Sunburn

Overview of Sunburn

Basically, Sunburns are even more common in younger people. Between half and three-quarters of children younger than 18 have sunburns each year.

It is caused by direct exposure to ultraviolet light. Fair-skinned persons, especially newcomers are more commonly affected.

Sunburns are the first degree or superficial burns that people get on exposed areas like the face, limbs, also back.

Symptoms start with erythema also pruritus and proceed to acute painful edema, vesiculation and bullae formation.

Prolonged and repeated exposure results in increased pigmentation and improved tolerance. Local application of calamine lotion gives soothing relief. [1]

Epidemiology:

Causes of Sunburn

• Sunburn is caused by exposure to two types of ultraviolet rays from the sun: UVA rays and UVB rays. Both types of rays can burn your skin.

Your chance of getting a sunburn increase depending on i.e.:

• Amount of time you spend in the sun.
• Certain medications you take, including antibiotics such as doxycycline and Bactrim, nonsteroidal anti-inflammatory drugs (in other words, NSAIDs), retinoids and heart medications such as diuretics.
• Intensity of UV rays, affected by the time of day, cloud coverage, altitude also closeness to the equator.
• Ozone depletion, depending on where you are in the world.
• All in all, Skin type and pigmentation including tanning, although anyone can get a sunburn.[1][2]

Classification of Sunburn

Sunburns are categorized based on the severity of skin damage. Furthermore, The two most common types of sunburn include:

First-degree sunburn i.e.: 

• Damage to your skin’s outer layer. Additionally, This usually heals on its own in a few days to a week.

Second-degree sunburn i.e.: 

• Damage to the inner layer of your skin (especially, dermis). This may cause blistering. In detail, It can take weeks to heal and may need medical treatment.

Third-degree sunburn i.e.:

• Very rare cases, people might get This type of sunburn:
• Severely damages all layers of your skin, including the fat layer beneath the skin.
• May destroy nerve endings.
• Requires emergency treatment.[2]

Risk factor of Sunburn

• Having light skin, blue eyes, and either red or blond hair
• Living or vacationing somewhere sunny, warm or at high altitude
• Working outdoors
• Swimming or spraying your skin with water, as wet skin tends to burn more than does dry skin
• Mixing outdoor recreation also drinking alcohol
• Regularly exposing unprotected skin to UV light from sunlight or artificial sources, such as tanning beds
• Taking a drug that makes you more likely to burn (photosensitizing medications).[3]

Pathogenesis:

Direct DNA Damage and Inflammation

The primary cause of sunburn is direct damage to DNA by ultraviolet radiation (UVR), particularly UVB. This damage leads to the following:

• Inflammation: The body responds to DNA damage by initiating an inflammatory response. This involves the release of various inflammatory mediators, such as histamine, prostaglandins, and cytokines. These mediators cause vasodilation (widening of blood vessels), leading to the characteristic redness (erythema) of sunburn.
• Apoptosis: Cells with severe DNA damage undergo programmed cell death (apoptosis) to prevent the propagation of mutated DNA. This contributes to the peeling of skin that often occurs after a sunburn.

Key Processes

• UVB Absorption: UVB is primarily absorbed by DNA and proteins in the epidermis (outer layer of skin).
• DNA Damage: UVB photons cause the formation of pyrimidine dimers, which are abnormal bonds between adjacent DNA bases. These dimers disrupt DNA replication and transcription, leading to cell dysfunction and death.
• Inflammatory Response: Damaged cells release signaling molecules that trigger an influx of inflammatory cells, such as neutrophils and macrophages. These cells further contribute to the inflammatory response and tissue repair.
• Delayed Effects: Some effects of sunburn, like pigmentation changes (tanning), may take days to appear due to the time required for melanin production and distribution.

Additional Factors

• UVA: Although less efficient at causing sunburn than UVB, UVA can also contribute to DNA damage and skin aging.
• Individual Variation: Sunburn severity varies depending on factors like skin type, sun exposure duration, and intensity.
• Long-Term Effects: Repeated sunburns increase the risk of skin cancer and premature aging. [10]

Pathophysiology:

Acute Inflammatory Response

Sunburn is classified as a first-degree burn, affecting only the epidermis. The pathophysiology involves a complex cascade of events:

• UV Radiation Absorption: The initial step is the absorption of UV radiation, primarily UVB, by chromophores in the skin, including DNA, proteins, and lipids.
• Direct DNA Damage: UVB photons directly damage DNA, leading to the formation of pyrimidine dimers and other lesions that disrupt cellular function and trigger apoptosis (programmed cell death).
• Oxidative Stress: UV radiation also generates reactive oxygen species (ROS) that cause oxidative damage to cellular components, further contributing to cell death and inflammation.
• Inflammatory Mediator Release: Damaged cells and keratinocytes release a variety of inflammatory mediators, including prostaglandins, histamine, cytokines, and chemokines.
• Vascular Changes: Inflammatory mediators induce vasodilation (widening of blood vessels) and increased vascular permeability, leading to erythema (redness) and edema (swelling).
• Sensory Nerve Activation: Inflammatory mediators also sensitize sensory nerves, causing pain and discomfort.
• Immune Cell Infiltration: Chemokines attract immune cells, such as neutrophils and macrophages, to the site of injury, further amplifying the inflammatory response and initiating tissue repair.

Delayed Effects

• Apoptosis and Desquamation: Apoptosis of damaged cells leads to desquamation (peeling) of the epidermis several days after sunburn.
• Melanogenesis: UV radiation stimulates melanogenesis (pigment production), resulting in delayed tanning as a protective response.
• Long-term Consequences: Repeated sunburns increase the risk of chronic skin damage, including premature aging and skin cancer.

Key Points:

• Sunburn is an acute inflammatory response triggered by UV radiation-induced damage to the skin.
• The pathophysiology involves DNA damage, oxidative stress, release of inflammatory mediators, vascular changes, and immune cell infiltration.
• Delayed effects include apoptosis, desquamation, and melanogenesis.
• Repeated sunburns have significant long-term consequences for skin health. [11]

Clinical Features

Acute Sunburn

• Erythema: The most prominent feature is erythema (redness) caused by vasodilation and increased blood flow in the affected skin.
• Tenderness/Pain: Sunburned skin is typically tender or painful to the touch due to inflammation and sensitization of nerve endings.
• Edema: Swelling (edema) may occur, particularly in areas with loose skin, such as the face and eyelids.
• Warmth: The skin may feel warm due to increased blood flow and inflammation.
• Blistering: In severe cases, blisters may form, indicating damage to the deeper layers of the epidermis.
• Systemic Symptoms: Occasionally, sunburn can be accompanied by systemic symptoms like fever, chills, nausea, and headache, particularly in cases of extensive sunburn.

Delayed Features

• Desquamation: Peeling of the skin (desquamation) usually occurs several days after sunburn, as damaged cells are shed.
• Hyperpigmentation: Increased melanin production can lead to hyperpigmentation (darkening) of the skin, which may persist for weeks or months.
• Hypopigmentation: In some cases, hypopigmentation (lightening) of the skin may occur due to damage to melanocytes (pigment-producing cells).

Severity

The severity of sunburn is classified based on the extent of skin involvement and the presence of systemic symptoms:

• Mild: Erythema and tenderness without blistering or systemic symptoms.
• Moderate: Erythema, tenderness, and blistering with possible mild systemic symptoms.
• Severe: Extensive erythema, blistering, and significant systemic symptoms, often requiring medical attention.

Key Points:

• Sunburn presents with erythema, tenderness, edema, and sometimes blistering.
• Delayed features include desquamation and pigmentation changes.
• Severity ranges from mild to severe, depending on the extent of skin damage and systemic symptoms. [12]

Sign & Symptoms of Sunburn

Symptoms of sunburn depend on how severe your burn is. Symptoms may include:

First-degree symptoms i.e.

• Redness
• Skin feels hot or tight
• Pain or tenderness
• Blistering
• Swelling
• Peeling skin (after several days)
• Fatigue
• Fever
• Headache
• Nausea

Second-degree symptoms i.e.

• Extremely red skin
• Blistering and swelling over a larger area
• Wet-looking skin
• Pain
• White discoloration within the burn
• Confusion, Dizziness
• Exhaustion
• Fast breathing
• Fever, Headache
• Muscle cramps
• Nausea
• Shivers

Third-degree symptoms i.e.

• Leathery-looking burn
• Numb skin
• White or dull skin Color
• All of the above systemic heat illness symptoms including shock and/or heat stroke.[2][5]

Clinical Examination

Inspection:

• Erythema: Assess the extent and intensity of redness (erythema) on sun-exposed areas.
• Edema: Look for swelling (edema), especially in areas with loose skin like the face and eyelids.
• Blisters: Note the presence, size, and distribution of blisters, if any.
• Desquamation: Observe for peeling skin (desquamation) in later stages.
• Pigmentation Changes: Look for hyperpigmentation (darkening) or hypopigmentation (lightening) in healed areas.

