Tanning accelerators: Prevalence, predictors of use, and adverse effects Jennifer L. Herrmann, MD, Rachel Cunningham, MD, Alan Cantor, PhD, Boni E. Elewski, MD, and Craig A. Elmets, MD Birmingham, Alabama Background: Tanning accelerators are topical products used by indoor tanners to augment and hasten the tanning process. These products contain tyrosine, psoralens, and/or other chemicals. Objective: We sought to better define the population using accelerators, identify predictors of their use, and describe any related adverse effects. Methods: This cross-sectional study surveyed 200 indoor tanners about their tanning practices and accelerator use. Primary analysis compared accelerator users with nonusers with respect to questionnaire variables. Descriptive statistics and x2 contingency tables were applied to identify statistically significant variables. Results: Of respondents, 53% used accelerators; 97% were female and 3% were male with a median age of 22 years (range: 19-67). Users were more likely to spray tan, tan frequently, and be addicted to tanning. Acne and rashes were more common in accelerator users. Adverse reactions to accelerators prevented their further use 31% of the time. Limitations: A limited adult population was evaluated; exact accelerator ingredients were not examined. Conclusions: Tanning accelerator users are high-risk indoor tanners who tan more frequently and who are more likely addicted to tanning. Acne and rashes are more common with these products and act as only mild deterrents to continued use. Additional research should investigate accelerators’ longer-term health effects. ( J Am Acad Dermatol 2015;72:99-104.) Key words: indoor tanning; tanning accelerator; tanning addiction; tanning dependence; tanning lotions.
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everal studies have shown that exposure to ultraviolet (UV) radiation from indoor tanning devices is associated with an increased risk of melanoma and nonmelanoma skin cancer.1-5 Based on these data, the US Department of Health and Human Services and the International Agency for Research on Cancer panel have declared UV radiation from tanning beds and sun lamps as a known carcinogen.6 Despite the growing awareness that it poses a health threat, indoor tanning continues to grow exponentially. In the United States, at least 28 million people tan indoors annually, and of these, 2.3
million are teens.7,8 In a study of more than 10,000 children and adolescents, 35% of teenage girls were found to use tanning devices.9 A common practice among tanning bed users is to apply tanning accelerators. Tanning accelerators are
From the Department of Dermatology, University of Alabama at Birmingham. Supported by National Institutes of Health Grants P30 AR050948 and P30 AR050948 (Dr Elmets) and by funds from the Alabama Dermatological Society. Conflicts of interest: None declared. Accepted for publication October 15, 2014.
Reprint requests: Jennifer L. Herrmann, MD, University of Alabama at Birmingham, 1530 Third Ave S, EFH 414, Birmingham, AL 35294. E-mail: [email protected]. Published online November 13, 2014. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.10.020
Abbreviations used: DSM-IV: SRD: UV:
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition substance-related disorder ultraviolet
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better characterize tanning accelerator users, questopical lotions, creams, or sprays that are designed to tions examined frequency and reasons for accelerdeliver faster, deeper tans after exposure to UV ator use and whether respondents had a favorite radiation. These products are sold in tanning salons, accelerator, used added bronzers (ie, dyes that and over 500 distinct varieties are available at darken the skin), and/or had experienced an adverse Amazon.com. Tanning accelerators attribute their event with an accelerator. The survey also assessed efficacy to tyrosine and plant extracts, such as participants’ views on tanning accelerator efficacy bergamot orange (Citrus bergamia), lime (Citrus and whether accelerators aurantiifolia), and fig-leaf affected their risk of skin (Ficus carica), all of which CAPSULE SUMMARY cancer. contain photo-sensitizing Tanning addiction, which psoralens. Tanning accelerators are topical products is associated with the proVery little is known about designed to deliver faster, deeper tans duction of endorphins stimthe effects of tanning accelafter ultraviolet exposure. ulated by UV radiation, is a erators or those who use Women who tan frequently and have recently described disorder them. There is only 1 report tanning addiction/addiction tendencies that can affect frequent tanexploring the efficacy of are more likely to use accelerators. ners.11 A series of questions tyrosine-based tanning ac10 celerators, and no studies was included to assess poAccelerator use may therefore identify tential tanning addiction/ have examined psoralens or higher-risk indoor tanners. addictive tendencies. Two psoralen-containing botanmeasures frequently used to ical accelerators. This study define a substance-related disorder (SRD) were was designed to reveal more about tanning accelermodified: the 4-item CAGE (cut down, annoyed, ator use. For this purpose, a group of 200 indoor guilty, eye-opener) questionnaire, and the 7 diagtanners were asked to complete a survey designed to nostic criteria for SRD as outlined in the Diagnostic assess the prevalence of tanning accelerator use, the and Statistical Manual of Mental Disorders, Fourth reasons why they are used, and their adverse effects. Edition (DSM-IV) as reported previously.11 