An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology
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41 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2018 • Volume 11 • Number 2 O R I G I N A L R E S E A R C H U Ultraviolet (UV) radiation has been strongly associated with both melanoma and non-melanoma skin cancer, as well as a variety of other dermatological conditions. 1,2 Despite these dangers, potential benefits exist for photoresponsive skin conditions. 3 Specific beneficial UV wavelengths have been filtered into medical phototherapy devices with narrowed emission spectrums and overall UV exposure has been reduced through standardized protocols and treatment localization. 4–9 In this article, "phototherapy" refers to in-office, physician-directed UV radiation, while any reference to "tanning" refers to broad-spectrum UV radiation via commercial tanning devices. There is a growing global public health movement to limit UV radiation as a risk factor for skin cancer. Recently, the medical and public health communities have improved education regarding the harmful effects of UV radiation and championed public policy efforts to restrict UV tanning access to minors. Tanning industry lobbyists, officials, and their affiliated publications have argued that these activities are the result of "the cosmetic dermatology industry attacking indoor tanning for strictly financial gain." 10 They describe dermatologic diseases as "purely cosmetic" and allege that physicians are either dishonest about the dangers of tanning bed use and "violating their Hippocratic oath" by harming patients for cosmetic benefits. 10–12 Through social media and industry publications, commercial tanning leaders refute peer-reviewed literature and question the integrity of medical and research institutions. 13–15 The industry also provides misleading information to consumers, while simultaneously dismissing the growing body of research substantiating the dangers directly linked to UV exposure. 16–26 Referencing a study by Feldman et al 27 that reviewed the declining usage of phototherapy in the treatment of psoriasis, the tanning industry claims that "dermatology's anger for the loss of billions of dollars of phototherapy treatment" is the motivation behind legislation to restrict underage tanning. 10 Rather than acknowledge the concurrent advances in the biologic treatment of psoriasis and changes in insurance coverage that have led to increased cost and decreased availability of phototherapy, the tanning industry seeks to equate tanning beds with in-office phototherapy devices, claiming that many patients are treating diseases in commercial tanning beds at the behest of their dermatologists or other physicians. 10,11,27,28 This study was designed to clarify physician referrals for exposure to UV light. For physicians referring to tanning salons, we sought the reasons for referral, as well as recommended treatment schedules. Additionally, we gathered A B S T R A C T BACKGROUND: The commercial tanning industry has opposed efforts to educate the public on the risks of tanning as well as attempts to restrict minors' access to tanning services. Despite a paucity of supporting literature, statements from the tanning industry claiming that dermatologists routinely use in-office phototherapy for cosmetic treatments and refer patients to tanning salons have successfully derailed and defeated legislation in many states. OBJECTIVE: This study aims to evaluate dermatologist referrals for ultraviolet radiation for cosmetic and medical purposes via tanning beds or phototherapy, as well as their opinions on tanning, legislation, and ultraviolet radiation counseling practices. DESIGN: The study was conducted using a 10-question anonymous survey. SETTING: The participants were surveyed during meetings of three regional dermatologic societies. PARTICIPANTS: One hundred and fifty-two dermatologists attending society meetings participated in the study. MEASURES: The authors measured physician referrals, opinions, and recommendations regarding ultraviolet exposure. RESULTS: Zero physicians (0/152) recommended tanning salons for cosmetic reasons. These 152 dermatologists referred 458 (417 adult, 41 pediatric) out of an estimated 809,369 patients (0.057%) to tanning salons for medical treatment. Of these physicians, 76 out of 152 and 15 out of 152 reported referring at least one adult or one pediatric patient, respectively, within the last year. All respondents supported ultraviolet tanning legislation and discouraged cosmetic tanning. CONCLUSION: These findings directly contradict the assertion that dermatologists use ultraviolet radiation for cosmetic purposes or routinely refer patients to tanning salons. This study underscores the complex nature of ultraviolet radiation, as dermatologists infrequently utilize ultraviolet radiation for medical purposes and unanimously support restrictive legislation. In addition, these dermatologists counsel against cosmetic tanning and list tanning bed use among their highest concerns with regard to the health of pediatric patients. KEY WORDS: Dermatologist referrals, legislation, pediatric dermatology, phototherapy, public health policy, tanning, tanning regimen, tanning salon, tanning bed, ultraviolet radiation, UV, UV counseling practices, UV exposure Examining Dermatologist Use and Opinions of Ultraviolet Radiation for Cosmetic and Medical Purposes by BLAKE P. SAMPSON, MD; AARON M. SECREST, MD, PhD; CHRISTOPHER B. HANSEN, MD; and ALAN C. GELLER, MPH, RN Dr. Sampson is with Oregon Health & Sciences University in Portland, Oregon. Drs. Secrest and Hansen are with the Department of Dermatology at the University of Utah in Salt Lake City, Utah. Mr. Geller is with the Harvard T.H. Chan School Of Public Health in Boston, Massachusetts. J Clin Aesthet Dermatol. 2018;11(2):41–46 FUNDING: No funding was provided for this study. DISCLOSURES: The authors have no conflicts of interest to relevant to the content of this article. CORRESPONDENCE: Blake P. Sampson, MD; Email: Blake.Sampson@hsc.utah.edu