Just when we thought that this year’s attacks on the indoor tanning industry were over (at least for the summer), I recently came across another study that was released:
“Erythema and ultraviolet indoor tanning: findings from a diary” – from the University of Medicine and Dentistry of New Jersey
It was certainly an intriguing title, and I began my review of it. The basis for the research was six bi-monthly diary surveys from 198 college coeds split evenly between a Northeastern and a Southeastern university. The conclusion? One in five UV sessions resulted in sunburn and these findings contradict the tanning industry’s claim that the risk of sunburn from indoor tanning is minimal.
I immediately contacted their media relations person and asked her a series of questions. She told me that the answers to these questions could be found within the study, which is the same response I received when I questioned the recent Mayo Clinic study a few months ago.
So, let’s take a look at the flaws. Here are the questions that I originally submitted and then, what I uncovered after reviewing the study.
1. Although the FDA regulates the indoor tanning industry with 21CFR1040.20, not all states have regulations/restrictions on sunbed use and not all require mandatory operator training. New Jersey, Pennsylvania, and Tennessee (current states for the researchers) do not. What states were involved in this study?
My findings: No states were given. The study indicated participants were from a Northeastern and Southeastern university.
2. The tanning equipment warning label required by the FDA’s 21 CFR 1040.20 states that fair-skinned individuals (Skin Type I on the Fitzpatrick Scale) are not recommended to use sunbeds/sunlamps. Professional tanning salons do not allow people of Skin Type I to use their UV equipment. What percentage of the study subjects was Skin Type I/fair-skinned?
My findings: Skin-typing in this study was not determined by a trained, professional tanning salon staff member or by a medical professional. Participants were asked to determine their own skin type, by stating whether their skin would burn or tan, “if you were to lie in the sun for one hour unprotected in the early summer when you had NO tan”.
Although the study was applied using the Fitzpatrick Skin Type Scale, this specific question is not part of the Fitzpatrick Scale (skincancer.org/prevention/are-you-at-risk/fitzpatrick-skin-quiz.) Further, allowing participants to quantify themselves in this manner clearly could have resulted in skin type misclassification and explains why there were so few Skin Type I participants in the study. It is a significant reason why many states mandate that salon professionals use the Fitzpatrick Scale and disallow any form of “customer performed” skin-typing. Allowing self-skin-typing is a confounding factor not admitted by the researchers.
3. It was noted that 39 percent of the study subjects did not use eye protection during their sessions. Of the 39 percent, how many were given FDA-compliant eye protection, were explained the need for protective eyewear and then made an individual decision not to use the protective eyewear?
My findings: The session-level data states that goggles were used in 61.4 percent of the sessions. Many states, as well as the FDA, mandate the use of FDA compliant eyewear during indoor tanning sessions. The study omitted whether or not a salon professional made the participant aware of the possibility of eye damage from UV exposure when using a sunbed without compliant eyewear, or if the participant signed a disclaimer that they were made aware and chose not to use the eyewear. The study did not admit whether or not these critical variables were present.
4. Certain medications increase the likelihood of reddening as a result of a UV exposure, indoors or outdoors. Of the study population, how many were using medications?
My findings: The study omitted any reference or possibility of the participants experiencing erythema as the result of UV exposure combined with a photosensitizing medication; another confounding factor the study overlooked.
5. The study noted that “… the duration of the sessions however, was not significantly associated with sunburn risk”. The result of a UV exposure is affected by the combination of the intensity of the source and the duration of the exposure. Please explain how a UV session under the FDA maximum allowed time limit for a particular sunbed (i.e.; a 5-minute session on a 20-minute sunbed) was determined to have no significant effect on sunburn risk.
My findings: The study indicated that as the participants increased session time and increased their number of sessions, the likelihood of erythema (sunburn) was reduced. This results from building a base tan that offers a form of photoprotection (although typically only akin to an SPF of 2-3). This possibility/probability was not addressed in the study.
6. The effect of UV exposure on the skin can be intensified when outdoor UV exposures are followed by indoor UV exposures. How did the researchers control to exclude all outdoor exposures?
My findings: The study claimed that it was done in “winter months” when erythema due to outdoor exposure was unlikely. Although lessened in intensity, it is still possible to achieve erythema during the winter in a Southeastern locale due to proximity to the equator, as well as a Northeastern one. Additionally, activities such as snow skiing increase intensity of UV due to the higher altitude and reflectivity of snow.
7. The study concluded that these “findings contradict the tanning industry’s claim that the risk of sunburn is minimal with indoor tanning”.
My findings: Interestingly, each of the three assessment questions was slanted to ask only about damage (likely to get burned, leave my skin red, leave my skin painful). Clearly sufficient confounding factors have been indicated here to suggest more balanced studies should be undertaken.
I have addressed my comments to the lead study researcher for a response, but as of this writing, a response had not been received.
