INDOOR TANNING CERTIFICATION MANUAL

A Training Program For Indoor Tanning Facility Owners And Operators

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Course Director: Rick Mattoon

rick@tanningprogram.com

Published 2004, American Tanning Institute

24833 N. 36th Avenue Glendale, AZ 85310

Toll Free (866) 869-6790 / Fax (623) 298-5667 info@TanningProgram.com / www.TanningProgram.com

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Table Of Contents ________________________________________________________________________ ▪ Introduction To The Program Page3 ▪ Indoor Tanning Specialist Code of Ethics Page 4 ▪ Chapter 1 Your Skin And The Tanning Process Page 5 ▪ Chapter 2 UV Light In The Tanning Process Page 11 ▪ Chapter 3 Indoor Vs. Outdoor Exposure Page 14 ▪ Chapter 4 Photosensitive Reactions Page 16 ▪ Chapter 5 Adverse Effects of Overexposure to UV Light Page 28 ▪ Chapter 6 The Eyes And UV Light Page 31 ▪ Chapter 7 Tanning Salon Procedures Page 34 ▪ Chapter 8 Federal Guidelines For Indoor Tanning Page 38 ▪ Chapter 9 State Indoor Tanning Regulations Page 46

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Introduction To The Course _______________________________________________________________________

American Tanning Institute (ATI) developed this program as an important educational resource for the indoor tanning professional. With our indoor tanning certification program, you�ll find indoor tanning education more accessible and comprehensive. Our tanning program is available worldwide and is offered in formats that meet the requirements of each state across the U.S. North Carolina, South Carolina, Louisiana and Oregon require that you take a course like ours in a classroom setting. If you happen to live in any of those states, please go to the tanning regulations page on our website at www.TanningProgram.com for information on how to contact your state regulatory office for a list of courses offered in your area. Staff at ATI have carefully selected the educational material available through this program. We are confident that the material we offer will help you develop a tanning facility that is professional, profitable and compliant with federal and state regulations.

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Indoor Tanning Specialist Code of Ethics ________________________________________________________________________

� The indoor tanning specialist conducts himself or herself in a professional manner, responds to customer needs and supports colleagues and associates in providing quality customer service.

� The indoor tanning specialist acts to advance the principal objective of the indoor tanning industry to provide services to clients with full respect for their overall well-being.

� The indoor tanning specialist practices tanning techniques founded upon theoretical knowledge and concepts, uses equipment and accessories consistent with the purpose for which they were designed and employs procedures and techniques appropriately while adhering to local, state, and federal guidelines.

� The indoor tanning specialist assesses situations; exercises care, discretion and judgment; assumes responsibility for professional decisions; and acts in the best interest of the client.

� The indoor tanning specialist uses equipment and accessories, employs techniques and procedures, performs services in accordance with an accepted standard of practice and demonstrates expertise in offering moderate, sensible and responsible amounts of ultraviolet exposure to the client, self and other members of the tanning facility.

� The indoor tanning specialist practices ethical conduct appropriate to the indoor tanning industry and protects the clients right to moderate, sensible and responsible exposure to ultraviolet radiation during the tanning session.

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Chapter 1 Your Skin And The Tanning Process ________________________________________________________________________

The Skin

Although the skin is less complicated than most other organs, it is still one of the most architecturally advanced of all. It covers the entire body and accounts for about 7% of our total body weight, making it the largest organ. It has been estimated that every square centimeter (cm) of skin contains 70 cm of blood vessels, 55 cm of nerves, 100 sweat glands, 15 oil glands, 230 sensory receptors, and about 500,000 cells that are constantly dying and being replaced.

The skin, which varies in thickness from 1.5 to 4 millimeters (mm) or more in different regions of the body, has two distinct layers. The outer layer is the epidermis, a thick membranous tissue. Located below the epidermis is the dermis, a fibrous connective tissue. And, just below the dermis lies a fatty layer called the hypodermis. Although the hypodermis is usually not thought of as part of the skin or integumentary system, it shares some of the skins functions and will be discussed in this chapter.

The skin performs many functions, most but not all of are protective. It cushions and insulates the deeper body organs and protects the entire body from physical damage like bumps and cuts. The skin also offers helpful protection from harmful chemicals, thermal damage (heat and cold), and invading bacteria. The epidermis is waterproof, preventing unnecessary loss of water across the body surface. The skins rich abundance of blood flow and sweat glands regulate the loss of heat from the body, helping to control body temperature. The skin also acts as a mini-excretory system: Urea, salts, and water are lost as sweat. Skin also reduces ultraviolet (UV) rays from the sun, and its epidermal cells use these UV rays to synthesize vitamin D. Finally, the skin contains sensory organs called sensory receptors that are associated with nerve endings. By sensing touch, pressure, temperature, and pain, these receptors keep us aware of what is happening at the body surface. As this chapter describes the anatomy of the skin, we will explore its function in greater detail.

HYPODERMIS

Just below the skin is the fatty layer of the hypodermis (�below the skin� in Greek). This layer is also called the subcutaneous layer (�below the skin� in Latin). It consists of both areolar and adipose connective tissue, although the adipose tissue normally dominates. Besides storing fat, the hypodermis anchors the skin to the underlying structures (mostly to muscles) and allows the skin to slide relatively freely over those structures. Sliding skin protects us by ensuring most blows just glance off our bodies. The hypodermis is

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also and insulator: Since fat is a poor conductor of heat, it helps prevent heat loss from the body. The hypodermis thickens distinctly when one gains weight, but this thickening occurs in different body areas in the two sexes. In females, subcutaneous fat accumulates first in the thighs and breasts, whereas in males it first accumulates in the front abdominal area.

DERMIS

The dermis, the second major layer of the skin, is a strong, flexible connective tissue. The cells in the dermis are identical to those of any connective tissue in the body. The dermis binds the body together like a body stocking. This layer is your �hide� and is the same as animal hides made to make leather products.

The dermis is richly supplied with nerve fibers and blood vessels. The blood vessels of the dermis are so extensive that it can hold 5% of all blood in the body. When organs, such as exercising muscles, need more blood, the nervous system constricts the blood vessel located in the dermis. This shunts more blood into the general circulation, making it available to the muscles and other organs. On the other hand, the dermal blood vessels swell with warm blood on hot days, allowing heat to radiate from the body creating a cooling effect.

The collagen fibers of the dermis give skin its strength and resilience. Thus, many jabs and scrapes usually do not penetrate the tough dermis. Furthermore, elastic fibers in the dermis provides the skin with stretch and recoil properties.

The deeper part of the dermis is responsible for markings on our skin surface called flexure lines. These lines are easily observed as the deep skin creases on the palms. Flexure lines result from a continual folding of the skin, often over joints, where the dermis attaches tightly to underlying structures. Flexure lines are also visible on the wrists, soles of the feet, fingers, and toes.

EPIDERMIS

The epidermis contains four distinct types of cells: keratinocytes, melanocytes, Merkel cells, and Langerhans cells. Keratinocytes are by far the most abundant cells of these, so we will discuss them first. We will discuss the other types of cells later as we examine the various layers of the epidermis.

Keratinocytes

The chief role of the keratinocytes is to produce keratin, a tough fibrous protein that gives the epidermis its protective properties. Tightly connected to one another by a large number of desmosomes, the keratinocytes arise in the deepest part of the epidermis from cells that undergo almost continuous mitosis, or cell division. As these cells are pushed toward the skin surface by the production of new cells beneath them, they manufacture

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the keratin that eventually fills their cytoplasm. The cytoplasm makes up the bulk of the cell and is located between the outer layer of the cell and the nucleus.

By the time the keratinocyte reaches the skin surface, they are dead, flat sacs completely filled with keratin. Millions of these dead cells rub off every day, giving us an entirely new epidermis every 30 to 45 days-the average time from �birth� of a keratinocyte to its final wearing away. In the normal healthy epidermis, the production of new cells balances the loss at the surface of the skin. Where the skin experiences friction, both cell production and keratin formation are accelerated.

Layers of the Epidermis

In thick skin, which covers the palms of the hand and soles of the feet, the thickened epidermis consists of five layers, or strata. In thin skin, which covers the rest of the body, only four strata are present.

1. Stratum Basale (Basal Layer)

The stratum basale, the deepest layer of the epidermis, is firmly attached to the dermis along a wavy borderline. Also called the germinating layer, this stratum consists of a single row of cells representing the youngest keratinocytes. These cells divide rapidly. Occasional Merkel cells are seen among the keratinocytes. Each semi-circular Merkel cell is closely associated with a disc-like sensory nerve ending and may serve as a receptor for touch.

Between 10% and 25% of the cells in the stratum basale are melanocytes (�melanin cells�). These make the dark skin pigment melanin. The spider-shaped melanocytes have many branching processes that reach and touch all of the keratinocytes in the basal layer. Melanin is made in membrane-lined granules and then transferred through the cell processes to nearby keratinocytes. Consequently, the basale keratinocytes contain more melanin than do the melanocytes themselves. The melanin granules accumulate on the surface of each keratinocyte, forming a shield of pigment over the nucleus. In Caucasians, the melanin disappears a short distance above the basal layer, where it is digested by lysosomes in the keratinocytes. In black skinned individuals, no such digestion occurs, so melanin occupies keratinocytes throughout the epidermis. Although black skinned individuals have darker melanin and more pigment in each melanocyte, they do not have more melanocytes in their skin. In all but the darkest people, melanin builds up in response to ultraviolet rays, the response that we know as suntanning.