Two or more affirmative responses to questions on the METHODS modified CAGE questionnaire and 3 or more affirA total of 200 indoor tanners were recruited mative responses to items on the modified DSM-IV between January and July 2013 to complete a 30questionnaire were considered to indicate a likely question survey for this cross-sectional study. Booths SRD involving indoor tanning. For questions in the with signs reading ‘‘Do you indoor tan?’’ were set up modified DSM-IV-Text Revision with multiple parts, at a university recreational center (55 participants) scores were calculated using the method of Mosher and 2 public beaches (70 and 75 participants each), and Danoff-Burg.12 Tanning addiction was defined neither of which had indoor tanning facilities. as meeting criteria for a SRD by both the CAGE and Individuals who approached the booths were DSM-IV questionnaires, and tanning addiction tenoffered surveys if they had both indoor tanned in dency was defined as meeting criteria for either the the past year and were at least 19 years old (both CAGE or DSM-IV questionnaires but not both. study inclusion criteria). Age of at least 19 years was The primary analyses compared tanners who use chosen to eliminate a parental consent form. accelerators with those who do not with respect to a Participants who completed surveys could volunnumber of variables. For categorical variables such tarily enter a drawing for a $25 gift card. All study as eye color, skin type, tanning frequency, tanning materials and procedures were approved by the addiction (yes/no), and tanning addictive tendencies university’s institutional review board. Participants (yes/no), x 2 contingency tables were used to compare were limited to a single survey. All participants tanning accelerator users with nonusers. For ordinal completed questionnaires anonymously. Ten quesvariables such as age, the Wilcoxon rank sum test was tionnaires were excluded from the data set because applied. Given that tanning frequency is used in the respondents had answered fewer than 95% of the calculation for tanning addiction/addictive tendency, questions. If respondents indicated not using accelCochran-Mantel-Haenszel tests were used to adjust for erators but answered questions pertaining to acceltanning frequency when comparing tanning addicerators, those responses were also omitted from the tion/addictive tendency among accelerator users and analysis. Questions were designed to capture denonusers. All tests were conducted at the 2-sided .05 mographic data of respondents (age, sex, eye color, significance level. Software (SAS, Version 9.3, SAS Fitzpatrick skin type), frequency of indoor tanning, Institute Inc, Cary, NC) was used for calculations. use of spray tans, and use of tanning accelerators. To d
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RESULTS Characteristics of tanning accelerator users Table I summarizes demographics of survey respondents. In all, 200 people responded to the survey; 190 completed more than 95% of the questions and were included in the analysis. Of those, 92.6% were female, 7.3% were male, and their median age was 22 years (range: 19-67). Most had Fitzpatrick skin types II, III, or IV. In all, 89% had blue, green, hazel, or light-medium brown eyes. A total of 49% had spray tanned at least once, and nearly all (96%) respondents had heard of tanning accelerators. Predictors of accelerator use Of survey respondents, 53% reported tanning accelerator use. Predictors of use are summarized in Table II. Women were more likely to have applied accelerators than men. Specifically, 97% of accelerator users were female and 3% were male; nonusers were 88% female and 12% male (P = .01). Age, Fitzpatrick skin type, and eye color did not differ statistically between accelerator users and nonusers. Accelerator users tanned more frequently than nonusers: 32% of users compared with 7% of nonusers reported tanning 60 times or more yearly, whereas 9% of users compared with 34% of users reported tanning less than 5 times yearly (P\.01). Accelerator users (48%) were more likely to have spray tanned than nonusers (22%, P \ .01). However, spray tanning was infrequent in both groups. Of those who had spray tanned, 86% of accelerator users and 82% of nonusers had spray tanned less than 5 times total. Of the accelerator users, 38% reported always using a tanning accelerator, whereas 34%, 21%, and 7% reported using products more than half of the time, less than half of the time, and a few times only, respectively. Tanning accelerator users also had greater tanning addictive tendencies or were considered tanning addicted compared with nonusers (P \ .01). After adjusting for tanning frequency, accelerator users were still more likely to have tanning addictive tendencies (modified CAGE, P = .02; modified DSM-IV, P \ .01) and/or be addicted to tanning (P = .01). Reasons for accelerator use/nonuse The most common reasons for using tanning accelerators were ‘‘to tan faster’’ (83%), ‘‘to tan deeper’’ (74%), and ‘‘to make my tan last longer’’ (59%) (Fig 1). The majority (71%) of accelerator users stated that they preferred using accelerators with added bronzer (tanning dye) because their tans
Table I. Characteristics of survey respondents Respondents, n (%)
Sex Female Male Age, y Skin type* I II III IV V VI Eye color Blue Green Hazel Light-medium brown Dark brown-black Spray tan Ever use No use Accelerator users Yes No
176 (93) 14 (7) 25.4 6 8 SD (mean) 22 (median) 2 31 88 62 7 0
(1) (16) (46) (33) (4) (0)
60 30 34 45 21
(32) (16) (18) (24) (11)
93 (49) 97 (51) 101 (53) 89 (47)
SD, Standard deviation. *Respondent-reported.
