Sunless tanning
`
`Jennifer M. Fu, BA, Stephen W. Dusza, MPH, and Allan C. Halpern, MD, MS
`New York, New York
`
`Background: Americans continue to desire and pursue the tan. Recent data indicate continued high
`incidence of sunburn and ultraviolet tanning despite public health skin cancer prevention messages. The
`rising popularity of recently available sunless tanning booths prompted this review.
`
`Objective: To present an overview of the history of sunless tanning and the sunless tanning booth industry,
`and to describe the current availability and safety practices of sunless tanning booth providers.
`
`Methods: The current literature and internet resources were reviewed. Phone surveys of 300 businesses
`were conducted in July, 2003.
`
`Results: Sunless tanning services were offered by 43% (39/90) of businesses with tanning services of any
`type. Sunless tanning booths were the most commonly offered sunless tanning application modality. The
`safety precautions most commonly offered to sunless tanning customers were recommendations to close
`their eyes (100%, 17/17), hold their breath (77%, 13/17), and utilize post-sunless tanning sun protection
`(82%, 14/17).
`
`Conclusion: Uniform guidelines should be developed to address safety issues associated with sunless
`tanning booth use. Future investigations are warranted to assess both the medical and behavioral implica-
`tions of perpetuating the aesthetic appeal of the tan. (J Am Acad Dermatol 2004;50:706-13.)
`
`D espite almost two decades of public educa-
`
`tion about skin cancer, the dangers of sun
`exposure, and the importance of sun pro-
`tection, Americans continue to embrace a standard
`of beauty that celebrates the tanned look. According
`to a recent survey1 by the American Academy of
`Dermatology (AAD), more Americans now recog-
`nize that overexposure to ultraviolet (UV) radiation
`is unhealthy. Yet many, particularly those 25 years of
`age or younger, fail to implement this knowledge
`when it comes to modifying sun-seeking behavior.
`Although the number of sunburns incurred by
`older individuals has decreased since the AAD last
`surveyed the public in 1996, individuals under the
`
`From the Memorial Sloan-Kettering Cancer Center, Dermatology
`Service, Department of Medicine.
`Funding sources: None.
`Conflicts of interest: None identified.
`Accepted for publication December 1, 2003.
`Reprints not available from authors.
`Correspondence to: Allan C. Halpern, MD, MS, Dermatology
`Service, Memorial Sloan-Kettering Cancer Center, 160 East 53rd
`St., New York, NY 10022. E-mail: halperna@mskcc.org.
`Published online March 12, 2004.
`0190-9622/$30.00
`© 2004 by the American Academy of Dermatology, Inc.
`doi:10.1016/j.jaad.2003.12.006
`
`706
`
`age of 25 are spending more time outdoors, using
`less sunscreen, and accruing more sunburns.1 Re-
`cent studies have demonstrated significant rates of
`tanning bed use among American youth.2,3 Nearly
`10% of respondents to a large national survey on the
`sun protection attitudes and practices of 12- to 18-
`year-olds reported tanning bed use within the pre-
`vious year.2 The continued susceptibility of young
`Americans to the allure of the tan is concerning
`given that childhood sun exposure has been impli-
`cated in the development of both moles and malig-
`nant melanoma,4 and that childhood behaviors tend
`to persist in adulthood.
`Increased awareness of the medical and cosmetic
`effects of UV radiation coupled with improved sun-
`less tanning products are promoting the rapid
`growth of a sunless tanning industry. A novel tech-
`nology recently introduced by this industry is the
`sunless tanning booth which employs misters to
`apply an even coat of sunless tanning solution to the
`consumer’s bare skin. The technique is promoted as
`the means to a perfect tan and healthy skin. Never
`before has a cosmetically acceptable, full-body, sun-
`less tan been so accessible and so affordable for the
`masses.
`We review the literature of sunless tanning prod-
`
`1
`
`

`

`J AM ACAD DERMATOL
`VOLUME 50, NUMBER 5
`
`Fu, Dusza, and Halpern 707
`
`Fig 1. Pattern of participation in phone-based survey. Forty-eight businesses were considered
`ineligible and excluded because: 1) the phone was not in service (n⫽27); 2) the business was
`not a tanning salon, spa, or gym (n⫽11); 3) there were multiple numbers for a facility that we
`had already surveyed (n-9); and 4) the facility was not opening until August, 2003 (n⫽1).
