Addiction to Indoor Tanning Relation to Anxiety, Depression, and Substance Use

STUDY Addiction to Indoor Tanning Relation to Anxiety, Depression, and Substance Use

Catherine E. Mosher, PhD; Sharon Danoff-Burg, PhD

Objective: To assess the prevalence of addiction to Main Outcome Measures: Self-reported addiction to indoor tanning among college students and its associa- indoor tanning, substance use, and symptoms of anxi- tion with substance use and symptoms of anxiety and ety and depression. depression. Results: Among 229 study participants who had used Design: Two written measures, the CAGE (Cut down, indoor tanning facilities, 90 (39.3%) met DSM-IV-TR cri- Annoyed, Guilty, Eye-opener) Questionnaire, used to teria and 70 (30.6%) met CAGE criteria for addiction to screen for alcoholism, and the Diagnostic and Statistical indoor tanning. Students who met DSM-IV-TR and CAGE Manual of Mental Disorders (Fourth Edition, Text Revi- criteria for addiction to indoor tanning reported greater sion) (DSM-IV-TR) criteria for substance-related disor- symptoms of anxiety and greater use of alcohol, mari- ders, were modified to evaluate study participants for ad- juana, and other substances than those who did not meet diction to indoor tanning. Standardized self-report these criteria. Depressive symptoms did not signifi- measures of anxiety, depression, and substance use also cantly vary by indoor tanning addiction status. were administered. Conclusion: Findings suggest that interventions to re- duce skin cancer risk should address the addictive quali- Setting: A large university (approximately 18 000 stu- ties of indoor tanning for a minority of individuals and dents) in the northeastern United States. the relationship of this behavior to other addictions and affective disturbance. Participants: A total of 421 college students were recruited from September through December 2006. Arch Dermatol. 2010;146(4):412-417

XTENSIVE EVIDENCE HAS of SRDs that involve self-reported tanning linkedsunlamporsunbedex- behavior have not been conducted. Research posure to increased risk of also has not specifically focused on SRD with melanomaandnonmelanoma respect to indoor tanning and its relation to skin cancers.1-3 Despite ongo- otherpsychopathologicalconditions.Wehy- ingE efforts to educate the public about the pothesizedthataminorityofcollegestudents health risks associated with natural and non- would meet the criteria for an SRD with re- solar UV radiation, recreational tanning con- spect to indoor tanning and that having this tinues to increase among young adults.4 disorder (determined by self-report) would In addition to the desire for appearance be positively related to anxiety, depression, enhancement, motivations for tanning and substance use. include relaxation, improved mood, and 5-7 socialization. These reinforcing properties METHODS of UV tanning have been conceptualized within an addiction framework.8 That is, re- A total of 421 undergraduates were recruited peated exposure to UV light may result in from the psychology department research par- a behavior pattern similar to other types of ticipant pool at a state university in the north- substance-related disorder (SRD). In sup- eastern United States from September through port of this hypothesis, a significant propor- December 2006. All study materials and proce- tion (12%-53%) of young adults and beach- dures were approved by the university’s insti- Author Affiliations: goers has met the criteria for having an SRD tutional review board. After providing written Department of Psychiatry and withrespecttoUVlighttanningbehavior.7,9,10 informed consent, study participants anony- Behavioral Sciences, Memorial In addition, having an SRD that involves tan- mously completed questionnaires in groups Sloan-Kettering Cancer Center, ranging from 15 to 30 people. Participants re- ning behavior and the use of indoor tanning New York, New York ported their demographic information, whether (Dr Mosher), and Department devices has been positively associated with they had ever tanned indoors, and frequency of 9,11 of Psychology, University at cigarette smoking among young adults. indoor tanning during the past year. Albany, State University of New However, to our knowledge, in-depth analy- To assess potential dependence on indoor tan- York, Albany (Dr Danoff-Burg). ses of the reliability and validity of measures ning,wemodified2measuresthatarewidelyused

