An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology
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42 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 physician opinions on tanning, including legislation, non-UV tanning, counseling practices, and pediatric wellbeing. METHODS A 10-question anonymous survey evaluating physicians referrals by and attitudes toward artificial UV exposure was developed and exempted from International Review Board (IRB) review by the Harvard TH Chan School of Public Health IRB Committee. Data collection was completed from 2012 to 2013, with statistical analysis from 2015 to 2016. Three regional dermatologic organizations participated in the survey: Intermountain Dermatology Society (IDS; members primarily from Idaho, Utah, and neighboring states), Colorado Dermatology Society (CDS, members primarily from Colorado and neighboring states), and Pennsylvania Academy of Dermatology (PAD, members primarily from Pennsylvania and neighboring states). Member dermatologists in attendance at these meetings were offered a paper survey. The surveys were collected in anonymous drop boxes. The survey queried members on their recommendation of UV tanning devices at a tanning salon and medical phototherapy devices to adults and minors within the past year. Each recommendation was stratified by either cosmetic or medical conditions. The survey included recommendations for non-UV tanning alternatives, opinions on legislation prohibiting minors from using commercial UV tanning, how often UV tanning device usage was included in the social history of patients, which patients receive counseling regarding UV exposure, what counseling is provided, and level of concern for twelve common issues impacting pediatric patients' wellbeing. (Survey included as Appendix 1) Univariate significance was tested using the Student's t-test or the χ 2 test, as appropriate. Statistical significance was considered using a two-sided p<0.05. All analyses were performed using SPSS 22 (IBM, Armonk, New York). Where applicable, standard error was calculated. The patient population represented in this survey was estimated by multiplying the average number of patients seen per week by 52 weeks, then multiplied by the number of responding providers (average patients per week x 52 weeks x n providers). RESULTS Referrals to tanning salons and phototherapy. In this study, zero out of the 152 physicians surveyed recommended tanning salons for cosmetic reasons to any patient, adult or pediatric. Phototherapy was recommended to 0.00025 percent of adult patients (2/809,369) by 1.3 percent of physicians (2/152) for non- medical reasons, and was not recommended to any children for non-medical reasons. Regarding tanning salons, the 152 physicians referred approximately 0.051 percent of adults (417/809,369) and 0.005 percent of pediatric patients (41/809,369) for medical treatment, or about three patients (2.74 adults and 0.27 minors) per provider per year. Fifty percent of the responding physicians (76/152) reported having referred at least one adult within the last year; 9.9 percent (15/152) reported having referred at least one pediatric patient. Regarding phototherapy, an estimated 3,147 (0.389%) adult and 353 (0.044%) pediatric patients were referred for medical treatment, with 83.6 percent (127/152) and 43.4 percent (66/152) respondents referring at least one adult or pediatric patient, respectively, within in the past year. Specific conditions recommended for UV light treatment included psoriasis, atopic dermatitis, vitiligo, pruritus, cutaneous T-cell lymphoma, lichen planus, pityriasis rosea, graft versus host disease, alopecia, granuloma annulare, contact dermatitis, urticaria, prurigo nodularis, polymorphous light eruption, lipodermatosclerosis, lymphomatoid papulosis, pityriasis lichenoides chronica, folliculitis, actinodermatitis, necrobiosis lipoidica diabeticorum, and tinea versicolor (Table I). Providers who recommended medical treatment in tanning beds were asked to provide the specific regimens they instruct patients to follow. Of these 76 physicians, 41 percent (31/76) reported a complete regimen with instructions for 1) number of sessions per week, 2) duration of each session, and 3) treatment duration. An additional 20 percent (15/76) reported incomplete regimens. Of the 31 complete regimens reported, 90 percent (28/31) were unique from one another. For physicians referring minor patients to tanning salons for medical treatment, 47 percent (7/15) provided complete regimens and an additional 13 percent (2/15) provided incomplete regimens. Of the seven complete regimens, 86 percent (6/7) were unique from one another (Figure 1). Non-UV tanning. Of the 152 responders, 89.5 percent (136/152) and 65.1 percent (99/152) reported recommending non-UV tanning methods, such as spray tanning or self-tanners, as alternatives to UV tanning devices to adult and minor patients, respectively, within the last year. Tanning legislation. Every provider surveyed expressed support for legislation prohibiting minors under age 18 years from using UV tanning devices at commercial tanning salons. Patient counseling. Providers reported actively discussing the use of UV tanning devices with a variety of patients, including minors and their parents/guardians and patients with skin cancer history. For pediatric patients, female patients received counseling more frequently than male patients (82% vs. 37%, p<0.01). Similar discrepancies were seen by patient sex at all age groups (p<0.01). Female providers were significantly less likely to discuss tanning bed use with male patients of all ages compared to their male provider counterparts (Table 2). When counseling patients, 99.3 percent (150/151) opposed cosmetic tanning (92.7 percent strongly discouraged it and 6.6 percent moderately discouraged the practice). Concern for pediatric patients' wellbeing. Physicians rated their level of concern for the wellbeing of pediatric patients related to a variety of health issues using a 1 to 3 scale (1=none, 2=moderate, 3=high) (Figure 2). The highest average levels of concern were for smoking (2.92±0.32), illicit drug use (2.87±0.38), UV tanning (2.77±0.44), texting while driving (2.74±0.54), alcohol (2.68±0.47), and obesity (2.66±0.50). Practice setting. A trend was noted for increased patient referrals to tanning beds for medical reasons from providers located in rural areas compared to providers located in urban areas (64% vs. 35%, respectively, p=0.06). An inverse trend was noted between rural and urban providers recommending adult phototherapy (62% vs. 82%, respectively, p=0.09). Providers with access to an in-office phototherapy unit were significantly more likely to recommend phototherapy than providers without an in-office unit for both adults (92% vs. 69%, respectively, p<0.001) and minors (57% vs. 26%, respectively, p<0.001). However, physicians were no less likely to recommend tanning beds for medical reasons if they had