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Exposure to Dihydroxyacetone in Sunless Tanning Products Understanding the Risks Mary Gallagher

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Exposure to Dihydroxyacetone in Sunless Tanning Products Understanding the Risks Mary Gallagher FEATURE ARTICLE Exposure to Dihydroxyacetone in Sunless Tanning Products Understanding the Risks Mary Gallagher ABSTRACT: The public has been warned for years about tiatives to educate the public on skin cancer prevention, the dangers of ultraviolet exposure from natural sunlight substantial numbers of people continue to believe that and tanning beds due to the associated risk for skin their appearance is improved with a tan (Martin et al., cancer development. An alternative to obtaining the 2009). The desire for bronzed skin, albeit concerns of sun-kissed look without ultraviolet exposure has been skin cancer development, has led many to opt for sunless self-tanning products, which are applied directly to the tanning products to achieve a bronzed appearance. How- skin via lotions, sprays, foams, and wipes. However, recent ever, recent evidence has suggested that one of the main research has indicated that the chemical dihydroxyac- active ingredients in sunless tanning products, called dihy- etone (DHA), which is the active agent in most sunless droxyacetone (DHA), may have more adverse effects to tanning lotions, may cause cell damage via free radical consumers’ health than previously understood. This inte- reactions. Changes in pigmented lesion appearance grative review of literature will examine recent research in during dermoscopic examinations after use of products regard to the use of DHA in tanning products. It will containing DHA have been documented, and these present evidence that suggests that there is no clear, safe findings will be analyzed. This integrative research review exposure of mucous membranes to DHA during inhala- will examine evidence-based research regarding the risks tion of tanning spray application, which may pose un- of using DHA-containing products. Nola Pender’s health known health risks; that DHA makes the skin more promotion model is recommended to identify strategies susceptible to UV damage; and that DHA can cause alter- that healthcare providers can use when developing antic- ations in the appearance of skin during dermoscopic ipatory guidance to address factors leading to barriers in examinations, leading to unnecessary biopsies and the health promoting behaviors. This model is focused on possibility of misdiagnoses. improvement of well-being while preventing diseases. Key words: Cell Damage, Dihydroxyacetone, OBJECTIVE Dermoscopy, Free Radicals, Sunless Tanning The purpose of this integrative review was to determine if there is plausible evidence to suggest that the use of sunless he public has been warned for years about tanning products containing DHA contributes to disease the dangers of ultraviolet (UV) exposure from development via systemic absorption in adults. The goals natural sunlight and tanning beds due to the of this review were to improve current educational and increased risk of developing skin cancer. UV anticipatory guidance to patients related to this topic, to radiation has been shown to cause an in- ameliorate overall health and well-being by guiding nursing creased incidence of melanoma, basal cell carcinoma, and practice with evidence-based research, and to identify Tsquamous cell carcinoma in adults. Despite current ini- implications for further research. Mary Gallagher, MSN, FNP-C, MCPHS University, Worcester, MA. METHODOLOGY The author declares no conflict of interest. This integrative research review will examine studies re- Correspondence concerning this article should be addressed to lated to the safety of DHA when introduced beyond the MaryGallagher,MSN,FNP-C,MCPHSUniversity,19FosterSt., stratum corneum and the effects DHA has on dermoscopy Worcester, MA 01608. E-mail: [email protected] findings so appropriate anticipatory guidance can be devel- Copyright B 2018 by the Dermatology Nurses’ Association. oped for clients. Evidence-based qualitative and quantitative DOI: 10.1097/JDN.0000000000000366 studies and systematic reviews accessed through databases VOLUME 10 | NUMBER 1 | JANUARY/FEBRUARY 2018 11 Copyright © 2018 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. including CINAHL, PubMed, MEDLINE, and one aca- the chemical and physical properties, pharmacology and demic Web search engine (Google Scholar) were reviewed. biochemistry, use and manufacturing, toxicity, safety and Most of the studies referenced for this review were pub- hazards, and biological test results of DHA. The toxicity lished within the last 5 years to utilize the most current information included in this report noted that cells that research available. Nola Pender’s health promotion model were treated with DHA showed dose- and