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Table 1. Demographic Characteristics of Study Participants Table 2. Association Between mCAGE and mDSM-IV-TR Findingsa No. (%) of Characteristic 421 Participants mDSM-IV-TR, No. Total, Sex mCAGE Negative Positive No. (%) Female 284 (67.5) Male 133 (31.6) Negative 119 40 159 (69.4) Not reported 4 (1.0) Positive 20 50 70 (30.6) Age, y Total, No. (%) 139 (60.7) 90 (39.3) 229 (100) 18-19 313 (74.3) 20-21 78 (18.5) Abbreviations: mCAGE, modified CAGE (Cut down, Annoyed, Guilty, 12 22-24 20 (4.8) Eye-opener) questionnaire ;mDSM-IV-TR, modified Diagnostic and 13 Ն25 6 (1.4) Statistical Manual of Mental Disorders (Fourth Edition, Text Revision). a PϽ.001. Not reported 4 (1.0) Skin type Burns, never tans 6 (1.4) Descriptive statistics were used to characterize the demo- Burns easily, then develops light tan 51 (12.1) graphics of study participants, use of indoor tanning facilities, Burns moderately, then develops light tan 70 (16.6) and indoor tanning addiction status. Addiction to indoor tan- Burns minimally, then develops moderate tan 167 (39.7) ning was defined as meeting both mCAGE and mDSM-IV-TR Does not burn, develops dark tan 111 (26.4) criteria for addiction. Study participants with addictive ten- Does not burn, shows no noticeable 10 (2.4) change in appearance dencies met the criteria for addiction on either the mCAGE or Not reported 6 (1.4) mDSM-IV-TR. Study participants’ frequency of indoor tan- Lifetime use of indoor tanning devices ning during the past year and affirmative responses to items Yes 237 (56.3) from the mCAGE and mDSM-IV-TR were computed to deter- ␹2 No 181 (43.0) mine indoor tanning addiction status. Pearson tests were used Not reported 3 (0.7) to examine associations among mCAGE, mDSM-IV-TR,and demographic factors (sex and skin type17). Logistic regression models were used to examine study participants’ frequency of indoor tanning during the past year, symptoms of anxiety, symp- to identify SRDs: the 4-item CAGE (Cut down, Annoyed, Guilty, toms of depression, and substance use as predictors of indoor Eye-opener) questionnaire,12 used for alcoholism screening, and tanning addiction status. Substance use variables included the the 7 diagnostic criteria for an SRD as outlined in the Diagnostic use of tobacco, alcohol, and marijuana as well as the use of stimu- and Statistical Manual of Mental Disorders (Fourth Edition, Text Re- lants (ie, cocaine, amphetamines, and/or the nicotine in to- vision) (DSM-IV-TR).13 Versions of these measures were used in bacco). Other substance categories were not analyzed owing prior research to assess addiction to UV light tanning.9,10 In this to the small number (1-14) of participants who reported sub- study, CAGE and DSM-IV-TR criteria referred to indoor tanning stance use; this small number would compromise the validity behaviors. Following the scoring procedures of Warthan and col- of the results.18 In addition, use of depressants (alcohol, mari- leagues,10 2 or more affirmative responses to items on the modi- juana, sedatives, and/or opiates) was not analyzed because only fied CAGE (mCAGE) and 3 or more affirmative responses to items 5 participants with addictive tendencies or addiction to in- onthemodifiedDSM-IV-TR(mDSM-IV-TR)were,respectively,clas- door tanning did not report use of these substances. Finally, sified as indicating a probable SRD that involved indoor tanning. Pearson ␹2 tests were used to examine relationships among anxi- Scoring procedures for 3 questions in the mDSM-IV-TR with mul- ety, depression, the number of substances used during the past tiple parts were as follows: (1) question 1 was counted as affirma- month (excluding alcohol), and lifetime use of indoor tanning tive only if both subparts were answered yes; (2) question 5 was devices and tanning addiction status. Alcohol use was ex- counted as affirmative with 2 or 3 positive responses (any response cluded from these analyses because only 5 students with ad- other than none was classified as a positive response to subpart 5a); dictive tendencies or addiction to indoor tanning did not re- and (3) question 7 required a response of no to subpart 7c and a port alcohol use. response of yes to subparts 7a and/or 7b to be considered an affirmative response. Internal consistencies for the mCAGE and RESULTS mDSM-IV-TR were .58 and .56, respectively. Deletion of individual items did not significantly alter the ␣ values, which are relatively low but consistent with those found in prior research on SRDs re- Demographic characteristics of the sample are given in lated to tanning behavior9 and most likely reflect the wide range Table 1. When asked whether they had ever tanned in- of behaviors assessed by the measures and the brevity of those mea- doors, 237 of the 421 study participants (56.3%) answered sures. affirmatively. Data from 8 of the 237 participants who had Participants completed the Beck Anxiety Inventory14 and the tanned indoors were omitted from subsequent analyses be- Beck Depression Inventory,15 which are widely used 21-item scales cause of missing values on the mCAGE or mDSM-IV-TR that assess symptoms of anxiety and depression, respectively, dur- measures. The mean (SD) number of visits to tanning sa- ing the past week. Internal consistencies for the Beck Anxiety In- lons during the past year among study participants with a ventory and the Beck Depression Inventory in the present study lifetime history of indoor tanning was 23 (24). In addition, were .91 and .87, respectively. In addition, participants com- datafrom70oftheremaining229studyparticipants(30.6%) pleted portions of the Core Alcohol and Drug Survey,16 a vali- dated measure of substance use. Participants reported the num- met mCAGE criteria and 90 (39.3%) met mDSM-IV-TR cri- ber of days they had used 1 or more of 12 different substances teria for addiction to indoor tanning. The mCAGE and (including tobacco, alcohol, and marijuana) during the past month. mDSM-IV-TR results were significantly correlated (␬=0.43, Response choices were 0, 1 through 2, 3 through 5, 6 through 9, PϽ.001; Table 2) and were not significantly associated 10 through 19, 20 through 29, and all 30 days. with sex (P=.12) or skin type (P=.43).

