Teenagers, Parents, and the Truth About Indoor Tanning Dangers

Sarah E. Ellison, MD, and Linda S. Nield, MD—Series Editor

A Parent Asks

My teenaged daughter wants to look tanned for her prom. Is a tanning bed a safe alternative to the sun?

The Parent Coach Advises

A tanning bed is not a safe alternative to the sun for an adolescent hoping to obtain a golden glow for the prom. Ultraviolet radiation (UVR) exposure is a well known and easily avoidable risk factor for skin cancer, including malignant melanoma and non-melanoma skin cancers (NMSC). Indoor tanning and intense intermittent sun exposure significantly increase the risk of malignant melanoma, which has the highest mortality rate among all skin cancer types.1-4

Despite the recognized association between UVR and skin cancer, an estimated 28 million people in North America use indoor tanning devices yearly, 2.3 million of whom are adolescents.5 The prevalence of indoor tanning use by high school–aged girls, for example, ranges from 20% to 30%,6 despite that that indoor tanning beginning during adolescence or young adulthood increases the risk of developing melanoma later in life by 50% to 75%.2,6,7

In addition to preparing for a landmark social event like the prom, another common justification for tanning bed use is to prepare the skin before sun exposure, or “pre-vacation” tanning.8 But while using a tanning bed to develop a pre-vacation tan does increase skin pigmentation, it offers no protection against UVR-induced sun damage.9

Understanding UV Radiation

UVR encompasses wavelengths of 100 nm to 400 nm. UVA has a wavelength of 315 nm to 400 nm and makes up the majority of solar radiation. UVB has a wavelength of 280 nm to 315 nm and comprises approximately 4% to 5% of solar radiation and 0.5% to 4% of tanning bed radiation. UVB is well known to be carcinogenic, leading to damage of epidermal keratinocyte DNA via production of cyclobutane pyrimidine dimers and pyrimidine-pyrimidone (6-4) photoproducts.10-12

The higher the sun is in the sky, the higher the amount of solar UVB radiation that reaches the surface of the earth. Thus, the risk of sunburn and acute damage secondary to UVR is higher when the sun is highest in the sky. Given that UVB is the main cause of acute sunburn, and given the evidence that more than 5 severe sunburns per year during adolescence doubles the risk of melanoma,3,13 it is beneficial to avoid the sun when peak UVB rays will be absorbed by the skin, typically between 10:00 am and 4:00 pm.

The idea that tanning beds offer a “safer” alternative to outdoor sunbathing is based on the assumption that only UVB radiation contributes to skin cancer. But numerous studies provide overwhelming evidence for UVA’s involvement in photocarcinogenesis. Not only do tanning beds emit an amount of UVR essentially equal to that of the sun, but also the UVR intensity of tanning beds is 10 to 15 times higher than that of the midday sun,14 leading to an exposure well beyond that of an average outdoor exposure.

Both UVA and UVB radiation lead to pigment production (ie, tanning), photoimmunosuppression, and skin cancers. The World Health Organization’s International Agency for Research on Cancer has classified the entire spectrum of indoor tanning beds, both UVA and UVB, as carcinogenic to humans, based on evidence implicating UVA radiation in direct DNA damage and photocarcinogenesis.15 UVA radiation has been observed in vivo to induce cyclobutane pyrimidine dimers in DNA,16 a mutagenic mechanism well known to be associated with UVB rays. UVA also is mutagenic via the oxidation of pyrimidine DNA bases.17,18 DNA damage from UVA reaches a greater depth than does DNA damage from UVB, with the majority of UVA radiation reaching the basal layer of the epidermis where melanocytes are housed and where a relative shortage of DNA repair enzymes exists.16,17

Effects of Indoor Tanning

It is well known that exposure to UVR, including that from indoor tanning beds, is directly associated with malignant melanoma. Melanoma accounts for the majority of skin cancer deaths and is one of the most commonly diagnosed cancers in U.S. adolescents.19 Numerous studies have demonstrated a high association of melanoma with the onset of tanning bed use at a younger age.2,20 An increased risk of melanoma has been associated with all types of tanning devices, but higher risks have been associated specifically with high-speed or high-pressure devices.1 A dose-response effect has been noted between the frequency of tanning and the risk of melanoma, even after controlling for baseline UV exposure, skin type, and geography.1,2 One group of researchers concluded that as few as 4 tanning sessions per year leads to an 11% increased risk of developing melanoma.21

