The significant health threat from tanning bed use as a self-treatment for psoriasis.

To the Editor: Little is known about commercial tanning bed use in psoriasis sufferers.1Turner R.J. Farr P.M. Walshaw D. Many patients with psoriasis use sunbeds.BMJ. 1998; 317: 412Crossref Google Scholar Given that psoriasis improves with ultraviolet (UV) exposure, it is likely that patients self-administer treatment via commercial tanning beds. Our cross-sectional study quantified tanning bed usage and whether tanning behaviors result in addictive-like tanning disorders in psoriasis patients. An online questionnaire was sent to approximately 14,000 subscribers of National Psoriasis Foundation email-list serve (between February and April 2014). Questions about demographics, psoriasis history, and UV usage were included. Answers from 1932 respondents were analyzed. Of 1830 respondents who answered queries regarding tanning bed use, 34% (n = 617) had used tanning beds consistent with 36% in studies of the general population,2Wehner M.R. Chren M.M. Nameth D. et al.International prevalence of indoor tanning: a systematic review and meta-analysis.JAMA Dermatol. 2014; 150: 390-400Crossref PubMed Scopus (211) Google Scholar and 28% (n = 512) were current users. Respondents who tanned were younger, diagnosed with psoriasis when younger, and predominantly female (P < .0001 for all). Sixty-two percent of 617 tanners started tanning to treat psoriasis; they were more likely to have received medical phototherapy (P < .0001) and had more severe psoriasis (previous hospitalization or erythroderma; P < .01, P < .0001). Table I lists reasons for tanning.Table IReasons for tanning as a self-treatment for psoriasis from 383 respondents∗Responses sum to more than 383 because respondents were asked to identify all reasons that may apply.Reasonn (%)Inconvenient to go to doctor's office for ultraviolet light treatment145 (31%)Other treatments prescribed by doctor not working141 (30%)Too expensive to go doctor's office for ultraviolet light treatment139 (30%)Waiting list at doctor's office for prescribed ultraviolet light treatment too long14 (3%)Recommended by doctor13 (3%)Phototherapy not available at doctor's office9 (2%)No insurance/not covered by insurance/high deductible8 (2%)∗ Responses sum to more than 383 because respondents were asked to identify all reasons that may apply. Open table in a new tab Ninety-nine percent of 170 current users disclosed their tanning-frequency; 55% tanned once a week or more (n = 93). Tanning in winter was the predominant seasonal pattern (37%; n = 119), but 23% (n = 73) tanned year-round. The highest ranking reason for tanning was “preventing sunburn,” followed by “relax, reduce stress, or improve mood.” To “prevent psoriasis from coming back” and “treat or improve existing psoriasis” were the least important reasons, even in the majority (55%) of those who previously started tanning for psoriasis self-treatment. Eleven percent of those who tanned in the last 5 years (322 participants) met modified Diagnostic Statistical Manual (DSM)-IV criteria for addiction-like tanning behaviors,3Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Association, Arlington, VA2000Google Scholar of which 79% (n = 27) were classified as mild, 18% (n = 6) moderate, and 3% (n = 1) severe. Individuals who started tanning as self-treatment were more likely to exhibit addictive-like tanning behaviors than those who started for alternate reasons (P < .05). Table II lists modified DSM-IV criteria.Table IIDistribution of responses adapted from the Diagnostic Statistical Manual (DSM-IV) criteria for substance use disorder from 301 respondents∗Responses sum to less than 301 because respondents confirmed only applicable criteria.Survey questionnAre there times your indoor tanning is more important to you than most other things in your life such as friends, family, school or job?8Has your indoor tanning caused you any problems with other people such as family members, friends, romantic partners, or people at work or school?3Did you find that when you started using indoor tanning you ended up using it much more than you were planning to?30Have you tried to cut down or stop indoor tanning but been unsuccessful?24Have you found that you needed a lot more indoor tanning sessions in order to get the feeling you wanted (for example, feel good, reduce stress, feel relaxed, etc) than when you first started indoor tanning?20When you haven't tanned for a while, do you have a strong desire to tan?36Have you been diagnosed with a skin cancer and continued to use a tanning bed after this diagnosis?15∗ Responses sum to less than 301 because respondents confirmed only applicable criteria. Open table in a new tab To date, few studies have assessed tanning bed usage in psoriasis patients1Turner R.J. Farr P.M. Walshaw D. Many patients with psoriasis use sunbeds.BMJ. 1998; 317: 412Crossref Google Scholar and none have addressed their addictive-like tanning behaviors. In the general public, recreational tanning continues unabated despite skin cancer health campaigns.2Wehner M.R. Chren M.M. Nameth D. et al.International prevalence of indoor tanning: a systematic review and meta-analysis.JAMA Dermatol. 2014; 150: 390-400Crossref PubMed Scopus (211) Google Scholar Addictive behavioral patterns of UV self-administration, similar to those of other substance-related disorders, have been reported.4Harrington C.R. Beswick T.C. Leitenberger J. Minhajuddin A. Jacobe H.T. Adinoff B. Addictive-like behaviors to ultraviolet light among frequent indoor tanners.Clin Exp Dermatol. 2011; 36: 33-38Crossref PubMed Scopus (77) Google Scholar These so-called “tanorexics” reported symptoms including anxiety if their tan is not maintained, inability to stop tanning, and continued tanning despite adverse consequences (eg, premature aging, skin cancer).5Warthan M.M. Uchida T. Wagner Jr., R.F. UV light tanning as a type of substance-related disorder.Arch Dermatol. 2005; 141: 963-966Crossref PubMed Scopus (128) Google Scholar Such symptoms were reported by a significant proportion of our respondents. Our results imply that tanning bed usage among psoriasis sufferers is widespread and linked with tanning addiction. Practitioners should be particularly vigilant to the possibility of tanning bed usage in at-risk patients: younger, female patients diagnosed at early age, those with severe psoriasis and previously prescribed phototherapy treatment were more likely to exhibit problematic tanning behaviors. Additionally, tanners with psoriasis may be at increased risk for skin cancer, and studies assessing skin cancer risk in phototherapy patients may be biased by tanning bed usage. Future research should incorporate similar surveys in European centers where the availability of phototherapy differs. The authors would like to thank the National Psoriasis Foundation for their generous assistance in disseminating the survey to its members. This study was supported, in part, by the National Institute of Arthritis and Musculoskeletal and Skin Diseases AR063018.