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Table 3. mCAGE and mDSM-IV-TR Responses and Indoor Tanning Frequency by Tanning Addiction Statusa

No. (%) of Participants

Not Addicted to Addictive Addicted to Indoor Tanning Tendencies Indoor Tanning Item (n=119) (n=60) (n=50) mCAGE Do you try to cut down on the time you spend in tanning beds or booths, but find 6 (5.0) 13 (21.7) 39 (78.0) yourself still tanning? YES NO Do you ever get annoyed when people tell you not to use tanning beds or booths? 19 (16.0) 25 (41.7) 41 (82.0) YES NO Do you ever feel guilty that you are using tanning beds or booths too much? YES NO 15 (12.6) 22 (36.7) 39 (78.0) When you wake up in the morning, do you want to use a tanning bed or booth? 3 (2.5) 8 (13.3) 13 (26.0) YES NO mDSM-IV-TR 1a. Do you think you need to spend more and more time in tanning beds or booths 15 (12.6) 33 (55.0) 27 (54.0) to maintain your perfect tan? YES NO 1b. Do you think your tan will fade if you spend the same amount of time in a tanning 5 (4.2) 10 (16.7) 11 (22.0) bed or booth each time? YES NO 2. Do you continue to use tanning beds or booths so your tan will not fade? YES NO 27 (22.7) 49 (81.7) 47 (94.0) 3. When you go to tanning salons, do you usually spend more time in the tanning bed 2 (1.7) 3 (5.0) 6 (12.0) or booth than you had planned? YES NO 4. Do you try other non–tanning-related activities, but find you really still like spending 7 (5.9) 10 (16.7) 20 (40.0) time in tanning beds or booths best of all? YES NO 5a. How many days a week do you spend in tanning beds or booths? 0 1234567 42 (35.3) 52 (86.7) 46 (92.0) 5b. Do you tan year round? YES NO 21 (17.6) 36 (60.0) 46 (92.0) 5c. Have you ever missed work, a social engagement, or school because of a burn 0 (0) 1 (1.7) 3 (6.0) from tanning bed or booth use? YES NO 6. Have you ever missed any scheduled activity (social, occupational, or recreational 2 (1.7) 2 (3.3) 12 (24.0) activities) because you decided to use tanning beds or booths? YES NO 7a. Do you believe you can get skin cancer from the sun? YES NO 118 (99.2) 58 (96.7) 49 (98.0) 7b. From tanning beds or booths? YES NO 117 (98.3) 60 (100) 50 (100) 7c. Does this keep you from spending time in the sun or using tanning beds 73 (61.3) 51 (85.0) 49 (98.0) or booths? YES NO Frequency of indoor tanning during the past year, mean (SD) 13 (17.4) 28 (21.9) 40 (28.1)

