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US Pharm. 2007;32(4):33-37.
In the United States, the indoor tanning industry
(ITI)--currently estimated at $5 billion--inaccurately advertises vitamin D
production and UV (ultraviolet) protection as health benefits of tanning.
1,2 People who tan in an indoor tanning facility may be susceptible to
skin cancer due to unrestricted, uninhibited, long-term UV radiation exposure.
While many believe that indoor tanning is safer than outdoor tanning, many of
the same health risks, including skin cancer, skin/eye burns, photoaging,
photo-drug reactions, and alterations of the immune system are associated with
this activity.
The World Health Organization (WHO) suggests
limiting access to indoor tanning facilities and creating awareness to prevent
at-risk individuals from developing skin damage in the long term.3
Background on Skin Cancer
Skin cancer is diagnosed in more than 1.5 million people each year, and this
staggering number is projected to grow.4 Forty percent to 50% of
Americans older than 65 years will develop skin cancer at least once in their
lifetime.
Short-term adverse effects of UV radiation
exposure include nausea, itching, and dry, scaly skin, as well as skin
diseases, such as bulbous dermatitis (pseudoporphyria) and polymorphous light
eruption. Preexisting photosensitivity observed in lupus erythematosus, an
autoimmune disease, and rosacea can be significantly exacerbated by exposure
to indoor tanning.5 Recently, the WHO estimated that up to 60,000
deaths a year are caused by excessive UV radiation exposure; 48,000 of these
deaths are due to malignant melanomas, which have a high cure rate if detected
early.6 Pharmacists, in their professional capacity, are in a
unique position to advise patients who are being treated for such ailments
(and others at higher risk) to use sunscreen and limit outdoor and indoor UV
radiation exposure.
Epidemiologic Features: Skin cancer
is the most commonly diagnosed cancer in the U.S. About 62,190 new cases of
melanoma were diagnosed in 2006, with about 7,910 resulting deaths.7
The incidence of melanomas and nonmelanomas (including basal cell and
squamous cell carcinomas) increases exponentially with age.
Malignant melanoma is the fastest growing, most
fatal cancer in the U.S., with incidence rates rising by 4% to 8% each year.
Risk factors for development include ample sun exposure, fair skin, family
history, advanced age, and atypical or congenital nevi. Exposure at tanning
salons may enhance the carcinogenicity of sun exposure, which is extremely
alarming considering the current utilization trend.
Screening: The ABCDs (asymmetry,
border, color, diameter) of melanoma provide a guide for making a diagnosis.
8 Some dermatology experts also add E for evolution/elevation above skin
level.9 Several organizations vary on their opinion about the
appropriateness of melanoma screening in the general population. The American
Academy of Dermatology (AAD) and the American College of Preventive Medicine
recommend that people at high risk be examined regularly by a dermatologist,
while the American Academy of Family Physicians and the U.S. Preventive
Services Task Force recommend periodic screening in at-risk populations.8
Fitzpatrick's Classification of Skin Types:
Originated in 1977, this classification system (Table 1) is most
commonly used to adjust for sun sensitivity in population-based and
case-control studies evaluating causes of skin cancer, exposure to UV
radiation, tanning, and protective behaviors.10,11 National and
international guidelines discourage use of sun beds among persons with skin
types I and II.12 However, tanning salon patrons often rely on
either minimally informed self-assessments or tanning salon operators to
identify their skin type. Self-assessment of sun sensitivity may also be
influenced by a recent experience of sunburn.12,13
Regulation of Indoor Tanning
Manufacturers of indoor tanning apparatuses are regulated by the FDA and the
Federal Trade Commission (FTC). Tanning salon operators cannot market these
devices for any purpose other than cosmetic tanning and are subject to
confiscation and fines if claims are made about safety and health benefits.
