Approach
No current treatments can reverse ultraviolet-induced skin damage.[11] Thus, primary prevention of sunburn via sun avoidance, physical protection, and the appropriate use of sunscreen is key to managing the condition.
Symptomatic treatment
No definitive algorithm for the treatment of acute sunburn exists. Studies evaluating the use of oral and topical corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), antioxidants, and antihistamines after ultraviolet (UV) exposure have generally shown little to no improvement in recovery time.[11][24] Therefore, conservative management with bland emollients to facilitate skin healing is recommended.[24] Emollients have not been shown to decrease recovery time from acute sunburn.[11] Petrolatum may retain heat, leading some to argue against its use in acute burns, although occlusive ointments have been shown to accelerate wound healing.[9] Aqueous creams may ameliorate desquamation and pain associated with therapeutic radiation.[25]
There is no clinical evidence to support the use of aloe vera over other emollients, as aloe vera has been shown to produce no significant improvement in postexposure erythema or healing and may be associated with contact dermatitis.[26][27] However, given its limited side effect profile and symptomatic benefits, this treatment should be reserved for a second-line intervention.
Adjunctive therapeutic options include analgesics and drying agents in case of significant pain and blistering. Analgesics can alleviate sunburn-related discomfort and systemic symptoms. NSAIDs are thought to be effective in treating sunburn reactions via their inhibition of prostaglandin inflammatory mediators. Although studies have shown systemic and topical NSAIDs can decrease UV-induced erythema, these reductions are typically mild and/or transient and require use of medication before or immediately after exposure.[11][24] Pramoxine is a topical anesthetic that can be used second line, although it may cause contact dermatitis.[28]
Compresses should be applied prior to application of emollients. Aluminum acetate is astringent with antiseptic properties. It can help dry and heal areas of blistering. Cool compresses or baths +/- colloidal oatmeal may also be beneficial, although evidence is limited for these interventions.
Volume depletion, systemic symptoms, and blistering
Very young children with greater than 10% body surface area (BSA) coverage and adults with greater than 15% to 25% BSA blistering and those with systemic symptoms should be considered for hospitalization for intravenous fluids and supportive care.[29][30]
Ongoing prevention
Despite controversy, sunscreen remains the most frequently used method of primary prevention of sunburn across all age groups.[31] UVB radiation is the primary cause of sunburn. UVB and UVA radiation (including UVA2, blocked by most sunscreens, and UVA1, blocked by select sunscreens) can contribute to skin cancer and skin aging. Therefore, for most purposes, any broad-spectrum UVA/UVB sunscreen is sufficient to protect against sunburn, provided that it is used properly. However, many commercially available sunscreens do not provide full UVA protection. The best sunscreen agents target the entire spectrum of UVA and UVB radiation. These include the inorganic physical ultraviolet (UV) blocker zinc oxide and the organic chemical UV absorbing sunscreens avobenzone and ecamsule.[32] Titanium dioxide is also widely used as an inorganic UV blocker but has a decreased spectrum of UVA blocking compared with zinc oxide. Because organic sunscreens can be absorbed, zinc oxide is generally recommended for protection of young children. It is also widely used by all age groups in parts of the world where UV ozone layer penetration is high. Controversy over the potential of micronized zinc oxide to generate superoxide anions has so far not been supported by in-vivo studies demonstrating that superoxide anions can penetrate the stratum corneum to cause damage.
In Europe, UVA protection is indicated by a star system or the term "UVA" within a circle.
FDA regulations that went into effect in 2012 aim to make sunscreen labels more clear for the public. FDA: for consumers - sunscreen products Opens in new window The FDA regulations ban the use of the words “waterproof”, “sweatproof”, or “sunblock”, as these terms are misleading. Sunscreens with water or sweat resistance are labeled as offering 40 minute or 80 minute protection. The regulations also establish a standard test to determine which products can be labeled as “broad spectrum” UVA/UVB protection. To meet this test, sunscreens must protect against UVB with a sun protection factor (SPF) of 15 or higher, and must also shield at least a part of the UVA spectrum. However, as discussed above, many of the sunscreens that will be labeled as “broad spectrum” do not block UVA1. The consequence of ineffective UVA1 exposure is tanning, which has been associated with skin cancer and skin aging. In 2019, the FDA issued a proposed rule with updated requirements for sunscreens, in addition to providing guidance on how to apply and store sunscreen, and information regarding the sunscreen label and ingredients.[33] The FDA reports the following as acceptable active ingredients for sunscreen: Aminobenzoic acid, avobenzone, cinoxate, dioxybenzone, homosalate, meradimate, octocrylene, octinoxate, octisalate, oxybenzone, padimate O, ensulizole, sulisobenzone, titanium dioxide, trolamine salicylate, and zinc oxide. Only two of these 16 ingredients, zinc oxide and titanium dioxide, are “generally recognized as safe and effective.” The 2019 proposed rule also includes a proposal to increase maximum SPF value on sunscreen from 50 to 60.[34]
The use of long-sleeved shirts (tightly woven material provides the best UV protection) and wide-brimmed hats should be encouraged. Clothing with UV protection ratings as well as laundering agents such as bis-ethylhexyloxyphenol methoxyphenyl triazine that improve a fabric's ability to shield the skin from sunlight are commercially available.[35]
A global solar ultraviolet index (UVI) has been developed by the World Health Organization through an international collaboration. This depicts, through a simple numerical scale, the intensity of UV radiation at the Earth’s surface that is relevant to effects on the human skin. Global Solar UV Index Opens in new window UV indices of 1 to 2 indicate that it is safe to be outside without sun-protective measures, UV indices of 3 to 7 recommend shade during midday hours and sun-protective measures at all other times, and UV indices of 8 or above indicate that individuals should practice sun avoidance during midday hours, with mandatory sun protection at all times. A consensus statement for Australia and New Zealand recommends the application of daily sunscreen when the UVI is 3 or higher.[17]
Recommendations from the UK’s National Institute for Health and Care Excellence discuss how to counsel patients at risk of either sunburn or vitamin D deficiency on sun-safe behaviors.[16] Counseling of young adults and pediatric patients (and their parents) regarding minimizing exposure to ultraviolet radiation is recommended by the U.S. Preventive Services Task Force for pediatric patients through age 24 years with fair skin types.[12]
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