Abbreviations: mCAGE, modified CAGE (Cut down, Annoyed, Guilty, Eye-Opener) questionnaire12;mDSM-IV-TR, modified Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision).13 a Affirmative responses appear in bold. (Note: a reply of no to question 7c in combination with a reply of yes to 7a and/or 7b is considered an affirmative response.) Affirmative mCAGE and mDSM-IV-TR responses indicate addiction to indoor tanning. Affirmative responses to either the mCAGE or mDSM-IV-TR criteria indicate addictive tendencies.

Frequency of indoor tanning during the past year and Alcohol use during the past month was affirmed by affirmative responses to items from the mCAGE and 210 of 229 study participants (91.7%) who had tanned mDSM-IV-TR by tanning addiction status are given in indoors, whereas 82 (35.8%) and 84 (36.7%) reported Table 3. Study participants who met criteria for addic- use of tobacco and marijuana, respectively, during the tion to indoor tanning reported more indoor tanning ses- past month. Other substances (including cocaine, am- sions during the past year than those with addictive ten- phetamines, opiates, and steroids) were used by 1 to 14 dencies (Table 4). In addition, both groups reported students (range=0.4% to 6.0%) during the past month. more indoor tanning sessions during the past year than Although tobacco use and use of stimulants (cocaine, am- those who did not meet the criteria for addiction to in- phetamines, and/or the nicotine in tobacco) did not dif- door tanning. Clinical categories of anxiety symptoms fer by tanning addiction status, students who met crite- did not significantly vary as a function of lifetime use of ria for addictive tendencies or addiction to indoor tanning indoor tanning history or tanning addiction status (P=.07; reported greater alcohol and marijuana use during the Table 5). However, as indicated in Table 4, study par- past month than those who did not (Table 4). In addi- ticipants who met criteria for addiction to indoor tan- tion, the number of substances other than alcohol used ning on both the mCAGE and mDSM-IV-TR reported during the past month varied by lifetime use of indoor greater symptoms of anxiety than those who did not. tanning devices and tanning addiction status (Table 5). Symptoms of depression did not significantly vary by life- The highest rate of substance use was found among those time use of indoor tanning devices or tanning addiction who met criteria for addiction to indoor tanning, with status. When anxiety, depressive symptoms, and fre- 21 of 50 study participants (42.0%) affirming use of 2 or quency of indoor tanning during the past year were in- more substances during the past month. Only 29 of 181 cluded in the same logistic regression model, only fre- study participants who had never tanned indoors (16.0%) quency of indoor tanning significantly predicted tanning and 20 of 119 study participants who tanned indoors and addiction status (addiction vs nonaddiction: Wald who were not addicted to this behavior (16.8%) af- ␹2=16.55, OR=1.03, PϽ.001). firmed this degree of substance use.

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Not Addicted to Indoor Tanning Not Addicted vs Addictive Tendencies vs vs Addictive Tendencies Addicted to Indoor Tanning Addicted to Indoor Tanning

Odds Ratio Wald Odds Ratio Wald Odds Ratio Wald Predictor (95% CI) ␹2 (95% CI) ␹2 (95% CI) ␹2 Frequency of indoor tanning 1.04 (1.02-1.06)a 15.78 1.05 (1.03-1.07)a 26.54 1.02 (1.00-1.04)b 5.38 during the past year Symptoms of anxiety 1.01 (0.97-1.04) 0.13 1.03 (1.00-1.07)b 4.24 1.03 (.99-1.07) 2.42 Symptoms of depression 1.02 (0.97-1.07) 0.39 1.02 (0.97-1.07) 0.54 1.01 (.95-1.06) 0.03 Tobacco use 0.94 (0.79-1.12) 0.47 1.07 (0.91-1.26) 0.69 1.13 (.93-1.37) 1.56 Alcohol use 1.34 (1.05-1.71)b 5.50 1.40 (1.07-1.84)b 6.01 1.04 (.77-1.41) 0.06 Marijuana use 1.36 (1.07-1.73)b 6.28 1.33 (1.02-1.74)b 4.38 0.96 (.74-1.24) 0.09 Use of stimulantsc 0.99 (0.52-1.87) 0 1.47 (0.75-2.85) −1.26 1.49 (.69-3.18) 1.04

