The Dangers of Indoor Tanning

By now, dermatology nurses should be exceedingly aware of the dangers of indoor tanning. Over 10 years ago, the World Health Organization and the U.S. Department of Health and Human Services proclaimed artificial tanning through tanning beds and sun lamps to be carcinogenic (American Academy of Dermatology, 2022a). In 2014, after multiple proposed bans on indoor tanning, The U.S. Food and Drug Administration (FDA) required a black box warning to be placed on all indoor tanning products restricting access to minors (^{FDA, 2019}). Numerous studies have shown a strong link between indoor tanning and premature skin aging, skin cancers, and ocular melanoma (^{FDA, 2015}). Specifically, studies showed that with any reported history of indoor tanning use, the risk of basal and squamous cell carcinomas increased by 24% and 58%, respectively (American Academy of Dermatology, 2022a). In individuals who first used a tanning bed before the age of 35 years, the risk of melanoma—the deadliest form of skin cancer—increased by a startling 75% (^{Chien & Jacob, 2022}). In fact, indoor tanning has led to more cases of skin cancer worldwide than smoking has to lung cancer (^{Chien & Jacob, 2022}; Figure 1).

FIGURE 1.: Squamous cell carcinoma on the posterior leg. Photo courtesy of Maral Skelsey, MD, Dermatologic Surgery Center of Washington. Used with permission.

Despite the overwhelming evidence of its risks, approximately 7.8 million adults in the United States continued to participate in indoor tanning activities as of 2015 (^{Guy et al., 2017}). Surveys on the global prevalence of indoor tanning between 2013 and 2018 revealed utilization rates of 6.5% for adolescents and 10.4% for adults (American Academy of Dermatology, 2022a). Although these numbers have been declining over time, indoor tanning remains a significant public health threat (Figure 2).

FIGURE 2.: Image of an indoor tanning bed. Photo credit: pixel2008.

In individuals who desire a sun-tanned appearance, the application of artificial tanning products containing dihydroxyacetone (DHA) may provide a safer alternative to indoor tanning (^{Misitzis & Weinstock, 2019}). DHA is FDA approved for topical skin application but “should not be inhaled, ingested, or exposed to areas covered by mucous membranes” (^{FDA, 2022}). With topical application, DHA triggers the formation of brown pigment in the top layer of skin. This short-term tanned skin effect is eventually removed by the normal skin sloughing process (^{Wickett, 2005}).

The increasing availability and use of sunless tanning products prompts questions about their efficacy as a skin cancer risk reduction measure. In this issue of the Journal of the Dermatology Nurses' Association (JDNA), authors Andrew Seidenberg, PhD, MPH, Anne K. Julian, PhD, MA, Anne M. Hartman, MS, MA, and Dawn Holman, MPH, analyzed data from the 2015 National Health Interview Survey to “determine the prevalence and risk factors associated with sunless and indoor tanning use among non-Hispanic white women, ages 18–49” (^{Seidenberg et al., 2023}). They showed that a significant portion of non-Hispanic white women reported engaging in sunless tanning (^{Seidenberg et al., 2023}). Although sunless tanning product application (both lotion and spray tanning) was more prevalent than indoor tanning, engaging in both behaviors—known as “dual tanning behavior”—was fairly common (^{Seidenberg et al., 2023}). This association was particularly strong in younger women, which the authors point out may reflect societal pressure among this cohort to “idealize tanned skin” (^{Seidenberg et al., 2023}). Regarding this important research, one of the authors states:

“In our study, nearly one in five women reported using sunless tanning products,” said Dawn Homan, MPH, behavioral scientist, Epidemiology and Applied Research Branch, CDC’s Division of Cancer Prevention and Control. “These products allow users to get a tanned appearance without UV damage to their skin from the sun or indoor tanning devices. However, the use of these products may reinforce societal pressures for women to change their natural skin color.”

Furthermore, a 2018 study in JAMA Dermatology found that the use of sunless tanning products was associated with a higher risk of sunburn (^{Holman et al., 2018}). This may be attributed to increased unprotected sun exposure in individuals who use sunless tanning products, a false sense of sun protection when using these lotions and sprays, or a possible heightened photosensitivity effect of the sunless tanning product on the skin (^{Seidenberg et al., 2023}). Although further research is needed, these findings suggest that recommending sunless tanning as a risk reduction behavior may not be entirely straightforward.

Dermatology nurses can utilize this new information when performing skin cancer risk assessments and education on tanning behaviors. For example, in patients who endorse sunless tanning product use, concurrent use of indoor tanning should be assessed, and patients should be cautioned that sunless tanning products do not provide adequate protection against sun damage or burns (^{Holman et al., 2018}). Nurses must also be aware of the cultural pressure for many individuals to achieve tanned skin and work toward public health measures to help change societal norms.

With skin cancer diagnosis and treatment resulting in an enormous strain on the healthcare system and rates continuing to escalate, it will become increasingly important for dermatology nurses to be proficient in detecting and managing these cancers. Research shows that approximately one in five Americans will develop skin cancer in their lifetime, and more than one million people in the United States are currently living with melanoma (American Academy of Dermatology, 2022b). Melanoma rates doubled between 1982 and 2011 and continue to rise in older individuals (American Academy of Dermatology, 2022b). Yet, studies have shown gaps in the knowledge of nursing and medical students regarding sun protective behaviors (^{Haney et al., 2018}; ^{Ivanov et al., 2018}). Future measures to incorporate adequate skin cancer and sun protective training into the health sciences curriculum are essential (Figure 3).

FIGURE 3.: Malignant melanoma on the forehead. Photo courtesy of Maral Skelsey, MD, Dermatologic Surgery Center of Washington. Used with permission.

To help instruct dermatology nurses in the early detection and management of skin cancers, JDNA set out to provide a simplified review of various skin cancers in the Back-to-Basics, Skin Cancer Column, which debuted in early 2020. Since that time, talented authors from the nursing and medical community contributed thoughtful and well-written articles, covering topics such as squamous cell carcinoma, amelanotic melanoma, Merkel cell carcinoma, basal cell carcinoma, actinic keratosis, anogenital squamous cell carcinoma, and dermatofibrosarcoma protuberans. We hope readers have found these articles to be informative and helpful in expanding their knowledge of skin cancer detection and management.

Articles from the “Skin Cancer Column,” as well as cutting-edge research from ^{Seidenberg et al. (2023)}, show that the JDNA strives to provide the material dermatology nurses need to best care for their patients. When it comes to continuing education, this time of the year is particularly important for reviewing the literature on sun protective behaviors. Selected topics on indoor tanning and skin cancer were strategically published in this issue of JDNA to fall between “Melanoma Monday” and “Don't Fry Day”—a heightened time of awareness of the need for public health measures to prevent sunburn and skin cancer. By continuing to work toward becoming more knowledgeable about skin cancer and sun protective behaviors, nurses can help reduce the impact of skin cancer on their patients and communities.

Kyleen E. Davis
Dermatologic Surgery Center of Washington, Chevy Chase, MD