The Only Safe Tan is an Artificial One

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By

Sheila Krishna, M.D.

 

Tanning is a physiological mechanism by which the skin darkens in response to ultraviolet light exposure.  Tanning typically occurs either due to exposure to natural ultraviolet light from the sun or from indoor sources of ultraviolet light, such as a tanning bed.  Tanning damages DNA and induces a variety of mutations in the skin and thus increases the risk of skin cancer.  As a result, tanning (and indoor tanning in particular) is classified as a World Health Organization level 1 carcinogen associated with the development of malignant melanoma and non-melanoma ( basal cell and squamous cell) skin cancer.

 

There have been major public health initiatives to regulate indoor tanning and to educate the public about sun and ultraviolet light safety.  In addition, there have been efforts to redirect  people to non-ultraviolet (artificial) sources of tanning.  Artificial sources of tanning have the potential to reduce the risk of skin cancer and reduce sun induced skin damage.

 

Tanning occurs when the skin is exposed to ultraviolet (UV) light, at which time the pigment producing cells called melanocytes, that reside in the lower layer of the epidermis, begin to produce more melanin (pigment) in an effort to shield the skin from further UV induced damage. This forms the basis of the tanning response which is, at best, a delayed and incomplete protective mechanism. In fact, a tan is indicative of damage to the skin that has already occurred.  Stated another way, there is no safe level of tan, just as there is no safe level of tobacco use.

 

Tanning traditionally occurred with exposure to natural ultraviolet light during the course of outdoor work or recreational exposure.  However, with the advent of cultural inclinations toward the benefit of tanned skin (with over 90% of women stating that tanned skin is more attractive than untanned skin), tanning now occurs frequently in both outdoor and indoor settings, in order to produce a year-round tanned appearance.

 

The natural ultraviolet light from the sun that reaches the earth is mainly composed of UVA and UVB rays.  UVB rays cause sunburns and create mutations in DNA which can lead to to skin cancer.  UVA rays penetrate the skin more deeply, and are the primary driver of the tanning response.  They also damage DNA and increase skin cancer risk. In addition, UVA exposure  creates structural changes in the skin which lead to an aged appearance which is referred to as photoaging and is characterized by wrinkles, permanent pigmented spots, and rough skin texture.

 

Indoor tanning beds are composed of fluorescent lamps with phosphor blends that emit approximately 97% UVA rays and 3% UVB.  Due to the lower amount of UVB in tanning beds, burns are less common than from natural sunlight   That said, the risks of skin cancer and premature aging, primarily from the UVA exposure from indoor tanning are very real

 

About 10% of the US population uses indoor tanning devices, and the highest use is seen in young, non-Hispanic white women.  On a worldwide scale, the majority of college age students have tanned at least once in an indoor tanning machine, as have 1 in 5 high school students.  These individuals use indoor tanning because they feel they look healthier and more attractive with a tan.

 

It is also known that the UV response to tanning is associated with the production of endorphins by the central nervous system resulting in the pleasant sensation of well being reported by many who use tanning beds.  Indeed, it has been shown that for some, tanning has an addictive quality, likely due to the increased endorphins.   Tanning behavior in this group may also be associated with an increased risk of substance abuse, anxiety, and obsessive compulsive disorder..

 

Ultraviolet light exposure, whether outdoors or indoors, is strongly associated with skin cancer and has limited health benefits.  A recent international study attributes 450,000 cases of skin cancer to indoor tanning alone.  Indoor tanning specifically accounts for 3400 cases of melanoma yearly in Europe and more than 170,000 cases of non-melanoma skin cancer in the United States.  The risks are highest for those exposed at young ages.  Tanning bed use before the age of 25 increases the risk of non-melanoma skin cancer by 40-100%.

 

Even more urgently, melanoma is the leading cause of skin cancer and deaths from skin cancer in those under 20 years of age.  Indoor tanning prior to the age of 35 increases the risk of melanoma by 59-75%.   Further, the incidence of melanoma has increased more quickly than any other cancer in young people, and specifically in young women, perhaps due to tanning bed use.

