Sunburn Clinical Presentation

  • Author: Christopher M McStay, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 18, 2010
 

History

History and symptoms for sunburn may include the following:

  • Recent sun exposure or outdoor activity; outdoor occupations or hobbies; use of indoor tanning equipment
  • Erythema develops after 3-4 hours and peaks at 12-24 hours.[7]
  • Pain
  • Possible fever, chills, malaise, nausea, or vomiting in severe cases
  • Blistering
  • Erythema that resolves over 4-7 days, usually with skin scaling and peeling[7] Subacute sunburn of shoulder with peeling in a 21-Subacute sunburn of shoulder with peeling in a 21-year-old male.
  • Assess for exposure to photosensitizing drugs. See eMedicine article Drug-Induced Photosensitivity for an in-depth discussion and list of common photosensitizing drugs.
  • Assess for heavy alcohol use, which is associated with sunburning.[10, 15]
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Physical

  • Patients at highest risk typically have fair skin, blue eyes, and red or blond hair.[13]
  • The acute inflammatory response is greatest 12-24 hours after exposure.[7]
    • Erythema
    • Warmth
    • Tenderness
    • Edema
    • Blistering (severe cases), a sign of either a superficial partial-thickness or deep partial-thickness (second-degree) burn[16]
  • Fever can present in severe cases.[7]
  • UVR may be transmitted through clothing, especially when wet, so sunburn may occur under clothed skin.[17]
  • Delayed scaling and desquamation occurs 4-7 days after exposure.[7]
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Causes

Sunburn is caused by excessive exposure of the skin to UVR. The ultraviolet spectrum can be divided into ultraviolet A-I (UVA-I), 340-400 nm; ultraviolet A-II (UVA-II), 320-340 nm, ultraviolet B (UVB), 290-320 nm; and ultraviolet C (UVC), 200-290 nm.[1] Solar UVR of wavelengths shorter than 290 nm are filtered out or absorbed in the outer atmosphere and are not encountered at sea level.[1] Shorter wavelength UVB rays are much more effective at inducing erythema than UVA rays and, therefore, are the principal cause of sunburn.[1] However, UVA comprises the majority of UVR reaching the surface of the earth (about 95-98% at midday) and, therefore, accounts for a significant percentage of the immediate and long-term cutaneous effects of UVR.[1]

The minimal single dose of UVR (energy per unit area) required to produce erythema after 24 hours at an exposed site is known as the minimal erythema dose (MED). This dose differs by skin type.[2]

Multiple factors influence UVR-induced erythema; these are listed below.

  • Wavelength: UVB is more erythemogenic than UVA.[2]
  • Skin type/pigmentation: Compared with type I-II skin, patients with type IV-V skin require 3-5 times more UVR exposure to cause erythema.[13]
  • Hydration: UVR causes erythema in moist skin more effectively than dry skin.[18]
  • Environmental reflection: Radiation is 80% reflected by snow and ice, compared with 15% by sand.[12]
  • Ozone coverage: Increased levels of ozone filter out more UVR.[12]
  • Altitude: Thinner atmosphere at higher altitudes absorbs less UVR.[12]
  • Latitude: Exposure is greater nearer the equator.[12]
  • Time of day: UVR exposure is greatest from 10 am to 4 pm, when the sun is highest in the sky.[12]
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Contributor Information and Disclosures
Author

Christopher M McStay, MD  Assistant Professor, Department of Emergency Medicine, New York University School of Medicine, Bellevue Hospital Center

Christopher M McStay, MD is a member of the following medical societies: American College of Emergency Physicians and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ershad Elahi, MD  Resident Physician, Department of Emergency Medicine, Bellevue Hospital Center, New York

Disclosure: Nothing to disclose.

Specialty Editor Board

James Li, MD  Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A Antoine Kazzi  MD, Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Amy Caron, MD, to the development and writing of this article.

References

  1. Kochevar IE, Taylor CR. Photophysics, photochemistry and photobiology. In: Freedberg IM, ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:1267-1275.

  2. Walker SL, Hawk JL, Young AR. Acute effects of ultraviolet radiation on the skin. In: Freedberg IM, ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:1275-1282.

  3. Walsh LJ. Ultraviolet B irradiation of skin induces mast cell degranulation and release of tumour necrosis factor-alpha. Immunol Cell Biol. Jun 1995;73(3):226-33. [Medline].

  4. Terui T, Takahashi K, Funayama M, Terunuma A, Ozawa M, Sasai S, et al. Occurrence of neutrophils and activated Th1 cells in UVB-induced erythema. Acta Derm Venereol. Jan-Feb 2001;81(1):8-13. [Medline].

  5. Clydesdale GJ, Dandie GW, Muller HK. Ultraviolet light induced injury: immunological and inflammatory effects. Immunol Cell Biol. Dec 2001;79(6):547-68. [Medline].

  6. Van Laethem A, Claerhout S, Garmyn M, Agostinis P. The sunburn cell: regulation of death and survival of the keratinocyte. Int J Biochem Cell Biol. Aug 2005;37(8):1547-53. [Medline].

  7. Kramer DA, Shayne P. Sun-induced disorders. In: Schwartz GR, ed. Principles and Practice of Emergency Medicine. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999:1581.

