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Summary
Sunburn is an acute self-limited inflammatory skin reaction that occurs after excessive ultraviolet radiation (UVR) exposure and typically manifests as a first-degree burn. It more commonly affects individuals with light skin than those with darker skin. Most sunburns are superficial, manifesting with redness, pain, pruritus, and swelling that begins a few hours after exposure and typically resolves within 1 week. Diagnosis is based on skin examination, recent UVR exposure, and the exclusion of differential diagnoses using clinical history. Management primarily involves symptomatic treatment of pain and pruritus with topical ointments, oatmeal baths, and moisturizers (e.g., petroleum jelly). Analgesics and antihistamines may be used as needed for persistent pain and pruritus. The use of photoprotective measures should be recommended to all individuals to prevent sunburn and chronic complications of UVR exposure.
Epidemiology
- ∼ 1 in 3 of adolescents and adults report sunburn every year. [2][3]
- ∼ 50% of children < 11 years of age have reportedly experienced sunburn. [4]
- Sunburn most commonly occurs in non-Hispanic White individuals. [2][3]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
Sunburn is most commonly caused by ultraviolet B (UVB) radiation. [5][6]
Risk factors for sunburn [3]
- Individuals who are sensitive to UV radiation, e.g. those with: [7]
- Light skin tones [5][6]
- History of sunburn within 1 hour of exposure to UVR
- History of photodermatoses
- Nonadherence to photoprotective measures
- Use of indoor tanning beds or tanning products [3]
- Extensive time spent outdoors for work or recreation [7]
Pathophysiology
UV radiation → DNA mutations → apoptosis of keratinocytes in the epidermis and release of inflammatory markers (including chemokines, prostaglandins) → inflammation of the dermis hours after exposure [8]
Clinical features
- The following typically manifest 4–12 hours after UVR exposure: [5][7]
- Erythema
- Pruritus
- Tenderness
- Swelling
- Blanching
- Warmth
- Features of severe sunburn may also be present and include: [7][9]
- Peak severity is usually 24–36 hours after exposure. [5]
- Resolution typically occurs within 3–8 days; characterized by dry, hyperpigmented skin that easily peels. [4][10]
Individuals may also develop photokeratitis if the eyes are exposed to UVR. [11]
Diagnosis
- Sunburn is a clinical diagnosis based on:
- Recent history of UVR exposure
- Clinical features of sunburn [4][9]
- Diagnostic uncertainty: Consider diagnostics for photodermatoses. [7][12]
Differential diagnoses
The differential diagnoses listed here are not exhaustive.
Management
General principles [4][10]
- Sunburn is typically managed with supportive therapy in the outpatient setting.
- Further sun exposure should be avoided.
- Clean, loose cotton clothing can protect the skin while it heals. [13]
-
Sunburn with severe features may require:
- Dressings and topical antiseptic ointment for blisters
- Treatment of dehydration
- See “Treatment of burns” for details.
- To reduce the risk of recurrence, educate patients on prevention of sunburn.
Blisters should be left intact to reduce the risk of infection. [7]
Supportive therapy [4][7][10]
- Encourage oral hydration to compensate for excessive fluid loss. [10][13]
- For pain and pruritus [4][7]
- Oatmeal baths
- Moisturizers (e.g., coconut oil, petroleum jelly, lotions); can be refrigerated before use to increase relief [7]
- Cooling ointments (e.g., aloe vera)
- Wet gauze or a cool cloth
- If symptoms do not improve, consider adding the following: [4]
- For persistent pain: oral analgesics (e.g., NSAIDs) [7][14]
- For intense pruritus: oral antihistamines [4]
- Topical steroids are widely used to treat sunburn; however, there is a lack of evidence supporting their use. [15]
Do not use very cold wet dressings or ice to cool sunburn; ice causes vasoconstriction of blood vessels in the dermis, which can damage the tissue further. [4]
Avoid using moisturizers and cooling ointments on broken skin (e.g., open blisters). [10]
Complications
Skin conditions [6]
- Common acquired melanocytic nevi [16]
- Precancerous skin lesions (e.g., actinic keratoses) [6]
- Aging changes in the skin (e.g., wrinkles, solar lentigines) [5][7][10]
- Malignancy (melanoma and nonmelanoma skin cancers) [5][7]
- Herpes labialis [11][16]
One sunburn during childhood doubles the risk of melanoma as an adult. [16]
Ocular conditions [11]
- Cataracts
- Blindness caused by chronic conditions, i.e.:
We list the most important complications. The selection is not exhaustive.