Palpation:

• Tenderness: Gently palpate the affected skin to assess for tenderness or pain.
• Warmth: Feel for increased warmth in the sunburned areas.
• Texture: Note any changes in skin texture, such as roughness or dryness.

Additional Considerations:

• Sun Exposure History: Ask about the duration and intensity of sun exposure, use of sunscreen, and any predisposing factors.
• Systemic Symptoms: Inquire about fever, chills, nausea, headache, or other systemic complaints.
• Medical History: Assess for any underlying medical conditions or medications that may increase sunburn susceptibility.
• Skin Type: Note the patient’s skin type (Fitzpatrick classification) to assess their risk for sunburn.

Key Points:

• Sunburn is primarily diagnosed clinically based on the characteristic appearance and history of sun exposure.
• Examination focuses on assessing the extent of erythema, edema, blistering, desquamation, and pigmentation changes.
• Palpation helps evaluate tenderness and warmth.
• A thorough history is crucial to understand the context of the sunburn and identify any contributing factors. [13]

Diagnosis of Sunburn

• Your doctor is likely to conduct a physical exam and ask questions about your symptoms, UV exposure also sunburn history.
• Look at the amount of affected skin, type of sunburn and your symptoms. Additionally, Then they can recommend the appropriate treatment.[1][5]

Differential Diagnosis of Sunburn

• Phototoxic reaction
• Photoallergic reaction
• Phyto photodermatitis
• Solar urticaria
• Lupus erythematosus(in other words, SLE)
• Dermatomyositis
• Acne
• Atopic dermatitis [3]

Complication of Sunburn

• Premature aging of your skin
• Precancerous skin lesions
• Skin cancer
• Eye damage. [4]

Investigations

Generally, sunburn doesn’t necessitate extensive investigations. However, in severe cases or when complications are suspected, the following may be considered:

• Biopsy: In rare instances, a skin biopsy might be performed to rule out other conditions mimicking sunburn or to assess the extent of skin damage.
• Blood Tests:
  
  • Complete Blood Count (CBC): To evaluate for infection or systemic inflammatory response in severe cases.
  • Electrolytes: To check for dehydration, especially if the patient has extensive sunburn or systemic symptoms.
• Urinalysis: To assess for dehydration and potential kidney involvement in severe cases.
• Imaging Studies:
  
  • Ultrasound or MRI: May be used to assess the depth of skin damage in severe burns or when complications like cellulitis are suspected.

Key Points:

• Sunburn is typically diagnosed clinically based on the patient’s history and physical examination findings.
• Investigations are generally not required for mild to moderate cases.
• In severe cases or when complications are suspected, investigations like biopsy, blood tests, urinalysis, or imaging studies may be considered.
• The choice of investigations depends on the individual patient’s presentation and clinical judgment. [14]

Treatment of Sunburn

• Local application of calamine lotion containing 0.5% either crystal violet or any antihistaminic cream gives relief.
• Moreover, Para-amino benzoic acid, which absorbs ultraviolet light, gives some protection and this can be applied as a cream (5%) or lotion.
• Excessive washing of the skin with strong soap should be avoided.
• Besides this, Use of bland soaps and regular use of gingeli oil (sesame oil) over the skin applied for one hour weekly prevents this lesion in the native population.
• Lastly, In established cases, stay in a cold environment and use of loose clothing brings about relief in 2-3 weeks.[1][5]

Prevention of Sunburn

• Prevention consists of avoidance of direct exposure and the use of protective clothing and umbrella. [1]
• Avoid sun exposure between 10 a.m. and 4 p.m., the sun’s rays are strongest during these hours.
• Avoid sun tanning and tanning beds.
• Cover up, when outside, wear a wide-brimmed hat and clothing that covers you, including your arms and legs.
• Use sunscreen frequently and generously.
• Wear sunglasses when outdoors.
• Be aware of sun-sensitizing medications, some common prescription and over-the-counter drugs, including antibiotics, retinoids and ibuprofen, can make skin more sensitive to sunlight. [2][3]

Homeopathic Treatment of Sunburn

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Sunburn:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:  

Belladonna

• The affected area appears swollen, smooth, also red.
• The skin may get dry, hot, and sensitive especially to touch.
• Lastly, The key feature in such cases is that on touching the skin, it seems to be extremely hot.

Cantharis

• Patients may complain specifically of vesicular eruptions on the face which may be highly sensitive to touch.
• In detail, These eruptions may turn black later.
• There may also be sharp pain and burning.
• Patients get relief especially by cold application to the affected area.

