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
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.
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