Abbreviation: CI, confidence interval. a PϽ.001. b PϽ.05. c Stimulants include cocaine, amphetamines, and the nicotine in tobacco.

Table 5. Symptoms of Anxiety, Symptoms of Depression, and Substance Use by Lifetime History of Indoor Tanning and Tanning Addiction Statusa

No. (%) of Participants

No Lifetime Indoor Not Addicted to Addictive Addicted to Tanning History Indoor Tanning Tendencies Indoor Tanning P (n=181) (n=119) (n=60) (n=50) ␹2 Value Beck Anxiety Inventory scores 11.81 .07 None (0-9) 119 (65.7) 71 (59.7) 32 (53.3) 22 (44.0) Mild to moderate (10-18) 40 (22.1) 30 (25.2) 16 (26.7) 14 (28.0) Moderate to severe (19-63) 21 (11.6) 18 (15.1) 12 (20.0) 14 (28.0) Missing data 1 (0.6) 0 0 0 Beck Depression Inventory scores 4.28 .64 None (0-9) 127 (70.2) 80 (67.2) 39 (65.0) 33 (66.0) Mild to moderate (10-18) 41 (22.7) 34 (28.6) 15 (25.0) 11 (22.0) Moderate to severe (19-63) 9 (5.0) 5 (4.2) 5 (8.3) 5 (10.0) Missing data 4 (2.2) 0 1 (1.7) 1 (2.0) No. of substances used during 22.78 .001 the past month (excluding alcohol) 0 103 (56.9) 58 (48.7) 24 (40.0) 19 (38.0) 1 47 (26.0) 41 (34.5) 22 (36.7) 10 (20.0) Ն2 29 (16.0) 20 (16.8) 14 (23.3) 21 (42.0) Missing data 2 (1.1) 0 0 0

Abbreviations: mCAGE, modified CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire12;mDSM-IV-TR, modified Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision). a Affirmative mCAGE and mDSM-IV-TR responses indicated “addiction to indoor tanning.” Affirmative responses to either the mCAGE or mDSM-IV-TR indicated “addictive tendencies.”

COMMENT validity of the measures. The lack of association between skin type and addiction to indoor tanning may be This study provides further support for the notion that attributable to the underrepresentation of darker skin tanning may be conceptualized as an addictive behavior tones. In addition, sex was not associated with addic- for a subgroup of individuals who tan indoors8;itex- tion to indoor tanning, as in prior research on SRDs that 9,10 tends prior work by relating indoor tanning addiction to involve UV-light tanning. Women were overrepre- 9,10 substance use and affective disturbance. Among the 229 sented in this study and previous research ; thus, fur- study participants who had tanned indoors, 70 (30.6%) ther studies with sex-balanced samples are needed. met mCAGE criteria and 90 (39.3%) met mDSM-IV-TR An interesting pattern of findings emerged with criteria for addiction to indoor tanning. Similarly, Poor- regard to the relations between substance use and SRDs sattar and Hornung7 found that 28% of undergraduates that involve indoor tanning. Of the 50 study partici- who had tanned indoors met mCAGE criteria for addic- pants who tanned indoors and had positive mDSM- tion to tanning. In this study, greater use of indoor tan- IV-TR and mCAGE responses, 42.0% reported use of 2 ning devices was associated with greater likelihood of ad- or more substances (excluding alcohol) during the past diction to this behavior, which supports the construct month, whereas 20 (16.8%) of those who tanned

