Science of Skin

Sunbeds and solariums


tanning-bed-thumb
Figure 1. A sunbed/solarium

Tanning beds, tanning booths, sunbeds, sunlamps, solaria and solariums are names given to various artificial tanning devices which emit ultraviolet (UV) radiation. Solariums are designed for a person to stand or lie for a period of time in a chamber fitted the length with light tubes which emit UV radiation, this elicits a tanning response from the skin. The use of solariums is particularly prevalent in young people, with 50% of patrons under the age of 29, notably, 71% of users are women.  A common misconception is that solariums offer a ‘safer’ option for tanning than one obtained from solar UV radiation and that people who use indoor tanning devices have no increased risk of skin cancer. In actual fact, solariums are able to produce UV radiation up to 5 times the strength of midday sun in an Australian summer and individuals who have used a solarium before the age of 35 have been shown to have a 75% greater risk of developing malignant melanoma, the deadliest form of skin cancer.

Solariums

Solariums can be found in tanning and beauty salons, apartment buildings, private homes or as part of recreational and fitness facilities. The artificial tanning industry was first established in North America in the early 1980’s and solariums have since become a popular cosmetic treatment, with the number of consumers doubling in the past decade. In 2007 it was estimated that nearly 30 million Americans had used an indoor tanning facility and nearly two million attended a facility each day. 

The variety of devices used for tanning is extensive. While the majority of salons use beds or walk-in booths, there are also freestanding and desktop units available, in-wall units and machines which target a specific area of the body, such as “foot tanners”. There are also considerable differences in device power and design which can alter the amount and intensity of UV radiation incurred during treatment. These differences include: the type, number and arrangement of lights used; the substances used as filters; the distance between the UV source and the consumer’s skin; and the age and pressure of the UV lamps.

Traditionally, the longer wavelength of ultraviolet, UVA radiation (320-400 nm), is primarily emitted by sunbeds, with only a fraction emitted in the UVB (290-320 nm) spectrum. Increasingly, the lights in solariums are being altered to produce a greater amount of UVB radiation; the newer lamps more closely imitate the UV spectrum found in natural sunlight and aim to accelerate tanning.  While both UVA and UVB have been implicated in skin cancer formation, UVB is considered to be more strongly carcinogenic; it is also the wavelength which stimulates the synthesis of vitamin D.

Health effects

Sunbeds and solariums produce adverse affects similar to those created by prolonged exposure to natural UV light. Most severe among these is the increased risk of skin cancer due to skin damage, including a considerable increase in the incidence of melanoma, the most lethal type of skin cancer, in solarium users. The International Agency for Research on Cancer (IARC) is a section of the United Nations World Health Organization (WHO) responsible for classifying agents depending on their carcinogenic (cancer causing) potential. In 2009, the IARC categorized ultraviolet-emitting tanning devices in the highest risk class for cancer, “Group 1: the agent (mixture) is definitely carcinogenic to humans”, along with asbestos and tobacco smoking.

There is a 75% increase in risk of melanoma for people who have used a solarium before the age of 35.

The UV radiation emitted by sunbeds has also been shown to induce the pre-cancerous actinic keratoses and Bowen’s disease; a disease similar to early stage squamous cell carcinoma skin cancer, characterised by patches of hardened, scaly skin. Immediate skin damage from solariums may occur in the form of redness, burning (sunburn) or scarring, or as lasting damage such as wrinkles and the decreased suppleness and flexibility of photoaging; this is caused by UV damage to collagen fibres in the skin.

The UV radiation of solariums can also induce several types of ocular (eye) ailments including cataracts, pterygium (a fleshy growth over the cornea) and photokeratitis or photoconjunctivitis (inflammations of the eye). UV radiation may also cause immunosupression which can increase the risk of infection and other disease. 

Light-skinned individuals are more susceptible to skin damage from tanning devices as their reduced pigmentation provides less natural protection from UV sources. Individuals with skin type I, the fairest skin complexion, may not be able to achieve any level of tan despite multiple sunbed treatments as their skin tends to react by burning instead. Solarium use is particularly dangerous for children (under the age of 18) as the degree of UV exposure and the incidence of sunburn in childhood is a central factor to the development of skin cancer, especially melanoma, later in life. Some medications (e.g. antibiotics and psoralens) and cosmetics photosensitise the skin, making it more susceptible to damage from the UV radiation produced by tanning devices.

Sunburn-skinblock
Figure 2. UV Radiation penetrating the skin

Artificial UV sources are sometimes used therapeutically for the treatment of skin conditions such as psoriasis and eczema. In such cases, whole body treatment is not always necessary. Where possible, physicians limit UV exposure to the affected portion of skin to minimise harmful effects. In addition to the medical benefits for sufferers of some dermatoses, tanning devices also stimulate the production of vitamin D; a group of prehormones essential in small quantity for healthy bodily function. Vitamin Dis manufactured in the skin upon exposure to UVB radiation; it can also be obtained through diet and oral supplementation. It is radiation in the UVB wavelength that induces vitamin D synthesis. Typically, solariums only emit a small proportion of radiation in this spectrum, with most (more than 95%) in the UVA spectrum.

Due to their associated health consequences, several authorities, including the World Health Organization (WHO), American Academy of Dermatologists (AAD) and the Australian Cancer Council (ACC) advise that the public avoid the use of solariums for cosmetic reasons. They recommend dietary changes or medically-supervised supplementation to boost levels of vitamin D where incidental sun exposure is insufficient. 

