Sunlight for the prevention and treatment of hyperbilirubinemia in term and late preterm neonates.

BACKGROUND: Acute bilirubin encephalopathy (ABE) and the other serious complications of severe hyperbilirubinemia in the neonate occur far more frequently in low- and middle-income countries (LMIC). This is due to several factors that place babies in LMIC at greater risk for hyperbilirubinemia, including increased prevalence of hematologic disorders leading to hemolysis, increased sepsis, less prenatal or postnatal care, and a lack of resources to treat jaundiced babies. Hospitals and clinics face frequent shortages of functioning phototherapy machines and inconsistent access to electricity to run the machines. Sunlight has the potential to treat hyperbilirubinemia: it contains the wavelengths of light that are produced by phototherapy machines. However, it contains harmful ultraviolet light and infrared radiation, and prolonged exposure has the potential to lead to sunburn, skin damage, and hyperthermia or hypothermia. OBJECTIVES: To evaluate the efficacy of sunlight administered alone or with filtering or amplifying devices for the prevention and treatment of clinical jaundice or laboratory-diagnosed hyperbilirubinemia in term and late preterm neonates. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 5), MEDLINE, Embase, and CINAHL on 2 May 2019. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster RCTs. We updated the searches on 1 June 2020. SELECTION CRITERIA: We included RCTs, quasi-RCTs, and cluster RCTs. We excluded crossover RCTs. Included studies must have evaluated sunlight (with or without filters or amplification) for the prevention and treatment of hyperbilirubinemia or jaundice in term or late preterm neonates. Neonates must have been enrolled in the study by one-week postnatal age. DATA COLLECTION AND ANALYSIS: We used standard methodologic procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Our primary outcomes were: use of conventional phototherapy, treatment failure requiring exchange transfusion, ABE, chronic bilirubin encephalopathy, and death. MAIN RESULTS: We included three RCTs (1103 infants). All three studies had small sample sizes, were unblinded, and were at high risk of bias. We planned to undertake four comparisons, but only found studies reporting on two. Sunlight with or without filters or amplification compared to no treatment for the prevention and treatment of hyperbilirubinemia in term and late preterm neonates One study of twice-daily sunlight exposure (30 to 60 minutes) compared to no treatment reported the incidence of jaundice may be reduced (risk ratio [RR] 0.61, 95% confidence interval [CI] 0.45 to 0.82; risk difference [RD] -0.14, 95% CI -0.22 to -0.06; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 17; 1 study, 482 infants; very low-certainty evidence) and the number of days that an infant was jaundiced may be reduced (mean difference [MD] -2.20 days, 95% CI -2.60 to -1.80; 1 study, 482 infants; very low-certainty evidence). There were no data on safety or potential harmful effects of the intervention. The study did not assess use of conventional phototherapy, treatment failure requiring exchange transfusion, ABE, and long-term consequences of hyperbilirubinemia. The study showed that sunlight therapy may reduce rehospitalization rates within seven days of discharge for treatment for hyperbilirubinemia, but the evidence was very uncertain (RR 0.55, 95% CI 0.27 to 1.11; RD -0.04, -0.08 to 0.01; 1 study, 482 infants; very low-certainty evidence). Sunlight with or without filters or amplification compared to other sources of phototherapy for the treatment of hyperbilirubinemia in infants with confirmed hyperbilirubinemia Two studies (621 infants) compared the effect of filtered-sunlight exposure to other sources of phototherapy in infants with confirmed hyperbilirubinemia. Filtered-sunlight phototherapy (FSPT) and conventional or intensive electric phototherapy led to a similar number of days of effective treatment (broadly defined as a minimal increase of total serum bilirubin in infants less than 72 hours old and a decrease in total serum bilirubin in infants more than 72 hours old on any day that at least four to five hours of sunlight therapy was available). There may be little or no difference in treatment failure requiring exchange transfusion (typical RR 1.00, 95% CI 0.06 to 15.73; typical RD 0.00, 95% CI -0.01 to 0.01; 2 studies, 621 infants; low-certainty evidence). One study reported ABE, and no infants developed this outcome (RR not estimable; RD 0.00, 95% CI -0.02 to 0.02; 1 study, 174 infants; low-certainty evidence). One study reported death as a reason for study withdrawal; no infants were withdrawn due to death (RR not estimable; typical RD 0.00, 95% CI -0.01 to 0.01; 1 study, 447 infants; low-certainty evidence). Neither study assessed long-term outcomes. Possible harms: both studies showed a probable increased risk for hyperthermia (body temperature greater than 37.5 °C) with FSPT (typical RR 4.39, 95% CI 2.98 to 6.47; typical RD 0.30, 95% CI 0.23 to 0.36; number needed to treat for an additional harmful outcome [NNTH] 3, 95% CI 2 to 4; 2 studies, 621 infants; moderate-certainty evidence). There was probably no difference in hypothermia (body temperature less than 35.5 °C) (typical RR 1.06, 95% CI 0.55 to 2.03; typical RD 0.00, 95% CI -0.03 to 0.04; 2 studies, 621 infants; moderate-certainty evidence). AUTHORS' CONCLUSIONS: Sunlight may be an effective adjunct to conventional phototherapy in LMIC settings, may allow for rotational use of limited phototherapy machines, and may be preferable to families as it can allow for increased bonding. Filtration of sunlight to block harmful ultraviolet light and frequent temperature checks for babies under sunlight may be warranted for safety. Sunlight may be effective in preventing hyperbilirubinemia in some cases, but these studies have not demonstrated that sunlight alone is effective for the treatment of hyperbilirubinemia given its sporadic availability and the low or very low certainty of the evidence in these studies.