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 indoors and had negative mDSM-IV-TR and mCAGE to underestimate reliability, especially when measures con- responses and 29 (16.0%) of those who had never tain fewer than 10 items.25 Further reliability testing and tanned indoors reported this degree of substance use. in-depth analyses of the measures, such as cognitive in- Furthermore, study participants who met the criteria terviewing, should be conducted in future studies to for addiction to indoor tanning on either the mDSM- strengthen their validity for use with those who tan. For IV-TR or mCAGE reported greater use of alcohol and example, use of cognitive interviewing would allow re- marijuana, compared with those who did not meet searchers to ascertain whether affirmative responses to these criteria. Other studies11,18-20 have found positive item 1a (Table 3) indicate a preoccupation with tanning associations between substance use and indoor tanning or agreement with the notion that more time spent tan- among adolescents and young adults. In this study, ning darkens the skin. Research is needed to further vali- tobacco use and the use of stimulants (cocaine, amphet- date the self-report measures of addiction to indoor tan- amines, and/or the nicotine in tobacco) did not differ by ning by including objective measures of UV radiation tanning addiction status, whereas another study9 found exposure (eg, spectrophotometry). It also would be in- a positive association between cigarette smoking and teresting to explore the physiologic and psychological addiction to tanning. Overall, findings suggest that indi- mechanisms underlying the relations among addiction viduals who use drugs may be more likely to develop to indoor tanning, other addictive behaviors, and affec- dependence on indoor tanning because of a similar tive disturbance. Such research would inform bio- addictive process. In addition, tanning and drug use psychosocial conceptualizations of tanning behavior and may be reinforced by peer group norms. tailored interventions that address individuals’ motiva- Anxiety and depression are often comorbid with sub- tions for tanning and the relation of those motivations stance dependence,21 and the present findings suggest that to psychopathological conditions. affective disturbance may also be comorbid with dependence on indoor tanning. Specifically, study partici- Accepted for Publication: November 6, 2009. pants who tanned indoors and had positive mDSM- Correspondence: Catherine E. Mosher, PhD, Depart- IV-TR and mCAGE responses had approximately twice ment of Psychiatry and Behavioral Sciences, Memorial the rate of moderate-to-severe anxiety and depressive Sloan-Kettering Cancer Center, 641 Lexington Ave, Sev- symptoms than study participants who tanned indoors enth Floor, New York, NY 10022 (mosherc@mskcc and had negative responses on both measures and those .org). who had never tanned indoors. Similarly, prior research Author Contributions: Both authors had full access to found a positive association between seasonal affective 22 all the data in the study and take responsibility for the disorder and indoor tanning frequency. In this study, integrity of the data and the accuracy of the data analy- however, anxiety symptoms predicted group classifica- sis. Study concept and design: Mosher and Danoff-Burg. tion (ie, affirmative vs negative mDSM-IV-TR and mCAGE Analysis and interpretation of data: Mosher. Drafting of the responses), whereas depressive symptoms did not pre- manuscript: Mosher. Critical revision of the manuscript for dict this classification. In addition, study participants with important intellectual content: Mosher and Danoff-Burg. addictive tendencies (either affirmative mDSM-IV-TR or Statistical analysis: Mosher. Obtained funding: Mosher. mCAGE responses) had levels of anxiety and depressive Administrative, technical, and material support: Mosher and symptoms that did not significantly differ from those who Danoff-Burg. Study supervision: Mosher and Danoff- were not addicted to indoor tanning. Burg. If associations between affective factors and indoor tan- Financial Disclosure: None reported. ning behavior are replicated, results suggest that treat- Funding/Support: The work of Dr Mosher was sup- ing an underlying mood disorder may be a necessary step ported by grant F32CA130600 from the National Can- in reducing skin cancer risk among those who fre- cer Institute. quently tan indoors. Researchers have hypothesized that Role of the Sponsor: The sponsor had no role in the de- those who tan regularly year round may require more in- sign and conduct of the study; in the collection, analy- tensive intervention efforts, such as motivational inter- sis, and interpretation of data; or in the preparation, re- viewing, relative to those who tan periodically in re- 23,24 view, or approval of the manuscript. sponse to mood changes or special events. Further Previous Presentation: This study was presented in part research should evaluate the usefulness of incorporat- at the Society of Behavioral Medicine Annual meeting; ing a brief anxiety and depression screening for indi- April 23, 2009; Montreal, Quebec, Canada. viduals who tan indoors. Patients with anxiety or depression could be referred to mental health professionals for diagnosis and treatment. REFERENCES Limitations of this study include its cross-sectional design and reliance on self-report measures. In addition, 1. Gallagher RP, Spinelli JJ, Lee TK. Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiol Biomarkers Prev. 2005;14(3): the sample consisted of undergraduate students in the 562-566. northeastern United States; thus, results may not be 2. Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. generalizable across individuals of different age groups, Use of tanning devices and risk of basal cell and squamous cell skin cancers. socioeconomic levels, and geographic regions. Al- J Natl Cancer Inst. 2002;94(3):224-226. 3. Veierød MB, Weiderpass E, Thörn M, et al. A prospective study of pigmentation, though results supported the convergent validity of our sun exposure, and risk of cutaneous malignant melanoma in women. J Natl Can- new self-report measures of addiction to indoor tan- cer Inst. 2003;95(20):1530-1538. ning, the ␣ values were relatively low. These values tend 4. Robinson JK, Kim J, Rosenbaum S, Ortiz S. Indoor tanning knowledge, atti-