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2. Stratum Spinosum (Spiny Layer)

The stratum spinosum is several cell layers thick. Mitosis, or cell production through division, occurs here, but less frequently than in the basal layer. Under microscopic imaging, the keratinocytes in this layer have many spine-like extensions.

Scattered among the keratinocytes of the stratum spinosum are Langerhans cells. These star-shaped cells are particulate ingesting microphages that help activate the immune system.

3. Stratum Granulosum (Granular Layer)

The thin stratum granulosum consists of three to five layers of flattened kearatinocytes. These keratinocytes contribute to the formation of keratin in the upper layers of the epidermis. This keratin contains a waterproofing material that is secreted into the areas between the cells and is the major factor for slowing water loss from the epidermis. Further more, the external wall of the cells thicken, so that they become more resistant to destruction. You might say that the keratinocytes are �toughening up� to make the outer layers of the epidermis the strongest.

4. Stratum Lucida (Clear Layer)

The stratum lucida only occurs in thick skin, not thin skin. This layer consists of a few rows of flat dead keratinocytes. Electron microscopes show that its cells are identical to cells at the stratum corneum, the next layer.

5. Stratum Corneum (Horny Layer)

The most external part of the epidermis, the stratum corneum, is many cells thick. This layer is far thicker in thick skin than in thin skin. Its dead cells are flat sacs completely filled with keratin, because their nuclei and organelles were digested away by the lysosome enzymes upon cell death. Both the keratin and the thickened plasma membranes of the cells in the stratum corneum protect the skin against abrasion and penetration. It is amazing that a dead layer of cells can still perform such important functions.

The cells of the stratum corneum are referred to as horny cells. These cells are the dandruff shed from the scalp and the flakes that come off dry skin. The average person sheds about 40 pounds of these flakes in a lifetime. The common saying �Beauty is only skin deep� is especially interesting in the light of the fact that nearly everything we see when we look at someone is dead!

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Skin Color

Three pigments contribute to skin color: melanin, carotene, and hemoglobin. Carotene is a yellow to orange pigment derived from certain plant products, such as carrots. It tends to accumulate in the stratum corneum of the epidermis and in fat tissue of the hypodermis. Color derived from carotene is most obvious in the palms and soles, where the stratum corneum is thickest.

The pink tone of Caucasian skin reflects the red color of oxygenated hemoglobin in the capillaries of the dermis. Since Caucasian skin contains little melanin, the epidermis is nearly transparent in untanned individuals and allows blood�s color to show through more predominantly.

Melanin, the most prominent pigment and is made from an amino acid called tyrosine. Melanin ranges in color from yellow to reddish to brown to black. Its production depends on an enzyme in melanocytes called tyrosinase. Freckles and pigmented moles are localized accumulations of melanin.

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Anatomy Of The Skin

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Chapter 2 UV Light And The Tanning Process ________________________________________________________________________

Light is a form of energy radiated by moving charged particles. Light from the sun provides the energy needed for plant growth. Plants convert the energy in sunlight into storable chemical form through a process called photosynthesis.

Scientists have learned through experimentation that all light, visible or not, behaves like a particle at times and like a wave at other times. These particle-like features are called photons. Photons are different from particles of matter in that they don�t have any mass and always move at the constant speed of 186,000 miles per second (the speed of light).

When light bends slightly as it passes around a corner, it shows wavelike behavior. The waves associated with light are called electromagnetic waves because they consist of changing electric and magnetic waves.

Wavelength

The distance between two consecutive (one after another) crests or troughs of a wave is called the wavelength. The wavelength can be measured from any point on a wave as long as it is measured to the same point on the next wave.

Frequency

The number of complete waves, or complete cycles, per unit of time is called the frequency. Because every complete wave has one crest and one trough, you can think of the frequency as the number of crests or troughs produced per unit time. The unit used to measure wave frequency is called the hertz (Hz). The frequency of a wave depends on the frequency at which its source is vibrating. Frequency, which is often used to describe waves, is an important characteristic. Frequency is used to distinguish one color of light from another, as well as one sound from another. For example, red light is different from blue light because red light has a lower frequency. A dog can hear a whistle that you cannot hear because dogs can hear sounds at higher frequencies than humans can.

Electromagnetic Spectrum

You actually know more about the electromagnetic spectrum than you may think! The electromagnetic (EM) spectrum is just a name that scientists give a bunch of types of light or radiation when they want to talk about them as a group. Radiation is energy that travels and spreads out as it goes�visible light that comes from a lamp in your house or ultraviolet radiation emitted from a tanning bed are two types of electromagnetic

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radiation. Other examples of EM radiation are microwaves, infrared and X-rays and gamma-rays. Electromagnetic Spectrum

SPECTRUM APPROXIMATE WAVELENGTH

X-Ray 0.1 - 100 angstroms Vacuum 10 - 200 nanometers Ultraviolet C (UVC) 200 - 290 nanometers Ultraviolet B (UVB) 290 - 320 nanometers Ultraviolet A (UVA) 320 - 400 nanometers Visible light 400 - 700 nanometers Near Infrared 0.74 - 1.5 micrometers Middle Infrared 1.5 - 5.6 micrometers Far Infrared 5.6 - 1,000 micrometer Microwave/Radiowaves greater than one millimeter

As you can see from the above chart, the useful unit of measure for the tanning rays of ultraviolet radiation is the nanometer (nm). Radiations shorter than 10 nanometers (i.e. gamma rays or X-rays) generally ionize molecules (remove electrons) producing positively or negatively charged ions and are, therefore, known as ionizing radiation. Ultraviolet radiation is absorbed by molecules and is known as nonionizing radiation.

Sunlight is the most common source of ultraviolet radiation (UVR) but there are also many other sources such as indoor tanning devices. UVR emitting artificial light sources can be produced to generate any of the UVR wavelengths by using the appropriate materials and energies.

Ultraviolet radiation is divided into 3 categories:

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UVA 320 nm to 400 nm UVB 290 nm to 320 nm UVC 200 nm to 290 nm

UVA

Ultraviolet A is the closest to the wavelengths of visible light. The waveband is from about 320 nm to 400 nm. UVA is mostly responsible for the oxidation or darkening of existing melanin within the epidermis.

UVB

Ultraviolet B has a shorter wavelength, more energetic wave. It is the main cause of erythema (sunburn) but is also the basis of delayed tanning. UVB wavelengths are from about 290 nm to 320 nm and stimulates the tanning response, especially the delayed tanning response, as discussed below.

UVC

This band of ultraviolet light is the shortest of the three. Although not used in the indoor tanning process, it can be used for sterilization and germicidal application. It can cause skin injury on exposure of relatively short duration. UVC from the sun is completely absorbed by the earth�s ozone layer at present, however, as the ozone loss occurs there is an increasing possibility that this energy will penetrate to the earth surface.

*Remember: UVC is not used in the tanning process.

Ultraviolet Light And Your Skin

Tanning is the natural response of the skin to Ultraviolet light exposure. There are two types of tanning which occur. The first is known as Immediate Pigment Darkening which occurs during ultraviolet exposure and increases until exposure ends. It occurs in response to both UVA and certain visible wavelengths. No melanin production is involved. This response depends on various factors including previous exposure and skin pigmentation type. Darker skin will produce a more pronounced effect.

The second type is called Delayed Tanning. Delayed tanning occurs 48 -72 hours after exposure and increases for 7 - 10 days. Duration depends on various factors including repeat exposure and may last for several weeks or months. This result is due in part to an increase in the size of melanin containing cells (melanocytes) in the skin and the increase in melanosomes within these cells. Many studies show that this may serve to protect the skin from UVA and UVB damage due to overexposure. Both of these bands will produce delayed tanning, however, much less UVB is required to produce the effect.

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Chapter 3 Indoor Vs. Outdoor Exposure _______________________________________________________________________

Indoor tanners are at a great advantage by having access to the control that goes into the indoor tanning process. In addition to various state and local regulations in place, national guidelines set by the Federal government enhance the controllable factors involved in indoor tanning. Since 1986, the Performance Standards For Sunlamp Products have been in place to cover many of the following aspects of indoor tanning:

• Timer control • Protective eyewear • Temperature control • Electrical safety • Protection from lamps • Equipment access and support, and more

VARIABLES INVOLVED IN OUTDOOR ULTRAVIOLET EXPOSURE

1. Solar elevation (height of the sun in the sky)

The intensity of outdoor ultraviolet light (the sun), and especially UVB, depends on the height of the sun in the sky. This will vary depending on the season of the year, time of day and latitude in which you live. UV intensities are highest during the summer months in the 4-hour period around noon (or 13:00 if daylight saving is in effect).

UVB intensity varies more with the time of the day than does UVA. As a rule of thumb �when your shadow is shorter than your own height� you may receive half or more of UVB during the 4 hours around solar noon on a clear summer day. In summer at noontime, UVB is two to three times more intense in equatorial areas than in northern Europe. At about 600 latitude the total UVB exposure during the months of January and February can be less than one clear day�s exposure around midsummer.

2. Latitude and Altitude

The UV intensity at the earth�s surface is related to the angle at which the UV rays pass through the atmosphere. In the tropics (close to 00 latitude, or near the equator) solar UV is more intense because it has less distance to travel through the atmosphere to the earth�s surface.

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UV intensities increase with altitude. This is because the amount of atmosphere available to absorb UV is reduced, and so more and shorter wavelength UV is able to reach higher altitude areas. In high altitudes, skiers can be exposed to higher intensities of UV, especially as snow is an excellent reflector.