appeared faster (60%), deeper (43%), and/or more even in color (19%). Those who disliked added bronzers reported that these dyes made their tans look ‘‘faker’’ (27%) and ‘‘streakier’’ (10%). The most common reported reasons for not using accelerators were tanners were content with their tans without an accelerator (43%), accelerators were too expensive (34%), and tanners had bad experiences with accelerators previously (9%). For those reporting cost as a barrier, their median age was 19 years (range: 19-36), whereas the median age for those not using accelerators was 23 years (range: 19-50). Adverse effects Reported adverse reactions associated with accelerators are summarized in Table III. Of tanning accelerator users, 18% reported sustaining at least 1 slight sun burn after tanning both with and without accelerators. There was no statistically significant difference between reported moderate sun burns when using accelerators (11%) versus not using accelerators (7%). More tanners developed acne (15%) and rashes (7%) when using accelerators than when not using these products (2% and 1%, respectively). Having any problem with a tanning accelerator prevented its future use 15% of the time. Of tanners using accelerators, 62%, 33%, and 5%
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Table II. Factors associated with tanning accelerator use Accelerator users, % [95% CI]
Annual tanning frequency \5 5-14 15-29 30-44 45-59 $ 60 Spray tan Ever use No use Addictive tendency (CAGE) Yes No Addictive tendency (DSM-IV) Yes No Tanning addiction Yes No
8.91 7.92 8.91 21.78 20.79 31.68
[3.36-14.46] [2.65-13.19] [3.36-14.46] [13.73-29.83] [12.88-28.70] [22.61-40.75]
Nonusers, % [95% CI]
33.71 16.85 16.85 17.98 7.87 6.74
[23.89-43.63] [9.24-24.46] [9.24-24.46] [13.85-22.11] [2.28-13.46] [1.53-11.95]
x 2 P value
Adjusted for tanning frequency P value
\.01
.01 47.62 [45.09-50.15] 52.38 [42.64-62.12]
22.22 [13.58-30.86] 77.78 [69.14-86.52]
46.15 [34.43-55.87] 53.85 [44.13-63.57]
13.13 [6.07-20.19] 86.87 [79.85-93.89]
50.48 [40.73-60.23] 49.42 [49.67-59.24]
7.07 [2.28-13.46] 92.93 [87.60-98.26]
32.38 [23.25-41.41] 67.62 [58.49-76.75]
4.04 [0-8.13] 95.96 [91.87-100]
\.01 \.01 \.01
.020
\.01
.011
Tanning addiction was defined as meeting criteria for a substance-related disorder by both the CAGE and DSM-IV questionnaires, and tanning addiction tendency was defined as meeting criteria for either the CAGE or DSM-IV questionnaires but not both. CAGE, Cut down, annoyed, guilty, eye-opener; CI, confidence interval for proportion; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Fig 1. Accelerator user responses in percentages. Reasons for using tanning accelerators. The black bars represent the upper and lower bounds of 95% confidence intervals.
believed accelerators did not affect their risk for developing skin cancer, increased their risk for developing skin cancer, and decreased their risk for skin cancer, respectively.
DISCUSSION Our results demonstrate that over half of tanning bed users apply tanning accelerators. Their use is more common in women and in people who spray
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Table III. Adverse reactions associated with accelerator use With accelerator, Without accelerator, no. of users [95% CI] no. of users [95% CI]
Slight burn Moderate burn Acne Rash
18 [0.34-0.66] 11 [0.39-0.84]
18 [0.34-0.66] 7 [0.41-0.61]
15 [0.73-1.00] 7 [0.65-1.0]
2 [0.00-0.27] 1 [0.00-.36]
x2 P value
1 .117 \.01 \.01
CI, Confidence interval for proportion.
tan, tan frequently, and have tanning addictive tendencies. Although spray tan use was high among accelerator users, the overall frequency of spray tanning was very low. Frequent tanners have higher exposure to in-salon spray tanning and therefore may have been more likely to have tried spray tanning once or twice. The fact that accelerator users tan more frequently and/or are addicted to tanning underscores the fact that this highest risk tanning group is willing to do more to boost their tans, even though the longer-term effects of accelerators are unknown. Some tanning accelerator manufacturers advertise their products as promoting skin health with claims such as ‘‘a blend of important nutrients.for a darker tan and healthier skin,’’13 and a minority of accelerators include antioxidants, such as vitamin E and C. However, skin youthfulness and skin protection were among the least cited reasons for using accelerators. Only 5% of respondents believed that tanning accelerator use would decrease their risk of developing skin cancer. In contrast, 33% believed accelerators would increase their risk for skin cancer, even though they continued to use these products. Although this subset of respondents was not more likely to be addicted to tanning, continuing to engage in a perceived harmful action is characteristic of a SRD. Problems associated with tanning accelerators served as a minor deterrent for their continued use. Because our questionnaire asked about acne generically, it is not known if reported acne represented facial acne or chest/back folliculitis. Previous studies have reported bacterial growth from directly swabbed commercial tanning beds,14 which may have been relevant to our respondents. The high oil content (coconut, palm, olive, seed oils) of accelerators may have also contributed to respondents’ acne. Rashes were also more frequent in accelerator users. Potential causes include photo-related eruptions or contact dermatitis. Ingredient lists for tanning accelerators commonly reveal more than 30 items, including emulsifiers, stabilizers, preservatives, and dyes, which can be contact allergens.