The use of commercially available personal UV-meters does cause less safe tanning habits: a randomized-controlled trial.

UV Index information is currently recommended as a vehicle to raise public awareness about the risk of sun-exposure. It remains unknown to what extent this information can change personal sun-protective behavior. The aim of the study was to analyze the effects of UV-Index (UV-I) information provided by low cost, commercially available UV-I sensors on major indicators of sun-tanning behavior. A randomized-controlled trial was carried out on 94 healthy volunteers aged 21-23 years. After the exclusion of subjects with photosensitive disorders (n=3), 91 subjects were randomized in two arms after stratification based on phototype and sex. Both arms received a diary to be filled every day with a log of intentional sun-exposure during summer. Subjects in the intervention group also received a commercially available UV-I sensor. The UV-I sensors were switched on and the UV-value was recorded in 77% of days with sun-exposure. During days of sun-exposure, subjects randomized to the intervention group had longer average time of sun-exposure (227.7 vs 208.7 min per day, P=0.003), also between noon and 4 pm (P<0.001), and less frequently adopted sun protective measures than controls (hat [6.4%vs 10.2%, P=0.007], sunglasses [23.9%vs 30.8%, P=0.003], sunscreen [41.4%vs 47.2%, P=0.02]) and they experienced more frequent sunburns (27.8%vs 21.5%, P=0.004). The odd ratio of sunburns was 1.60 for subjects in the intervention group compared with controls (after adjustment for sex, sunscreen use and skin type). The mean UV-I value recorded by volunteers was lower (5.6 [SD+/-0.9]) than that (7.3 [SD+/-0.46]) recorded by a professional instrument in the same period at the same latitude. Poststudy laboratory tests showed that the sensor was able to detect only about 60% of the solar diffuse radiation. The use of UV-I sensors changed the sun protective behavior of sunbathers in the direction of less use of sun protective measures. One possible explanation is that the low cost UV-meters may have functioned incorrectly and under-reported UV exposure. This may have led to an underestimation of UV-I values, erroneously reassuring subjects and causing a less protective sunbathing behavior. Another hypothesis relies on a cognitive pitfall in the subjects' dealing with intermediate UV-I values, as they may have been discouraged in the use of sunscreen as they did not feel that they had yet been exposed to very harmful UV radiation.

Measuring the stringency of states' indoor tanning regulations: instrument development and outcomes.

