Sunless Tanners

Coloring the skin with dihydroxyacetone to create an artificial tan was discovered serendipitously in the 1950s by Eva Wittgenstein, whose patients were taking DHA orally. She observed that when patients regurgitated the DHA, pigmented spots remained on the skin (Science 1960;132:894-5).

The change in pigmentation results from the interaction of DHA with amino acids in the stratum corneum (Br. J. Dermatol. 2003;149:332-40).

Although the first product brought to market to exploit this new knowledge in 1959 met with initial success, it fell into disuse because of the poor cosmetic results (J. Am. Acad. Dermatol. 2003;49:1096-106; South. Med. J. 2005;98:1192-5).

Public awareness of sunless tanning has grown in recent years, however, and has been met with formulations that afford a much improved cosmetic performance, with DHA remaining as the main active ingredient in sunless-tanning agents (South. Med. J. 2005;98:1192-5; Am. J. Clin. Dermatol. 2002;3:317-8).

This column will briefly review the role of sunless-tanning lotions and sprays in dermatology, and will try to place recommendations to patients about sunless tanners in the context of sunscreens and tanning attitudes.

Sunless tanners have been used, with varying degrees of popularity, for 50 years; recent evidence suggests that the use of these products has increased in recent years. A long track record of usage and research indicates that sunless-tanning compounds are safe (J. Environ. Pathol. Toxicol. Oncol. 1984;5:349-51; Am. J. Clin. Dermatol. 2002;3:317-8; South. Med. J. 2005;98:1192-5; J. Am. Acad. Dermatol. 2007;56:387-90.) However, there is some debate as to whether the use of these products renders users more inclined to stay in the sun longer. Also, ongoing research has raised some safety issues regarding DHA.

Chemical Protection

In 2004, Petersen et al. investigated the effects of DHA on cell survival and proliferation of a human keratinocyte cell line, HaCaT. Significant genotoxic activity was identified in these cultured cells, as researchers noted dose- and time-dependent morphologic alterations as well as cytoplasmic budding and cell detachment in DHA-treated cells, and apoptosis and marked declines in proliferation 1 day after DHA exposure. Interestingly, the development of DNA strand breaks was prevented via preincubation with antioxidants. The authors suggested that their findings raised concerns about the long-term use of treating the skin with DHA-containing formulations (Mutat. Res. 2004;560:173-86).

A small study by Faurschou et al. showed that DHA provided human skin with modest UVB protection, with a 5% DHA cream applied three times or a 20% DHA cream applied once yielding an effect similar to an SPF 1.6. They acknowledged that most commercial DHA products contain 3%-5% DHA and offer scant protection. A potential advantage of sunless tanners, if they offer protection, suggested the authors, would be that no spots would be left unattended since such gaps would be conspicuous for lack of browning (Arch. Dermatol. 2004;140:886-7).

Howe, Reed, and Dellavalle contended that DHA in self-tanning agents provided enough UVA protection to warrant use as an adjunct to daily sunscreen use for broad-band protection (J. Am. Acad. Dermatol. 2008;58:894). The researchers referenced a 1975 study in which 3% DHA augmented sunlight tolerance among five patients with UVA-sensitive dermatoses (Dermatologica 1975;150:346-51; J. Am. Acad. Dermatol. 2008;58:894).

In 2009, Choquenet et al. assessed the sun protection potency of self-tanners and foundations using an in vitro method to identify indicators such as sun protection factor (SPF), UVA protection factor (PF-UVA), and UVB/UVA ratio. Using seven amino acids in the corneal cells of the epidermis, the investigators identified SPFs virtually equivalent to zero (approximately SPF 2). Conversely, they found foundations to exhibit satisfactory photostability and a non-negligible SPF, noting that such products are safe given their typically once-daily application (J. Dermatol. 2009;36:587-91).

Attitudes and Behavior

Users of sunless-tanning products were found, in a survey of 2,005 randomly selected South Australian adults published in 2001, to be more likely to use sunscreen but less likely to wear a hat or other sun-protective clothing. Sunburns were also linked to the use of sunless tanners in this study (Med. J. Aust. 2001;174:75-8; J. Am. Acad. Dermatol. 2007;56:387-90).