`Sixty-eight businesses did not respond or refused to take part in the survey.
`
`ucts and report on a survey of the current availability
`and safety practices of sunless tanning booth pro-
`viders in 3 major US cities.
`
`METHODS
`Literature review
`A review of the current literature (MEDLINE) and
`Internet resources on sunless tanning and sunless
`tanning booths was conducted using PubMed and
`Google search engines. Primary searches were per-
`formed using keywords such as “sunless tanning,”
`“sunless tanning booth,” and “suntanning industry.”
`Secondary searches were conducted to locate refer-
`enced sources. Representatives from the major sun-
`less tanning booth manufacturers, tanning industry
`organizations, the Food and Drug Administration,
`and 3 state agencies involved in the regulation of UV
`tanning, were contacted via phone and e-mail. The
`3 state agencies contacted—New York, Illinois, and
`California—were chosen to correspond to the 3 cit-
`ies selected for the survey component of this study.
`
`Survey
`A telephone-based survey was conducted with 20
`questions relating to description of the facility, the
`availability and utilization of sunless tanning ser-
`vices (with focus on sunless tanning booths), safety
`issues associated with sunless tanning booth use,
`and the availability and utilization of UV tanning
`equipment at each facility. Utilizing Verizon Super
`Pages.com telephone directories for 2003, a compre-
`hensive list of businesses categorized as Tanning
`Salons (tanning salons), Beauty & Day Spas (spas),
`and Health Clubs & Gymnasiums (gyms) was gen-
`erated for three cities: New York City (New York),
`Chicago, Illinois (Chicago), and Los Angeles/Beverly
`Hills, California (Los Angeles). Eight hundred twen-
`ty-eight businesses were identified. A stratified ran-
`dom sample was selected by city and type of facility.
`The final sample included 300 businesses (30 tan-
`ning salons, 30 spas, and 40 gyms for each city) (Fig
`1). If a company had multiple facilities in a given
`
`2
`
`

`

`708 Fu, Dusza, and Halpern
`
`J AM ACAD DERMATOL
`MAY 2004
`
`city, only one was made eligible for the sample. This
`was done because some businesses had one central-
`ized phone number to make reservations at any one
`of their multiple facilities in a given city. The phone
`survey questions were pilot tested on a sample of 10
`facilities that were not selected in the final sample.
`All phone surveys were completed in one week in
`July 2003. All facilities were contacted once during
`normal business hours, unless an alternative survey
`time was set up during the initial call.
`Descriptive frequencies and percentages were
`calculated to characterize survey responses. Stata
`version 8 was used for all analyses.
`
`OVERVIEW OF TANNING PRODUCTS
`Tanning products have become increasingly pop-
`ular over the years, appealing to consumers at both
`ends of the spectrum—those seeking to avoid UV
`exposure as well as those desiring enhancement of
`their UV tan. Driven by the public’s insatiable quest
`for sun-kissed skin, sunless tanners, bronzers, and
`tanning preparations have increased exponentially
`in number and variety.
`Sunless tanners are topical products containing
`dihydroxyacetone (DHA), the only color additive
`currently approved by the Food and Drug Adminis-
`tration (FDA) for use as a tanning agent.5 Bronzers
`are water-soluble dyes, often formulated as tinted
`moisturizers or brush-on powders, which work by
`temporarily staining the skin. Unlike other tanning
`products, bronzers create a tanned look that can
`easily be removed with soap and water. Tanning
`preparations are topical products that contain low
`sun protection factor (SPF) sunscreens and are de-
`signed to prolong the consumer’s ability to endure
`UV exposure without burning.
`In the 1980s, tyrosine-containing pills and topical
`applications were marketed heavily as tan accelera-
`tors, based on their purported ability to provide
`increased substrate for and enhance the body’s nat-
`ural production of melanin. After a number of stud-
`ies6,7 called these claims into question, the FDA
`issued warnings against the production of tan accel-
`erators.8 Tanning pills typically contain canthaxan-
`thin (␤-carotene-4,4⬘-dione), a naturally occurring
`carotenoid found in plants, mushrooms, bacteria,
`crustaceans, sea trout, algae, and bird feathers.9 Ac-
`cumulation of canthaxanthin in the epidermis and
`subcutaneous fat turns the skin orange-brown. Al-
`though canthaxanthin is FDA-approved for use in
`small amounts as a color additive in food, it is not
`approved for use as a tanning agent.10 Ingestion in
`large quantities has been associated with retinopa-
`thy, urticaria, hepatitis, and aplastic anemia.11,12,13
`Despite FDA regulations banning their sale in the
`
`United States, both tan accelerators and tanning pills
`can be readily obtained through unapproved ven-
`dors.
