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INTERNATIONAL COMMISSION ON NON‐IONIZING RADIATION PROTECTION
ON HEALTH ISSUES OF ULTRAVIOLET TANNING
APPLIANCES USED FOR COSMETIC PURPOSES
PUBLISHED IN: HEALTH PHYSICS 84(1):119‐127; 2003
ICNIRP PUBLICATION – 2003
HEALTH ISSUES OF ULTRAVIOLET TANNING APPLIANCES
USED FOR COSMETIC PURPOSES
The International Commission on Non-Ionizing Radiation Protection*
l Low-pressure fluorescent tubes, emitting mostly UVA
or mostly UVB, with broad-band or narrowband emis-
Consumer d e m a n d for a cosmetic tan is the eco-
nomic basis of the “suntanning industry,” which devel-
l Filtered high pressure and high intensity discharge
ops and distributes equipment for commercial suntanning
lamps, emitting virtually only UVA or a mixture of
and markets suntanning services to consumers.
Tanning appliances are currently the subject of an
Exposure from sunbeds and other tanning ap-
international standard established by the International
pliances has the same potential risks as exposure to the
Electrotechnical Commission (IEC 1995), which has
UVR in solar radiation. The term “sunbed” is frequently
regulatory status in some countries. Four types of appli-
used to describe all tanning appliances consisting of
ances are recognized in this standard and defined by this
either a single UVR-emitting lamp (emitting UVA and/or
UVB radiation) as in some facial tanners or a number ofsuch lamps incorporated into a bed, canopy, panel, or any
UV type 1 appliances are those that emit UV radiation
such that the biological effect is caused by radiation
Potential adverse health effects of exposure to UVR
having wavelengths longer than 320 nm and charac-
are well documented and reasonably well quantified
terized by a relatively high irradiance 0.15 W m-2 )’
(WHO 1994). The purpose of this document is to
in the range 320 nm to 400 nm. The emission at
summarize the potential adverse effects of exposure to
wavelengths less than 320 nm is limited to 0.5 mW
ultraviolet radiation from tanning appliances and to
provide recommendations to minimize the risks of such
UV type 2 appliances are those that emit UV radiation
effects. Recommendations in this document apply o ly to
such that the biological effect is caused by radiation
the use of sunbeds for cosmetic purposes.
having wavelengths both shorter and longer than 320nm and characterized by a relatively high irradiance
0.15 W m-2;) in the range 320 nm to 400 nm. The
it-radiance at wavelengths less than 320 nm is in the
There are two distinctly different categories of
UV type 3 appliances are those that emit UV radiation
ultraviolet appliances used in tanning applications, each
such that the biological effect is caused by radiation
with different UVR emission characteristics and different
having wavelengths both shorter and longer than 320
requirements for filtering to eliminate undesirable wave-
nm and characterized by a limited it-radiance
W m - 2 ) in each UV radiation band; andUV type 4 appliances are those that emit UV radiation
such that the biological effect is mainly caused by
* ICNIRP c/o BfS, Institut fiir Strahlenhygiene, Ingolstaedter
radiation having wavelengths shorter than 320 nm (at
Landstr. 1, 85764 Oberschleissheim, Germany.
For correspondence or reprints contact: R. Matthes at the above
an irradiance greater than 0.15 W m -2, and in the
address, or email at email@example.com.
wavelength range 320-400 nm, the it-radiance is
The International Commission on Illumination (CIE) defines
UVR as optical radiation between 100 and 400 nm, and this spectralregion is divided into three photobiological spectral regions: UVC(l00-280 nm), UVB (280-315 nm) and UVA (315-400 nm).
All it-radiances are erythemally weighted. In their international
2002; accepted 23 July 2002)
standard, the International Electrotechnical Commission (IEC), has
used the wave length ranges from 320-400 nm and <320 nm to
The emission characteristics and the health risks
Delayed tanning (neo-melanogenesis). The
associated with the use of each type of appliance are
pigmentation takes at least 3 d to develop and results
different (Gies et al. 1986). Type 4 appliances, associated
from exposure to UVA but is more effectively produced
with high levels of emission of UVB (280-3 15 nm), are
by UVB (Parrish et al. 1982; Gange et al. 1985).
intended to be used following medical advice and should
UVR-induced neo-melanogenesis is strongly dependent
not be used for tanning purposes, mainly because of the
on cellular responses arising from UVR-induced DNA
publicized association between UVB and skin cancer.
damage in cellular nuclei (Eller et al. 1996; Gilchrest et
Most of the appliances that are in use today are UVA-
al. 1996). Delayed tanning is more persistent than IPD
emitting (315-400 nm) appliances, UV types 1, 2, and 3.
and results from an increase in the number, size, and
The term “sunbeds” in this document refers to UV-
pigmentation of melanin granules (Bech-Thomsen et al.
emitting appliances of UV type 1, 2, and 3, although UV
1994). Exposure to UVB results also in an increase in the
type 4 appliances are still marketed to commercial
thickness and scattering properties of the epidermis
(outer layer of the skin) (Bech-Thomsen and Wulf 1995).
