what is our obligation to our patients? How do we balance their desire for the perception of beauty and health with the reality of the effects of UV radiation on the skin?
There are several options that we as professionals, charged with the safeguarding of our patients’ health, can present. While recommending a course of UVA and UVB sunblock to protect the skin, we can also present a variety of options in the field of sunless tanning to those patients who wish to sport a “healthy glow” and emulate a suntan without accepting the inherent risks.
When speaking to the population of patients with the highest risk — teenage girls — it is important to stress the long-term risk factors associated with indoor tanning. This includes not only melanoma but other types of skin cancers, such as basal cell carcinoma, non-basal cell carcinomas and other diseases. Another important issue to raise with teens and young adults is the long-term effects of indoor tanning and sun exposure, such as premature aging, long-term impacts on the texture of the skin and the appearance of wrinkles. Many young adults who may not be receptive to risks of cancer may be more likely to pay attention to other concerns, so it is important to determine which message works best with each individual patient.
Offering Patients Alternative Options
The dermatology practice often holds a competitive advantage above other sunless tanning options in the marketplace. Patients are more likely to trust a medical practitioner than a licensed beauty parlor or tanning salon when it comes to the care of their skin. Likewise, parents of minor children are more likely to trust the health of their children’s skin to a medical doctor then to a licensed beautician. That being said, it is important to ensure the dermatology practice is offering the highest-quality products to clients. While many sunless tanning salons offer assembly-line mechanized spray tans at a low cost, these are not always the best or most natural-looking products on to the market.
The sunless tanning market presents an important revenue stream for the dermatology practice, especially in those jurisdictions where minors are prohibited from using tanning beds without parental consent. Many teens, especially teenage girls, do not wish to have pale skin, especially at winter or early spring social events. In these instances dermatology practices can capitalize on a gap in the marketplace by offering quality, professional, medically-safe sunless tanning options. Often, demand for this service already exists in the marketplace — many parents have said they have a higher level of trust and confidence for cosmetic treatments, like sunless tanning, when offered for their children through a physician’s office instead of a beauty salon.
When considering sunless tanning services for a dermatology practice, it is important to remember that not all sunless tanning systems and products are created equal. All products offered by the dermatology practice must be evaluated for safety, quality and overall satisfaction before being recommended to patients. Just because it is a cosmetic product does not mean it deserves any less attention than medical products and drugs presented to patients through the normal course of practice.
Likewise, not all sunless tanning technicians have the same level of skill. Dermatology practices that offer sunless tanning to their patients must ensure that highly qualified technicians are available to apply the sunless tanning product. The products work by coloring the top layer of skin; this change often lasts 1 or 2 weeks, depending on the products used after the initial application. If a sunless tanning technician does a poor job, the patient must walk around with an uneven or unnatural looking complexion for a week or longer. When seeking a sunless tan technician, it is important to not only examine the prospective employee’s credentials and certifications but also the length and quality of his or her experience. There are certain skills to look for: sculpting, for example, and other education and training components beyond basic certification.
Educating the Patient
Since 2002, the US Department of Health and Human Services has classified UV radiation, from natural and artificial sources, as a known human carcinogen. In 2009, the IARC re-categorized indoor tanning devices as carcinogenic to humans, placing indoor tanning in the highest-risk category along with tobacco smoke. The US Federal Trade Commission prohibits the Indoor Tanning Association (ITA) from making false health and safety claims about indoor tanning; the organization must ensure its advertising and claims of safety or health benefits for indoor tanning are not misleading. The ITA claims must also be substantiated and clearly and prominently disclose that exposure to UV may increase the risk of developing skin cancer.
However, apart from a federal tanning bed tax that took effect in 2010, federal legislation addressing the issue does not appear to be in the immediate future. It is up to state and local government agencies to determine the laws and regulations within their jurisdictions. It is up to dermatologists to ensure their patients’ health is safeguarded through education and the presentation of alternative methods of achieving a “healthy glow” while not increasing the risk of diseases like melanoma and other hazards to health.
For more information on indoor tanning, please see the document from the American Academy of Dermatology, “Federal and state regulations on indoor tanning support scientific evidence that indoor tanning is not safe,” by clicking here.
Dr. Crandell is co-owner of Southern Tier Dermatology & Aesthetics. She founded the practice, which specializes in medical, surgical and cosmetic dermatology, in 2006. Dr. Crandell is a Fellow of the American Academy of Dermatology, an active member of the American Society of Dermatologic Surgery and a recognized expert in medical, surgical and cosmetic dermatology.
Dr. Fenkl is co-owner of the practice. He has undergone extensive training and professional development in all areas of medical, surgical and cosmetic dermatology.
Disclosure: The authors have no conflicts of interest to report.