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Sunburn

  • Author: Christopher M McStay, MD; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Jul 31, 2015
 

Background

Sunburn is an acute cutaneous inflammatory reaction that follows excessive exposure of the skin to ultraviolet radiation (UVR). UVR exposure can come from a variety of sources, including sun, tanning beds, phototherapy lamps, and arc lamps.[1] Long-term adverse health effects of repeated exposure to UVR are well described but are beyond the scope of this article. Most sunburns are classified as superficial or first-degree burns.

See the image below.

Acute sunburn of face after a soccer match in a 15 Acute sunburn of face after a soccer match in a 15 year-old female.
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Pathophysiology

Exposure to solar radiation has the beneficial effects of stimulating the cutaneous synthesis of vitamin D and providing radiant warmth. Unfortunately, when the skin is subjected to excessive radiation in the ultraviolet range, deleterious effects may occur. The most conspicuous is acute sunburn or solar erythema.[2]

The principal injury responsible for sunburn is direct damage to DNA by UVR, resulting in inflammation and apoptosis of skin cells.[3] Sunburn inflammation causes vasodilation of cutaneous blood vessels, resulting in the characteristic erythema. Within an hour of UVR exposure, mast cells release preformed mediators including histamine, serotonin, and tumor necrosis factor, leading to prostaglandin and leukotriene synthesis.[2, 4] Cytokine release additionally contributes to the inflammatory reaction, leading to an infiltrate of neutrophils and T lymphocytes.[5] Within 2 hours after UV exposure, damage to epidermal skin cells is seen. Both epidermal keratinocytes ("sunburn cells") and Langerhans cells undergo apoptotic changes as a consequence of UVR-induced DNA damage.[6, 7] Erythema usually occurs 3-4 hours after exposure, with peak levels at 24 hours.[8]

See the image below.

Note the apoptotic sunburn cells in the epidermis. Note the apoptotic sunburn cells in the epidermis. Photograph courtesy of David Shum, MD, Division of Dermatology, University of Western Ontario.

Less intense or shorter-duration exposure to UVR results in an increase in skin pigmentation, known as tanning, which provides some protection against further UVR-induced damage.[9] The increased skin pigmentation occurs in 2 phases: (1) immediate pigment darkening and (2) delayed tanning. Immediate pigment darkening occurs during exposure to UVR and results from alteration of existing melanin (oxidation, redistribution). It may fade rapidly or persist for several days. Delayed tanning results from increased synthesis of epidermal melanin and requires a longer period of time to become visible (24-72 h). With repeated exposure to UVR, the skin thickens, primarily due to epidermal hyperplasia with thickening of the stratum corneum. UVR exposure also suppresses cutaneous cell–mediated immunity, which might contribute to nonmelanoma skin cancer and certain infections.[2]

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Epidemiology

Frequency

United States

Previous reports have stated that about one third of US adults have a sunburn each year[10, 11] and about two thirds of US children have a sunburn each summer.[12] The US Centers for Disease Control and Prevention (CDC) reported in 2012 that just over 50% of all adults reported at least one sunburn in the past 12 months and that just over 65% of whites aged 18-29 years reported at least one sunburn in the past 12 months.[13]

International

Risk of sunburn is increased in regions that are closer to the equator and that are higher in altitude.[14]

Race

Lighter-skinned individuals are affected more frequently and severely. Skin types are traditionally classified into the following Fitzpatrick categories, based on an individual's tendency to tan, burn, or both (see the Table below).

Table. Fitzpatrick Skin Types and Recommended Sunscreen Sun Protection Factor (SPF) Levels[2, 15, 16] (Open Table in a new window)

Skin Type Description Skin Color Routine SPF SPF for Outdoor Activity
I Always burns, never tans White 15 25-30
II Always burns, tans minimally White 12-15 25-30
III Burns minimally, tans slowly White 8-10 15
IV Burns minimally, tans well Olive 6-8 15
V Rarely burns, tans profusely/darkly Brown 6-8 15
VI Rarely burns, always tans Black 6-8 15

Sex

Surveys of US adults show that men have a slightly higher prevalence of sunburn than women.[10]

Age

Sunburn is more common in children than in adults.[11, 12] Easy sunburning during infancy may indicate a serious underlying disease, such as porphyria or xeroderma pigmentosum. Referral for further evaluation is prudent.[17]

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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, 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

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

Acknowledgements

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

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

  3. Matsumura Y, Ananthaswamy HN. Toxic effects of ultraviolet radiation on the skin. Toxicol Appl Pharmacol. 2004 Mar 15. 195(3):298-308. [Medline].

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

  5. 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. 2001 Jan-Feb. 81(1):8-13. [Medline].

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

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

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

  12. 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. 2006 Sep. 118(3):853-64. [Medline].

  13. Centers for Disease Control and Prevention. Sunburn and sun protective behaviors among adults aged 18-29 years--United States, 2000-2010. MMWR Morb Mortal Wkly Rep. 2012 May 11. 61(18):317-22. [Medline].

  14. World Health Organization. Ultraviolet radiation: global solar UV index. Fact sheet No. 271. August 2002. Available at http://www.who.int/uv/publications/en/GlobalUVI.pdf. Accessed: August 5, 2014.

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

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

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

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

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

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

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

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

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

  27. 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. 1998 Dec. 102(6):E64. [Medline].

  28. 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. 2007 Feb. 161(2):146-52. [Medline].

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

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

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

  32. Wightman JM, Hamilton GC. Red and painful eye. 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 [2, 15, 16]
Skin Type Description Skin Color Routine SPF SPF for Outdoor Activity
I Always burns, never tans White 15 25-30
II Always burns, tans minimally White 12-15 25-30
III Burns minimally, tans slowly White 8-10 15
IV Burns minimally, tans well Olive 6-8 15
V Rarely burns, tans profusely/darkly Brown 6-8 15
VI Rarely burns, always tans Black 6-8 15
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