In 2005, Mahler et al. conducted a randomized, controlled trial with 1-month follow-up of 146 Southern California college students to study the impact of UV photoaging photographs and data on the sun protection plans and behaviors of young adults, and whether sunless-tanning lotion might play a role in sun-protective behavior. Of the 146 volunteers, 91.1% completed the "surprise" 1-month follow-up. The intervention consisted of volunteers being shown a UV facial photo and short video illustrating the etiology and results of photoaging. The investigators found that the UV photographic intervention was successful insofar as significantly better sun protection strategies and behaviors were employed by the test group, compared with controls. In addition, they noted that those who used sunless-tanning lotion were more likely to exhibit extensive sun-protective behavior, compared with individuals who received the intervention alone. The authors suggested that such interventions represented a cost-effective approach that might yield behaviors with long-term health benefits in the form of a lower incidence of skin cancer (Arch. Dermatol. 2005;141:373-80).

Later that year, Sheehan and Lesher reported on their anonymous survey of 121 adults (107 women and 14 men) who received spray-on sunless-tanning treatments between February and May 2004. Most reported that sunless tanning had not or would not affect their use of sunscreen or time spent outdoors. Interestingly, though, 73% of the respondents who had used tanning beds indicated that they had reduced or would reduce their use of indoor tanning. The researchers concluded that practitioners should recommend sunless tanning to their patients who use conventional tanning beds as a way to lower their solar exposure and risk of skin cancer (South. Med. J. 2005;98:1192-5).

In 2006, Brooks et al. reported on their July 2004, greater Boston, cross-sectional survey of 448 nonrandomly selected people aged 18-30 years on the subjects of artificial tanning products, recent history of sunburns, and tanning-bed use. During the preceding year, 22% of respondents had used sunless-tanning products and the same percentage hadn’t but would consider using them in the next year. Users of these lotions were more likely to have been severe burners and, after controlling for skin type, the investigators found that previous and potential users were more likely to have experienced sunburns during the summer and to have used tanning beds than were respondents who had neither used nor planned to use sunless tanners. The researchers concluded that the option of sunless tanning did not seem to lower the incidence of sunburn or the use of tanning beds. Further, they urged caution in offering broad support for artificial tanning products, even though looking for alternatives to UV exposure is to be encouraged (J. Am. Acad. Dermatol. 2006;54:1060-6).

A 2007 study using data from 5,491 completed interviews as part of the National Cancer Institute’s HINTS (Health Information National Trends Survey) 2005 set out to determine the prevalence of sunless-tanning formulation use and to understand the relationship between sunless tanning, indoor tanning, and sun-protective behavior. In so doing, the investigators found that the use of sunless-tanning products was relatively rare, with an estimated 11% of U.S. adults claiming to have used such products in the previous year. Of this group, 13% used sunless tanners more than 25 times; 12% used them 11-24 times; 35% used them 3-10 times; and 40% used them just once or twice. Users and exclusive users were more likely to be women, well educated, and living in the West (J. Am. Acad. Dermatol. 2007;56:387-90).

Recent Cause for Pause

In 2008, Jung et al. used the electron spin resonance spectroscopy–based radical sun protection factor, which measures free-radical reactions in skin biopsies during UV exposure and can determine the protective effect of UV filters and sunscreens, to analyze three different self-tanning agents, including DHA. Noting that the reaction of the reducing sugars in such products and amino acids (Maillard reaction) in the skin layer engendered Amadori products that created free radicals during UV irradiation, the investigators reported that in DHA-treated skin, more than 180% additional radicals were produced during sun exposure, compared with untreated skin. They concluded that the use of self-tanners necessitated reducing solar exposure duration (Spectrochim. Acta A. Mol. Biomol Spectrosc. 2008;69:1423-8). Consequently, DHA users would be well advised to wait at least 24 hours before solar exposure following application of sunless lotion or spray (Dermatol. Clin. 2009;27:149-54).