3. Atmospheric Scattering

Solar UV is composed of direct and scattered radiation. The sky looks blue because the blue rays from sunlight are highly scattered by the atmosphere. UV is scattered even more than blue light, and this can lead to an increase in a person�s exposure.

4. Clouds and Haze

UV intensities are highest under cloudless skies. Clouds generally reduce UV intensity, but light or thin clouds have little effect and under certain conditions may even enhance the UV intensity. Hazy days generally have higher amounts of water vapor; UV scatter in the atmosphere increases and can result in a higher personal UV exposure. Thus, even though haze or cloud cover can cause one to feel cooler, the UV exposure can still be high.

5. Ground reflection

The reflective properties of the ground have an influence on UV exposure. Most natural surfaces such as grass, soil and water reflect less than 10% of incident UV. However, fresh snow strongly reflects (80%) UV. During spring in higher altitudes, under clear skies, reflection from snow could increase UV exposure levels to those encountered during summer. Sand also reflects (10-25%) and can significantly increase UV exposure at the beach.

Reflected UV is a key source of exposure to the eye. Acute effects, such as snow-blindness while skiing or photokeratitis at the beach, can result from UV reflected from snow or sand respectively.

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Chapter 4 Photosensitive Reactions ______________________________________________________________________

The pharmacist is in a unique position to counsel tanning consumers on both prescription and non-prescription medications, herbal and other �natural� products and perhaps even cosmetics, shampoos and similar purchases that may make people sensitive to ultraviolet light. This is also known as photosensitivity. Many medications and topical products can cause photosensitive reactions or increase a person�s risk of developing sunburn. This chapter will describe photosensitive reactions, discuss what people are most at risk, and list the medications, common herbal products and topical agents most likely to cause these reactions.

What is a drug-induced photosensitivity reaction?

A drug-induced photosensitive reaction most commonly appears as an exaggerated sunburn. It occurs when a person takes certain medications or applies, either intentionally or unintentionally, offending substances to the skin and is exposed to ultraviolet radiation. A photosensitive reaction should be considered in people experiencing sunburn of greater severity than would normally be expected for them, or who develop rashes in areas exposed to the sun or tanning unit.

How common are drug-induced photosensitive reactions?

Drug-induced photosensitive reactions are not uncommon, and are actually increasing in frequency with the increased emphasis on health that includes outdoor exercise during both the summer and winter, and, because sunbathing and the use of tanning salons continue to be popular. People are living longer and are likely to retire to sunny climates, which usually increases exposure to the ultraviolet light; older �seasoned citizens� also tend to take more medications, many of which may be implicated in drug-induced photosensitive reactions. The use of herbal and other �natural� products is also increasing, and people may not be aware that some of these can also cause photosensitive reactions. Photosensitive chemicals are widely used in medications, cosmetics, lotions, shampoos, hair dyes, soaps and other topical products.

Who experiences drug-induced photosensitive reactions?

As discussed above, drug-induced photosensitive reactions are quite common and can occur in virtually anyone, though to widely varying degrees of severity. People with fair complexions; red, blonde or light brown hair; blue or green eyes; and who generally sunburn easily and do not tan are most at risk. A history of severe sunburn(s) may also increase the risk, as may a history of allergies, especially contact hypersensitivities, to

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cosmetics or other topical agents. The frequency, type and amount of UVR the person is likely to receive should also be considered. For example, a person who receives only casual exposure to sunlight outside its most intense hours of 10 a.m to 3 p.m. would be less likely to have a reaction than would someone who routinely sunbathes or visits a tanning salon.

Are all drug-induced photosensitive reactions the same?

Drug-induced photosensitive reactions, which include reactions caused by medications, herbal products or other agents either intentionally or unintentionally applied to the skin, can be divided into two types, phototoxic and photoallergic reactions. The same medication or agent may produce both phototoxic and photoallergic reactions, and it can sometimes be difficult to differentiate between the two types of reactions clinically.

By far, the most common type of induced photosensitive reaction is the phototoxic type, where the offending substance is thought to act as a chromophore, absorbing ultraviolet radiation. When the chromophore reaches a sufficient concentration in or on the skin, and when the skin is exposed to the appropriate wavelength of ultraviolet radiation, energy is emitted which damages the adjacent tissue to cause a phototoxic reaction. The wavelength of radiation necessary to produce such a reaction depends on the absorption spectrum of the offending substance.

Phototoxic Reactions are dose-dependent, and will occur in almost any one who takes or applies an adequate amount of the offending substance. The dose necessary to produce such a reaction varies from person to person, and will depend upon such factors as complexion, hair and eye color, usual ability to tan (skin type) and the amount of ultraviolet radiation exposure. Phototoxic photosensitive reactions are not allergic reactions and can occur on first exposure to the substance.

A phototoxic reaction usually has a rapid onset (within several hours after exposure to ultraviolet radiation) and presents as an exaggerated or intensified sunburn with erythema (redness), pain and prickling or burning. Blistering, peeling and abnormally increased coloration of the skin may occur in severe cases. Symptoms usually peak 24 to 48 hours after initial exposure and are usually limited to the areas of the skin exposed to ultraviolet radiation.

In Photoallergic Reactions, the offending substance is altered in the presence of ultraviolet radiation to become antigenic and can act as a toxin. These reactions are less common and involve antigen-antibody or immune-mediated reactions. Photoallergic reactions do not occur on first exposure to the medication, but like other allergic reactions, they require prior or prolonged exposure (sensitization period) to the offending substance. Once sensitization has occurred, subsequent exposure to even small amounts of the offending substance will produce a photoallergic reaction.

Photoallergic reactions are not dose-related. They probably represent a type of delayed hypersensitivity reaction, and since time is needed for the body to mount an immune

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response, the onset of a photoallergic reaction is usually delayed for 24 hours or even several days. Recovery is also often slower than from a phototoxic reaction, with the reaction sometimes persisting for some time after the offending substance has been discontinued.

These reactions may appear as warmth and swelling, noncontagious inflammation of the skin, characterized mostly by redness, itching, and the outbreak of lesions that may discharge matter and become encrusted and scaly.

Photoallergic reactions may also be small, flat lesions which differ in color from the surrounding skin, large blisters, usually 2 cm or more In diameter. Severe hives and lesions may also develop within minutes after exposure to ultraviolet radiation. In small percentage of cases, sensitivity to light may continue even after the offending substance is discontinued.

Photoallergic reactions primarily occur on the areas of the skin that are exposed to ultraviolet radiation, but may extend beyond these to other areas. They are more common in adults than children, possibly because adults have usually been exposed to more medications and topical agents. Photoallergic reactions are more often caused by topical agents, but may also occur with systemically administered medications.

Which medications are most likely to cause photosensitivity?

Many medications and some herbal and other �natural� products have been reported to cause photosensitive reactions. In addition to topically-applied medications, cosmetics, foods and other chemicals may also produce photosensitive reactions, as may agents unintentionally applied to the skin (by handling plants, exposure to airborne allergens or wearing certain types of jewelry or leather). Some ingredients in cosmetics, perfumes, colognes, after-shaves, soaps, deodorants, lotions, shampoos, hair sprays, hair dyes, contact lens solutions and even sunscreens may also cause reactions.

Not only are the properties of the medication important, but the consumers most likely to use such products must also be considered. For example, oral contraceptives and similar hormones are commonly used by people likely to sunbathe and use tanning salons, so counseling these clients on drug-induced photosensitive reactions is especially important.

How are photosensitivity reactions diagnosed?

Although indoor tanning salon operators aren�t typically qualified to diagnose disorders, a photosensitive reaction should be considered in any client experiencing sunburn of greater severity than would normally be expected for them, or developing a rash in areas exposed to the sun or tanning unit. A trained clinician will typically diagnose based on the person�s history and clinical presentation. All prescription and non-prescription medications, herbal and other �natural� products, topical agents, cosmetics, perfumes, colognes, after-shaves, soaps, deodorants, lotions, shampoos, hair sprays, hair dyes,

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sunscreens and similar products, particularly new ones, would most likely be reviewed. Work, hobbies and other sources of unusual chemical exposures may also be considered.

How can photosensitivity reactions be prevented or minimized?

Tanning should be avoided while taking medications that commonly cause photosensitive reactions. Since some medications remain in the body for significant periods of time after discontinuation, consumers should also be careful for a few days after suspected medications are discontinued. If a person insists on spending significant time in the sun or indoor tanning, an alternate medication should be considered, if possible and under a doctor�s care.

How should photosensitivity reactions be treated?

Like sunburn, photosensitive reactions are better prevented than treated. Most photosensitive reactions can be treated the same as an ordinary sunburn, with cool wet dressings, emollients or cool baths. Oral analgesics may be helpful. Topical anesthetics should be avoided, or at least used sparingly (perhaps only at bedtime), since they may cause contact sensitization and photosensitive reactions.

Under a doctor�s care, topical corticosteroids, such as hydrocortisone, may be helpful; topical or systemic antipruritic agents may be useful in some cases, and oral diphenhydramine taken at bedtime may help the person sleep. If they experiences fever, chills, nausea, vomiting or prostration (exhaustion), a healthcare provider should be consulted. Systemic corticosteroids, such as prednisone, may be necessary to treat severe reactions.