During the last decade, increasing evidence of long
Due, at least in part, to these processes, the tan obtained
term UVA-induced risks for the skin and the eye has led
from a pure UVA appliance, while perhaps cosmetically
the sun-tanning industry to increase the UVB content in
acceptable, is not as effective in protecting against
the emission spectrum of tanning lamps in order to more
further exposure to solar UVR as the equivalent pigmen-
closely simulate natural sun exposure. This change has
tation induced by exposure to solar radiation.
also permitted shorter tanning exposures. It is known that
The degree to which an individual successfully tans
the ratio of UVA to UVB in the solar spectrum changes
as the result of exposure on a sunbed depends critically
during the day and undergoes large variations according
on his/her skin phototype as judged by his/her ability to
to season and latitude. It is also important to recognize
tan and the susceptibility to sunburn as a result of
that there is no firm scientific evidence to indicate that
exposure to solar UVR. Different skin phototypes (clas-
tanning with either UVA-dominated or a UVB-
sified as phototypes I through VI) are presented in Table
dominated sources poses less risk; and, likewise, the use
1. In principle, the reaction of a person to UVR with
of a simulated solar spectrum is not necessarily “safer”
respect to tanning or sunburning is similar whether the
exposure is on a sunbed or to solar radiation.
Among users of artificial suntanning devices, persons
EFFECTS ON SKIN
of skin phototypes I and II, who do not tan well and/or whosunburn easily, are likely to be disappointed with the
cosmetic results of using a sunbed. It has also been
When skin is exposed to UVR, two distinct tanning
recognized that many users experience minor adverse cuta-
neous effects such as mild erythema, itching, and skin
Immediate pigment darkening (IPD).
dryness (Diffey 1986; Rivers et al. 1989; Diffey et al. 1990).
immediately on exposure to UVR and is caused by the
Individual users of tanning appliances and attendants at
darkening of the pigment melanin that is already present
tanning salons may incorrectly evaluate individual skin
in the skin; it is normally seen only in people who have
sensitivity to UVR and underestimate the user’s sensitivity.
at least a moderate constitutive tan. Such pigmentation
begins to fade within a few minutes after cessation of
exposure. Radiation between 320 and 400 nm is regarded
Minor sunburn is a skin reddening (actinic ery-
as being most effective for IPD (Irwin et al. 1993).
thema) that appears up to 12 h after UVR exposure.
Classification of skin phototypes based on their susceptibility to sunburn in sunlight and their ability to tan
(Fitzpatrick et al. 1995).
phototype Sun sensitivity Sunburn susceptibility” Tanning ability Classes of individuals
I Very sensitive Always sunburn (<2 SED) No tan Melano-compromizedbIT Moderately sensitive High (2-3 SED) Light tan
III Moderately insensitive Moderate (3-5 SED) Medium tan Melano-competentIV Moderately resistant Low (5-7 SED) Dark tan Melano-competentV Resistant Very low (7-10 SED) Natural brown skin Melano-protectedVI Very resistant Extremely low (> 10 SED) Natural black skin Melano-protected
a The ranges of SEDs in parentheses are only indicative.
b Melano-compromized individuals have a greater risk of developing skin cancers than melano-competent individuals.
Health issues of ultraviolet tanning appliances ICNIRP 121
Erythema gradually fades after a few days, replaced by
been limited to non-melanoma skin cancer, and such
some tanning in individuals with tanning capability.
estimates necessarily require a number of assumptions
Severe sunburn is painful and results in inflammation,
such as the dose-response function, the use of ecological
blistering, and peeling of the skin. Aside from photoim-
rather than individual-based data to estimate the relation
munological effects (discussed later), systemic effects of
between UV exposure and risk, the extent of natural
severe sunburn are unknown except for transient fever.
exposure, and neglecting its intermittency. For example,
Sunburn severity depends critically on skin phototype
estimates of the risk of incidence of NMSC due to the use
(Table 1) and UV dose. For fair-skinned people (skin
of UVA sunbeds suggest a doubling of risk for no more
phototypes I and II, melano-compromised), the relative
than 20 sessions per year over 30 y in Northern Europe
effectiveness of UVR for tanning and for erythema is
population (Diffey 1987). Despite these health risks, if
approximately the same over the entire range of UVB
individuals insist on acquiring a tan, there are conclu-
and UVA wavelengths (Parrish et al. 1982). For people
sions that can be drawn from the scientific data to
who tan well and who rarely sunburn (skin phototypes III
minimize risk such as presented in the recommendation.
and IV, melano-competent), the tanning efficacy of UVA
Based upon a modeling of human skin-cancer risk
is higher than its erythemal efficacy (Gange et al. 1985).
(Diffey 1987), 10 sessions of 30 min per year will
For a given sunbed type, there is a range of radiant
increase by 5% the risk of skin cancer compared with
exposures which can be expressed in terms of Standard
non-users of solaria. A “safe” level of solarium use does
Erythemal Dose (SED) unit related to the Minimal
Cutaneous malignant melanoma (MM), while much
effects in people of different skin phototypes.
less frequent than NMSC, is much more serious andaccounts for the majority of deaths from skin cancer.