Conclusion

In addition to the need to continually persuade patients to engage in skin-protective behavior – namely, limiting sun exposure, avoiding peak-time exposures, wearing wide-brimmed hats and clothing with SPF value, and using sunscreens (preferably those containing avobenzone, Mexoryl, zinc oxide, or titanium dioxide) every day – it is incumbent upon dermatologists to disabuse our patients of the idea that untanned skin is less attractive or, conversely, that tans should be equated with attractive skin. Although healthy messages (that there is no such thing as a healthy tan, and that a tan indicates skin damage) are slowly spreading, sunless tanners appear to be a medically and cosmetically acceptable intermediary step, far surpassing the patently detrimental effects of indoor tanning. That said, patients should be advised to refrain from solar exposure for a full 24 hours after applying sunless tanners. Furthermore, much more research is necessary to truly establish that DHA delivers even modest protection from UVA or UVB. Accordingly, patients should be counseled that sunless tanners do not suffice as a base, nor do they justify extended solar exposure, and that sunscreens should also be applied.

This column, "Cosmeceutical Critique," regularly appears in Skin & Allergy News, an Elsevier publication. Dr. Baumann is in private practice in Miami Beach. To respond to this column, or to suggest topics for future columns, e-mail Dr. Baumann.

Coloring the skin with dihydroxyacetone to create an artificial tan was discovered serendipitously in the 1950s by Eva Wittgenstein, whose patients were taking DHA orally. She observed that when patients regurgitated the DHA, pigmented spots remained on the skin (Science 1960;132:894-5).

The change in pigmentation results from the interaction of DHA with amino acids in the stratum corneum (Br. J. Dermatol. 2003;149:332-40).

Although the first product brought to market to exploit this new knowledge in 1959 met with initial success, it fell into disuse because of the poor cosmetic results (J. Am. Acad. Dermatol. 2003;49:1096-106; South. Med. J. 2005;98:1192-5).

Public awareness of sunless tanning has grown in recent years, however, and has been met with formulations that afford a much improved cosmetic performance, with DHA remaining as the main active ingredient in sunless-tanning agents (South. Med. J. 2005;98:1192-5; Am. J. Clin. Dermatol. 2002;3:317-8).

This column will briefly review the role of sunless-tanning lotions and sprays in dermatology, and will try to place recommendations to patients about sunless tanners in the context of sunscreens and tanning attitudes.

Sunless tanners have been used, with varying degrees of popularity, for 50 years; recent evidence suggests that the use of these products has increased in recent years. A long track record of usage and research indicates that sunless-tanning compounds are safe (J. Environ. Pathol. Toxicol. Oncol. 1984;5:349-51; Am. J. Clin. Dermatol. 2002;3:317-8; South. Med. J. 2005;98:1192-5; J. Am. Acad. Dermatol. 2007;56:387-90.) However, there is some debate as to whether the use of these products renders users more inclined to stay in the sun longer. Also, ongoing research has raised some safety issues regarding DHA.

Chemical Protection

In 2004, Petersen et al. investigated the effects of DHA on cell survival and proliferation of a human keratinocyte cell line, HaCaT. Significant genotoxic activity was identified in these cultured cells, as researchers noted dose- and time-dependent morphologic alterations as well as cytoplasmic budding and cell detachment in DHA-treated cells, and apoptosis and marked declines in proliferation 1 day after DHA exposure. Interestingly, the development of DNA strand breaks was prevented via preincubation with antioxidants. The authors suggested that their findings raised concerns about the long-term use of treating the skin with DHA-containing formulations (Mutat. Res. 2004;560:173-86).

A small study by Faurschou et al. showed that DHA provided human skin with modest UVB protection, with a 5% DHA cream applied three times or a 20% DHA cream applied once yielding an effect similar to an SPF 1.6. They acknowledged that most commercial DHA products contain 3%-5% DHA and offer scant protection. A potential advantage of sunless tanners, if they offer protection, suggested the authors, would be that no spots would be left unattended since such gaps would be conspicuous for lack of browning (Arch. Dermatol. 2004;140:886-7).