Some accelerators contain bergamot orange (Citrus bergamia), lime (Citrus aurantiifolia), and fig-leaf (Ficus carica) extract. The augmentation in tanning can be attributed to psoralens found in these products. Exposure to specific wavelengths of UVA radiation enable psoralens to absorb energy and attain high-energy states. These activated molecules form photoaddition products with DNA pyrimidine bases via DNA interstrand cross-linking, resulting in epidermal cell nucleic acid damage. Activated psoralens can also produce oxygen, superoxide anion, and hydroxy radicals, which can cause cellular membrane damage. Ultimately, both mechanisms result in arachidonic acid pathway activation, cellular dysfunction, inflammation, and tissue destruction.15,16 It is therefore plausible that tanning accelerators containing psoralens place indoor tanners at greater risk for cutaneous damage than tanning alone. Numerous studies have linked the combination of psoralens and UVA radiatione the main type of radiation emitted from tanning devicesewith phototoxicity, photocarcinogenesis, and increased rates of squamous cell carcinoma and melanoma.17-20 Although our cohort did not report a higher incidence of acute skin burns when using accelerators compared with nonuse, reports in the literature have exemplified the potential danger associated with unsupervised topical psoralen use before UV radiation.21-24 Tanners using fig-leaf lotions containing psoralens have experienced severe skin burns involving up to 81% of their body surface area and requiring intensive care unit hospitalizations.21 Psoralens, which were incorporated into some sunscreens several decades ago either as bergamot oil or as purified 5-methoxypsoralen for the purpose of tan enhancement, have since been banned from these products because multiple reports demonstrated that psoralen-containing sunscreen induced phototoxicity, epidermal ornithine decarboxylase activity, and tumorigenesis in hairless mice.25-28 Multiple clinical studies demonstrating increased risk of nonmelanoma skin cancer in patients undergoing prolonged psoralen plus UVA treatments for psoriasis have confirmed this carcinogenic effect.29 Limitations of this study included its relatively small sample size and population limited to those aged at least 19 years on a college campus and at 2 public beaches, which may preclude generalizability. Tanners also voluntarily chose to complete surveys, which may have introduced selection bias. Self-reporting may have resulted in inaccuracies, and definitions of tanning accelerators may have been interpreted differently among tanners. In addition, individual tanning accelerators were not examined
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for their content and the amount of tanning accelerator used by tanners was not quantified. In conclusion, we sought to better characterize the population using tanning accelerators, a group of largely uninvestigated products used by indoor tanners, to better understand the motivations behind their use and to identify any associated adverse effects. Accelerator users are high-risk tanners who tan more frequently and who are more likely to be addicted to tanning. Additional studies should be aimed at scrutinizing individual products more closely and more thoroughly investigating potential associated problems, including longer-term effects. We would like to thank Hillary delaRosa and Thy Huynh for their help with questionnaires. REFERENCES 1. Whitmore SE, Morison WL, Potten CS, Chadwick C. Tanning salon exposure and molecular alterations. J Am Acad Dermatol. 2001;44:775-780. 2. Swerdlow AJ, Weinstock MA. Do tanning lamps cause melanoma? An epidemiologic assessment. J Am Acad Dermatol. 1998;38:89-98. 3. Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer Epidemiol Biomarkers Prev. 2010;19:1557-1568. 4. The International Agency for Research on Cancer Working Group on Artificial Ultraviolet (UV) Light and Skin Cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2007;120:1116-1122. 5. Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst. 2002;94:224-226. 6. US Department of Health and Human Services, Public Health Service, National Toxicology Program. Report on carcinogens, 11th ed: Exposure to sunlamps or sunbeds. Available from: URL: http://ntp.niehs.nih.gov/pubhealth/roc/roc13/index.html. Accessed November 2, 2014. 7. Kwon HT, Mayer JA, Walker KK, Yu H, Lewis EC, Belch GE. Promotion of frequent tanning sessions by indoor tanning facilities: two studies. J Am Acad Dermatol. 2002;46:700-705. 8. Dellavalle RP, Parker ER, Ceronsky N, et al. Youth access laws: in the dark at the tanning parlor? Arch Dermatol. 2003;139:443-448. 9. Geller AC, Colditz G, Oliveria S, et al. Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics. 2002;109:1009-1014. 10. Jaworsky C, Ratz JL, Dijkstra JW. Efficacy of tan accelerators. J Am Acad Dermatol. 1987;16:769-771. 11. Warthan M, Uchida T, Wagner R Jr. UV light tanning as a type of substance-related disorder. Arch Dermatol. 2005;141:963-966. 12. Mosher CE, Danoff-Burg S. Addiction to indoor tanning: relation to anxiety, depression, and substance use. Arch Dermatol. 2010;146:412-417.