There are some mammalian data (Ley et al. 1989; Ley
The most serious long-term effects attributed to
1997) for MM that indicate a strong UVB melanoma
UVR exposure of the skin are the skin cancers (IARC
etiology, but these data are not entirely consistent with
1992). Squamous and basal cell carcinomas are common,
data from a fish melanoma model that indicate a strong
rarely fatal forms of skin cancer, which are often referred
implication of UVA in addition to UVB in the induction
to collectively as non-melanoma skin cancers (NMSCs).
of fish melanoma (Setlow 1993). The animal models
Experimental studies clearly indicate that UVA and UVB
demonstrate an increased impact of neonatal exposure on
can cause squamous cell carcinomas (SCCs) in mice. The
tumor induction including malignancy (Robinson et al.
same effects are likely in humans (Sterenborg 1987; van
2000; Noonan et al. 2001). The evidence for the indict-
Weelden et al. 1988). The erythemal potential of a UVR
ment of sunlight as a causal agent is limited to epidemi-
source is gaining acceptance as a reasonable approxima-
ological data. The data indicate that intermittent exposure
tion for a quantitative measure of its carcinogenic poten-
to high levels of solar UVR, particularly at an early age,
tial (Cole et al. 1985). A series of publications (Berg et
may be a contributing causal factor (for recent review see
al. 1993; de Gruijl et al. 1993; de Gruijl and van der Leun
Armstrong and Kricker 1995; Gilchrest et al. 1999). The
1994; de Gruijl and Forbes 1995) has been a source for
individual risk of MM is higher in people who have a
the proposal of an action spectrum for photocarcinogen-
large number of nevi (moles) and who sunburn readily
esis by CIE TC 6-32 (CIE 2000). It will be used to
and tan poorly with exposure to solar UVR. Some data
evaluate the maximal number of authorized yearly ses-
suggesting an association between the use of sunbeds and
sions as the basis of a recommendation in the next
an increased risk of MM have been published, but it is
revision of the international standard, IEC 335-2-27.
unclear as to the relative importance of UVB, UVA, and
Efforts to estimate the increased risk of a series of
other factors (especially, general sun-seeking behavior)
tanning sessions have been made; however, these have
in causing this association (Swerdlow et al. 1988; Walteret al. 1990; Autier et al. 199 1; Higgins and du Vivier
A minimum erythemal dose (MED) is defined as the UVR
1992; Westerdahl et al. 1994; Autier et al. 1994; Spencer
exposure that will produce a “just noticeable” erythema on previously
and Amonette 1995; Stem et al. 1997; Miller et al. 1998;
unexposed skin of an individual. If the exposure is spectrally weightedby the CIE erythemal action spectrum, the MED corresponds to an
Swerdlow and Weinstock 1998; Westerdahl et al. 2000).
effective radiant exposure expressed in Standard Erythemal Dose (SED)
Taken collectively, both experimental and epidemi-
units, depending on individual skin phototype (Table 1). Erythemally
ological data on skin cancer all indicate that cumulative
effective it-radiances (W m - 2 eff.), expressed in SEDs per hour, can becalculated for any source of UVR using spectral k-radiance data for the
exposure increases the risk for skin cancers. This in-
source, at the point of interest, and the relative spectral weighting factors
cludes childhood exposures. Therefore, the added expo-
for erythema, promulgated by the CIE (McKinlay and Diffey 1987;CIE/ISO 1999). One SED (Diffey et al. 1997) is a CIE/ISO official unit,
sure from UV tanning appliances is likely to add to the
and effective radiant exposure of 100 J m -2.
detrimental consequences of natural solar exposure.
Premature skin aging
Other skin effects
There is considerable evidence that cumulative
People who have excessively used UVA sunbeds have
UVR (UVA and UVB) exposure results in premature
exhibited increased skin fragility and blistering (Farr- et al.
skin aging characterized by a dry, coarse, leathery, and
1988; Murphy et al. 1989) and atypical melanocytic lesions
wrinkled appearance. It has been clearly demonstrated
(Jones et al. 1987; Williams et al. 1988; Roth et al. 1989;
that UVA causes skin damage in mice (Kligman et al.
Salisbury et al. 1989; Kadunce et al. 1990).
1987; Bissett et al. 1989). Similar effects might be
expected in humans as a result of excessive use of
Photodermatosis and photosensitivity
Polymorphic light eruption (PLE) is a common
Daily exposures to suberythemogenic purely UVA
photodermatosis readily produced in some people by
within the spectral region 320-400 nm for 8 d or
exposure to UV sunbed radiation (Rivers et al. 1989).
exposure to longer UVA wavelengths between 340-400
Other photoaggravated dermatoses such as systemic
nm for 2 mo result in cumulative morphological skin
lupus erythematosus are also exacerbated by the use of
alterations, which are indicative of tissue injury (Lavker
UV sunbeds (Stern and Docken 1986). Certain medicines
et al. 1995; Lowe et al. 1995; Seité et al. 1998). In a
and chemical and topical products (Table 2) such as
5-year longitudinal study of women who used or did not
perfumes and lotions may cause skin photosensitization
use tanning salons (Piérard 1998), serious modifications
of skin elasticity and extensibility were found in thetanning salon user group. In that group, the severity of
skin disorders was inversely correlated with their natural
UVR exposure causes localized skin and systemic
pigment capacities. It has been concluded from the study
modifications due to photoimmunological reactions
that the unremitting use of sunbeds induces a functional
(Noonan and De Fabo 1990), also a particular concern
decline of the dermis resembling premature aging.
with UVA sunbed radiation (Hersey et al. 1988; Rivers et
Agents producing photosensitivity.
Agents producing photosensitivity at local administration
Sulphonamides and related chemicals
(salicylanilide compounds n.a. phototoxic and
(creams, dyes and n.a.