Howe, Reed, and Dellavalle contended that DHA in self-tanning agents provided enough UVA protection to warrant use as an adjunct to daily sunscreen use for broad-band protection (J. Am. Acad. Dermatol. 2008;58:894). The researchers referenced a 1975 study in which 3% DHA augmented sunlight tolerance among five patients with UVA-sensitive dermatoses (Dermatologica 1975;150:346-51; J. Am. Acad. Dermatol. 2008;58:894).

In 2009, Choquenet et al. assessed the sun protection potency of self-tanners and foundations using an in vitro method to identify indicators such as sun protection factor (SPF), UVA protection factor (PF-UVA), and UVB/UVA ratio. Using seven amino acids in the corneal cells of the epidermis, the investigators identified SPFs virtually equivalent to zero (approximately SPF 2). Conversely, they found foundations to exhibit satisfactory photostability and a non-negligible SPF, noting that such products are safe given their typically once-daily application (J. Dermatol. 2009;36:587-91).

Attitudes and Behavior

Users of sunless-tanning products were found, in a survey of 2,005 randomly selected South Australian adults published in 2001, to be more likely to use sunscreen but less likely to wear a hat or other sun-protective clothing. Sunburns were also linked to the use of sunless tanners in this study (Med. J. Aust. 2001;174:75-8; J. Am. Acad. Dermatol. 2007;56:387-90).

In 2005, Mahler et al. conducted a randomized, controlled trial with 1-month follow-up of 146 Southern California college students to study the impact of UV photoaging photographs and data on the sun protection plans and behaviors of young adults, and whether sunless-tanning lotion might play a role in sun-protective behavior. Of the 146 volunteers, 91.1% completed the "surprise" 1-month follow-up. The intervention consisted of volunteers being shown a UV facial photo and short video illustrating the etiology and results of photoaging. The investigators found that the UV photographic intervention was successful insofar as significantly better sun protection strategies and behaviors were employed by the test group, compared with controls. In addition, they noted that those who used sunless-tanning lotion were more likely to exhibit extensive sun-protective behavior, compared with individuals who received the intervention alone. The authors suggested that such interventions represented a cost-effective approach that might yield behaviors with long-term health benefits in the form of a lower incidence of skin cancer (Arch. Dermatol. 2005;141:373-80).

Later that year, Sheehan and Lesher reported on their anonymous survey of 121 adults (107 women and 14 men) who received spray-on sunless-tanning treatments between February and May 2004. Most reported that sunless tanning had not or would not affect their use of sunscreen or time spent outdoors. Interestingly, though, 73% of the respondents who had used tanning beds indicated that they had reduced or would reduce their use of indoor tanning. The researchers concluded that practitioners should recommend sunless tanning to their patients who use conventional tanning beds as a way to lower their solar exposure and risk of skin cancer (South. Med. J. 2005;98:1192-5).

In 2006, Brooks et al. reported on their July 2004, greater Boston, cross-sectional survey of 448 nonrandomly selected people aged 18-30 years on the subjects of artificial tanning products, recent history of sunburns, and tanning-bed use. During the preceding year, 22% of respondents had used sunless-tanning products and the same percentage hadn’t but would consider using them in the next year. Users of these lotions were more likely to have been severe burners and, after controlling for skin type, the investigators found that previous and potential users were more likely to have experienced sunburns during the summer and to have used tanning beds than were respondents who had neither used nor planned to use sunless tanners. The researchers concluded that the option of sunless tanning did not seem to lower the incidence of sunburn or the use of tanning beds. Further, they urged caution in offering broad support for artificial tanning products, even though looking for alternatives to UV exposure is to be encouraged (J. Am. Acad. Dermatol. 2006;54:1060-6).