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©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 tudes, and behavior among young adults from 1988-2007. Arch Dermatol. 2008; Survey: initial findings and future directions. J Am Coll Health. 1994;42(6): 144(4):484-488. 248-255. 5. Feldman SR, Liguori A, Kucenic M, et al. Ultraviolet exposure is a reinforcing 17. Mahler HI, Kulik JA, Gibbons FX, Gerrard M, Harrell J. Effects of appearance- stimulus in frequent indoor tanners. J Am Acad Dermatol. 2004;51(1):45-51. based interventions on sun protection intentions and self-reported behaviors. 6. Kaur M, Liguori A, Lang W, Rapp SR, Fleischer AB Jr, Feldman SR. Induction of Health Psychol. 2003;22(2):199-209. withdrawal-like symptoms in a small randomized, controlled trial of opioid block- 18. Cohen J, Cohen P, West SG, Aiken LS. Applied Multiple Regression/Correlation ade in frequent tanners. J Am Acad Dermatol. 2006;54(4):709-711. Analysis for the Behavioral Sciences. 3rd ed. Mahwah, NJ: Lawrence Erlbaum 7. Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among Associates; 2003. undergraduate college students. J Am Acad Dermatol. 2007;56(3):375-379. 19. Demko CA, Borawski EA, Debanne SM, Cooper KD, Stange KC. Use of indoor 8. Nolan BV, Taylor SL, Liguori A, Feldman SR. Tanning as an addictive behavior: tanning facilities by white adolescents in the United States. Arch Pediatr Ado- a literature review. Photodermatol Photoimmunol Photomed. 2009;25(1): lesc Med. 2003;157(9):854-860. 12-19. 20. O’Riordan DL, Field AE, Geller AC, et al. Frequent tanning bed use, weight con- 9. Heckman CJ, Egleston BL, Wilson DB, Ingersoll KS. A preliminary investigation cerns, and other health risk behaviors in adolescent females (United States). Can- of the predictors of tanning dependence. Am J Health Behav. 2008;32(5):451- cer Causes Control. 2006;17(5):679-686. 464. 21. Hesse M. Integrated psychological treatment for substance use and co-morbid 10. Warthan MM, Uchida T, Wagner RF Jr. UV light tanning as a type of substance- anxiety or depression vs treatment for substance use alone: a systematic review related disorder. Arch Dermatol. 2005;141(8):963-966. 11. Heckman CJ, Coups EJ, Manne SL. Prevalence and correlates of indoor tanning of the published literature. BMC Psychiatry. 2009;9:6. doi:10.1186/1471-244X among US adults. J Am Acad Dermatol. 2008;58(5):769-780. -9-6. 12. Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new al- 22. Hillhouse J, Stapleton J, Turrisi R. Association of frequent indoor UV tanning coholism screening instrument. Am J Psychiatry. 1974;131(10):1121-1123. with seasonal affective disorder. Arch Dermatol. 2005;141(11):1465. doi:10 13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental .1001/archderm.141.11.1465. Disorders (Fourth Edition, Text Revision). Washington, DC: American Psychiat- 23. Hillhouse J, Turrisi R, Shields AL. Patterns of indoor tanning use: implications ric Association; 2000. for clinical interventions. Arch Dermatol. 2007;143(12):1530-1535. 14. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxi- 24. Pagoto SL, Hillhouse J. Not all tanners are created equal: implications of tan- ety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893-897. ning subtypes for skin cancer prevention. Arch Dermatol. 2008;144(11):1505- 15. Beck AT. Depression Inventory. Philadelphia, PA: Center for Cognitive Therapy; 1508. 1978. 25. Cortina JM. What is coefficient alpha?: an examination of theory and applications. 16. Presley CA, Meilman PW, Lyerla R. Development of the Core Alcohol and Drug J Appl Psychol. 1993;78(1):98-104.