OBJECTIVES: We sought to describe the development of an instrument to quantify the stringency of state indoor tanning legislation in the United States, and the instrument's psychometric properties. The instrument was then used to rate the stringency of state laws. METHODS: A 35-item instrument was developed. An overall stringency measure and 9 stringency subscales were developed, including one measuring minors' access to indoor tanning. Stringency measures showed good internal consistency and interrater reliability. RESULTS: In all, 55% of the 50 states and the District of Columbia had any indoor tanning law, and 41% had any law addressing minors' access. Oregon, Illinois, South Carolina, Florida, Indiana, Iowa, and Rhode Island had high overall stringency scores, and Texas and New Hampshire were the most restrictive with regard to minors' access. LIMITATIONS: Measurement of actual enforcement of the laws was not included in this study. CONCLUSIONS: The instrument appears to be an easy-to-use, reliable, and valid methodology. Application of the instrument to actual laws showed that, in general, state laws are relatively weak, although there was considerable variability by state.

Reintroduction of a classic vitamin D ultraviolet source.

As early as 1930 sunlamps claiming to provide ultraviolet (UV) exposure to make vitamin D were sold to the public in the US and Canada for home use. Today even with dietary supplementation of vitamin D many people do not get enough solar UV exposure to maintain sufficient vitamin D levels. There is growing interest in the availability of sunlamps for this purpose. The original Sperti Sunlamp, with label claiming vitamin D benefit was approved by the American Medical Association in 1940 as a sunlamp. This intermediate pressure mercury lamps ultraviolet B emission lines, at 297, 302, and 313 nm are able to convert 7-dehydrocholesterol in the skin to vitamin pre-D3 initiating the natural process of vitamin D formation. Today's KBD Vitamin D lamp, an updated model of the earlier type source. In order to comply with modern safety guidance, the source is filtered to remove unnecessary UVC radiation and is equipped with a timer to control the dose administered. The 5 min timer provides an exposure, at 20 in. from the user's skin, of one standard erythemal dose (SED). The SED represents a suberythemal dose for even the most sensitive skin type I individual.

Sanitarians' work with indoor-tanning businesses: findings from interviews in two major metropolitan areas.

In spite of health risks, indoor tanning is a popular practice and a growing industry. Although published studies indicate that tanning businesses' compliance with regulations is poor, no studies describe enforcement activity and the related knowledge and perceptions of environmental health professionals. As part of a larger study of indoor tanning in Minnesota and Massachusetts, both states with statutes that regulate tanning, the investigation reported in this paper involved interviews of 27 sanitarians in the Twin Cities and 30 sanitarians in the Boston metropolitan area about their awareness, experiences, and practices. Overall, Massachusetts performed better than Minnesota with respect to familiarity with regulations (93 percent versus 67 percent), routine business inspections (90 percent of agencies versus 27 percent), and priority given by agencies to indoor-tanning work-differences likely attributable to a stronger state statute. Participants in both states, however, recalled few aspects of the regulations and were able to identify few of the health risks associated with indoor tanning, and most reported receiving inadequate training. Various steps must be taken to improve environmental health work with tanning businesses, including educating the public, strengthening regulations, addressing resource issues, and training sanitarians.

The role of commercial tanning beds and ultraviolet A light in the treatment of psoriasis.

BACKGROUND: Phototherapy is an effective, safe psoriasis treatment administered via office-based units or home devices. There is controversy over the use of commercial tanning beds; ultraviolet B (UVB) has documented efficacy although commercial beds emit largely UVA. OBJECTIVE: To determine the efficacy of UVA and the role of commercial tanning beds in treating psoriasis. METHODS: A literature search of UVA and commercial tanning was performed. RESULTS: UVA can be effective for psoriasis, but achieving the high doses required may not be practical. Tanning beds do emit UVB although amounts are variable. Because of variability in UVA and UVB output in different tanning bulbs, it is difficult to predict response rates using commercial tanning beds. CONCLUSIONS: UVA can be used to treat psoriasis but may not be practical. Commercial tanning beds, emitting both UVA and UVB, have a role in treating psoriasis as an alternative to office-based therapy.

Biological UV dosimeters in quality control of tanning tubes.