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13. Tanning accelerators. Available from: URL: http://www. amazon.com/gp/product/B0012C6PD6/ref=s9_simh_se_p194_ d0_i3?pf_rd_m= ATVPDKIKX0DER&pf_rd_s=auto-no-resultscenter-1&pf_rd_r=0NXAEW2WA7N132ZVVABE&pf_rd_t=301& pf_rd_p=1263465782&pf_rd_i=tanning%20accelerator%20 Ficus%20carica. Accessed November 15, 2014. 14. Russak JE, Rigel DS. Tanning bed hygiene: microbes found on tanning beds present a potential health risk. J Am Acad Dermatol. 2010;62:155-157. 15. Aboul-Enein HY, Kladna A, Kruk I, Lichszteld K, Michalska T. Effect of psoralens on Fenton-like reaction generating reactive oxygen species. Biopolymers. 2003;72:59-68. 16. Stern RS, Lunder EJ. Risk of squamous cell carcinoma and methoxsalen (psoralen) and UV-A radiation (PUVA): a metaanalysis. Arch Dermatol. 1998;134:1582-1585. 17. Kipp C, Lewis EJ, Young AR. Furocoumarin-induced epidermal melanogenesis does not protect against skin photocarcinogenesis in hairless mice. Photochem Photobiol. 1998;67: 126-132. 18. Grekin DA, Epstein JH. Psoralens, UVA (PUVA) and photocarcinogenesis. Photochem Photobiol. 1981;33:957-960. 19. Stern RS; PUVA Follow-up Study. The risk of melanoma in association with long-term exposure to PUVA. J Am Acad Dermatol. 2001;44:755-761. 20. Autier P, Dore JF, Cesarini JP, Boyle P. Should subjects who used psoralen suntan activators be screened for melanoma? Epidemiology and Prevention Subgroup, EORTC Melanoma Cooperative Group EORTC Prevention Research Division. Ann Oncol. 1997;8:435-437. 21. Sforza M, Andjelkov K, Zaccheddu R. Severe burn on 81% of body surface after sun tanning. Ulus Travma Acil Cerrahi Derg. 2013;19:383-384. 22. Bollero D, Stella M, Rivolin A, Cassano P, Risso D, Vanzetti M. Fig leaf tanning lotion and sun-related burns: case reports. Burns. 2001;27:777-779. 23. Micali G, Nasca MR, Musumeci ML. Severe phototoxic reaction secondary to the application of a fig leaves’ decoction used as a tanning agent. Contact Dermatitis. 1995;33:212-213. 24. Piccolo-Lobo MS, Piccolo NS, Piccolo-Daher MT, Cardoso VM. Sun tanning-related burnsea 3-year experience. Burns. 1992; 18:103-106. 25. Cartwright LE, Walter JF. Psoralen-containing sunscreen is tumorigenic in hairless mice. J Am Acad Dermatol. 1983;8: 830-836. 26. Walter JF, Gange RW, Mendelson IR. Psoralen-containing sunscreen induces phototoxicity and epidermal ornithine decarboxylase activity. J Am Acad Dermatol. 1982;6: 1022-1027. 27. Halprin KM, Comerford M, Taylor JR. Skin cancer in patients treated with 8-methoxypsoralen plus longwave ultraviolet radiation. Natl Cancer Inst Monogr. 1984;66:185-189. 28. Yurkow EJ, Laskin JD. Mechanism of action of psoralens: isobologram analysis reveals that ultraviolet light potentiation of psoralen action is not additive but synergistic. Cancer Chemother Pharmacol. 1991;27:315-319. 29. Archier E, Devaux S, Castela E, et al. Carcinogenic risks of psoralen UV-A therapy and narrowband UV-B therapy in chronic plaque psoriasis: a systematic literature review. J Eur Acad Dermatol Venereol. 2012;26(Suppl):22-31.
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everal studies have shown that exposure to ultraviolet (UV) radiation from indoor tanning devices is associated with an increased risk of melanoma and nonmelanoma skin cancer.1-5 Based on these data, the US Department of Health and Human Services and the International Agency for Research on Cancer panel have declared UV radiation from tanning beds and sun lamps as a known carcinogen.6 Despite the growing awareness that it poses a health threat, indoor tanning continues to grow exponentially. In the United States, at least 28 million people tan indoors annually, and of these, 2.3
million are teens.7,8 In a study of more than 10,000 children and adolescents, 35% of teenage girls were found to use tanning devices.9 A common practice among tanning bed users is to apply tanning accelerators. Tanning accelerators are
From the Department of Dermatology, University of Alabama at Birmingham. Supported by National Institutes of Health Grants P30 AR050948 and P30 AR050948 (Dr Elmets) and by funds from the Alabama Dermatological Society. Conflicts of interest: None declared. Accepted for publication October 15, 2014.
Reprint requests: Jennifer L. Herrmann, MD, University of Alabama at Birmingham, 1530 Third Ave S, EFH 414, Birmingham, AL 35294. E-mail: [email protected]. Published online November 13, 2014. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.10.020
Abbreviations used: DSM-IV: SRD: UV:
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition substance-related disorder ultraviolet
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better characterize tanning accelerator users, questopical lotions, creams, or sprays that are designed to tions examined frequency and reasons for accelerdeliver faster, deeper tans after exposure to UV ator use and whether respondents had a favorite radiation. These products are sold in tanning salons, accelerator, used added bronzers (ie, dyes that and over 500 distinct varieties are available at darken the skin), and/or had experienced an adverse Amazon.com. Tanning accelerators attribute their event with an accelerator. The survey also assessed efficacy to tyrosine and plant extracts, such as participants’ views on tanning accelerator efficacy bergamot orange (Citrus bergamia), lime (Citrus and whether accelerators aurantiifolia), and fig-leaf affected their risk of skin (Ficus carica), all of which CAPSULE SUMMARY cancer. contain photo-sensitizing Tanning addiction, which psoralens. Tanning accelerators are topical products is associated with the proVery little is known about designed to deliver faster, deeper tans duction of endorphins stimthe effects of tanning accelafter ultraviolet exposure. ulated by UV radiation, is a erators or those who use Women who tan frequently and have recently described disorder them. There is only 1 report tanning addiction/addiction tendencies that can affect frequent tanexploring the efficacy of are more likely to use accelerators. ners.11 A series of questions tyrosine-based tanning ac10 celerators, and no studies was included to assess poAccelerator use may therefore identify tential tanning addiction/ have examined psoralens or higher-risk indoor