 

Finally, tanning bed use does not provide any protection against damage from future sun exposure, despite popular belief to the contrary, as UVA light simply redistributes existing pigment, rather than creating new pigment for sun protection.  Therein lies the myth of the  “base tan.”

 

With respect to health benefit, it has been shown that although vitamin D is generated by sun exposure, the benefit of the amount produced does not outweigh the risk of UV damage resulting in skin cancer.  Further, while UV light is used in the treatment of some skin conditions, this treatment is usually only undertaken if the patient does not have significant risk factors for skin cancer.

 

Taken together, tanning is an extremely unsafe activity that has little to no health benefit and is conclusively linked to the development of all types of skin cancer, including malignant melanoma.  Tanning is particularly dangerous for young people, who have an even higher risk of skin cancer if exposed to excessive ultraviolet light.

 

There have been major public health initiatives to educate people about the hazards of tanning along with legislative efforts to regulate indoor tanning.  Several states restrict or prohibit indoor tanning for minors, and studies have shown that female students in states with indoor tanning restrictions are less likely to engage in tanning and thus, are likely to reduce their risk of skin cancer.

 

Several professional organizations, including the American Academy of Dermatology, have large programs that educate the public about the risks of excessive sun exposure and indoor tanning. Recent efforts have focused on  social media, with campaigns on various social media platforms  to educate young people about  the risks of skin cancer from tanning.

 

There have been efforts to develop alternatives to conventional tanning, in order to produce the physical appearance of tanned skin without the risks of UV exposure.  The best tanning alternative is the use of topical self tanners.  These are safe and commonly used and come in many different formulations.  Most are readily available and can be applied by the individual, and others are applied by a professional, as a spray tan.

 

Temporary bronzers last about 24 hours, while longer lasting topicals contain dihydroxyacetone and last for several days to a week.  Dihydroxyacetone binds to the outer layers of the skin (epidermis) and creates a tanned appearance that is eventually shed with the epidermal cells as part of the normal process of skin turnover.  These products, while effective at creating a tanned appearance, do not protect from UV light and can form UV induced free radicals in the skin.  Therefore, when using these products, it is critical to continue sun protection including the use of sunscreens.

 

Tanning pills are available, but are not a safe alternative to conventional tanning.  The possible side effects of visual disturbance, severe anemia, and skin rashes preclude their use.  These pills are typically made of canthaxanthin.  Canthaxanthin is a red-orange colored carotenoid found in plants, mushrooms, fish, algea and bacteria.  It is lipid soluble and deposits orange to brown color in the skin and fat cells of the body

 

In summary, tanning is a response to both natural and indoor ultraviolet light exposure.  Tanning behaviors should be minimized in order to reduce the risk of skin cancer, including melanoma and non-melanoma types.  Indoor tanning has been restricted in many states due to these dangers, particularly for young people, and great effort has been made to educate people of all ages on the dangers of tanning.  Alternatives to ultarviolet light tanning such as dihydroxyacetone are available and provide aesthetic results without the dangers of UV exposure.  As more individuals utilize artificial tanning over ultraviolet light tanning, it is hoped that the epidemic of skin cancer will lessen with the consequent reduction in morbidity and mortality.

 

References

Wehner MR et al.  International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol. 2014 Apr;150(4):390-400.

OLeary RE et al.  Update on tanning: more risks fewer benefits.  J Am Acad Dermatol. 2014 Mar;70(3):562-8.

 

Ernst A et al.  Tanning lamps: health effects and reclassification by the Food and Drug Administration.

J Am Acad Dermatol. 2015 Jan;72(1):175-80.

 

Falzone A, Brindis C, Chren M-M, et al. Teens, Tweets and tanning beds: rethinking the use of social media for skin cancer prevention. Am J Prev Med. 2017;53(suppl):S86-S94.

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