Coal tar and derivatives
(phenolic n.a. phototoxic
(perfumes and colognes) n.a. phototoxic
(psoralens) n.a. phototoxic
(tattoos) n.a. phototoxic
Agents producing photosensitivity after oral or parenteral administration
Non steroid anti-inflammatory drugs
Health issues of ultraviolet tanning appliances ICNIRP 123
al. 1989). The clinical improvement of atopic dermatitis
with sub-erythemal UVA exposure indicates that UVR is
At least for the chronic effects of exposure to solar
able to modify substantially normal and pathological
radiation and to radiation from conventional light
immunological reactions. UVB radiation can promote the
sources, the most important retinal damage mechanism is
development of skin cancer, perhaps by suppressing the
immune system allowing the tumor to escape immune
(Sliney and Wolbarsht 1980). The gradual brunescence
surveillance (Duthie et al. 1999). The action spectra in
of the lens as it ages results in its decreased transmission
the UVB for mixed lymphocyte reaction and mixed
of blue-light and of UVR thereby affording increased
epidermal cell lymphocyte reaction were found to be
protection to the retina. Young children and people who
similar to the induction of thymine dimers upon DNA
have had a lens surgically removed (aphakes) are at a
higher risk of retinal damage from UVR and blue-light.
There is also evidence that exposure to UVR can
Until the last decade, many implanted artificial lens did
activate and accelerate the growth of human viruses
not effectively absorb UVA. Macular injuries to two
(Otani and Mori 1987; Perna et al. 1987), including
tanning booth users were mentioned in one study but not
human immunodeficiency virus (HIV) (Zmudzka and
confirmed (Walters and Kelley 1987).
Beer 1990), and have effects on infectious disease
The crystalline lens and cornea serve in considerable
(Halliday and Norval 1997). At present, the significance
measure to protect the retina from most UV tanning
of these observations with respect to human health is
booth radiation, even without protective goggles. As
unclear. The effects of UVA exposure on the immune
discussed previously, the crystalline lens blocks UVR
system are even more uncertain (Schwarz 1998; Vermeer
below 400 nm and the cornea blocks UVR below 300
nm, but trace amounts of UV-B radiation between 300and 315 nm may reach the retina (Boettner and Wolter
The principal adverse effect of the absorption of
The use of protective eyewear (goggles) will prevent
UVR (UVC and UVB) by the cornea is termed photo-
exposure of the eyes to harmful levels of UVR and
keratitis (“welder’s flash” or “snow-blindness”), and
blue-light. This represents a very important issue for
damage is generally limited to the epithelial (front
sunbed exposures since an individual is normally pro-
surface) cells of the cornea (Sliney and Wolbarsht 1980).
tected from most of the overhead solar UVR by geomet-
After a 6- to 12-h latent period that depends inversely on
rical shading by the brow ridge and upper lids. The
the severity of the exposure, there is severe cornea1 pain,
exposure from sunbeds is geometrically greatly different.
Furthermore, oblique rays can be focused into the nasal
symptoms are terribly distressing (with incapacitation),
equatorial region of the lens (Coroneo et al. 1991). UVR
but typically resolve in 24 h. There is some evidence of
can only reach the critically important germinative re-
possible long-term effects of UVR absorption by the
gion of the lens by the focusing of oblique rays. Eyewear
cornea (Taylor et al. 1989) and evidence of endothelial
that does not incorporate side protection is not suitable to
Transmission of UVA to the lens is much greater
CONCLUSION AND RECOMMENDATIONS
than that of UVB. Animal data indicate that thresholdlenticular damage is limited mainly to UVR exposure in
A review of scientific evidence shows that solar
the 295 to 325 nm wavelength band. Experimental
UVR is a cause of squamous cell cancer, basal cell
spectral efficiency for acute cataracts in laboratory ani-
cancer, and cutaneous melanoma as well as causing
mals has been measured only in this spectral region.
accelerated skin aging and other adverse health effects.
Although UVA sunbeds produce limited 295-325 nm
Because of this strong evidence on the adverse health
radiation, it should not be inferred that UVA is safe with
effects of UVR, even though there is not conclusive
respect to lens exposure. Crystalline lens aging is char-
direct evidence that sunbed exposure causes skin cancer,
acterized in part by loss of elasticity and browning
it is ICNIRP’s view that any use of suntanning appli-
(brunescence), both of which may be caused partly by
ances is likely to raise the risk of cancer. This risk is
UVA. Certain medicines may act as UVA photosensitiz-
particularly high for people having skin phototypes I and
124 Health Physics January 2003, Volume 84, Number 1
ICNIRP, therefore, recommends against the use of
W-emitting appliances for tanning or other non-medical
A. Swerdlow (UK), since 2000L. Szabo (Hungary), until 2000
purposes. The following groups are at particularly high
risk of incurring adverse health effects from UVR, and
therefore should be particularly counseled against the
R. Matthes, Scientific Secretary (Germany)M.H. Repacholi, Chairman Emeritus (Switzerland)
People who have skin phototypes I or II;Children (i.e., less than 18 y of age);People who have large numbers of nevi (moles);
During the preparation of this document, the composition of the ICNIRP
Standing Committee IV and task group was: D.H. Sliney (USA), Chairman
Individuals who have a history of frequent childhood
J-P. Césarini (France) F. R. de Gruijl (The Netherlands) B.L. Diffey (U.K.)M. Hietanen (Finland) M.A. Mainster (USA) T. Okuno (Japan) B.E. Stuck
People who have premalignant or malignant skinlesions;
People who have sun-damaged skin;Those who are wearing cosmetics. These may enhance
Armstrong BK, Kricker A. Skin cancer. Dermatologic Clinics
Autier P, Joarlette M, Lejeune F, Lienard T, Andre J, Achten
Persons taking medications. In this case they should
G. Cutaneous malignant melanoma and exposure to sun-
seek advice from their physician to determine if the
lamps and sunbeds: descriptive study in Belgium. Mela-
medication will make them UV-sensitive.