Apis Mellifica 

• The patient may complain of sensitivity to heat, and dry also sensitive skin.
• Sudden puffiness may appear in the whole body, additionally the swollen areas may become sensitive to touch.
• Apis Mellifica is an important homeopathic medicine especially for sunburn with water-filled blisters and stinging pain.

Sulphur 

• Basically, The skin looks unhealthy and dry, and small pimples may develop.
• The patient has the urge to scratch, which may cause burning.
• In some cases, the itching may get worse especially at night or after washing.
• It works well in cases where there has been excessive use of local ointments for sunburn in the past.

Urtica Urens

• When a burn is mild and the primary symptoms are redness and stinging pain, this remedy often brings relief.
• It is often useful for sunburn when the pain is prickly and stinging.[7][8]

Diet & Regimen of Sunburn

• Take frequent either cool baths or showers to help relieve the pain.
• Use a moisturizer that contains either aloe Vera or soy to help soothe sunburned skin.
• Drink extra water.
• Besides this, A diet rich in omega-3s from fish oil can help make sunburns.
• Antioxidants: edible sunscreens use.
• Tomatoes are an excellent source of lycopene, an antioxidant pigment that may play a role in protecting against sunburns.
• All in all, Oranges, grapefruit and kiwi are loaded with vitamin C, which protects against free radical damage. [6]

Do’s and Don’ts 

Sunburn do’s and don’ts 

Do’s:

• Cool Compresses or Baths: Apply cool compresses or take cool baths to soothe the skin and reduce inflammation.
• Hydration: Drink plenty of fluids to avoid dehydration, as sunburn can draw fluid to the skin surface.
• Moisturizers: Apply fragrance-free moisturizers to keep the skin hydrated and reduce peeling.
• Pain Relief: Take over-the-counter pain medications like ibuprofen or acetaminophen as directed.
• Loose Clothing: Wear loose-fitting, breathable clothing to avoid irritating the sunburned skin.
• Protect from Further Sun Exposure: Avoid further sun exposure until the sunburn has healed completely.
• Seek Medical Attention: If the sunburn is severe (blistering, fever, chills), seek medical attention.

Don’ts:

• Don’t Pick or Peel Skin: Avoid picking or peeling the skin, as this can increase the risk of infection and scarring.
• Don’t Use Petroleum Jelly: Petroleum jelly traps heat and moisture, which can worsen inflammation.
• Don’t Apply Ice Directly: Applying ice directly to the skin can cause further damage.
• Don’t Use Harsh Soaps or Scrubs: These can irritate the already sensitive skin.
• Don’t Use Topical Anesthetics: These can cause allergic reactions and may mask the severity of the burn.
• Don’t Ignore Signs of Infection: Seek medical attention if you notice increasing redness, swelling, pus, or fever.

Terminology

References use for Article Sunburn

1. Textbook of Medicine, 5th Edition
2.  https://my.clevelandclinic.org/health/diseases/21858-sunburn
3. https://www.mayoclinic.org/diseases-conditions/sunburn/
4. Davidson’s Principles and Practice of Medicine
5. Kumar & Clark’s Clinical Medicine, 7th Edition
6.  https://edition.cnn.com/2019/05/17/health/healthy-skin-diet-sunscreen-drayer
7. Allen’s-keynotes-of-some-leading-remedies-of-our-Materia-medica
8. https://www.drhomeo.com/homeopathic-treatment/
9. Sundar et al. (2023) found that 35.8% of their nationally representative sample (N = 1560) had experienced sunburn in the past 12 months.
10. Fitzpatrick’s Dermatology in General Medicine, 8th Edition, Authors: Klaus Wolff, Lowell A. Goldsmith, Stephen I. Katz, Barbara A. Gilchrest, Amy S. Paller, David J. Leffell, Year of Publication: 2012, Publication: McGraw Hill Medical
11. Burns: Pathophysiology and Emerging Therapies, 1st Edition
    Editors: David N. Herndon, Jeffrey L. Salisbury, Marc G. Jeschke, Michael D. Peck, Lorenzo Borghese, Michael R. Schurr, Year of Publication: 2012
    Publication: Elsevier
12. Rook’s Textbook of Dermatology, 9th Edition, Authors: Christopher Griffiths, Jonathan Barker, Tanya Bleiker, Richard Chalmers, Daniel Creamer, Year of Publication: 2016
    Publication: Wiley-Blackwell
13. Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 4th ed., Authors: Jean L. Bolognia, Joseph V. Schaffer, Lorenzo Cerroni, Year of Publication: 2018, Publication: Elsevier
14. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th Edition, Authors: Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, Donald M. Yealy, Garth D. Meckler, David Cline, Year of Publication: 2020, Publication: McGraw Hill Professional.

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