When possible, the offending medication or other agent should be discontinued. This usually results in regression of the reaction, though this may be slow. A person experiencing a photosensitive reaction should also be careful to avoid further significant exposure to the sun and should avoid ultraviolet light, at least until the photosensitive reaction subsides and the offending substance has been stopped. Approximately 10 percent to 20 percent of people may have persistent photosensitivity for prolonged periods of time. As indoor tanning professionals, it is important that you advise your clients to seek medical attention if symptoms are severe.

The most common photosensitizing materials are listed on the following pages. This is not a list of every material that could have photosensitizing effects. Again, if there is any question about a drug or product that a client uses, have that person consult a physician or pharmacist. Remember, it is always best to error on the side of safety.

Before using the list, remember the following:

1. NOT all individuals who use or take these medications will experience a photosensitive reaction. Also, an individual who experiences a photosensitive reaction on one occasion will NOT necessarily experience it again or every time.

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2. A medication will NOT cause the same degree of skin reaction in all individuals. 3. Brand names of products should be considered only as examples; they do NOT

represent all names under which the generic product may be sold.

Jerome I. Levine, M.S., R.Ph., prepared the following list for the Federal Drug Administration. The list was published under the title �Medications That Increase Sensitivity To Light: A 1990 Listing.� The FDA has confirmed this list to be the most recent.

The mention of commercial products, their sources, or their use in connection with material reported herein is not to be construed as either an actual or implied endorsement of such products by the Department of Health and Human Services.

Reported Photosensitizing Medications

Generic Name Brand Name Therapeutic Class

Acetazolamide Diamox Anticonvulsant, Antiglaucoma diuretic

Amiloride + Hydrochlorothizide Moduretic Antihypertensive, Thiazide

diuretic Amiodarone Cordarone (15%) Antiarrhythmic Amitriptyline Elavil Antidepressant (tricyclic) Amitriptyline Endep Antidepressant (tricyclic) Amoxapine Asendin (<1%) Antidepressant (tricyclic) Astemizole Hismanal Antihistamine

Atenolol + Chlorthalidone Tenoretic Beta-adrenergic blocker Thiazide diuretic

Auranofin Ridaura Antiarthritic, Gold compound Azatadine Optimine Antihistamine Azatidine + Pseudoephedrine Trinalin Repetabs Antihistamine,

Decongestant

Bendroflumethiazide Naturetin Antihypertensive, Thiazide diuretic

Benzthiazide Exna Antihypertensive, Thiazide diuretic

Bromodiphenhydramine Ambenyl Antihistamine Brompheniramine Dimetane Antihistamine Captopril Capoten Antihypertensive Captopril + Hydrochlorothiazide Capozide Antihypertensive, Thiazide

diuretic Carbamazepine Tegretol Analgesic, Anticonvulsant

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Generic Name

Brand Name

Therapeutic Class

Chlorothiazide Diuril Antihypertensive, Thiazide diuretic

Chlorpheniramine Chlorpheniramine Antihistamine Chlorpheniramin + D-Pseudoephedrine Deconamine Antihistamine, Decongestant

Chlorpheniramine + Phenylpropanolamine Ru-Tuss II Antihistamine, Decongestant

Chlorpromazine Thorazine Antiemetic, Tranquilizer Chlorpropamide Diabinese Antidiabetic (oral), SulfonylureaChlorprothixene Taractan Antiemetic, Tranquilizer

Chlorthalidone Hygroton Antihypertensive, Thiazide diuretic

Chlorthalidone Thalitone Antihypertensive, Thiazide diuretic

Chlorthalidone + Reserpine Demi-Regroton Antihypertensive, Thiazide diuretic

Chlorthalidone + Reserpine Regroton Antihypertensive, Thiazide diuretic

Ciprofloxacin Cipro (<1%) Anti-infective Clemastine Tavist Antihistamine Clofazime Lamprene (<1%) Antibacterial, Antileprosy agent

Clonidine Chlorthalidone + Combipres Antihypertensive, Thiazide diuretic

Coal Tar Estar Gel Antipsoriatic, Eczema Coal Tar Balnetar Antipsoriatic, Eczema

Contraceptive, oral Estrogen Birth control pill, Female sex hormone

Cromolyn Intal Inhaler Antiasthmatic Cyclobenzaprine Flexeril Anti-skeletal, Muscle spasms Cyproheptadine Periactin Antihistamine, Antiserotonergic

Dacarbazine DTIC-Dome Anti-Hodgkin�s disease, Antimetabolite

Danazol Danocrine Gonadotropin inhibitor Demeclocycline Declomycin Antibiotic Desipramine Norpramin Antidepressant (tricyclic) Desipramine Pertofrane Antidepressant (tricyclic) Dexchlorpheniramine Polaramine Antihistamine

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Diclofenac Voltaren (<1%) NSAID,* antiarthritic Diflunisal Dolobid (<1%) NSAID,* antiarthritic Diltiazem Calcium channel blocker Cardizem (<1%) Antianginal, Antihypertensive

Diphenhydramine Benadryl Antihistamine Diphenylpyraline Hispril Spansule Antihistamine Doxepin Sinequan Antidepressant (tricyclic) Doxycycline Vibramycin Antibiotic Doxycycline Hyclate Doryx Antibiotic Enalapril Vasotec Antihypertensive Enalapril + Hydrochlorothiazide Vaseretic Antihypertensive, Thiazide

diuretic Erythromycin Ethylsuccinate + Sulfisoxazole

Pediazole Antibiotic

Estrogens Contraceptive, oral Female sex hormone Generic Name Brand Name Therapeutic Class Etretinate Tegison Antipsoriatic Floxuridine FUDR Injectable Antimetabolite, Antineoplastic Flucytosine Ancobon Antifungal Fluorouracil Adrucil Antineoplastic Fluorouracil Efudex Antineoplastic Fluorouracil Fluorouracil Antineoplastic Fluphenazine Prolixin Antipsychotic, Tranquilizer Fluphenazine Permitil Antipsychotic, Tranquilizer Flurbiprofen Ansaid NSAID,* antiarthritic

Flutamide Eulexin Antimetastatic (prostatic carcinoma)

Furosemide Lasix Antihypertensive, Diuretic Gentamicin Garamycin Antibiotic Glipizide Glucotrol Antidiabetic (oral), SulfonylureaGlyburide Diabeta Antidiabetic (oral), SulfonylureaGlyburide Micronase Antidiabetic (oral), SulfonylureaGold Salts (compounds) Solganal Antiarthritic, Gold compound Gold Sodium Thiomalate Myochrysine Antiarthritic, Gold compound Griseofulvin Fulvicin U/F Antibiotic, Antifungal Griseofulvin Ultramicrosize Grisactin Ultra Antibiotic, Antifungal

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Guanethidine + Hydrochlorothiazide Esimil Antihypertensive, Thiazide

diuretic Haloperidol Haldol Antipsychotic, Tranquilizer Hexachlorophene Phisohex Antibacterial Hydralazine + Hydrochlorothiazide Apresazide Antihypertensive, Thiazide

diuretic

Hydralazine Apresoline-Esidrix Antihypertensive, Thiazide diuretic

Hydrochlorothiazide Esidrix Antihypertensive, Thiazide diuretic

Hydrochlorothiazide Hydrodiuril Antihypertensive, Thiazide diuretic

Hydrochlorothiazide Oretic Antihypertensive, Thiazide diuretic

Hydrochlorothiazide Oreticyl Antihypertensive, + Deserpidine Thiazide diuretic

Hydrochlorothiazide + Triamterene Dyazide Antihypertensive, Thiazide

diuretic

Hydrochlorothiazide Maxzide Antihypertensive, Thiazide diuretic

Hydroflumethiazide Diucardin Antihypertensive, Thiazide diuretic

Hydroflumethiazide Saluron Antihypertensive, Thiazide diuretic

Hydroflumethiazide + Reserpine

Salutensin/Salutensin-Demi

Antihypertensive, Thiazide diuretic

Ibuprofen Advil (<1%) NSAID,* antiarthritic Ibuprofen Motrin (<1%) NSAID,* antiarthritic Imipramine Tofranil Antidepressant (tricyclic) Indapamide Lozol Antihypertensive, Diuretic Interferon ALFA-2B Intron A (<1%) Antiviral agent Isocarboxazid Marplan Antidepressant, MAO inhibitor Isotretinoin Accutane Antiacne Ketoprofen Orudis (<1%) NSAID,* antiarthritic Generic Name Brand Name Therapeutic Class Labetalol + Hydrochlorothiazide Normozide Beta- and alpha-adrenergic

blocker, Thiazide diuretic

� � Trandate HCT Beta- and alpha-adrenergic blocker, Thiazide diuretic

Lisinopril + Hydrochlorothiazide Prinzide Antihypertensive, Thiazide

diuretic

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� � Zestoretic Antihypertensive, Thiazide diuretic

Lovastatin Mevacor Anticholesterol Maprotiline Ludiomil Antidepressant Meperidine + Promethiazine Mepergan Narcotic analgesic

Mesoridazine Serentil Antipsychotic, Tranquilizer Methacycline Rondomycin Antibiotic Methazolamide Neptazane Antiglaucoma Methdilazine Tacaryl Antihistamine, Antipruritic Methotrexate Folex Antimetabolite, Antipsoriatic � � Methotrexate Antimetabolite, Antipsoriatic � � Mexate & Mexate-AQ Antimetabolite, Antipsoriatic