Adolescents’ use of indoor tanning beds has been associated with the earlier development of NMSC such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Zhang and colleagues21 found an increased risk of BCC or SCC among those who started indoor tanning in high school. They noted that 4 or more tanning bed sessions per year led to a 15% increased risk of developing BCC or SCC.21

Photoaging is another significant adverse effect of indoor tanning bed use. UVA radiation is largely responsible for photoaged skin, which has been found to have significantly more deletions in mitochondrial DNA compared with sun-protected skin.22 Appearance-based motivations for tanning are strongly predictive of tanning bed use.23 Accordingly, appearance-driven counseling based on photoaging of skin secondary to UVR has been found to effectively decrease UVR exposure, both indoor and outdoor.24 The authors of one literature review found that appearance-based messages are more effective strategies for reducing indoor tanning than are health-based messages.25

Alternatives to Indoor Tanning

Offering a safer sunless option to adolescents who highly desire a tan can reduce their UVR exposure by reducing the use of indoor tanning.26-28 One in 10 adolescents use sunless tanning products to achieve a tanned complexion; two-thirds of this population had not used indoor tanning beds in the last year, thereby reducing their UVR exposure.28

The first sunless tanning product was introduced in 1959. Most sunless tanning agents use dihydroxyacetone (DHA), which combines with proteins in the outermost layer of the skin to produce a coloration reaction (the Maillard reaction), which simulates tanning.29 DHA is nontoxic and was discovered to produce the Maillard reaction while it was being tested as an artificial sweetener. Reactions such as contact dermatitis are uncommon with DHA.30 However, DHA does not provide adequate photoprotection.31

Some discredit the use of sunless tanners because they can produce an uneven or blotchy tan. Because protein-rich areas of the skin lead to a greater darkening effect, keratotic growths in the stratum corneum that are high in protein content can stain darker, leading to an uneven complexion. An even application can be achieved by skin exfoliation with scrubs, textured cloths, or a moisturizer containing α-hydroxy acids just before sunless tanning cream application. Extensor surfaces of joints (eg, elbows, knees) and palms and soles have a thicker layer of stratum corneum that stains darker, as well. For this reason, less of the product should be applied to these areas.29 Moreover, hands should be washed immediately and thoroughly, including the interdigital spaces, after applying a sunless tanner. Many types of application gloves are available, which help users apply sunless tanners more evenly and protect their hands from unnatural staining.

Advising Parents and Patients

Two of the strongest predictors of frequent indoor tanning by adolescents are a permissive attitude about tanning by parents and the use of indoor tanning beds by parents themselves.24,28-34 Inadequate parental knowledge about the risks associated with indoor tanning is a significant contributing factor to tanning bed use by adolescents.35

The U.S. Preventive Services Task Force24,36 and the American Academy of Pediatrics37 recommend behavioral counseling in the clinical setting for children, adolescents, and young adults about minimizing their UV exposure to decrease the risk of skin cancer. Moreover, it is important to keep in mind that associations between indoor tanning and other risky and unhealthy behaviors such as tobacco use, alcohol use, recreational drug use, and multiple sex partners has been found in adolescents.6

In addition to avoiding indoor tanning, the liberal and frequent use of sunscreens to prevent the effects of solar UVR cannot be overemphasized. Sunscreen protects the skin by preventing gene regulatory events mediated by UVA radiation in the dermis and epidermis.38

By assessing parents’ and adolescents’ perceptions of indoor tanning risks and parents’ knowledge about their children’s tanning behaviors, pediatricians can help engage parents and adolescents to prevent this risky behavior. A more difficult task is addressing the societal norm that tanned skin is more attractive that one’s natural skin tone.

Sarah E. Ellison, MD, is a transitional year and dermatology resident at the West Virginia University School of Medicine in Morgantown, West Virginia.

Linda S. Nield, MD—Series Editor, is a professor of pediatrics at the West Virginia University School of Medicine in Morgantown, West Virginia.

References

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2. Boniol M, Autier P, Boyle P, Gandini, S. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757. doi:10.1136/bmj.e4757.

3. Gandini S, Sera F, Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer. 2005;41(1):45-60.

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