`Tan promoters are topical products that contain
`5-methoxypsoralen (5-MOP, bergapten), a photo-
`sensitizing furocoumarin found in oil of bergamot.14
`5-MOP-containing products induce melanogenesis
`upon exposure to ultraviolet A (UVA) radiation and
`were initially marketed as sunscreens capable of
`preventing ultraviolet B (UVB)–induced radiation
`damage. They have since been shown to contain
`psoralen concentrations sufficient to cause cutane-
`ous phototoxicity and photocarcinogenicity,14,15,16
`are not FDA-approved, and are no longer commer-
`cially available.
`
`Dihydroxyacetone
`DHA, the 3-carbon sugar moiety that forms the
`active ingredient in sunless tanning preparations,
`was first introduced as a therapeutic in the 1920s, as
`a proposed substitute for glucose in the treatment of
`diabetics.17 In the 1950s, researchers at the Univer-
`sity of Cincinnati Children’s Hospital began studying
`its use as a tolerance test for glycogen storage dis-
`ease.18 Characteristic pigmentation changes were
`observed in children who inadvertently regurgitated
`and exposed their skin to test material, leading to the
`identification of DHA as a tanning agent.
`It is now known that DHA reacts preferentially
`with basic amino acids found in abundance in the
`keratinized stratum corneum to form brown-black
`compounds called melanoidins.19,20 This interaction,
`also known as the Maillard or browning reaction, is
`a common occurrence between carbohydrates and
`amines and is the cause of browning of sugar-con-
`taining foods kept in storage. When applied topi-
`cally, DHA works at the level of the stratum cor-
`neum, as evidenced by its inability to induce tanning
`in areas that lack a stratum corneum (eg, mucous
`membranes), and its deeper tanning of areas with a
`thickened stratum corneum (eg, palms, soles, el-
`bows, knees, ankles, and hyperkeratotic lesions).17
`Although a toxicity study performed shortly after
`the discovery of DHA’s tanning properties revealed
`no adverse effects in adults administered oral DHA
`for 2 to 3 weeks,21 more recent safety studies are
`lacking. At this time, FDA approval of the use of
`DHA as a color additive in sunless tanning prepara-
`tions is restricted to external application, not includ-
`ing the lips or any body surface covered by mu-
`cous membranes.5,22,23 DHA-containing sunless
`tanning products are not currently approved for
`use in the area of the eye—prior modalities of
`
`3
`
`

`

`J AM ACAD DERMATOL
`VOLUME 50, NUMBER 5
`
`Fu, Dusza, and Halpern 709
`
`application having not involved exposure of that
`region.24*
`Sunless tanning preparations typically contain 3%
`to 5% DHA, in combination with any number of
`additional
`ingredients,
`including
`sunscreens,
`bronzers, vitamins, botanical extracts, antioxidants,
`and alpha-hydroxy acids.17 Individuals using prepa-
`rations with added UV filters must be educated to
`expect loss of UV protection on a time-scale of
`hours, despite persistence of their DHA-induced tan
`for days after application. Consumers using sunless
`tanning preparations without added UV filters
`should be cautioned that DHA and its melanoidin
`by-products afford only minimal UV protection—
`DHA alone provides an SPF of 3 or 4; melanoidins
`absorb predominantly in the visible spectrum with
`some overlap into the UVA.25 Of note, according to
`the FDA’s final monograph on sunscreen drug prod-
`ucts for over-the-counter human use,8 sunless tan-
`ning products without sunscreen ingredients must
`include a warning informing the consumer that the
`product does not provide protection against UV ra-
`diation or sunburn.
`Cosmetic results with DHA may be enhanced by
`exfoliation of the skin prior to application. For more
`natural coloration, the palms, soles, nails, and hair
`should be protected from exposure, and less DHA
`applied to areas prone to uneven coloration, such as
`the elbows, knees, and ankles. Color change should
`be apparent within 1 hour, with maximal darkening
`between 8 and 24 hours.17 Most individuals report
`the disappearance of color over 5 to 7 days.