  8. Narbutt J, Lesiak A, Sysa-Jedrzejowska A, Boncela J, Wozniacka A, Norval M. Repeated exposures of humans to low doses of solar simulated radiation lead to limited photoadaptation and photoprotection against UVB-induced erythema and cytokine mRNA up-regulation. J Dermatol Sci. Mar 2007;45(3):210-2. [Medline].

  9. Centers for Disease Control and Prevention (CDC). Sunburn prevalence among adults--United States, 1999, 2003, and 2004. MMWR Morb Mortal Wkly Rep. Jun 1 2007;56(21):524-8. [Medline]. [Full Text].

  10. Brown TT, Quain RD, Troxel AB, Gelfand JM. The epidemiology of sunburn in the US population in 2003. J Am Acad Dermatol. Oct 2006;55(4):577-83. [Medline].

  11. Cokkinides V, Weinstock M, Glanz K, Albano J, Ward E, Thun M. Trends in sunburns, sun protection practices, and attitudes toward sun exposure protection and tanning among US adolescents, 1998-2004. Pediatrics. Sep 2006;118(3):853-64. [Medline].

  12. Ultraviolet radiation: global solar UV index. Fact sheet No. 271. August 2002. World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs271/en/index.html.

  13. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. Jun 1988;124(6):869-71. [Medline].

  14. Lowe NJ. An overview of ultraviolet radiation, sunscreens, and photo-induced dermatoses. Dermatol Clin. Jan 2006;24(1):9-17. [Medline].

  15. Mukamal KJ. Alcohol consumption and self-reported sunburn: a cross-sectional, population-based survey. J Am Acad Dermatol. Oct 2006;55(4):584-9. [Medline].

  16. Edlich RF, Martin ML, Long WB. Thermal burns. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, PA: Mosby Elsevier; 2006:918-9.

  17. Hatch KL, Osterwalder U. Garments as solar ultraviolet radiation screening materials. Dermatol Clin. Jan 2006;24(1):85-100. [Medline].

  18. Moehrle M, Koehle W, Dietz K, Lischka G. Reduction of minimal erythema dose by sweating. Photodermatol Photoimmunol Photomed. Dec 2000;16(6):260-2. [Medline].

  19. Bickers DR. Sun-induced disorders. Emerg Med Clin North Am. Nov 1985;3(4):659-76. [Medline].

  20. Rapaport MJ, Rapaport V. Preventive and therapeutic approaches to short- and long-term sun damaged skin. Clin Dermatol. Jul-Aug 1998;16(4):429-39. [Medline].

  21. Han A, Maibach HI. Management of acute sunburn. Am J Clin Dermatol. 2004;5(1):39-47. [Medline].

  22. Faurschou A, Wulf HC. Topical corticosteroids in the treatment of acute sunburn: a randomized, double-blind clinical trial. Arch Dermatol. May 2008;144(5):620-4. [Medline].

  23. Dietrich AJ, Olson AL, Sox CH, Stevens M, Tosteson TD, Ahles T, et al. A community-based randomized trial encouraging sun protection for children. Pediatrics. Dec 1998;102(6):E64. [Medline].

  24. Norman GJ, Adams MA, Calfas KJ, Covin J, Sallis JF, Rossi JS, et al. A randomized trial of a multicomponent intervention for adolescent sun protection behaviors. Arch Pediatr Adolesc Med. Feb 2007;161(2):146-52. [Medline].

  25. Gasparro FP, Brown D, Diffey BL, Knowland JS, Reeve V. Sun protective agents: formulations, effects and side effects. In: Freedberg IM, ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:2344-2352.

  26. Autier P, Boniol M, Severi G, Dore JF,. Quantity of sunscreen used by European students. Br J Dermatol. Feb 2001;144(2):288-91. [Medline].

  27. Maier T, Korting HC. Sunscreens - which and what for?. Skin Pharmacol Physiol. Nov-Dec 2005;18(6):253-62. [Medline].

  28. Hawk JLM, Norris PG, Honigsmann H. Abnormal responses to ultraviolet radiation: idiopathic, probably immunologic, and photoexacerbated. In: Freedberg IM, ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York, NY: McGraw-Hill; 2003:1290-1295.

  29. Wightman JM, Hamilton GC. Red and painful eye. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, PA: Mosby Elsevier; 2006:294.

 
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Note the apoptotic sunburn cells in the epidermis. Photograph courtesy of David Shum, MD, Division of Dermatology, University of Western Ontario.
Acute sunburn of face after a soccer match in a 15 year-old female.
Subacute sunburn of shoulder with peeling in a 21-year-old male.
Table. Fitzpatrick Skin Types and Recommended Sunscreen Sun Protection Factor (SPF) Levels[13, 2, 14]
Skin Type Description Skin Color Routine SPF SPF for Outdoor Activity
IAlways burns, never tansWhite1525-30
IIAlways burns, tans minimallyWhite12-1525-30
IIIBurns minimally, tans slowlyWhite8-1015
IVBurns minimally, tans wellOlive6-8 15
VRarely burns, tans profusely/darklyBrown6-815
VIRarely burns, always tansBlack6-815
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