A 2007 study using data from 5,491 completed interviews as part of the National Cancer Institute’s HINTS (Health Information National Trends Survey) 2005 set out to determine the prevalence of sunless-tanning formulation use and to understand the relationship between sunless tanning, indoor tanning, and sun-protective behavior. In so doing, the investigators found that the use of sunless-tanning products was relatively rare, with an estimated 11% of U.S. adults claiming to have used such products in the previous year. Of this group, 13% used sunless tanners more than 25 times; 12% used them 11-24 times; 35% used them 3-10 times; and 40% used them just once or twice. Users and exclusive users were more likely to be women, well educated, and living in the West (J. Am. Acad. Dermatol. 2007;56:387-90).

Recent Cause for Pause

In 2008, Jung et al. used the electron spin resonance spectroscopy–based radical sun protection factor, which measures free-radical reactions in skin biopsies during UV exposure and can determine the protective effect of UV filters and sunscreens, to analyze three different self-tanning agents, including DHA. Noting that the reaction of the reducing sugars in such products and amino acids (Maillard reaction) in the skin layer engendered Amadori products that created free radicals during UV irradiation, the investigators reported that in DHA-treated skin, more than 180% additional radicals were produced during sun exposure, compared with untreated skin. They concluded that the use of self-tanners necessitated reducing solar exposure duration (Spectrochim. Acta A. Mol. Biomol Spectrosc. 2008;69:1423-8). Consequently, DHA users would be well advised to wait at least 24 hours before solar exposure following application of sunless lotion or spray (Dermatol. Clin. 2009;27:149-54).

Conclusion

In addition to the need to continually persuade patients to engage in skin-protective behavior – namely, limiting sun exposure, avoiding peak-time exposures, wearing wide-brimmed hats and clothing with SPF value, and using sunscreens (preferably those containing avobenzone, Mexoryl, zinc oxide, or titanium dioxide) every day – it is incumbent upon dermatologists to disabuse our patients of the idea that untanned skin is less attractive or, conversely, that tans should be equated with attractive skin. Although healthy messages (that there is no such thing as a healthy tan, and that a tan indicates skin damage) are slowly spreading, sunless tanners appear to be a medically and cosmetically acceptable intermediary step, far surpassing the patently detrimental effects of indoor tanning. That said, patients should be advised to refrain from solar exposure for a full 24 hours after applying sunless tanners. Furthermore, much more research is necessary to truly establish that DHA delivers even modest protection from UVA or UVB. Accordingly, patients should be counseled that sunless tanners do not suffice as a base, nor do they justify extended solar exposure, and that sunscreens should also be applied.

This column, "Cosmeceutical Critique," regularly appears in Skin & Allergy News, an Elsevier publication. Dr. Baumann is in private practice in Miami Beach. To respond to this column, or to suggest topics for future columns, e-mail Dr. Baumann.

Coloring the skin with dihydroxyacetone to create an artificial tan was discovered serendipitously in the 1950s by Eva Wittgenstein, whose patients were taking DHA orally. She observed that when patients regurgitated the DHA, pigmented spots remained on the skin (Science 1960;132:894-5).

The change in pigmentation results from the interaction of DHA with amino acids in the stratum corneum (Br. J. Dermatol. 2003;149:332-40).

Although the first product brought to market to exploit this new knowledge in 1959 met with initial success, it fell into disuse because of the poor cosmetic results (J. Am. Acad. Dermatol. 2003;49:1096-106; South. Med. J. 2005;98:1192-5).

Public awareness of sunless tanning has grown in recent years, however, and has been met with formulations that afford a much improved cosmetic performance, with DHA remaining as the main active ingredient in sunless-tanning agents (South. Med. J. 2005;98:1192-5; Am. J. Clin. Dermatol. 2002;3:317-8).

This column will briefly review the role of sunless-tanning lotions and sprays in dermatology, and will try to place recommendations to patients about sunless tanners in the context of sunscreens and tanning attitudes.