Methyclothiazide Aquatensen Antihypertensive, Thiazide diuretic

� � Enduron Antihypertensive, Thiazide diuretic

Methyclothiazide + Deserpidine Enduronyl Antihypertensive, Thiazide

diuretic Methyclothiazide + Reserpine Diutensen-R Antihypertensive, Thiazide

diuretic Methyldopa + Hydrochlorothiazide Aldoril Antihypertensive, Thiazide

diuretic Methyldopa + Chlorothiazide Aldoclor Antihypertensive, Thiazide

diuretic

Metolazone Diulo Antihypertensive, Thiazide diuretic

� � Mykrox Antihypertensive, Thiazide diuretic

� � Zaroxolyn Antihypertensive, Thiazide diuretic

Metoprolol + Hydrochlorothiazide Lopressor HCT Beta-adrenergic blocker,

Thiazide diuretic Minocycline Minocin Antibiotic Minoxidol Rogaine Hair growth stimulator Nabilone Cesamet Antiemetic, Antinausea Nadolol + Bendroflumethiazide Corzide Antihypertensive, Beta-

adrenergic blocker Nalidixic Acid NegGram Antimicrobial Naprosyn Anaprox NSAID,* antiarthritic

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� � Naproxen NSAID,* antiarthritic

Nifedipine Adalat Antianginal, Antihypertensive, Calcium channel blocker

� � Procardia Antianginal, Antihypertensive, Calcium channel blocker

Norfloxacin Noroxin Antibacterial Nortriptyline Pamelor Antidepressant (tricyclic) Oxytetracycline Terramycin Antibiotic Perphenazine Trilafon Antipsychotic, Tranquilizer Perphenazine + Amitriptyline Etrafon Antidepressant (tricyclic)

Tranquilizer

Generic Name

Brand Name

Therapeutic Class Phenylbutazone Butazolidin NSAID,*antiarthritic Phenylpropanolamine + Chlorpheniramine Ornade Spansule Antihistamine, Decongestant

Phenylpropanolamine + Pheniramine + Pyrilamine Triaminic TR Decongestant, Antihistamine

Phenytoin Dilantin Anticonvulsant Piroxicam Feldene NSAID,* antiarthritic

Polythiazide Renese Antihypertensive, Thiazide diuretic

Prazosin + Polythiazide Minizide Antihypertensive, Thiazide diuretic

Prochlorperazine Compazine Antinausea, Anti-vomiting Promethazine Phenergan Antihistamine Propranolol + Hydrochlorothiazide Inderide Beta-adrenergic blocker,

Thiazide diuretic Protriptyline Vivactil Antidepressant (tricyclic) Pyrazinamide Pyrazinamide Anti-infective, Antituberculosis Quinethazone Hydromox Antihypertensive, Diuretic Quinidine Gluconate Quinaglute Dura-Tabs Antiarrhythmic Quinidine Sulfate Quindex Extentabs Antiarrhythmic � � Quinora Antiarrhythmic Quinine Quinamm Antiprotozoal Rauwolfia + Serpentina + Bendroflumethiazide Rauzide Antihypertensive, Thiazide

diuretic

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Reserpine + Chlorothiazide Diupres Antihypertensive, Thiazide diuretic

Reserpine + Hydrochlorothiazide Hydropres Antihypertensive, Thiazide

diuretic

� � Serpasil-Esidrix Antihypertensive, Thiazide diuretic

Reserpine + Hydralazine + Hydrochlorothiazide Ser-Ap-Es Antihypertensive, Thiazide

diuretic

Selegiline Eldepryl Anti-Parkinsonism, MAO inhibitor

Spironolactone + Hydrochlorothiazide Aldactazide Antihypertensive, Thiazide

diuretic Sulfacytine Renoquid Antibiotic Sulfadoxine + Pyrimethamine Fansidar Antimalarial, Antiprotozoal

Sulfamethizole + Phenazopyridine Thiosulfil-A Urinary analgesic, Antibiotic

Sulfamethoxazole Gantanol Antibiotic Sulfamethoxazole + Phenazopyridine Azo Gantanol Antibiotic, Urinary analgesic

Sulfapyridine (Generic only) Dermatitis herpetiformis suppressant

Sulfasalazine Azulfidine Bowel anti-inflammatory

Sulfinpyrazone Anturane Antigout agent, Antihyperuricemic

Sulfasoxazole Gantrisin Antibiotic Sulfasoxazole + Phenazopyridine Azo Gantrisin Antibiotic, Urinary analgesic

Sulfone Dapsone Antileprosy, Antimalarial Sunlindac Clinoril (<1%) NSAID,* antiarthritic Terfenadine Seldane Antihistamine

Tetracycline Achromycin

Antibiotic

Generic Name Brand Name Therapeutic Class Thioridazine Mellaril Antipsychotic, Tranquilizer Thiothixene Navane Antipsychotic, Tranquilizer Timolol + Hydrochlorothiazide Timolide Beta-adrenergic blocker,

Thiazide diuretic

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Tolazamide Tolinase Antidiabetic (oral), SulfonylureaTolbutamide Orinase Antidiabetic (oral), SulfonylureaTretinoin Retin-A Antiacne (topical) Triamterene Dyrenium Antihypertensive Diuretic Trifluoperazine Stelazine Antipsychotic, Tranquilizer Triflupromazine Vesprin Antiemetic, Antipsychotic Trimeprazine Temaril Antipsychotic, Tranquilizer Trimethoprim Trimpex Antibiotic Trimethoprim + Sulfamethoxazole Bactrim Antibiotic

� � Septra Antibiotic Trimipramine Surmontil Antidepressant (tricyclic) Tripelennamine PBZ Antihistamine Triprolidine Actidil Antihistamine Triprolidine + Pseudoephedrine Actifed Antihistamine, Decongestant

Visblastine Velban Antieoplastic * Non-Steroidal Anti-Inflammatory Drug

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Chapter 5 Adverse Effects Of Overexposure to UV Light ________________________________________________________________________

Since the appearance of an ozone hole over the Antarctic in the early 1980s, Americans have become aware of the health threats posed by ozone depletion, which decreases our atmosphere's natural protection from the sun's ultraviolet (UV) rays. Relative to misuse of tanning devices, the information in this chapter provides an overview of the major health issues linked to overexposure to UV Light:

• Skin Cancer (melanoma and nonmelanoma) • Premature aging of the skin and other skin problems • Cataracts and other eye damage • Immune system suppression • Sunburn

Understanding these risks and following state and federal tanning guidelines as well as manufacturer instructions will help individuals to enjoy UV light while lowering their chances of UV-related health issues later in life.

Skin Cancer

The incidence of skin cancer in the United States has reached epidemic proportions. One in five Americans will develop skin cancer in their lifetime, and one American dies every hour from this devastating disease. Medical research is helping us understand the causes and effects of skin cancer. Many health and education groups are working to reduce the incidence of this disease, of which more than 1 million cases have been predicted for 2005 alone, according to The American Cancer Society.

Melanoma

Originating in the melanocytes, melanoma, the most serious form of skin cancer, is also one of the fastest growing types of cancer in the United States. Many dermatologists believe there may be a link between childhood sunburns and melanoma later in life. Melanoma cases in this country have more than doubled in the past 2 decades, and the rise is expected to continue.

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Nonmelanoma Skin Cancers

Nonmelanoma skin cancers are less deadly than melanomas. Nevertheless, left untreated, they can spread, causing disfigurement and more serious health problems. More than 1 million Americans will develop nonmelanoma skin cancer in 2005 while more than 2,000 will die from the disease. There are two primary types of nonmelanoma skin cancers. These two cancers have a cure rate as high as 95 percent if detected and treated early. The key is to watch for signs and seek medical treatment.

Basal Cell Carcinomas are the most common type of skin cancer tumors. They usually appear as small, fleshy bumps or nodules on the head and neck, but can occur on other skin areas. Basal cell carcinoma grows slowly, and rarely spreads to other parts of the body. It can, however, penetrate to the bone and cause considerable damage.

Squamous Cell Carcinomas are tumors that may appear as nodules or as red, scaly patches. This cancer can develop into large masses, and unlike basal cell carcinoma, it can spread to other parts of the body.

The list below points out some of the differences between normal moles and melanoma. Watch for these possible signs of melanoma:

A. One half of the mole does not match the other half.

B. The edges of the mole are ragged or notched.

C. The color of the mole is not the same all over. There may be shades of tan, brown, black, red, blue, or white.

D. The mole is wider than about ¼ inch.

Other Skin Disorders

Other UV-related skin disorders include Actinic Keratoses and premature aging of the skin. Actinic keratoses are skin growths that occur on body areas exposed to the sun. The face, hands, forearms, and the "V" of the neck are especially susceptible to this type of lesion. Although premalignant, actinic keratoses are a risk factor for squamous cell carcinoma. Look for raised, reddish, rough-textured growths and seek prompt medical attention if you discover them. Chronic exposure to the UV light can also cause premature aging. Since it occurs gradually, often manifesting itself many years after the majority of a person's sun exposure, premature aging is often regarded as an unavoidable, normal part of growing older. With moderate, responsible and sensible exposure to UV light, however, most premature aging of the skin can be avoided.

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Cataracts and Other Eye Damage

Cataracts are a form of eye damage in which a loss of transparency in the lens of the eye clouds vision. If left untreated, cataracts can lead to blindness. Research has shown that UV light exposed to unprotected eyes increases the likelihood of certain cataracts. Although curable with modern eye surgery, cataracts diminish the eyesight of millions of Americans and cost billions of dollars in medical care each year. Other kinds of eye damage include pterygium (i.e., tissue growth that can block vision), skin cancer around the eyes, and degeneration of the macula (i.e., the part of the retina where visual perception is most acute). All of these problems can be lessened with proper eye protection from UV light. See Chapter 6 for more information on protective eyewear.