Autier P, Dore JF, Lejeune F, Koelmel KF, Geffeler 0, Hille P,
Although contrary to the above recommendation, if
Cesarini JP, Lienard D, Liabeuf A, Joarlette M, Chemaly P,
persons decide to use suntanning appliances, steps should
Hakim C, Koeln A, Kleeberg UR. (for the EORTC Mela-
be taken to minimize the risk. The recommendations
noma Cooperative Group). Cutaneous malignant melanomaand exposure to sunlamps or sunbeds: an EORTC multi-
provided in Appendix A have been made by several
center case-control study in Belgium, France, and Germany.
workshops, meetings, and publications which have
pointed to the identification of optical radiation hazards
Bech-Thomsen N, Ravnborg L, Wulf HC. A quantitative study
associated with the development and popularity of the
of the melanogenic effect of multiple suberythemal doses of
“suntanning industry” (Council on Scientific Affairs
different ultraviolet radiation sources. Photodermatol Pho-toimmunol Photomed 10:57- 64; 1994.
1989; ICNIRP/CIE Measurements of Optical Radiation
Bech-Thomsen N, Wulf HC. Photoprotection due to pigmen-
Hazards 1998; Miller et al. 1998; Moseley et al. 1998;
tation and epidermal thickness after repeated exposure to
USNIH 1998; Greinert et al. 2001). ICNIRP generally
ultraviolet light and psoralen plus ultraviolet A therapy.
supports these recommendations as a likely means to
Photodermatol Photoimmunol Photomed 11:2 13-2 18;
reduce the risk of skin cancers from the use of UV
Berg RJW, de Gruijl FR, van der Leun JC. Interaction between
tanning appliances and particularly to minimize the risks
ultraviolet A and ultraviolet B radiations in skin cancer
for high-risk groups. Suggestions for further reading can
induction in hairless mice. Cancer Res 53:42 12-4217;
Bisset DL, Hannon DP, Orr TV. Wavelength dependence of
histological, physical and visible changes in chronicallyUV-irradiated hairless mouse skin. Photochem Photobiol
support received by ICNIRP from the Interna-
tional Radiation Protection Association, the World Health Organization,
Boettner EA, Wolter JR. Transmission of the ocular media.
the International Labor Organization, the European Commission, and the
Invest Ophthalmol Vis Sci 1:776-783; 1962.
German Government is gratefully acknowledged.
CIE/ISO. Erythemal reference action spectrum and standard
erythemal dose. Geneva: ISO; IS0 17 166; 1999Nienna:CIE; CIE SOO7/E; 1998.
CIE. Action spectrum for photocarcinogenesis. Vienna: CIE;
During the preparation of this statement, the composition of the Interna-tional Commission on Non-Ionizing Radiation Protection was as follows:
A.F. McKinlay, Chairman (UK), Vice-chairman until 2000
Cole CA, Forbes PD, Davies RE. An action spectrum for UV
J.H. Bernhardt, Vice-chairman (Germany), Chairman until 2000
carcinogenesis. Photochem Photobiol 43:275-284; 1985.
Coroneo MT, Mueller-Stolzenbury NW, Ho A. Peripheral light
focusing by the anterior eye and the ophthalmohelioses.
Ophthalmic Surgery 22:705-711; 1991.
Council on Scientific Affairs. Harmful effects of ultraviolet
F. R. de Gruijl (The Netherlands)M. Hietanen (Finland)
light radiation. JAMA 262:380-384; 1989.
de Gruijl FR, Sterenborg HJCM, Forbes PD, Davies RE, Cole
C, Kelfken G, van Weelden H, Slaper H, van der Leun JC.
Health issues of ultraviolet tanning appliances ICNIRP 125
Wavelength dependence of skin cancer induction by ultra-
Hurks HMH, Out-luiting C, Vermeer PJ, Claas FHJ, Mommaas
violet irradiation of albino hairless mice. Cancer Res 53:53-
AM. The action spectra for UV-induced suppression of
MLR and MECLR show that immunosuppression is medi-
de Gruijl FR, van der Leun JC. Estimate of the wavelength
ated by DNA damage. Photochem Photobiol 62:449-453;
dependency of ultraviolet carcinogenesis in humans and its
relevance to the risk assessment of a stratospheric ozone
Jones SK, Moseley H, MacKie RM. UVA-induced melano-
depletion. Health Phys 67:314-325; 1994.
cytic lesions. Br J Dermatol 117:111-115; 1987.
de Gruijl FR, Forbes PD. UV-induced skin cancer in hairless
IARC. Solar and ultraviolet radiation. Monographs on the
mouse model. BioEssays 17:651-660; 1995.
evaluation of carcinogenic risk to humans. Vol. 55. Lyon:
Diffey BL. Use of UVA sunbeds for cosmetic tanning. Br J
International Agency for Research on Cancer; 1992.