time-dependent is used to guide suggestions for the development of antici- changes that included cytoplasmic budding, chromatin patory guidance to change unhealthy behaviors and pro- condensation, and cell detachment. There was a signifi- mote skin health. This model is directed at increasing the cant decrease in cell proliferation after 24 hours of DHA patient’s level of well-being and acknowledges the im- exposure. After exposure to a 5% DHA solution for portance of the ability of the nurse to motivate change by 21 days, epidermal thickening and dermatitis of the skin modification of behavior-specific knowledge variables. were noted in laboratory animals. After 42 days of treat- ment with the same solution, hyperplastic and dyskeratotic BACKGROUND AND SIGNIFICANCE changes and moderate inflammatory reactions were seen. Before the 20th century, pale skin was associated with Long-lasting topical tanning products contain the sugars high social class, wealth, and beauty. People would go DHA or erythrulose, which cause a ‘‘Maillard reaction’’ through tremendous efforts to keep skin light and blemish when contacting proteins in the outer layers of the stratum free. Skin bleaching products were often used to achieve corneum and epidermis (O’Leary et al., 2014). This reac- a pale appearance. In 1928, the number of articles and tion happens when free amino acids from skin proteins advertisements in women’s fashion magazines promoting combine with DHA in the stratum corneum. This combi- tanned skin dramatically increased (Martin et al., 2009). nation creates the tanned appearance of skin. Results are Tanned skin became associated with wealth and an im- generally seen within a few hours of application. UV light proved sense of self-image soon after the launch of these exposure is not needed to initiate this chemical reaction. advertisements. The incidence of melanoma has grown Adverse Effects of DHA on Cells more rapidly than any other cancer since tanned skin became more desirable (O’Leary, Diehl, & Levins, 2014). Jung, Seifert, Herrling, and Fuhs (2008) researched the In the 1950s, Dr. Eva Wittgenstein from the University role of self-tanners in the induction of free radicals in of Cincinnati started to research DHA and its ability to the skin. Researchers could quantitatively determine the produce tanned skin. Her research was prompted from free radical induction effects using the radical sun factor the brown coloring that was left on the skin of children method. During the Maillard reaction, sugars in DHA who were treated orally with DHA for glycogen storage react with keratinocyte proteins causing oxidation of the disease, which they often spat out, and the product landed sugar derivatives. This oxidation caused chain reactions, on their skin causing dark spotting. It was not long before which led to free radical injury to the skin. This is the sunless tanning lotion was introduced to the public in the process used to create the tanned appearance in skin. DNA 1960s. Since its public introduction, many people have glycation is a process of reducing sugars that can damage opted to use this as an alternative to natural sunlight or nucleic acids. Advanced glycation end products (AGEs) tanning beds to achieve their bronzed skin. For many are also known as glycotoxins. These are formed via the years, self-tanning products have been considered a safe Maillard reaction. AGEs of DNA are spontaneously formed alternative to UVA or UVB exposure. by the reaction of carbonyl compounds such as DHA. Self-tanning products can now be applied topically by Excessive amounts of AGEs in body tissues or circulation hand, sprayed on at home, airbrushed by a technician, or can become pathogenic causing oxidative stress and in- sprayed in a tanning booth with misters. DHA has been flammation, which can alter the structure and function of approved by the U.S. Food and Drug Administration proteins (Uribarri et al., 2010). AGEs have been associ- (FDA) for external application in cosmetic products since ated with the development of chronic degenerative dis- 1977 with a concentration of up to 15%. The FDA indi- orders such as Alzheimer’s disease, cardiovascular disease, cates that DHA should not be inhaled, ingested, or used in and diabetes. An investigation of the effects of DHA on such a way that the eyes, eye area, nose, or mouth is exposed cell survival and proliferation indicated that DHA caused to it because the risks, if any, are unknown (FDA, 2016). DNA damage as revealed by alkaline comet assay (National Institutes of Health, 2016). LITERATURE REVIEW An Amadori product is an intermediate in the produc- tion of AGEs described previously. The enolization pro- Mechanism of DHA Action cesses of these Amadori products and their oxidation DHA, also known as glycerone or dihydroxy-2-propanone, products are known to produce free radicals contributing
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