`At present, several modalities exist for the appli-
`cation of sunless tanning preparations. DHA-con-
`taining products meant for self-application can be
`found in most drug and cosmetic stores. Consumers
`willing to spend more for professional results can
`visit upscale salons and spas that offer personalized
`application of sunless tanning lotions and creams by
`experienced technicians (lotion application). At
`many of these same establishments, individuals can
`pay slightly less to have sunless tanning solution
`airbrushed onto their body (airbrushing). Now an-
`other option exists. At prices that are generally in-
`termediary between those of self-application and
`airbrushing, consumers can step into a sunless tan-
`ning booth and emerge with a full-body application
`of sunless tanning solution in less than a minute.
`
`*According to the FDA, no color additive may be used in cosmetics
`intended for use in the area of the eye— defined as “the area
`enclosed within the circumference of the supra-orbital ridge, in-
`cluding the eyebrow, the skin below the eyebrow, the eyelids
`and the eyelashes, and conjunctival sac of the eye, the eyeball,
`and the soft areolar tissue that lies within the perimeter of the
`infra-orbital ridge”— unless specifically approved for such use.
`
`Sunless tanning booths
`Sunless tanning booths were introduced to the
`market in 1999, as a collaboration between Thomas
`J. Laughlin of Mist-On Systems, Inc. and Troy
`Cooper, owner of the Dallas-based tanning store
`chain, Palm Beach Tan, Inc.26 Since 1999, several
`companies have entered the market. Mist-On Sys-
`tems, Inc. has placed over 240 Mist-On Tan Booths
`($50,000/unit) in stand-alone Mist-On salons, inde-
`pendent salons, spas, health clubs, and hotels
`worldwide (Laughlin TH, Mist-On Systems, Inc.).
`Mystic Tan, Inc., which manufactures and markets
`the less costly Mystic Tan Booth ($30,000/unit),27
`reports the sale of over 1000 units in 48 states
`(Brown H, Mystic, Inc.). Hollywood Tans, Inc., man-
`ufacturer of the Instant Tan Booth, currently has 189
`Hollywood Tan franchises, with over a hundred
`more to open this year (McQuillin B, Hollywood
`Tans, Inc.). Hollywood Tans, Inc. also produces the
`Sun Spritz Booth and the Summer Image Sunless
`Studio. Other manufacturers include European Tan-
`ning Systems, Inc., makers of the Sunless Express
`Spray Spa, and MagicTan, Inc., which manufactures
`the MagicTan Booth.
`Operational
`instructions are relatively uniform
`across the industry. Most facilities provide:
`1. a barrier cream and disposable foot coverings
`to shield the nails, palms, and soles from un-
`wanted coloration;
`2. a shower cap to protect the hair from un-
`wanted moisture; and
`3. a towel for the removal of excess sunless tan-
`ning solution.
`Once disrobed, customers are instructed to step
`into the booth and follow directions, either posted
`or audio-recorded, for proper body positioning dur-
`ing the session. The booths employ misters that are
`either mobile or stationary and positioned 360 de-
`grees around the customer
`to apply uniform
`amounts of sunless tanning solution to all parts of
`the body. Sessions range from 6 to 60 seconds, and
`in most cases end with the evacuation of mist from
`the booth. Users of
`the Mystic Tan Booth may
`choose from 3 levels of DHA-induced tan—session
`length may be varied depending on skin type, body
`size, and pre-existing level of tan.
`The number of sunless tanning solution manufac-
`turers is on the rise with multiple individual booth
`manufacturers producing their own brands. Three
`components comprise most commercial products:
`(1) DHA; (2) bronzers, for immediate coloration; and
`(3) moisturizers, a general term used by many man-
`ufacturers to refer to ingredients such as aloe vera
`and vitamins A, E, and C.
`
`4
`
`

`

`710 Fu, Dusza, and Halpern
`
`J AM ACAD DERMATOL
`MAY 2004
`
`In response to the growing popularity of the sun-
`less tanning booth, the FDA has issued an advisory
`that cautions consumers against unwanted expo-
`sures to DHA.5 Customers are advised to request
`measures to protect their eyes, lips, and mucous
`membranes and to prevent against inadvertent in-
`gestion and/or inhalation of DHA-containing prod-
`ucts.