Many users describe solarium treatments as enhancing feelings of relaxation and producing a greater sense of well-being. While it is hard to measure the extent of such claims, some theorise that a release of endorphins (mood-elevating chemicals) stimulated by UV exposure may be partially responsible for this reaction.

Solarium use and motivations

Among solarium users, the most frequently listed motivation for a tan is appearance; they desire tanned, bronzed skin with a ‘healthy’ glow for fashion or aesthetic purposes. Other common motivations were improved mood and socialization; this is supported by the fact that more than half of those frequenting tanning salons attended their first session with friends. Additional reasons include relaxation, confidence enhancement, preparation for a special event, feeling healthier and conforming or fitting-in socially; a few also claim that tanning improves their acne. 

There is a mistaken belief that an underlying solarium tan will protect skin in situations of extreme UV exposure. UVA radiation, the main wavelength emitted by most solariums, does not increase production of the photoprotective pigment melanin as UVB does. Instead, it is believed that the UVA-induced tan comes from either the oxidation of melanin precursors or from the spreading of existing melanin. Hence, studies show that a tan induced by UVA radiation provides only little photoprotection from subsequent UV exposure.

Some solarium users argue that their use of indoor tanning equipment is a way of controlling the amount of UV radiation they receive in place of solar exposure. However, in reality research indicates that regular indoor tanners may receive more than four and a half times the annual UVA dose than that obtained from solar sources, on top of the natural sunlight they are exposed to. In addition, indoor tanners have been shown to be more likely to participate in deliberate outdoor tanning activities than the general population. 

Attitudes on indoor tanning

Many people, particularly teens and young adults, feel that the positive aspects they experience from using solariums outweigh the health risks of skin aging and cancer. These incentives to tan tend to reinforce the pattern of behavior and, in a small number of cases, indoor tanning use has being likened to substance-related disorders and addictions.

The teenage and early adult years have been discovered as being the most relevant to the establishment of attitudes and beliefs about tanning. Surveys indicate that, once formed, opinions on tanning are not readily changed. Extreme personal experience, such as melanoma diagnosis, is the most likely event to influence views beyond this point. 

It has been demonstrated that adolescents perceive doctors, specifically dermatologists, as the most reliable source of information on tanning. Physicians are therefore considered to be in a powerful position to influence attitudes on tanning and improve the level of understanding of the risks of UV exposure in young people. Despite the high proportion of young solarium patrons, the majority of parents surveyed had not discussed the safety of these devices with their teenage children.

Regulations

Despite the health risks posed by solariums, they are still frequented in most western nations. In recent years, some countries have introduced regulations in an effort to reduce the dangers related to solarium operation, though they are far from uniform. 

Regulations governing the Australian tanning industry are among the tightest in the world, with harsh penalties for providers who do not comply. There is no national regulation of the industry, with the exception of a voluntary code of conduct, the Australian standard (AS/NZS 2635:2008 Solaria for cosmetic purposes); this was revised in 2009. However, most state governments have individual laws or are in the process of devising them. The following are common features of Australian solarium regulations in various states:

  • Prohibition of use, sale or hire of tanning devices for under 18’s
  • Prohibition of solarium operation by untrained personal
  • Ban of unsupervised solariums (i.e. coin operated)
  • Duty to display health information and solarium specifications
  • Duty to provide solarium client with information on health affects upon each visit
  • Enforcement officers rights to inspect salons
  • Maximum exposure times/frequency (depends on individuals solarium specification)
  • Maximum intensity levels for UV radiation and limits on the proportion of UVB radiation in total emission
  • Compulsory protective eyewear

The U.S. Food and Drug Administration (FDA) provides standards for manufacturers of sunbeds, necessitating solarium warning labels and advice on the use of protective goggles. American legislation varies from state to state, while some are relatively tough, others are merely guidelines. The manufacture of sunbeds in Europe is mainly regulated by the European Standard EN 60335-2-27, which was amended in 2009. There are no standard rules governing the use of solariums and safety of solarium services in Europe, though some countries, including France and Sweden, possess individual laws. In England and Wales, the Sunbeds (Regulation) Act 2010 is currently in force. This new legislation came into effect following Scotland’s introduction of sunbed regulations in 2008 (Part 8 of the Public Health etc. (Scotland) Act 2008 asp 5). 

Research shows that operators within the tanning industry often fail to notify individuals who are sun-sensitive (skin type I & II) of their inappropriateness for indoor tanning and inadequately restrict patients taking photosensitizing medication. There is also concern that operators commonly exceed the recommended frequency and duration of treatments. One U.S study revealed that 89% of facilities inspected did not abide by the regulation advising less than four solarium sessions in the first week of treatment. While marketing is usually focused on the notion of solariums being a quick, effective method of tanning, on the whole, information given to the consumer on the health risks is incomplete or misleading; some are even promoted as being “damage-free”, a wholly false claim. Some believe that governments and policy makers need to form more stringent regulations on solarium operation and more actively discourage young people from using these facilities.

Several media campaigns warning of the dangers of indoor tanning equipment have been created to raise awareness of the associated health threats. Despite these, the use of tanning beds increased by 25% from 1988 to 1994, indicating that such messages failed to change tanning behavior. Studies have shown that teenagers and young adults identify their friends and social group as their greatest source of knowledge on the safety of tanning equipment. As a result, it has been suggested that education programs on the risks of indoor tanning be directed at peer-to-peer networking to help young people make more informed choices regarding UV exposure.

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