Immune Suppression

Scientists have found that overexposure to UV light may suppress proper functioning of the body's immune system and the skin's natural defenses. All people, regardless of skin color, might be vulnerable to effects including impaired response to immunizations, increased sensitivity to sunlight, and reactions to certain medications. Sunburn Sunburns occur when the skin is exposed to excessive amounts of UV light. The severity can vary from mild pink with only minor discomfort to severe "lobster-red" burns that blister. Sunburn results when the amount of exposure to the sun or other ultraviolet light source exceeds the ability of the body's protective pigment, melanin, to protect the skin. A serious sunburn is as serious as a thermal burn, and may have the same systemic effects such as blistering, edema and fever. A sunburn is better prevented than treated. When outdoors for an extended amount of time, you should use a sunscreen. Most doctors recommend a sunscreen SPF level of 30 or greater. Whe tanning indoors, proper procedures based on manufactuerer�s suggestions should followed when determining a tanning session time. If you do get a sunburn:

• Try taking a cool shower or bath or placing wet, cold wash rags on the burn. • Avoid products that contain benzocaine, lidocaine, or petroleum (like Vaseline). • If blisters are present, dry bandages may help prevent infection. • If your skin is not blistering, moisturizing cream may be applied to relieve

discomfort.

Tanning Professionals Responsibilities

With the risks involved in individuals who overexpose themselves to UV light, it is the responsibility of the tanning salon owner and operator to eliminate the opportunity for consumers to burn while visiting an indoor tanning salon. It is also the responsibility of

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the tanning professional to make sure individuals who cannot biologically acquire a tan (skin type 1) do not tan indoors or out. The promotion of moderate, sensible and responsible exposure to ultraviolet light is always the best policy.

Chapter 6 The Eyes And UV Light ___________________________________________________________ When you look at an object, light rays are reflected from the object to the cornea, which is where the miracle begins. The light rays are bent, refracted and focused by the cornea, lens, and vitreous. The lens� job is to make sure the rays come to a sharp focus on the retina. The resulting image on the retina is upside-down. Here at the retina, the light rays are converted to electrical impulses, which are then transmitted through the optic nerve, to the brain, where the image is translated and perceived in an upright position!

The eye is essentially an opaque eyeball filled with a water-like fluid. In the front of the eyeball is a transparent opening known as the cornea. The cornea is a thin membrane, which has an index of refraction of approximately 1.38. The cornea has the dual purpose of protecting the eye and refracting light as it enters the eye. After light passes through the cornea, a portion of it passes through an opening known as the pupil. Rather than being an actual part of the eye�s anatomy, the pupil is merely an opening. The pupil is the black portion in the middle of the eyeball. Its black appearance is attributed to the fact that the light, which the pupil allows to enter the eye, is absorbed on the retina (and elsewhere) and does not exit the eye. Thus, as you look at another person�s pupil opening, no light is exiting their pupil and coming to your eye; subsequently, the pupil appears black.

Like the aperture of a camera, the size of the pupil opening can be adjusted by the dilation of the iris. The iris is the colored part of the eye - being blue for some people and brown for others (and so forth); it is a diaphragm, which is capable of stretching and reducing the size of the opening. In bright-light situations, the iris is dilated to reduce the size of the pupil and limit the amount of light, which enters the eye; and in dim-light situations, the iris adjusts its size so as to maximize the size of the pupil and increase the amount of light, which enters the eye.

Light which passes through the pupil opening, will enter the crystalline lens. The crystalline lens is made of a fibrous, jelly-like material, which has an index of refraction of 1.44. Unlike the lens on a camera, the lens of the eye is able to change its shape and thus serves to fine-tune the vision process. The lens is attached to the ciliary muscles. These muscles relax and contract in order to change the shape of the lens. By carefully

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adjusting the lenses shape, the ciliary muscles assist the eye in the critical task of producing an image on the back of the eyeball.

The inner surface of the eye is known as the retina. The retina contains the rods and cones, which serve the task of detecting the intensity and the frequency of the incoming light. An adult eye is typically equipped with 120 million rods, which detect the intensity of light, and 6 million cones, which detect the frequency of light. These rods and cones send nerve impulses to the brain. The nerve impulses travel through a network of nerve cells; there are as many as one million neural pathways from the rods and cones to the brain. This network of nerve cells is bundled together to form the optic nerve on the very back of the eyeball.

Eye Protection Is A Must!

Federal regulations (CFR 21 1040.20 (c)(4) require that tanners wear protective eyewear that block 99.9% of the UVB light and 99% of UVA. It is the operator�s responsibility that ALL tanning clients use federally compliant eyewear. Acceptable eyewear must state the product�s compliance with federal regulations on the package.

Indoor tanning salon owners and operators should verify every client using tanning equipment is using compliant eyewear. Educate customers about the fact that towels, scarves or eyelids do not adequately protect their eyes from UVR exposure. Also, never allow your clients to use cracked, pitted or discolored eyewear.

CFR 21 1040.20 (c) (4) Federal Protective Eyewear Rules, State: (i) Each sunlamp product shall be accompanied by the number of sets of protective eyewear that is equal to the maximum number of persons that the instructions provided under paragraph (e)(1)(ii) of this section recommend to be exposed simultaneously to radiation from such product.

(ii) The spectral transmittance to the eye of the protective eyewear required by paragraph (c)(4)(i) of this section shall not exceed a value of 0.001 over the wavelength range of greater than 200 nanometers 320 nanometers and an value of 0.01 over the wavelength range of greater than 320 nanometers through 400 nanometers, and shall be sufficient over the wavelength greater than 400 nanometers to enable the user to see clearly enough to reset the timer. When proper eyewear is not used during the tanning process, the potential for eye injury is greatly increased. Some eye injuries and disorders include: Photokeratitis (Cornea Sunburn)-If you are exposed, unprotected, to excessive amounts of UV radiation over a short period of time, you are likely to experience a condition called photokeratitis. Like a �sunburn of the eye� it may be painful and you may have symptoms including red eyes, a foreign body sensation or gritty feeling in the eyes, extreme sensitivity to light and excessive tearing. Fortunately, this is usually

33

temporary and rarely causes permanent damage to the eyes.

Cataracts-Long-term exposure to ultraviolet light can be more serious. Scientific research has shown that exposure to even small amounts of ultraviolet light over a period of many years may increase your chance of developing a clouding of the lens of the eye called a cataract and can cause damage to the retina, the nerve-rich lining of your eye that is used for seeing. Damage to the lens or the retina is usually not reversible.

Pterygium (Abnormal tissue growth)-Excessive exposure to ultraviolet light without proper eye protection can lead to a condition called pterygium. This condition is noted by tissue growth on the whites of the eyes that may expand enough to block the vision. Although the tissue can be removed, it often regrows and may cause vision loss if it?s left untreated.

Damage To The Cornea-Several degenerative conditions can occur after unprotected, long-term exposure to UVB rays. Degenerative corneal conditions can reduce vision and may require surgery to correct.

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Chapter 7 Tanning Salon Procedures

Indoor tanning salon owners and operators have a responsibility to operate their tanning facility under the structure of well-developed, up to date and principled procedures. The negative effects of overexposure to ultraviolet light are well established. The following list is considered to be a general and responsible list of operating procedures. NOTE: If your state has specific regulations regarding the operation of an indoor tanning salon, your state regulations must be included in your salon procedural policies.

CONSUMER INSTRUCTIONS

1. All consumers, prior to the first tanning session at the tanning facility should be required to sign and date a warning statement that has been read and understood. The tanning facility operator should require the consumer to complete a detailed medical and skin history form. An operator should review the warning statement, medical and skin typing information prior to the consumers first tanning session or upon any renewal of information. These documents should be signed and dated on the customers initial visit, and should be renewed at least annually thereafter.

2. Prior to the first tanning session, a minor�s parent or legal guardian should sign and complete a warning statement, and a detailed medical and skin history form for the minor in the presence of a facility operator.

3. Consumer�s use of medications should be discussed and documented by a tanning operator upon the initial visit by the consumer. Certain chemical substances contained in various drugs, perfumes, foods or cosmetics can result in a photosensitive reaction. Caution should be exercised when exposing any individual taking or topically applying any medications for treatment. If in doubt, have the consumer consult their doctor or pharmacist prior to tanning. A potentially photosensitive drugs and substances list must be available at all times and posted within the tanning facility.

4. If the consumer meets the basic profile of a tanner (skin type 2 and above, not on a photosensitive medication, hasn�t tanned within the last 24 hours), then the initial

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exposure time should be determined by a knowledgeable tanning operator. The exposure time should be determined by the requirements of the FDA product labeling at the time of manufacture.

5. Each time a consumer tans they must have protective eyewear compliant with the FDA�s regulations (21 CFR 1040.20(c) (4)). A trained operator should instruct the consumer in the proper use of the eyewear prior to allowing the consumer to tan for the first time. Periodically, the eyewear should be inspected for cracks and worn or missing straps. Consumers refusing to wear protective eyewear should not be allowed to tan. The consumer should be instructed to wear the eyewear so it fits properly. If the eyewear is designed with elastic straps, they should be present during use. The facility operator should explain to each consumer, prior to an initial tanning session, why protective eyewear is important for use during the tanning session. Eyewear provided by the tanning facility must be sanitized prior to consumer use (unless disposable eyewear is used).