`Most of the major sunless tanning booth manu-
`facturers operate Web sites that address some if not
`all of the above concerns.28,29,30,31,32 Although all
`sites visited asserted the safety of sunless tanning,
`many recommended that customers close their eyes
`and hold their breath for the duration of misting.
`Others advised pregnant
`individuals,
`those with
`asthma, or a history of allergy to sunless tanning
`products to consult with a personal physician. Three
`sites addressed the lack of UV protection afforded
`by sunless tanning and the importance of basic sun
`protection.29,30,31 Personal communication with rep-
`resentatives from the major sunless tanning booth
`manufacturers failed to reveal evidence of industry-
`published data to support the safety of DHA for any
`of the above exposures. A number of representa-
`tives did, however, report the initiation of industry-
`sponsored safety studies designed to gain FDA ap-
`proval
`for some of
`the exposures in question
`(Brown H, Mystic Tan, Inc.; Munro V, Dann E,
`MagicTan Los Angeles, Inc.).
`As of yet, no formal federal guidelines have been
`issued regarding the regulation of commercial estab-
`lishments that offer sunless tanning booth services.
`State agencies with jurisdiction over UV tanning in
`New York, Illinois, and California reported no exist-
`ing policies for sunless tanning booths (Dreibelbis
`M, State of New York, Department of Health, Bureau
`of Environmental Radiation Protection; Estes M,
`State of Illinois, Department of Public Health, Divi-
`sion of Food, Drugs, and Dairies; Cross M, State of
`California, Department of Consumer Affairs, Barber-
`ing and Cosmetology Program). Despite this lack of
`federal or state oversight, at least one tanning indus-
`try association, the National Tanning Training Insti-
`tute, has begun to advertise a sunless tanning certi-
`fication course33 similar to courses in UV tanning,
`popular in states that require the training of person-
`nel for salon licensing.
`
`SURVEY RESULTS
`The final study population was composed of 184
`completed and partially completed surveys (Fig 1).
`The overall response rate was 73% (184/300; 48
`ineligible). One establishment, from Chicago, was
`classified as a spa before randomization. After dis-
`
`covering that it was a tanning salon, we reclassified
`it to its correct designation.
`Survey responses from sunless and UV tanning
`facilities are outlined in Table I. Of the 166 busi-
`nesses that answered questions regarding sunless
`tanning services, 10% (17/166) offered sunless tan-
`ning booth services. Significant differences in prev-
`alence of sunless tanning services were noted
`among the different types of institutions. Twenty-
`nine percent (16/55) of tanning salons had sunless
`tanning booths versus 2% (1/61) of gyms. Although
`no spas had sunless tanning booths, 12% (6/50)
`offered airbrushing and 28% (14/50) offered lotion
`application. Significant geographic differences were
`also observed. Seventeen percent (9/54) of all busi-
`nesses in Los Angeles had sunless tanning booths, as
`compared with 8% (5/64) in New York and 5%
`(3/66) in Chicago.
`Data were also collected on UV tanning services
`provided by the surveyed establishments. Ninety-
`five percent (61/64) of tanning salons and 11% (8/
`67) of gyms offered UV tanning services (Table I).
`No spas surveyed reported UV tanning services. Of
`note, the two tanning salons (3%, 2/63) that did not
`offer UV tanning were businesses that had recently
`discontinued UV tanning services and redefined
`themselves as spas.
`Of the 90 businesses that had tanning services of
`any kind, 57% (51/90) only had UV tanning, 23%
`(21/90) only had sunless tanning, and 20% (18/90)
`had both. Median prices for sunless tanning services
`were as follows:
`1. $26.00 per sunless tanning booth session;
`2. $70.00 per airbrushing session; and
`3. $87.50 per lotion application session.
`The median price for a UV tanning session was
`$13.50.
`Of the 17 businesses that had sunless tanning
`booths, all reported advising clients to close their
`eyes, while 77% (13/17) reported advising their cli-
`ents to hold their breath for the duration of misting.