Prevention
General principles
- All individuals, regardless of age or skin tone, should combine the following photoprotective measures to reduce the risk of sunburn: [3][7][16]
- Sun avoidance when possible
- Protective clothing
- Sunscreen
- Children, especially those < 3 years of age, are at increased risk for sunburn compared to adults. [7][16][17]
- Ensure photoprotective measures are strictly adhered to.
- Advise caregivers that blistering sunburn in children < 18 years of age is associated with an increased lifetime risk of melanoma.
- Infants < 6 months of age may experience adverse effects from sunscreen ingredients; sun avoidance is the primary photoprotective strategy in this age group. [3][8][16]
Indoor tanning is associated with an increased risk of melanoma; individuals should be strongly counseled against it. [16][17]
Sun avoidance [4][7]
- Avoid sun exposure from 10 am to 4 pm. [4][7]
- Seek shade often (e.g., use umbrellas, stroller canopies).
Do not recommend sun exposure to prevent vitamin D deficiency; a healthy diet and/or oral supplements should be recommended instead. [18]
Protective clothing [3][7]
- Wide-brimmed hat with ≥ 3-inch diameter
- Long-sleeve shirt
- Full-length pants
- Sunglasses with UVR protection
UVR can penetrate wet clothing and thin fabric. [7]
Sunscreen [5][7][16]
- A topical solution applied to the skin to protect against UVR and, in some cases, visible light
- Protection is determined by the sun protection factor (SPF). [6]
Types of sunscreen [5][20]
- Chemical sunscreen: a type of sunscreen that contains organic UV filters that absorb UV radiation [7]
-
Mineral-based sunscreen (physical sunscreen)
- A type of sunscreen that contains inorganic UV filters (e.g., zinc oxide, titanium dioxide) that scatter or reflect UVR
-
Can protect against both UVR and visible light [21][22]
- Products containing zinc oxide or titanium oxide protect against UVR and visible light but have a chalky white appearance.
- Microionized formulas have reduced visibility on the skin but do not protect against visible light. [21]
- Tinted sunscreens use pigments such as iron oxides to match skin tones; these protect against visible light and UVR.
- Broad-spectrum sunscreen: protects against both UVB and UVA radiation
- Water-resistant sunscreen: provides protection for 40–80 minutes while sweating or in water [7]
Broad-spectrum sunscreens are preferred, as while UVB radiation is responsible for the majority of sunburns, UVA radiation is associated with photosensitivity reactions and premature skin aging. [7]
Mineral-based sunscreen may be preferred for individuals with sensitive skin (e.g., those with photodermatoses or contact dermatitis). [7][16]
Application of sunscreen [7]
- Apply a thin layer of sunscreen 15–30 minutes prior to sun exposure. [16]
- Adults and children ≥ 6 months of age [7]
- Children < 6 months of age: If sun exposure is unavoidable, use a mineral-based sunscreen with SPF ≥ 30. [7][8]
- Limit use to sun-exposed areas (e.g., cheeks, hands).
- Immediately wash off after sun exposure. [3][16]
- Spray-on sunscreen should be sprayed onto the palm and then spread onto the skin to avoid inhalation. [8]
- After the sunscreen dries, apply insect repellent, if needed. [7]
- Reapply sunscreen every 2–3 hours or more frequently if in water (e.g., swimming, showering) or sweating.