OPERATION OF TANNING EQUIPMENT

1. Prior to the first tanning session, a facility operator should give the consumer complete instructions on how to operate the tanning equipment. Examples include: Location of the on/off switch, how to lift and lower the canopy; description of user positioning to such as comfort positions; and an explanation of cooling systems such as fans. The salon staff must instruct the consumer as to the location and proper operation of the tanning equipment�s emergency shut-off switch.

2. All tanning equipment must be equipped with an override timer control and be located outside the room where the tanning device is located. Timers should always to set by knowledgeable tanning salon staff.

SANITATION

1. After each use, the tanning equipment must be properly cleaned with an EPA approved sanitizer and must be cleaned by a salon employee. The sanitizer shall be intended for use on tanning equipment and shall be mixed according to the directions stated on the container. Areas such as pillows, handles, acrylic surfaces and other areas that come in contact with consumers must be properly sanitized.

2. Protective eyewear must be sanitized prior to use (unless disposable) by a salon employee. The sanitizer used must be appropriate for use on eyewear and mixed according to the manufacturer�s instructions. The eyewear should be cleaned to remove buildup of mascara, etc. Straps must also be sanitized. The eyewear should be soaked if indicated by the sanitizer instructions.

EQUIPMENT TESTING AND MAINTENANCE

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1. Defective lamps and filters should be replaced with a type recommended and specified by the tanning equipment manufacturer. Replacement lamps or filters should have accompanying FDA compliancy information to prove equivalency or certification.

2. The salon owner should ensure replacement of lamps at the frequency specified by the manufacturer of the product or when a UV metering test shows a substantial decline in lamp production.

3. Maintenance should be performed on tanning equipment when noticeable deficiencies in equipment function are noted or as recommended by the manufacturer in the Users� Instruction Manual that comes with the equipment. A manual should be kept at the tanning facility for each piece of tanning equipment used. Testing of emergency cut-off switches and timer accuracy should be part of a routine salon procedure list.

RECORDS

1. A record of the consumer�s total number of tanning visits, dates, equipment used and duration of tanning exposure should be maintained at the facility. The skin type should be recorded and located so the operator can use this information to determine exposure times for subsequent visits.

2. Invoices and maintenance notes should be kept for two years documenting repairs and replacement of parts on the tanning equipment. Lamp equivalency documents should also be maintained at the tanning facility. All equipment maintenance should be documented in a maintenance log. Dates, maintenance performed, and the person�s name and initials performing the maintenance should be recorded in the log. Also, documentation of emergency off switch and timer accuracy testing should be maintained in the maintenance log.

3. The tanning facility should maintain records of Facility Specific Training and Formal Training for all current and past salon employees.

ULTRAVIOLET EXPOSURE INJURIES

1. The tanning facility should insure that a policy is in place to address the handling of consumer complaints involving actual or alleged UV exposure injury. Each tanning facility operator should be aware of these procedures.

A. The following procedures may be used: If a whole body overexposure to ultraviolet light occurs, the effects may be delayed several hours. However, medical advice should be sought as soon as possible. The attending physician needs to be told the amount of time the customer was supposed to tan versus the actual time tanned.

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B. Exposure to ultraviolet light should be stopped at once. For mild sunburn, cool compresses may be helpful. Do not use �caine� anesthetics, which could induce severe allergies.

C. If an eye injury is noted, immediately refer your client to an Emergency Room or Ophthalmologists (not an Optometrist or Optician).

2. A facility report should be filled out as soon as the client�s needs are handled. The report should include the following information:

a. The name, address and telephone number of the injured person.

b. The tanning facility name, address and phone number.

c. Name of staff on duty.

d. Diagnosed or documented injury type for either actual or alleged consumer injury and the name of the attending physician if applicable.

e. A copy of all the customer�s medical, skin and exposure history.

f. All other relevant information involving the consumer injury.

g. A reminder to contact the tanning facility owner or management as soon as reasonable to do so.

SAMPLE TANNING SKIN TYPE CHART

Use the table below as an example of skin types. Caucasians make up type 1 through 4 with types 5 and 6 being very brown skin or black.

*TYPE I Always burns easily and severely, then peels - never

tans, very fair skin, red or blond hair & freckles (unexposed skin is white)

TYPE II Burns easily, tans minimally or lightly and peels, usually fair skinned (unexposed skin is white)

TYPE III Burns moderately, tans eventually (unexposed skin is white)

TYPE IV Burns minimally, always tans well (unexposed skin is white)

TYPE V Rarely burns; tans easily and substantially. Brown-skinned persons, unexposed skin is brown (East Indians, Hispanics, etc.).

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TYPE VI Tans profusely and never burns. Persons with black skin (Africans and African Americans, Australian and South Indian Aborigines).

*A true skin type 1 should not be allowed to tan indoor or out.

Chapter 8 Federal Guidelines For Indoor Tanning ______________________________________________________________________ In addition to various state, county and local regulations, the Federal Trade Commission (FTC) and the Food and Drug Administration (FDA) have shared regulatory responsibility in regards to indoor tanning at the federal level. The FTC primarily focuses on advertising claims while the FDA monitors primarily the manufacturing, labeling and suggestive operations of tanning devices.

The Federal Trade Commission The Federal Trade Commission enforces a variety of federal antitrust and consumer protection laws. The Commission seeks to ensure that the nation�s markets function competitively, and are vigorous, efficient, and free of undue restrictions. The Commission also works to enhance the smooth operation of the marketplace by eliminating acts or practices that are unfair or deceptive. In general, the Commission�s efforts are directed toward stopping actions that threaten consumers� opportunities to exercise informed choice. Finally, the Commission undertakes economic analysis to support its law enforcement efforts and to contribute to the policy deliberations of the Congress, the Executive Branch, other independent agencies, and state and local governments when requested.

What truth-in-advertising rules apply to advertisers? Under the Federal Trade Commission Act:

• Advertising must be truthful and non-deceptive; • Advertisers must have evidence to back up their claims; and • Advertisements cannot be unfair.

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Additional laws apply to ads for specialized products like consumer leases, credit, 900 telephone numbers, and products sold through mail order or telephone sales. And all states have consumer protection laws that govern ads running in that state.

What makes an advertisement deceptive? Based on the FTC�s Written Deception Policy Statement, an ad is deceptive if it contains a statement-or omits information-that:

• is likely to mislead consumers acting reasonably under the circumstances; and • is �material��that is, important to a consumer�s decision to buy or use the

product.

How does the FTC determine if an ad is deceptive? A typical inquiry follows these steps:

• The FTC looks at the ad from the point of view of the �reasonable consumer��the typical person looking at the ad. Rather than focusing on certain words, the FTC looks at the ad in context�words, phrases, and pictures�to determine what it conveys to consumers.

• The FTC looks at both �express� and �implied� claims. An express claim is literally made in the ad. For example, �ABC Mouthwash prevents colds� is an express claim that the product will prevent colds. An implied claim is one made indirectly or by inference. �ABC Mouthwash kills the germs that cause colds� contains an implied claim that the product will prevent colds. Although the ad doesn�t literally say that the product prevents colds, it would be reasonable for a consumer to conclude from the statement �kills the germs that cause colds� that the product will prevent colds. Under the law, advertisers must have proof to back up express and implied claims that consumers would take from an ad.

• The FTC looks at what the ad does not say�that is, if the failure to include information leaves consumers with a misimpression about the product. For example, if a company advertised a collection of books, it would be deceptive if the ad did not disclose that what consumers actually would receive were abridged versions of those books.

• The FTC looks at whether the claim would be �material��that is, important to a consumer�s decision to buy or use the product. Examples of material claims are representations about a product�s performance, features, safety, price, or effectiveness.

• The FTC looks at whether the advertiser has sufficient evidence to support the claims in the ad. The law requires that advertisers have proof before the ad runs.

Food and Drug Administration When does the Federal Trade Commission regulate claims and when are they regulated by the Food and Drug Administration?

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The FTC and the FDA have a long-standing liaison agreement to allocate their efforts efficiently. As a general rule, advertising for foods, over-the-counter drugs, dietary supplements, medical devices, and cosmetics is regulated by the FTC. Labeling for these products is regulated by the FDA. In addition, the FDA handles most matters related to prescription drug advertising and labeling.

The FDA Rules On Indoor Tanning

FEDERAL REGULATIONS-21 CFR 1040.20

(a) Applicability.

(1) The provisions of this section, as amended, are applicable as specified herein to the following products manufactured on or after September 8, 1986.

(i) Any sunlamp product.

(ii) Any ultraviolet lamp intended for use in any sunlamp product.

(2) Sunlamp products and ultraviolet lamps manufactured on or after May 7, 1980, but before September 8, 1986, are subject to the provisions of this section as published in the FEDERAL REGISTER of November 9, 1979 (44 FR65357).

(b) Definitions. As used in this section the following definitions apply:

(1) �Exposure position� means any position, distance, orientation, or location relative to the radiating surfaces of the sunlamp product at which the user is intended to be exposed to ultraviolet radiation from the product, as recommended by the manufacturer.

(2) �Intended� means the same as �intended uses� in 801.4.

(3) �Irradiance� means the radiant power incident on a surface at a specified location and orientation relative to the radiating surface divided by the area of the surface, as the area becomes vanishingly small, expressed in units of watts per square centimeter (W/cm2).