ICNIRP/CIE. Measurements of Optical Radiation Hazards. A
Diffey BL. Analysis of the risk of skin cancer from sunlight
reference book based on presentations by health and safety
and solaria in subjects living in Northern Europe. Photoder-
experts on optical radiation hazards. Gaithersburg MD:
Diffey BL, Farr PM, Ferguson J, Gibbs NK, de Gruijl FR,
Hawk JLM, Johnson BE, Lowe G, MacKie RM, Magnus
International Electrotechnical Commission. Safety of house-
IA, McKinlay AF, Moseley H, Murphy GM, Norris PG,
hold and similar electrical appliances. Part 2: Particular
Young AR. Tanning with ultraviolet-A sunbeds. Br Med J
requirements for appliances for skin exposure to ultraviolet
and infrared radiation. Geneva: International Electrotechni-
Diffey BL, Jansen CT, Urbach F, Wulf HC. The standard
erythema dose: a new photo biological concept. Photoder-
Irwin C, Barnes A, Veres D, Kaidbey K. An UV radiation
matol Photoimmunol Photomed 13:64-66; 1997.
action spectrum for immediate pigment darkening. Photo-
Duthie MS, Kimber I, Norval M. The effects of ultraviolet
radiation on the human immune system. Br J Derm
Kadunce DP, Piepkom MW, Zone JJ. Persistent melanocytic
lesions associated with cosmetic tanning bed use: “sunbed
Eller MS, Ostrom K, Gilchrest BA. DNA damage enhances
lentigines.” J Am Acad Dermatol 23:1029-1031; 1990.
melanogenesis. Proc Ntl Acad Sci USA 93:1087-1092;
Kligman LH, Kaidbey KH, Hitchens VM, Miller SA. Long
wavelength (> 340 nm) UVA-induced damage in hairless
Farr PM, Marks JM, Diffey BL, Ince P. Skin fragility and
mice is dose dependent. In: Passchier W, Bosnjakovic
blistering due to the use of sunbeds. Br Med J 296: 1708 -
BFM, eds. Human exposure to ultraviolet radiatian: Risks
and regulations. Amsterdam: Elsevier Applied Science Pub-
Fitzpatrick TB, Cesarini JP, Young A, Kollias N, Pathak MA.
Reported in Fitzpatrick TB, Bolognia JL. Human melanin
Lavker RM, Veres DA, Irwin CJ, Kaidbey KH. Quantitative
pigmentation: Role in pathogenesis of cutaneous melanoma.
assessment of cumulative damage from repetitive exposures
In: Zeise L, Chedekel MR, Fitzpatrick B, eds. Melanin: Its
to suberythemogenic doses of UVA in human skin. Photo-
Role in Human Photoprotection. Overland Park, KS: Val-
denmar Publishing Co; 1995: 177-182.
Gange RW, Park YK, Auletta M, Kagetsu N, Blackett AD,
Ley RD. Ultraviolet radiation A-induced precursors of cuta-
Parrish JA, Action spectra for cutaneous responses to
neous melanoma in Monodelphis domestica.
ultraviolet radiation. In: Gange RW, Urbach F, eds. The
biological effects of UVA radiation. New York: Praeger;
Ley RD, Applegate LA, Padilla RS, Stuart TD. Ultraviolet
radiation-induced malignant melanoma in Monodelphis do-
Gies HP, Roy CR, Elliot G. Suntanning: Spectral irradiance
Photochem Photobiol 50: l-5; 1989.
and hazard evaluation of ultraviolet sources. Health Phys
Lowe NJ, Meyers DP, Wieder JM, Luftman D, Borget T,
Lehman MD, Johnson AW, Scott IR. Low doses of repet-
Gilchrest BA, Park HY, Eller MS, Yaar M. Mechanisms of
itive ultraviolet A induce morphologic changes in human
ultraviolet light-induced melanogenesis. Photochem Photo-
skin. J Invest Dermatol 105:739-743; 1995.
McKinlay AF, Diffey BL. A reference action spectrum for
Gilchrest BA, Eller MS, Geller AC, Yaar M. The pathogenesis
ultraviolet induced erythema in human skin. CIEJ 6: 17-22;
of melanoma induced by ultraviolet radiation. N Engl J Med
Miller SA, Hamilton SL, Wester UG, Cyr WH. An analysis of
Greinert R, McKinlay A, Breitbart EW. The European society
UVA emissions from sunlamps and the potential impor-
of skin cancer prevention-EUROSKIN: towards the pro-
tance for melanoma. Photochem Photobiol 68:63-70; 1998.
motion and harmonization of skin cancer prevention in
Moseley H, Davidson M, Ferguson J. A hazard assessment of
Europe. Recommendations Eur J Cancer Prev 10: 157-162;
artificial tanning units. Photodermatol Photoimmunol Pho-
Halliday KE, Norval M. The effect of UV on infectious
disease. Med Microbiol 8: 179-188; 1997.