Notable Notes

Steatoma Through the Early Medical History

Skin diseases become nosological entities mainly after the it using the handle of the scalpel; otherwise, the steatoma has Hellenistic period (fourth-first century BC). Among the to be detached from the flesh with the scalpel itself. If the skin lesions appearing in ancient medical texts of the “roots” of the growth are accidentally left in place, the sur- ancient Greek and Greco-Roman literature, steatoma,a geon should insert the hooks on the vertex of the growth and term that exists even nowadays, appears to have preoccu- then shake them violently, while dissecting the growth with pied numerous authors: references may be found in Celsus the left hand. If the growth is adherent, he or she should pull (first century AD), Galen (second century AD), Antyllus and detach the attachments of the growth with the handle of (second century AD), Oribasius (fourth century AD), Aëtius the scalpel and then proceed as described previously, leav- of Amida (sixth century AD), and Paulus Aegineta (seventh ing the adhering parts untouched.1 century AD). The ancient descriptions possibly correspond to steato- Ancient authors state that steatoma, which occurs on the cystoma, trichilemmal cyst, or epidermoid cyst, depending head, eyes, neck, armpits, and flanks, is a painless growth with on the differential diagnosis that is made with the informa- a narrow base and a rounded point. It is soft to the touch, tion provided by the ancient texts. It is interesting that al- and, when pressed hard, it is yielding and diminishing in such most all authors propose surgical excision of the growth as a a way that the mark of the fingers remains visible for some therapeutic method to prevent recurrence. Such an attitude time after pressure has been released.1-3 Total excision of the was expected by the ancient physicians, bearing in mind that, growth is proposed by almost all authors. Aëtius of Amida at that time, all cysts were considered potentially dangerous, alleges that, during surgery, the incision should be analo- and because there was no diagnostic method other than clini- gous to the size of the tumor and should be either simple or cal observation and experience, differentiation of those cysts myrsinoides (having the pattern of a climbing periwinkle), was impossible. avoiding, in any case, cutting through the tunic surrounding the growth.4 Antyllus described 2 types of steatoma: pedunculated and Niki Papavramidou, PhD adherent. In the first case, ie, when the steatoma is simply Maria Nasta, PhD attached to the skin, the surgeon should first stretch the skin Anthony Karpouzis, PhD from all sides and then make a straight incision, avoiding pierc- Drs Papavramidou, Nasta, and Karpouzis are with the ing the tunic. He or she should first identify the tunic of the School of Medicine, Democritus University of Thrace, growth and, in the case of a pedunculated steatoma, detach Alexandroupolis, Greece; [email protected].

1. Daremberg C, Bussemaker UC, eds. Oeuvres d’Oribase. Vol 4. Paris, France: Imprimerie Nationale; 1862:1-9. 2. Spencer WG. Celsus De Medicina. trans. Cambridge, MA: Harvard University Press; 1971:325. 3. Galenus C. Introductio seu medicus. In: Kuhn CG, ed. Opera Omnia. Vol 14. Berlin Germany: Georg Olms Verlag; 1827:778, 785. 4. Zervos S. Aetiou Amidenou logos dekatos pemptos. Athena. 1909;21:7-138.

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