Sunless tanners have been used, with varying degrees of popularity, for 50 years; recent evidence suggests that the use of these products has increased in recent years. A long track record of usage and research indicates that sunless-tanning compounds are safe (J. Environ. Pathol. Toxicol. Oncol. 1984;5:349-51; Am. J. Clin. Dermatol. 2002;3:317-8; South. Med. J. 2005;98:1192-5; J. Am. Acad. Dermatol. 2007;56:387-90.) However, there is some debate as to whether the use of these products renders users more inclined to stay in the sun longer. Also, ongoing research has raised some safety issues regarding DHA.

Chemical Protection

In 2004, Petersen et al. investigated the effects of DHA on cell survival and proliferation of a human keratinocyte cell line, HaCaT. Significant genotoxic activity was identified in these cultured cells, as researchers noted dose- and time-dependent morphologic alterations as well as cytoplasmic budding and cell detachment in DHA-treated cells, and apoptosis and marked declines in proliferation 1 day after DHA exposure. Interestingly, the development of DNA strand breaks was prevented via preincubation with antioxidants. The authors suggested that their findings raised concerns about the long-term use of treating the skin with DHA-containing formulations (Mutat. Res. 2004;560:173-86).

A small study by Faurschou et al. showed that DHA provided human skin with modest UVB protection, with a 5% DHA cream applied three times or a 20% DHA cream applied once yielding an effect similar to an SPF 1.6. They acknowledged that most commercial DHA products contain 3%-5% DHA and offer scant protection. A potential advantage of sunless tanners, if they offer protection, suggested the authors, would be that no spots would be left unattended since such gaps would be conspicuous for lack of browning (Arch. Dermatol. 2004;140:886-7).

Howe, Reed, and Dellavalle contended that DHA in self-tanning agents provided enough UVA protection to warrant use as an adjunct to daily sunscreen use for broad-band protection (J. Am. Acad. Dermatol. 2008;58:894). The researchers referenced a 1975 study in which 3% DHA augmented sunlight tolerance among five patients with UVA-sensitive dermatoses (Dermatologica 1975;150:346-51; J. Am. Acad. Dermatol. 2008;58:894).

In 2009, Choquenet et al. assessed the sun protection potency of self-tanners and foundations using an in vitro method to identify indicators such as sun protection factor (SPF), UVA protection factor (PF-UVA), and UVB/UVA ratio. Using seven amino acids in the corneal cells of the epidermis, the investigators identified SPFs virtually equivalent to zero (approximately SPF 2). Conversely, they found foundations to exhibit satisfactory photostability and a non-negligible SPF, noting that such products are safe given their typically once-daily application (J. Dermatol. 2009;36:587-91).

Attitudes and Behavior

Users of sunless-tanning products were found, in a survey of 2,005 randomly selected South Australian adults published in 2001, to be more likely to use sunscreen but less likely to wear a hat or other sun-protective clothing. Sunburns were also linked to the use of sunless tanners in this study (Med. J. Aust. 2001;174:75-8; J. Am. Acad. Dermatol. 2007;56:387-90).

In 2005, Mahler et al. conducted a randomized, controlled trial with 1-month follow-up of 146 Southern California college students to study the impact of UV photoaging photographs and data on the sun protection plans and behaviors of young adults, and whether sunless-tanning lotion might play a role in sun-protective behavior. Of the 146 volunteers, 91.1% completed the "surprise" 1-month follow-up. The intervention consisted of volunteers being shown a UV facial photo and short video illustrating the etiology and results of photoaging. The investigators found that the UV photographic intervention was successful insofar as significantly better sun protection strategies and behaviors were employed by the test group, compared with controls. In addition, they noted that those who used sunless-tanning lotion were more likely to exhibit extensive sun-protective behavior, compared with individuals who received the intervention alone. The authors suggested that such interventions represented a cost-effective approach that might yield behaviors with long-term health benefits in the form of a lower incidence of skin cancer (Arch. Dermatol. 2005;141:373-80).