Murphy GM, Wright J, Nicholls DSH, McKee PH, Messanger
Hersey P, MacDonald M, Henderson C, Schibeci S,
AG, Hawk JLM, Levene GM. Sunbed-induced pseudopor-
D’Alessandro G, Pryor M, Wilkinson FJ. Suppression of
phyria. Br J Dermatol 120:555-562; 1989.
natural killer cell activity in human by radiation from
Noonan FP, DeFabo EC. Ultrashort-B dose-response curves for
solarium lamps depleted of UVB. J Invest Dermatol
local and systemic immunosuppression are identical. Pho-
Higgins EM, du Vivier AWP. Possible induction of malignant
Noonan FP, Recio JA, Takayama H, Duray P, Anver MR, Rush
melanoma by sunbed use. Clin Exp Dermatol 17:357-359;
WL, De Fabo EC, Merlino G. Neonatal sunburn and
melanoma in mice. Nature 413:271-272; 2001.
Otani T, Mori R. The effects of UV irradiation of the skin on
Taylor HR, West SK, Rosenthal FS, Munoz B, Newland HS,
herpes simplex virus infection; Alteration in immune func-
Abbey H, Emmett SK. Effect of ultraviolet radiation on
tion mediated by epidermal cells and in the course of
cataract formation. N Engl J Med 319:1429-1433; 1989.
infection. Arch Virol 96:1-15; 1987.
US National Institutes of Health. Program and abstract book-
Parrish JA, Jaenicke KF, Anderson RR. Erythema and mela-
Research workshop on risks and benefits of exposure to
nogenesis action spectra of normal human skin. Photochem
ultraviolet and tanning. Bethesda: National Institutes of
Perna JJ, Mannix ML, Ronney JF, Notkins AL, Straus SE.
Van Weelden H, de Gruijl FR, van der Putte SCJ, Toonstra J,
Reactivation of latent herpes simplex virus infection by
van der Leun JC. The carcinogenic risks of modem tanning
ultraviolet light: A human model. J Am Acad Dermatol
equipment: Is UV-A safer than UV-B? Arch Dermatol
Pierard GE. Ageing in the sun parlor. Int J Cos Sci 20:25 l-259;
Vermeer BJ, Winstzen M, Claas FHJ, Schothorst AA, Hurks
HMH. UV-induced immunosuppression. The critical role of
Pitts DG, Bergmanson JPG, Chu LWF, Waxler M, Hitchins
wavelength. In: Rougier A, Schaefer H, eds. Protection of
VM. Ultrastructural analysis of cornea1 exposure to UV
the skin against ultraviolet radiations. Paris: John Libbey
radiation. Acta Ophthalmol (Copenh) 65:263-273; 1987.
Rivers JK, Norris PG, Murphy GM, Chu AC, Midgley G,
Walter SD, Marrett LD, From L, Hertzman C, Shannon HS,
Morris J, Morris RW, Young AR, Hawk JLM. UVA
Roy P. The association of cutaneous malignant melanoma
sunbeds: Tanning, photoprotection, acute adverse effects
with the use of sunbeds and sunlamps. Am J Epidemiol
and immunological changes. Br J Dermatol 120:767-777;
Walters BL, Kelley TM. Commercial tanning facilities: a new
Robinson ES, Hill RH Jr, Kripke ML, Setlow RB. The
source of eye injury. Am J Emerg Med 5:386-389; 1987.
Monodelphis melanoma model: initial report on large ultra-
Westerdahl J, Olsson H, Masback A, Ingvar C, Jonsson N,
violet A exposures of suckling young. Photochem Photobiol
Brandt L, Jonsson PE, Moller T. Use of sunbeds or
sunlamps and malignant melanoma in southern Sweden.
Roth DE, Hodge S, Callen JP. Possible ultraviolet A-induced
lentigines: a side effect of chronic tanning salon usage.
Westerdahl J, Olsson H, Masback A, Ingvar C, Jonsson N.
J Am Acad Dermatol 20:950-954; 1989.
Risks of cutaneous malignant melanoma in relation to use of
Salisbury JR, Williams H, du Vivier AWP. Tanning-bed
sunbeds: futher evidence for UV-A carcinogenicity. Br J
lentigines: Ultrastructural and histopathologic features.
J Am Acad Dermatol 21:689-693; 1989.
Williams HC, Salisbury J, Brett J, du Vivier A. Sunbed
Schwarz T. Effects of UVA light on the immune system. A
lentigines. Br Med J 296:1097; 1988.
settled issue? In: Rougier A, Schaefer H, eds. Protection of
World Health Organization. WHO Environmental Health Cri-
the skin against ultraviolet radiations. Paris: John Libbey
teria 160. Ultraviolet radiation. Geneva: World Health
Organization; 1994: 140, 150, 224-225, 245-246.
Seite S, Moyal D, Richard S, de Rigal J, Leveque JL, Hourseau
Zmudzka BZ, Beer JZ. Activation of human immunodeficiency
C, Fourtanier A. Effects of repeated suberythemal doses of
by ultraviolet radiation. Photochem Photobio16: 1153-l 162;
UVA in human skin. In: Rougier A, Schaefer H, eds.
Protection of the skin against ultraviolet radiations. Paris:John Libbey Eurotext; 1998: 47-58.
Setlow R, Grist E, Thompson K, Woodhead AD. Wavelengths
effective in induction of malignant melanoma. Proc Nat1Acad Sci USA 90:6666 - 6670; 1993.