(4) �Maximum exposure time� means the greatest continuous exposure time interval recommended by the manufacturer of the product.

(5) �Maximum timer interval� means the greatest timer interval setting on the timer of a product.

(6) �Protective eyewear� means any device designed to be worn by users of a product to reduce exposure of the eyes to radiation emitted by the product.

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(7) �Spectral irradiance� means the irradiance resulting from radiation within a wavelength range divided by the wavelength range as the range becomes vanishingly small, expressed in units of watts per square centimeter per nanometer (W/(cm2/nm)).

(8) �Spectral transmittance� means the spectral irradiance transmitted through protective eyewear divided by the spectral irradiance incident on the protective eyewear.

(9) �Sunlamp product� means any electronic product designed to incorporate one or more ultraviolet lamps and intended for irradiation of any part of the living human body, by ultraviolet radiation with wavelengths in air between 200 and 400 nanometers, to induce skin tanning.

(10) �Timer� means any device incorporated into a product that terminates radiation emission after a preset time interval.

(11) �Ultraviolet lamp� means any lamp that produces ultraviolet radiation in the wavelength interval of 200 to 400 nanometers in air and that is intended for use in any sunlamp product.

(C) Performance requirements.

(1) Irradiance ratio limits. For each sunlamp product and ultraviolet lamp, the ratio of the irradiance within the wavelength range of greater than 200 nanometers through 260 nanometers to the irradiance within the wavelength range of greater than 260 nanometers through 320 nanometers may not exceed 0.003 at any distance and direction from the product or lamp.

(2) Timer system.

(i) Each sunlamp product shall incorporate a timer system with multiple timer settings adequate for the recommended exposure time intervals for different exposure positions and expected results of the products as specified in the label required by paragraph (d) of this section.

(ii) The maximum timer interval(s) may not exceed the manufacturer�s recommended maximum exposure time(s) that is indicated on the label required by paragraph (d)(1)(iv) of this section.

(iii) No timer interval may have an error greater than 10 percent of the maximum timer interval of the product.

(iv) The timer may not automatically reset and cause radiation emission to resume for a period greater than the unused portion of the timer cycle, when emission from the sunlamp product has been terminated.

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(v) The timer requirements do not preclude a product from allowing a user to reset the timer before the end of the preset time interval.

(3) Control for termination of radiation emission. Each sunlamp product shall incorporate a control on the product to enable the person being exposed to terminate manually radiation emission from the product at any time without disconnecting the electrical plug or removing the ultraviolet lamp.

(4) Protective eyewear.

(i) Each sunlamp product shall be accompanied by the number of sets of protective eyewear that is equal to the maximum number of persons that the instructions provided under paragraph (e)(1)(ii) of this section recommend to be exposed simultaneously to radiation from such product.

(ii) The spectral transmittance to the eye of the protective eyewear required by paragraph (c)(4)(i) of this section shall not exceed a value of 0.001 over the wavelength�s range of greater than 200 nanometers through 320 nanometers and a value of 0.01 over the wavelength range of greater than 320 nanometers through 400 nanometers, and shall be sufficient over the wavelength greater than 400 nanometers to enable the user to see clearly enough to reset the timer.

(5) Compatibility of lamps. An ultraviolet lamp may not be capable of insertion and operation in either the �single contact medium screw� or the �double contact medium screw� lamp holders described in American National Standard C81.10-1976, Specifications for Electric Lamp Bases and Holders-Screw Shell Types, which is incorporated by reference. Copies are available from the American National Standards Institute, 1430 Broadway, New York, NY 10018 or available for inspection at the Office of the Federal Register, 1100 L St. NW, Washington, DC 20408.

(d) Label requirements. In addition to the labeling requirements in Part 801 and the certification and identification requirements of 1010.2 and 1010.3, each sunlamp product and ultraviolet lamp shall be subject to the labeling requirements prescribed in this paragraph and paragraph (e) of this section.

(1) Labels for sunlamp products. Each sunlamp product shall have a label(s) which contains:

(i) A warning statement with the words �DANGER-Ultraviolet radiation. Follow instructions. Avoid overexposure. As with natural sunlight, overexposure can cause eye and skin injury and allergic reactions. Repeated exposure may cause premature aging of the skin and skin cancer. WEAR PROTECTIVE EYEWEAR; FAILURE TO MAY RESULT IN SEVERE BURNS OR LONG-TERM INJURY TO THE EYES. Medications or cosmetics may increase your sensitivity to the

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ultraviolet radiation. Consult physician before using sunlamp if you are using medications or have a history of skin problems or believe yourself especially sensitive to sunlight. If you do not tan in the sun, you are unlikely to tan from use of this product.�

(ii) Recommended exposure position(s). Any exposure position may be expressed either in terms of a distance specified both in meters and in feet (or in inches) or through the use of markings or other means to indicate clearly the recommended exposure position.

(iii) Directions for achieving the recommended exposure position(s) and a warning that the use of other positions may result in overexposure.

(iv) A recommended exposure schedule including duration and spacing of sequential exposures and maximum exposure time(s) in minutes.

(v) A statement of the time it may take before the expected results appear.

(vi) Designation of the ultraviolet lamp type to be used in the product.

(2) Labels for ultraviolet lamps. Each ultraviolet lamp shall have a label which contains:

(i) The words �Sunlamp-DANGER-Ultraviolet radiation. Follow instructions.

(ii) The model identification.

(iii) The words �Use ONLY in fixture equipped with a timer.�

(3) Label specifications.

(i) Any label prescribed in this paragraph for sunlamp products shall be permanently affixed or inscribed on an exterior surface of the product when fully assembled for use so as to be legible and readily accessible to view by the person being exposed immediately before the use of the product.

(ii) Any label prescribed in this paragraph for ultraviolet lamps shall be permanently affixed or inscribed on the product so as to be legible and readily accessible to view.

(iii) If the size, configuration, design, or function of the sunlamp product or ultraviolet lamp would preclude compliance with the requirements for any required label or would render the required wording of such label inappropriate or ineffective, or would render the required label unnecessary, the Director, Office of Compliance, (HFZ-300), Center for Devices and Radiological Health, on the Center�s own initiative or upon written application by the manufacturer, may

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approve alternative means of providing such label(s), alternate wording for such labels, or deletion, as applicable.

(iv) In lieu of permanently affixing or inscribing tags or labels on the ultraviolet lamp as required by 1010.2(b) and 1010.3(a), the manufacturer of the ultraviolet lamp may permanently affix or inscribe such required tags or labels on the lamp packaging uniquely associated with the lamp, if the name of the manufacturer and month and year of manufacture are permanently affixed or inscribed on the exterior surface of the ultraviolet lamp so as to be legible and readily accessible to view. The name of the manufacturer and month and year of the manufacture affixed or inscribed on the exterior surface of the lamp may be expressed in code or symbols, if the manufacturer has previously supplied the Director, Office of Compliance (HFZ-300), Center for Devices and Radiological Health, with the key to such code or symbols and the location of the coded information or symbols on the ultraviolet lamp. The label or tag affixed or inscribed on the lamp packaging may provide either the month and year of manufacture without abbreviation, or information to allow the date to be readily decoded.

(v) A label may contain statements or illustrations in addition to those required by this paragraph if the additional statements are not false or misleading in any particular; e.g. if the do not diminish the impact of the required statements, and are not prohibited by this chapter.

(e) Instructions to be provided to users. Each manufacturer of a sunlamp product and ultraviolet lamp shall provide or cause to be provided to purchasers and, upon request, to others at a cost not to exceed the cost of publication and distribution, adequate instructions for use to avoid or to minimize potential injury to the user, including the following technical and safety information as applicable:

(1) Sunlamp products. The users� instructions for a sunlamp product shall contain:

(i) A reproduction of the label(s) required in paragraph (d)(1) of this section prominently displayed at the beginning of the instructions.

(ii) A statement of the maximum number of people who may be exposed to the product at the same time and a warning that only that number of protective eyewear has been provided.

(iii) Instructions for the proper operation of the product including the function, use, and setting of the timer and other controls, and the use of protective eyewear.

(iv) Instructions for determining the correct exposure time and schedule for persons according to skin type.

(v) Instructions for obtaining repairs and recommended replacement components and accessories which are compatible with the product, including compatible

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protective eyewear, ultraviolet lamps, timers, reflectors, and filters, and which will, if installed or used as instructed, result in continued compliance with the standard.

(2) Ultraviolet lamps. The users� instructions for an ultraviolet lamp not accompanying a sunlamp product shall contain:

(i) A reproduction of the label(s) required in paragraphs (d)(1)(i) and (2) of this section, prominently displayed at the beginning of the instructions.

(ii) A warning that the instructions accompanying the sunlamp product should always be followed to avoid or to minimize potential injury.

(iii) A clear identification by brand and model designation of all lamp models for which replacement lamps are promoted, if applicable.

(f) Test for determination of compliance. Tests on which certification pursuant to 1010.2 is based shall account for all errors and statistical uncertainties in the process and, wherever applicable, for changes in radiation emission or degradation in radiation safety with age of the product. Measurements for certification purposes shall be made under those operational conditions, lamp voltage, current, and position as recommended by the manufacturer. For these measurements, the measuring instrument shall be positioned at the recommended exposure position and so oriented as to result in the maximum out put.

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Chapter 9 State Indoor Tanning Regulations __________________________________________________________________ Please visit www.tanningprogram.com for a list of state specific regulations or, if applicable, see the inserted rules pertaining to your particular state.

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NOTES:

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