However, the ITI sends out misleading messages through advertising media
regarding the claimed benefits of tanning, such as vitamin D formation and
skin protection.14-16
With more than 25,000 indoor tanning salons in the
U.S., excluding hair salons and health clubs, the ITI serves an estimated 28
million patrons each year.1,17
Organized medicine and the ITI remain at odds over
the risks and benefits of indoor tanning. The AAD proposes banning the use of
advertising terms such as no harmful rays, safe tanning, and
no adverse effects, since UVA and UVB are both potent and harmful in cases
of overexposure due to cumulative oxidative damage.18 Commercial
tanning for cosmetic purposes is controversial, and numerous studies have
shown that indoor tanning is not completely safe.4,19,20 The ITA
has taken an aggressive stand, claiming that tanning is healthy and
preventive; however, sufficient evidence to support such claims is
unavailable. The ITA has even formed a political action committee to advocate
on its behalf at the federal level. However, per recent FTC regulations, use
of the term safe tanning is now banned.21
A new wave of clinical studies indicate some
reductions in breast, prostate, and colon cancers with UV radiation exposure.
22 However, the risk trade-off between skin cancer and other internal
cancers has not been sufficiently established, and until such a relationship
is scientifically accepted, pharmacists should advise their patients to apply
sunscreen and adopt sun-protective habits.
Tanning salon operators are certified through
private institutions that work closely with the ITA, and state legislatures do
not oversee training components. Salon operators and their clients may overuse
the equipment and be placed at high risk for radiation-related illnesses.
Available training courses do not appear to make provision for recognizing
radiation burns nor for emergency preparedness if adverse events occur.23
It is important to bear in mind that a burn from UV equipment significantly
increases the risk for skin cancers, especially in adolescents. While indoor
tanning appears to be more cosmetic, it may have consequences on the overall
health and well-being of individuals; therefore, health care providers,
particularly pharmacists with community accessibility, can help create greater
public awareness.24-27
The ITA has no legal obligation to provide
carcinogenic information to its patrons. Both the FDA and the FTC have certain
guidelines regulating indoor tanning practices. Yet, no federal legislation
addresses indoor tanning by adolescents, nor are there regulations providing
for enforcement of exposure adherence by tanning patrons or for the monitoring
of UVA and UVB amounts emitted by operational tanning units.1
Each state has its own regulations governing
inspection of tanning salons and age restrictions. In 2003, only three states
had set limits for indoor tanning customers: Texas, Illinois, and Wisconsin
banned tanning among adolescents younger than 13, 14, and 16, respectively.
Recently, the WHO recommended that health ministries ban tanning among
individuals younger than 18 and, if this is not feasible, to consider issuing
standards deemed appropriate in the interests of public health.6
The Role of Community Pharmacy
In their efforts to become more public health–oriented, community pharmacies
can develop neighborhood outreach and educational campaigns, as well as
services for screening skin ailments, much like programs that already exist
for diabetes, hypertension, smoking cessation, and emergency contraception.
Through continuing education programs, pharmacists could learn to identify
suspicious skin lesions--with the help of charts commonly used by family
physicians, nurse practitioners, and physician assistants--and detect and
arrange for referrals to appropriate dermatologic experts for treatment. In
addition, pharmacists can advise patients being treated for skin ailments to
limit outdoor and indoor tanning exposure and educate them on the proper use
of sunscreens.
Selective screening by community pharmacies may be
effective and could be facilitated by risk-assessment tools.8
Pharmacies may be a good place to display public health posters to aid in the
identification of suspicious lesions that require medical follow-ups, with
charts that selectively screen based on risk factors such as red or blond
hair, freckling on the upper back, history of three or more blistering
sunburns before age 20, history of three or more outdoor summer jobs before
age 20, actinic keratosis, and type I or II skin types (Fitzpatrick's
classification).9 These posters may also be useful in training
pharmacists on how to recognize melanomas. When detected early, melanomas can
be cured with surgery alone.28 In theory, prevention, education,
and early detection should reduce melanoma morbidity and mortality, since the
cancer is external and visible, the risk factors are known, and early
detection of melanoma is associated with a high five-year survival rate.29
Conclusions
Indoor tanning poses many health risks, including alterations of the immune
system. Adolescents who tan are likely to be unaware of such risks.5
While the perceived social value of a tan manifests immediately, the
development of photo-aging and skin cancer takes years to become apparent.
30
The pharmacy may be an ideal setting to create
awareness about melanomas and counsel on the importance of avoiding risky
behaviors. Despite attempts made by physicians and other health care providers
to educate the public about the dangers of tanning, both indoor and outdoor
tanning are popular in our culture. Like programs focused on smoking cessation
or diabetes control, counseling and screening programs would be best brought
to public awareness in the community pharmacy environment.
References
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