tanners. addictive tendencies. Two psoralen-containing botanmeasures frequently used to ical accelerators. This study define a substance-related disorder (SRD) were was designed to reveal more about tanning accelermodified: the 4-item CAGE (cut down, annoyed, ator use. For this purpose, a group of 200 indoor guilty, eye-opener) questionnaire, and the 7 diagtanners were asked to complete a survey designed to nostic criteria for SRD as outlined in the Diagnostic assess the prevalence of tanning accelerator use, the and Statistical Manual of Mental Disorders, Fourth reasons why they are used, and their adverse effects. Edition (DSM-IV) as reported previously.11 Two or more affirmative responses to questions on the METHODS modified CAGE questionnaire and 3 or more affirA total of 200 indoor tanners were recruited mative responses to items on the modified DSM-IV between January and July 2013 to complete a 30questionnaire were considered to indicate a likely question survey for this cross-sectional study. Booths SRD involving indoor tanning. For questions in the with signs reading ‘‘Do you indoor tan?’’ were set up modified DSM-IV-Text Revision with multiple parts, at a university recreational center (55 participants) scores were calculated using the method of Mosher and 2 public beaches (70 and 75 participants each), and Danoff-Burg.12 Tanning addiction was defined neither of which had indoor tanning facilities. as meeting criteria for a SRD by both the CAGE and Individuals who approached the booths were DSM-IV questionnaires, and tanning addiction tenoffered surveys if they had both indoor tanned in dency was defined as meeting criteria for either the the past year and were at least 19 years old (both CAGE or DSM-IV questionnaires but not both. study inclusion criteria). Age of at least 19 years was The primary analyses compared tanners who use chosen to eliminate a parental consent form. accelerators with those who do not with respect to a Participants who completed surveys could volunnumber of variables. For categorical variables such tarily enter a drawing for a $25 gift card. All study as eye color, skin type, tanning frequency, tanning materials and procedures were approved by the addiction (yes/no), and tanning addictive tendencies university’s institutional review board. Participants (yes/no), x 2 contingency tables were used to compare were limited to a single survey. All participants tanning accelerator users with nonusers. For ordinal completed questionnaires anonymously. Ten quesvariables such as age, the Wilcoxon rank sum test was tionnaires were excluded from the data set because applied. Given that tanning frequency is used in the respondents had answered fewer than 95% of the calculation for tanning addiction/addictive tendency, questions. If respondents indicated not using accelCochran-Mantel-Haenszel tests were used to adjust for erators but answered questions pertaining to acceltanning frequency when comparing tanning addicerators, those responses were also omitted from the tion/addictive tendency among accelerator users and analysis. Questions were designed to capture denonusers. All tests were conducted at the 2-sided .05 mographic data of respondents (age, sex, eye color, significance level. Software (SAS, Version 9.3, SAS Fitzpatrick skin type), frequency of indoor tanning, Institute Inc, Cary, NC) was used for calculations. use of spray tans, and use of tanning accelerators. To d
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RESULTS Characteristics of tanning accelerator users Table I summarizes demographics of survey respondents. In all, 200 people responded to the survey; 190 completed more than 95% of the questions and were included in the analysis. Of those, 92.6% were female, 7.3% were male, and their median age was 22 years (range: 19-67). Most had Fitzpatrick skin types II, III, or IV. In all, 89% had blue, green, hazel, or light-medium brown eyes. A total of 49% had spray tanned at least once, and nearly all (96%) respondents had heard of tanning accelerators. Predictors of accelerator use Of survey respondents, 53% reported tanning accelerator use. Predictors of use are summarized in Table II. Women were more likely to have applied accelerators than men. Specifically, 97% of accelerator users were female and 3% were male; nonusers were 88% female and 12% male (P = .01). Age, Fitzpatrick skin type, and eye color did not differ statistically between accelerator users and nonusers. Accelerator users tanned more frequently than nonusers: 32% of users compared with 7% of nonusers reported tanning 60 times or more yearly, whereas 9% of users compared with 34% of users reported tanning less than 5 times yearly (P\.01). Accelerator users (48%) were more likely to have spray tanned than nonusers (22%, P \ .01). However, spray tanning was infrequent in both groups. Of those who had spray tanned, 86% of accelerator users and 82% of nonusers had spray tanned less than 5 times total. Of the accelerator users, 38% reported always using a tanning accelerator, whereas 34%, 21%, and 7% reported using products more than half of the time, less than half of the time, and a few times only, respectively. Tanning accelerator users also had greater tanning addictive tendencies or were considered tanning addicted compared with nonusers (P \ .01). After adjusting for tanning frequency, accelerator users were still more likely to have tanning addictive tendencies (modified CAGE, P = .02; modified DSM-IV, P \ .01) and/or be addicted to tanning (P = .01). Reasons for accelerator use/nonuse The most common reasons for using tanning accelerators were ‘‘to tan faster’’ (83%), ‘‘to tan deeper’’ (74%), and ‘‘to make my tan last longer’’ (59%) (Fig 1). The majority (71%) of accelerator users stated that they preferred using accelerators with added bronzer (tanning dye) because their tans
Table I. Characteristics of survey respondents Respondents, n (%)
Sex Female Male Age, y Skin type* I II III IV V VI Eye color Blue Green Hazel Light-medium brown Dark brown-black Spray tan Ever use No use Accelerator users Yes No
176 (93) 14 (7) 25.4 6 8 SD (mean) 22 (median) 2 31 88 62 7 0
(1) (16) (46) (33) (4) (0)
60 30 34 45 21
(32) (16) (18) (24) (11)
93 (49) 97 (51) 101 (53) 89 (47)
SD, Standard deviation. *Respondent-reported.