`Only one business offered clients additional protec-
`tion—protective eyewear, petroleum jelly for the
`lips, and cotton balls for the nostrils. Eighty-two
`percent (14/17) of businesses with sunless tanning
`booths recommended post-sunless tanning sun pro-
`tection to their clients. Seventy-seven percent (13/
`17) of businesses reported not having age restric-
`tions on sunless tanning. Of the businesses that
`employed age restrictions, 3 required parental/
`guardian accompaniment for children under 18, and
`the other required the presence of a parent/guardian
`for individuals under the age of 16.
`
`5
`
`

`

`J AM ACAD DERMATOL
`VOLUME 50, NUMBER 5
`
`Fu, Dusza, and Halpern 711
`
`Table I. Characteristics of survey respondents (N ⫽ 184)
`
`Tanning salon (n ⴝ 64)
`
`Spa (n ⴝ 53)
`
`Gym (n ⴝ 67)
`
`Overall (n ⴝ 184)
`
`No. (%)*
`
`No. (%)*
`
`No. (%)*
`
`No. (%)*
`
`Sunless tanning services
`Sunless tanning booth
`Airbrushing
`Lotion application
`Do not offer sunless tanning services
`Percentage of clients that utilize sunless
`tanning booths†
`ⱕ20
`21–40
`41–60
`61–80
`81–100
`UV tanning services
`No
`Yes
`Percentage of clients that utilize UV
`tanning units‡
`ⱕ20
`21–40
`41–60
`61–80
`81–100
`
`16 (25.0)
`1 (1.6)
`0 (0.0)
`38 (59.4)
`
`5 (31.3)
`4 (25.0)
`6 (37.5)
`1 (6.3)
`0 (0.0)
`
`2 (3.1)
`61 (95.3)
`
`2 (3.3)
`2 (3.3)
`3 (4.9)
`4 (6.5)
`49 (80.3)
`
`*Columns may not total 100% due to missing or incomplete information.
`†Percentages calculated from those who offer sunless tanning booths.
`‡Percentages calculated from those who offer UV tanning services.
`
`0 (0.0)
`6 (11.3)
`14 (26.4)
`30 (56.6)
`
`0 (0.0)
`0 (0.0)
`0 (0.0)
`0 (0.0)
`0 (0.0)
`
`1 (1.5)
`0 (0.0)
`1 (1.5)
`59 (88.1)
`
`0 (0.0)
`0 (0.0)
`0 (0.0)
`0 (0.0)
`1 (100.0)
`
`17 (9.2)
`7 (2.2)
`15 (8.1)
`127 (69.0)
`
`5 (29.4)
`4 (23.5)
`6 (35.3)
`1 (5.9)
`1 (5.9)
`
`52 (98.1)
`0 (0.0)
`
`59 (88.1)
`8 (11.4)
`
`113 (61.4)
`69 (37.5)
`
`0 (0.0)
`0 (0.0)
`0 (0.0)
`0 (0.0)
`0 (0.0)
`
`6 (75.0)
`1 (12.5)
`0 (0.0)
`0 (0.0)
`1 (12.5)
`
`8 (11.6)
`3 (4.3)
`3 (4.3)
`4 (5.6)
`50 (72.5)
`
`DISCUSSION
`Since the introduction of DHA-containing sunless
`tanning products in the 1950s, sunless tanners have
`undergone a number of transformations to improve
`both formulation and ease of application. The ad-
`vent of the sunless tanning booth has provided
`Americans access to a relatively inexpensive, time-
`efficient, cosmetically-pleasing modality of sunless
`tanning. Yet certain safety issues persist. Studies
`evaluating the safety of DHA for a number of perti-
`nent exposures have yet to be performed—prior
`modalities of application of sunless tanning prod-
`ucts having not involved exposure to the area of the
`eye, the lips, mucous membranes, or internal organs
`via ingestion or inhalation. Although the FDA ad-
`vises consumers to ask for appropriate protection
`against such exposures, at this time, mechanisms for
`licensing or inspecting commercial facilities with
`sunless tanning booths are lacking.5
`Of note, the variety of bronzing and moisturizing
`ingredients used by sunless tanning solution manu-
`facturers to enhance the consumer’s DHA-induced
`tan is vast. Further investigations may be warranted
`to ensure that these products are safe for any new
`exposures introduced by the sunless tanning booth.
`In addition, since neither DHA nor melanoidins af-
`
`ford significant UV protection, it is imperative that
`consumers be warned of the need for post-sunless
`tanning sun protection.