If tanning devices are used, then the following
Sliney DH, Wolbarsht ML. Safety with lasers and other optical
specific recommendations from past workshops should
sources, a comprehensive handbook. New York: PlenumPress; 1980.
Sliney DH. Defining biologic exposures to light. In: Cronly-
Dillon J, Rosen ES, Marshall J, eds. Hazards of light. New
Claims of beneficial medical effects should not be
made. Any therapeutic use of tanning devices should
Spencer JM, Amonette RA. Indoor tanning: Risks, benefits and
future trends. J Am Acad Dermatol 33:288-298; 1995.
Tanning devices should comply with the requirements
Sterenborg HJCM. Investigations on the action spectrum of
tumor genesis by ultraviolet radiation. Utrecht: State Uni-
of the IEC standard (1995) and be limited to UV type
versity of Utrecht; 1987. Dissertation.
Stern RS, Docken W. An exacerbation of SLE after visiting a
Appropriate health warnings should be provided to the
Stern RS, Nichols KT, Väkeva LH. For the PUVA follow-up
Appropriate UV-protective goggles should be pro-
study. N Engl J Med 336:1041-1045; 1997.
Swerdlow AJ, English JSC, MacKie RM, O’Doherty CJ,
Hunter JAA, Clark J, Mole DJ. Fluorescent lights, ultravi-
Operator staff should be provided with appropriate
olet lamps, and risk of cutaneous melanoma. Br Med J
approved training (receive appropriate certification);
Professional operators are responsible for providing
Swerdlow AJ, Weinstock MA. Do tanning lamps cause mela-
noma? An epidemiologic assessment. J Am Acad Dermatol
client information and guidance on the safe use of
Health issues of ultraviolet tanning appliances ICNIRP 127
Minimize the number of sessions. For example, the
French Regulations (J. 0. Republique Francaise, An-
nexe 2, 1997) require that regular exposure, for pho-totypes III and IV, melano-competent skin, should not
l American Academy of Dermatology. Position State-
exceed two sessions per week with a maximum of 30
ment on Indoor Tanning. Dermatology World; March
sessions per year (erythemally effective exposure of
l EUROSKIN Towards the Promotion and Harmoniza-
500 J m -2 per session). An occasional break from the
tion of Skin Cancer Prevention; Session VI: WHO
Workshop-UVR Tanning Devices, 2 - 5 May 2000,
Manufacturers or dealers must supply exposure sched-
ules based on the tanning device lamp characteristics;
l Finnish Center for Radiation and Nuclear Safety:
Because the sensitivities of individuals vary greatly, it
is advisable to limit the duration of the first session to
l IRPA/INIRC Guidelines. Health issues of ultraviolet
“A” sunbeds used for cosmetic purposes. Health Phys
about one-half of a regular session in order to establish
the user’s skin response. If following the first session
l J. 0. Republique Francaise: Decret Nos. 97-6 17, Mai
any adverse reaction occurs, further use of the sunbed
1997 relatif a la vente et a la mise a disposition du
public de certains appareils de bronzage utilisant des
Products designed to enhance or accelerate tanning
l Norwegian Radiation Protection Authority: Code of
Any modifications, such as the replacement of lamps,
practice (modification of #2 & 5 of the Royal Resolu-tion concerning the use of x rays, 1983); 1992.
filters or reflectors should not change the IEC classi-
l NRPB Board statement on effects of ultraviolet radi-
fication of the device. Tanning devices should have an
ation on human health and health effects from ultravi-
Tanning devices in hotels or in recreational facilities
l NRPB Use of Sunbeds and cosmetic tanning. State-
should be subject to the same controls as noted above
ment by NRPB Advisory Group on Non-Ionising
radiation. Radiological Protection Bulletin No. 2 18,
Because of their possible misuse, unattended or coin-
l Senat de Belgique (May 1998): Proposition de loi
operated tanning devices should not be used;
reglementant l’exploitation des centres de bronzage,
By the nature of their use, sunlamps in the home are
not subject to the same degree of control as those used
under proper supervision in commercial outlets, so
l Swedish Radiation Protection Institute: Regulatory
additional safety information should be provided by
code concerning sunbeds (SSI FS 1998: 2).
the vendor or supplier of the tanning device. In these
l U.S. Food and Drug Administration. Policy on maxi-
circumstances only IEC type 3 tanning devices should
mum timer intervals and exposure schedule for sun-lamps. August 1986; FDA Rockville MD, USA.
l Radiation Protection Dosimetry-Ultraviolet Radia-
Recognizing that different countries will have different
tion Exposure, Measurement and Protection.
ways of implementing and determining compliance
lay AF, Repacholi MH, eds. Proceedings of an Inter-
with these recommendations, the tanning facilities
national Workshop St Catherine’s College, Oxford,
should comply with these recommendations, and that
England, October 18 -20; 1999. Radiation Protection
compliance should be checked by the appropriate
History of U.S. Military Contributions to the Guarantor: COL Christian F. Ockenhouse, MC USA Contributors: COL Christian F. Ockenhouse, MC USA*; COL Alan Magill, MC USA*; Dale Smith, PhD†;COL Wil Milhous, MS USA (Ret.)*More so than any other infectious disease, malaria has all tooprevention of diseases, particularly intermittent fevers. often affected the conduct of military operations in
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