appeared faster (60%), deeper (43%), and/or more even in color (19%). Those who disliked added bronzers reported that these dyes made their tans look ‘‘faker’’ (27%) and ‘‘streakier’’ (10%). The most common reported reasons for not using accelerators were tanners were content with their tans without an accelerator (43%), accelerators were too expensive (34%), and tanners had bad experiences with accelerators previously (9%). For those reporting cost as a barrier, their median age was 19 years (range: 19-36), whereas the median age for those not using accelerators was 23 years (range: 19-50). Adverse effects Reported adverse reactions associated with accelerators are summarized in Table III. Of tanning accelerator users, 18% reported sustaining at least 1 slight sun burn after tanning both with and without accelerators. There was no statistically significant difference between reported moderate sun burns when using accelerators (11%) versus not using accelerators (7%). More tanners developed acne (15%) and rashes (7%) when using accelerators than when not using these products (2% and 1%, respectively). Having any problem with a tanning accelerator prevented its future use 15% of the time. Of tanners using accelerators, 62%, 33%, and 5%
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Table II. Factors associated with tanning accelerator use Accelerator users, % [95% CI]
Annual tanning frequency \5 5-14 15-29 30-44 45-59 $ 60 Spray tan Ever use No use Addictive tendency (CAGE) Yes No Addictive tendency (DSM-IV) Yes No Tanning addiction Yes No
8.91 7.92 8.91 21.78 20.79 31.68
[3.36-14.46] [2.65-13.19] [3.36-14.46] [13.73-29.83] [12.88-28.70] [22.61-40.75]
Nonusers, % [95% CI]
33.71 16.85 16.85 17.98 7.87 6.74
[23.89-43.63] [9.24-24.46] [9.24-24.46] [13.85-22.11] [2.28-13.46] [1.53-11.95]
x 2 P value
Adjusted for tanning frequency P value
\.01
.01 47.62 [45.09-50.15] 52.38 [42.64-62.12]
22.22 [13.58-30.86] 77.78 [69.14-86.52]
46.15 [34.43-55.87] 53.85 [44.13-63.57]
13.13 [6.07-20.19] 86.87 [79.85-93.89]
50.48 [40.73-60.23] 49.42 [49.67-59.24]
7.07 [2.28-13.46] 92.93 [87.60-98.26]
32.38 [23.25-41.41] 67.62 [58.49-76.75]
4.04 [0-8.13] 95.96 [91.87-100]
\.01 \.01 \.01
.020
\.01
.011
Tanning addiction was defined as meeting criteria for a substance-related disorder by both the CAGE and DSM-IV questionnaires, and tanning addiction tendency was defined as meeting criteria for either the CAGE or DSM-IV questionnaires but not both. CAGE, Cut down, annoyed, guilty, eye-opener; CI, confidence interval for proportion; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Fig 1. Accelerator user responses in percentages. Reasons for using tanning accelerators. The black bars represent the upper and lower bounds of 95% confidence intervals.
believed accelerators did not affect their risk for developing skin cancer, increased their risk for developing skin cancer, and decreased their risk for skin cancer, respectively.
DISCUSSION Our results demonstrate that over half of tanning bed users apply tanning accelerators. Their use is more common in women and in people who spray
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Table III. Adverse reactions associated with accelerator use With accelerator, Without accelerator, no. of users [95% CI] no. of users [95% CI]
Slight burn Moderate burn Acne Rash
18 [0.34-0.66] 11 [0.39-0.84]
18 [0.34-0.66] 7 [0.41-0.61]
15 [0.73-1.00] 7 [0.65-1.0]
2 [0.00-0.27] 1 [0.00-.36]
x2 P value
1 .117 \.01 \.01
CI, Confidence interval for proportion.
tan, tan frequently, and have tanning addictive tendencies. Although spray tan use was high among accelerator users, the overall frequency of spray tanning was very low. Frequent tanners have higher exposure to in-salon spray tanning and therefore may have been more likely to have tried spray tanning once or twice. The fact that accelerator users tan more frequently and/or are addicted to tanning underscores the fact that this highest risk tanning group is willing to do more to boost their tans, even though the longer-term effects of accelerators are unknown. Some tanning accelerator manufacturers advertise their products as promoting skin health with claims such as ‘‘a blend of important nutrients.for a darker tan and healthier skin,’’13 and a minority of accelerators include antioxidants, such as vitamin E and C. However, skin youthfulness and skin protection were among the least cited reasons for using accelerators. Only 5% of respondents believed that tanning accelerator use would decrease their risk of developing skin cancer. In contrast, 33% believed accelerators would increase their risk for skin cancer, even though they continued to use these products. Although this subset of respondents was not more likely to be addicted to tanning, continuing to engage in a perceived harmful action is characteristic of a SRD. Problems associated with tanning accelerators served as a minor deterrent for their continued use. Because our questionnaire asked about acne generically, it is not known if reported acne represented facial acne or chest/back folliculitis. Previous studies have reported bacterial growth from directly swabbed commercial tanning beds,14 which may have been relevant to our respondents. The high oil content (coconut, palm, olive, seed oils) of accelerators may have also contributed to respondents’ acne. Rashes were also more frequent in accelerator users. Potential causes include photo-related eruptions or contact dermatitis. Ingredient lists for tanning accelerators commonly reveal more than 30 items, including emulsifiers, stabilizers, preservatives, and dyes, which can be contact allergens.