`Many of the major sunless tanning booth manu-
`facturers have established Web sites that offer an-
`swers to frequently asked questions as well as sug-
`gestions to consumers regarding sunless tanning
`booth use. Unfortunately, these recommendations
`are variable among manufacturers and often hap-
`hazard in the safety issues addressed.
`We initiated the survey component of this study
`to examine the correlation between manufacturer-
`reported sales and the current availability and utili-
`zation of sunless tanning booths in the marketplace,
`as well as to investigate the transmission of FDA-
`and manufacturer-generated safety precautions to
`consumers.
`We find that sunless tanning services are offered
`by a significant percentage of businesses involved in
`tanning. Forty-three percent (39/90) of businesses
`with tanning services of any kind offered sunless
`tanning—23% (21/90) only had sunless tanning,
`while 20% (18/90) had both sunless and UV tanning.
`New to the market since 1999, sunless tanning
`booths are already the most commonly offered mo-
`dality in sunless tanning—10% (17/166) of all busi-
`
`6
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`

`712 Fu, Dusza, and Halpern
`
`J AM ACAD DERMATOL
`MAY 2004
`
`nesses questioned about sunless tanning had sun-
`less tanning booths, whereas 9% (15/166) offered
`lotion application and only 4% (7/166) offered air-
`brushing. A greater percentage of businesses sur-
`veyed in Los Angeles (17%, 9/54) had sunless tan-
`ning booths, as compared to New York (8%, 5/64)
`and Chicago (5%, 3/66).
`Differences were noted in the types of commer-
`cial facilities that currently offer sunless tanning
`booth services. Approximately one third (29%, 16/
`55) of tanning salons had sunless tanning booths, as
`compared with 2% (1/61) of gyms and none of the
`spas surveyed. Only one tanning salon, which of-
`fered airbrushing, reported a sunless tanning modal-
`ity other than the sunless tanning booth. Spas
`tended to offer more labor-intensive and therefore
`more expensive application modalities—28% of-
`fered lotion application (28%, 14/50) and 12% of-
`fered airbrushing (12%, 6/50). Median prices for
`sunless tanning booth sessions, airbrushing ses-
`sions, and lotion application sessions were $26.00,
`$70.00, and $87.50 respectively. Gyms were the least
`likely of the 3 types of businesses surveyed to offer
`sunless tanning services.
`UV tanning services were offered by 95% (61/63)
`of tanning salons, 11% (8/67) of gyms, and none of
`the spas surveyed. The median price of UV tanning
`was significantly less expensive ($13.50/session)
`than that of any of the sunless tanning modalities
`discussed above.
`Although a number of sunless tanning booth
`manufacturers report the pursuit of studies to dem-
`onstrate the safety of DHA for all currently FDA-
`unapproved exposures, as of now, certain precau-
`tions are warranted. We found that the majority of
`businesses with sunless tanning booths suggested
`that clients close their eyes (100%, 17/17), hold their
`breath (77%, 13/17), and implement post-sunless
`tanning sun precautions (82%, 14/17). Recommen-
`dations for protection of the entire area of the eye as
`defined by the FDA, the lips, and the mucous mem-
`branes were, however, largely lacking. Only one
`establishment offered consumer safety equipment—
`disposable eyewear, petroleum jelly for the lips, and
`cotton balls for the nostrils. Of note, age restrictions
`were absent in most sunless tanning booth facilities
`(77%, 13/17).
`Although more Americans now realize the serious
`health implications of UV exposure, multiple recent
`surveys have demonstrated the persistence of
`beauty standards that glorify the tan. The rapidly
`expanding popularity of the sunless tanning booth
`may represent a confluence of these factors, as well
`as an important shift in the way Americans choose to
`tan. The development of uniform federal, state, and
`
`industry guidelines regarding unapproved expo-
`sures and post-sunless tanning sun precautions
`should be encouraged. Finally, although the advent
`of the sunless tanning booth may prove beneficial in
`steering already wary Americans away from UV tan-
`ning, anecdotal evidence from surveyed tanning es-
`tablishments suggests that many consumers may be
`utilizing sunless tanning to augment or enhance
`their UV-induced tans. Before any endorsements are
`made of the sunless tanning booth, further investi-
`gations are needed to evaluate the behavioral impli-
`cations of continuing to perpetuate the aesthetic
`appeal of the tan.
`
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