Later that year, Sheehan and Lesher reported on their anonymous survey of 121 adults (107 women and 14 men) who received spray-on sunless-tanning treatments between February and May 2004. Most reported that sunless tanning had not or would not affect their use of sunscreen or time spent outdoors. Interestingly, though, 73% of the respondents who had used tanning beds indicated that they had reduced or would reduce their use of indoor tanning. The researchers concluded that practitioners should recommend sunless tanning to their patients who use conventional tanning beds as a way to lower their solar exposure and risk of skin cancer (South. Med. J. 2005;98:1192-5).

In 2006, Brooks et al. reported on their July 2004, greater Boston, cross-sectional survey of 448 nonrandomly selected people aged 18-30 years on the subjects of artificial tanning products, recent history of sunburns, and tanning-bed use. During the preceding year, 22% of respondents had used sunless-tanning products and the same percentage hadn’t but would consider using them in the next year. Users of these lotions were more likely to have been severe burners and, after controlling for skin type, the investigators found that previous and potential users were more likely to have experienced sunburns during the summer and to have used tanning beds than were respondents who had neither used nor planned to use sunless tanners. The researchers concluded that the option of sunless tanning did not seem to lower the incidence of sunburn or the use of tanning beds. Further, they urged caution in offering broad support for artificial tanning products, even though looking for alternatives to UV exposure is to be encouraged (J. Am. Acad. Dermatol. 2006;54:1060-6).

A 2007 study using data from 5,491 completed interviews as part of the National Cancer Institute’s HINTS (Health Information National Trends Survey) 2005 set out to determine the prevalence of sunless-tanning formulation use and to understand the relationship between sunless tanning, indoor tanning, and sun-protective behavior. In so doing, the investigators found that the use of sunless-tanning products was relatively rare, with an estimated 11% of U.S. adults claiming to have used such products in the previous year. Of this group, 13% used sunless tanners more than 25 times; 12% used them 11-24 times; 35% used them 3-10 times; and 40% used them just once or twice. Users and exclusive users were more likely to be women, well educated, and living in the West (J. Am. Acad. Dermatol. 2007;56:387-90).

Recent Cause for Pause

In 2008, Jung et al. used the electron spin resonance spectroscopy–based radical sun protection factor, which measures free-radical reactions in skin biopsies during UV exposure and can determine the protective effect of UV filters and sunscreens, to analyze three different self-tanning agents, including DHA. Noting that the reaction of the reducing sugars in such products and amino acids (Maillard reaction) in the skin layer engendered Amadori products that created free radicals during UV irradiation, the investigators reported that in DHA-treated skin, more than 180% additional radicals were produced during sun exposure, compared with untreated skin. They concluded that the use of self-tanners necessitated reducing solar exposure duration (Spectrochim. Acta A. Mol. Biomol Spectrosc. 2008;69:1423-8). Consequently, DHA users would be well advised to wait at least 24 hours before solar exposure following application of sunless lotion or spray (Dermatol. Clin. 2009;27:149-54).

Conclusion

In addition to the need to continually persuade patients to engage in skin-protective behavior – namely, limiting sun exposure, avoiding peak-time exposures, wearing wide-brimmed hats and clothing with SPF value, and using sunscreens (preferably those containing avobenzone, Mexoryl, zinc oxide, or titanium dioxide) every day – it is incumbent upon dermatologists to disabuse our patients of the idea that untanned skin is less attractive or, conversely, that tans should be equated with attractive skin. Although healthy messages (that there is no such thing as a healthy tan, and that a tan indicates skin damage) are slowly spreading, sunless tanners appear to be a medically and cosmetically acceptable intermediary step, far surpassing the patently detrimental effects of indoor tanning. That said, patients should be advised to refrain from solar exposure for a full 24 hours after applying sunless tanners. Furthermore, much more research is necessary to truly establish that DHA delivers even modest protection from UVA or UVB. Accordingly, patients should be counseled that sunless tanners do not suffice as a base, nor do they justify extended solar exposure, and that sunscreens should also be applied.

This column, "Cosmeceutical Critique," regularly appears in Skin & Allergy News, an Elsevier publication. Dr. Baumann is in private practice in Miami Beach. To respond to this column, or to suggest topics for future columns, e-mail Dr. Baumann.