Some accelerators contain bergamot orange (Citrus bergamia), lime (Citrus aurantiifolia), and fig-leaf (Ficus carica) extract. The augmentation in tanning can be attributed to psoralens found in these products. Exposure to specific wavelengths of UVA radiation enable psoralens to absorb energy and attain high-energy states. These activated molecules form photoaddition products with DNA pyrimidine bases via DNA interstrand cross-linking, resulting in epidermal cell nucleic acid damage. Activated psoralens can also produce oxygen, superoxide anion, and hydroxy radicals, which can cause cellular membrane damage. Ultimately, both mechanisms result in arachidonic acid pathway activation, cellular dysfunction, inflammation, and tissue destruction.15,16 It is therefore plausible that tanning accelerators containing psoralens place indoor tanners at greater risk for cutaneous damage than tanning alone. Numerous studies have linked the combination of psoralens and UVA radiatione the main type of radiation emitted from tanning devicesewith phototoxicity, photocarcinogenesis, and increased rates of squamous cell carcinoma and melanoma.17-20 Although our cohort did not report a higher incidence of acute skin burns when using accelerators compared with nonuse, reports in the literature have exemplified the potential danger associated with unsupervised topical psoralen use before UV radiation.21-24 Tanners using fig-leaf lotions containing psoralens have experienced severe skin burns involving up to 81% of their body surface area and requiring intensive care unit hospitalizations.21 Psoralens, which were incorporated into some sunscreens several decades ago either as bergamot oil or as purified 5-methoxypsoralen for the purpose of tan enhancement, have since been banned from these products because multiple reports demonstrated that psoralen-containing sunscreen induced phototoxicity, epidermal ornithine decarboxylase activity, and tumorigenesis in hairless mice.25-28 Multiple clinical studies demonstrating increased risk of nonmelanoma skin cancer in patients undergoing prolonged psoralen plus UVA treatments for psoriasis have confirmed this carcinogenic effect.29 Limitations of this study included its relatively small sample size and population limited to those aged at least 19 years on a college campus and at 2 public beaches, which may preclude generalizability. Tanners also voluntarily chose to complete surveys, which may have introduced selection bias. Self-reporting may have resulted in inaccuracies, and definitions of tanning accelerators may have been interpreted differently among tanners. In addition, individual tanning accelerators were not examined
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for their content and the amount of tanning accelerator used by tanners was not quantified. In conclusion, we sought to better characterize the population using tanning accelerators, a group of largely uninvestigated products used by indoor tanners, to better understand the motivations behind their use and to identify any associated adverse effects. Accelerator users are high-risk tanners who tan more frequently and who are more likely to be addicted to tanning. Additional studies should be aimed at scrutinizing individual products more closely and more thoroughly investigating potential associated problems, including longer-term effects. We would like to thank Hillary delaRosa and Thy Huynh for their help with questionnaires. REFERENCES 1. Whitmore SE, Morison WL, Potten CS, Chadwick C. Tanning salon exposure and molecular alterations. J Am Acad Dermatol. 2001;44:775-780. 2. Swerdlow AJ, Weinstock MA. Do tanning lamps cause melanoma? An epidemiologic assessment. J Am Acad Dermatol. 1998;38:89-98. 3. Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer Epidemiol Biomarkers Prev. 2010;19:1557-1568. 4. The International Agency for Research on Cancer Working Group on Artificial Ultraviolet (UV) Light and Skin Cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2007;120:1116-1122. 5. Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst. 2002;94:224-226. 6. US Department of Health and Human Services, Public Health Service, National Toxicology Program. Report on carcinogens, 11th ed: Exposure to sunlamps or sunbeds. Available from: URL: http://ntp.niehs.nih.gov/pubhealth/roc/roc13/index.html. Accessed November 2, 2014. 7. Kwon HT, Mayer JA, Walker KK, Yu H, Lewis EC, Belch GE. Promotion of frequent tanning sessions by indoor tanning facilities: two studies. J Am Acad Dermatol. 2002;46:700-705. 8. Dellavalle RP, Parker ER, Ceronsky N, et al. Youth access laws: in the dark at the tanning parlor? Arch Dermatol. 2003;139:443-448. 9. Geller AC, Colditz G, Oliveria S, et al. Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics. 2002;109:1009-1014. 10. Jaworsky C, Ratz JL, Dijkstra JW. Efficacy of tan accelerators. J Am Acad Dermatol. 1987;16:769-771. 11. Warthan M, Uchida T, Wagner R Jr. UV light tanning as a type of substance-related disorder. Arch Dermatol. 2005;141:963-966. 12. Mosher CE, Danoff-Burg S. Addiction to indoor tanning: relation to anxiety, depression, and substance use. Arch Dermatol. 2010;146:412-417.
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