Although according to the International Radiological Protection Association-International Non-Ionizing Radiation Committee recommendation (1991) the use of sunbeds for cosmetic purposes is not recommended, tanning devices are used widely. Ten different types of commercially available sunbed tubes have been studied using a uracil biological UV dosimeter, and three of them were analyzed in detail. Dimerization effectiveness of the tubes was measured directly, whereas efficiency of erythema induction was calculated weighting the emission spectra by the Commission Internationale de l'Eclairage erythema action spectrum. The data obtained demonstrate that quality control of sunbed tubes has to include not only the determination of the UV doses administered but also the assessment of the health risk due to the UVB and UVA components of the lamp. A method of quality control using the uracil biological dosimeter was elaborated, and the estimation of the "acceptable" exposure time was checked/controlled on 15 volunteers by assessing individually the erythema induction threshold. A correct classification of the sunbed tubes is proposed by characterizing the erythema induction versus DNA-damaging effectiveness of tubes.

Ultraviolet emission spectra of sunbeds.

It is well known that UV radiation contributes to the development of skin cancer. Exposure to solar radiation is predominantly responsible for the high incidence rate of skin cancer, but there are also indications that sunbeds are involved. The aim of the present investigation was to determine the UV emission spectra of sunbeds. It included the most common sunbed models, which cover more than 50% of the Swiss market. The UV emission spectra of sunbeds have special characteristics and are different from the sun spectrum, which can be seen in high-resolution spectral measurements. Sunbed emission spectra are similar to the sun spectrum in the UVB (280-320 nm) range but reach values 10 to 15 times higher in the UVA (320-400 nm) range. An average erythema-effective irradiance of 0.33 W/m2 was determined for sunbeds. This corresponds to a UV index of 13, which is significantly higher than the UV index of 8.5 of the high summer sun at noon at intermediate latitudes. The measurements were spread over the whole effective area of the sunbeds, and an inhomogeneous distribution of the irradiances with variations of up to 30% from the average value was found.

Risk of cutaneous malignant melanoma in relation to use of sunbeds: further evidence for UV-A carcinogenicity.

In a population-based, matched, case-control study from southern Sweden of 571 patients with a first diagnosis of cutaneous malignant melanoma and 913 healthy controls aged 16-80 years, the association between sunbed use and malignant melanoma was evaluated. A total of 250 (44%) cases and 372 (41%) controls reported ever having used sunbeds. A significantly elevated odds ratio for developing malignant melanoma after regular exposure to sunbeds was found, adjusted for hair colour, raised naevi, skin type and number of sunburns (odds ratio (OR) 1.8, 95% confidence interval (CI) 1.2-2.7). A dose-response relationship between total number of sunbed uses and melanoma risk was only found up to the level of 250 times. The OR was higher in individuals younger than age 36 years (adjusted OR 8.1, 95% CI 1.3-49.5 for regular vs. never use). The association seemed to be true only for subjects with black/dark brown or light brown hair and among females. Lesions of the extremities showed the strongest association of increased risk with sunbed use. An increased risk was related to commercial exposure and to exposure during the winter. The results substantiate the hypothesis that exposure to sunbeds might increase the risk of developing malignant melanoma.

Attitudes, beliefs and behaviour regarding the use of sunbeds amongst healthcare workers in Bradford.

Although cosmetic tanning and unprotected solar exposure are common, little is known about general attitudes, beliefs and behaviour regarding the use of sunbeds. We sought to determine the frequency of sunbeds use in a select sample and to assess the knowledge and beliefs regarding this behaviour. A self-administered anonymous questionnaire was distributed to a sample of 648 employees work for Bradford Hospitals NHS Trust. The questionnaire explored demographic information (including hair and skin type, family history with skin cancer), frequency of sunbeds use, knowledge about the risks of UV exposure and motivations for practising this behaviour. Four hundred and eighteen women and 52 men completed the questionnaire, making a response rate of 73%. Nearly half of respondents (207; 44%) reported using sunbeds to some extent; of those 12% reported frequent use. Appearance ('to look better') was the most popular reason given by respondents for using sunbeds, followed by 'feel healthy'. Frequency of using sunbeds was found to be negatively correlated with the age of respondents and the existence of family experience with skin cancer, and strongly associated with the opinion that it is safer to use a sunbed than subathing outdoors, the female sex and smoking. It is clear from this study that the psychological factors that influence sunbeds use are complex and that so far public education campaigns have had little impact on it. This study highlights some of these psychological factors.

A population-based survey on the use of artificial tanning devices in the Province of Québec, Canada.

BACKGROUND: The suntanning industry has grown up over the last decade in North America, mainly because tanned skin is socially desirable and artificial tanning is perceived as a "safe tan." However, exposure to UV radiation is known to cause adverse health effects. OBJECTIVE: The purpose of this study was to estimate the prevalence of use of tanning equipment in the Province of Québec and to characterize people who reported using these devices. METHODS: In 1996, a telephone survey was carried out among adults from the two most densely populated regions (Montréal, Québec) of the Province of Québec. The final sample included 1003 white persons 18 to 60 years old. Interviewers used a standardized questionnaire to document the characteristics of the participant, skin phototype, and exposure habits to artificial UV radiation sources. RESULTS: During the last 5 years before the survey, 20.2% of the respondents reported they had used, at least once, a tanning device in a commercial tanning salon. The rate of use during the last 12 months before the study was 11.1%. A significantly higher proportion of female, young people (18 to 34 years old) and single persons was found among tanning bed users. Twenty-six percent of users experienced one or more acute adverse health effects from the artificial UV irradiation. Most of these were cases of skin burns. A high proportion (77.5%) of those who used tanning equipment during the last year before the study said they would return to tanning salons. The intention of returning to a tanning salon was not influenced by the occurrence of the acute adverse health effects. The most prevalent reason given for using tanning equipment was "to improve their appearance by a tan." Most people (60.4%) who used a tanning bed during the last 5 years before the study believe that tanning salons are not dangerous. CONCLUSION: This survey indicates that tanning bed use is very prevalent in the Province of Québec, mainly among young women. The high rate of acute adverse health effects related to artificial tanning, particularly skin burns, is of concern. Finally, our results underline the importance of changing attitudes and beliefs in the population regarding artificial tanning.

Survey of the variation in ultraviolet outputs from ultraviolet A sunbeds in Bradford.

Concerns have been expressed for some time regarding the growth of the cosmetic suntanning industry and the potential harmful effects resulting from these exposures. Recently published work has appeared to confirm a link between sunbed use and skin cancer. A previous survey in Oxford some years ago demonstrated significant output variations, and we have attempted to extend and update that work. Ultraviolet A, UVB and blue-light output measurements were made on 50 sunbeds using a radiometer fitted with broad-band filters and detectors. A number of irradiance measurements were made on each sunbed within each waveband so that the uniformity of the output could also be assessed. UVA outputs varied by a factor of 3, with a mean of 13.5 mW/cm2; UVB outputs varied by a factor of 60, with a mean of 19.2 microW/cm2; and blue-light outputs varied by a factor of 2.5, with a mean of 2.5 mW/cm2. Outputs fall on average to 80% of the central value at either end of the sunbed. Facial units in sunbeds ranged in output between 18 and 45 mW/cm2. Output uniformity shows wide variation, with 16% of the sunbeds having an axial coefficient of variation > 10%. UVB output is highly tube-specific. Eyewear used in sunbeds should also protect against blue light.

Use of sunbeds or sunlamps and malignant melanoma in southern Sweden.

In a population-based, matched case-control study from the South Swedish Health Care Region, which has the highest risk for melanoma in Sweden, the relation between the use of sunbeds or sunlamps and malignant melanoma was investigated. Between July 1, 1988, and June 30, 1990, a total of 400 melanoma patients and 640 healthy controls aged 15-75 years answered a comprehensive questionnaire containing different epidemiologic variables. Questions regarding the use of sunbeds or sunlamps were included. The odds ratio for developing malignant melanoma after ever having used sunbeds or sunlamps was 1.3. Considering all age groups, the odds ratio was significantly elevated after exposure more than 10 times a year to sunbeds or sunlamps (odds ratio (OR) = 1.8). When the study was restricted to patients and controls younger than age 30 years because the use of tanning devices is much more common among young persons, the odds ratio was higher (OR = 7.7 for more than 10 times a year vs. none). These findings were independent of constitutional factors and factors regarding sun exposure. A dose-response relation was evident. Furthermore, among melanoma patients in this young age group, the ratio of females to males was significantly higher than in older patients. When different melanoma presentation sites were considered, only lesions of the trunk were significantly associated with sunbed or sunlamp use (OR = 4.2 for more than 10 times a year vs. none).