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Sunburn

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Other Names

  • Sunburn
  • Solar Exposure
  • Skin Cancer
  • Melanoma
  • Basal Cell Carcinoma
  • Squamous Cell Carcinoma

Background

  • This page refers to 'Sun Burns', a general term for solar exposure related dermatological conditions in athletes
    • Definition: acute, transient, inflammatory response of the skin to excessive exposure to ultraviolet (UV) radiation

History

Epidemiology

  • Exposure times
    • Elite water sport athletes exposed for about 4 hours per day[1]
    • Elite kite surfers exposed for 13.93 hours per week, only 7% avoided peak hours[2]
    • 19% of Portugese runners train between 10 am and 6 pm[3]
    • 57% of Brazilian runners train before 10 am[4]
    • Spanish skateboarders spend more than 90 days per year and 4 hours each day outdoors[5]
    • US Collegiate athletes spend an average of 4 hours per day and 10 months per year training outside[6]
  • Sunscreen Use
    • Nearly half of Australian athletes in multiple sports used sunscreen inadequately, about 1/3 did not use it at all[7]
    • Another study found 29.5% reported no sunscreen use, only 20.2%% had adequate use[8]
    • 66%% of elite athletes in several New Zealand sports report concern about skin cancer, while only 9% regularly apply sunscreen[9]
    • Among collegiate athletes, 96% report sunscreen helps prevent skin cancer, more than half never use it[6]
    • Among surfers, windsurfers, olympic sailors, 22.5% report never using sunscreen and 31.1% did not reapply after 2 hours[1]
    • Approximately half of beach handball players did not apply sunscreen during training or competition[10]
    • Nearly 34% of mountain guides report occasionally rarely or never using sunscreen[11]
  • Protecting clothing
    • 66% of retired Australian cricketers always wear a hat following a match, 20% always wear long sleeve shirt[12]
    • Among Australian marathon runners, wore shorts (97%) and short sleeve shirt (88%), over half used sunscreen regularly
    • Among Portuguese runners, 17% always used a hat and only 4% used a long sleeve shirt[3]
    • Marathon runner in Spain used sunglasses (66.4%), sunscreen (58.2%), hats (33.6%) or long-sleeved clothing (10.9%)[13]
    • In another study, Brazilian runners wore protective clothing (86%), sunscreen (62%)[4]
    • Among Spanish cyclists, hats are worn 96% of the time, sunglasses 93%, long sleeved clothing 6.2%[14]
    • Skiers and snowboarders have inconsistent compliance with sun protective recommendations[15]
    • Among paralympic sailors, use of sunglasses (85.7%), sunscreen (83.9%) and hat (75%) were reported[14]
    • 66% of Spanish skateboarders were long sleeve shirts, however only 18.7% wear sunscreen[5]
    • Mountain guides wear long sleeve shirts (16%), trousers (44%), hats (79%)[16]
  • Sunburn Rates
    • Overall rates range from 19.7% in Brazilian runners up to 84.7% in elite Kite surfers[4][1]
    • Increased levels of physical activity are associated with higher levels of sunburn[17]
    • In one study, 86% of athletes reported sunburns in the previous 12 months compared to only third to one half of non-athletes[6]

Pathophysiology

The human sunburn cycle. (A) 48 h, redness & inflammation; (B) 96 h, new tissue formation; apoptosis (onset); (C) 120 h, apoptosis; (D) 168 h, apoptosis (end)[18]
  • General
    • Sunburns are commonly encountered by Athletes, who spend much more time outside than the general population
    • It is a self limited condition that typically resolves within 3 to 7 days
    • Sunscreen should be applied regularly with a minimum SPF 30 and re-applied every 2 hours
    • Sun protective clothing such as hats, sunglasses and long sleeved clothing should be worn when possible
    • Athletes should avoid training during peak hours of 10 AM to 2 PM

Background

  • Assessing for skin damage/ cancer risk
    • Erythema can be used as a surrogate for skin cancer risk, self-reported erythema is probably under reported
    • Peterson et al found that researchers detected up to 28% more of objectively measured erythema than subjects did[19]
      • Among skiers, they found agreement between subjects and researchers in just 57%
    • Another limitation is dark complexion/ phenotypes that due not burn easily are still exposed to dangerous radiation
  • Preventive Exams
    • 50-60% of mountain guides had undergone a skin exam by a medical professional in one study[11]
    • De Castro reported that 83.3% of elite water sport athletes had not had a medical skin exam, 87.5% did not self examine[1]
    • 87-95% of beach handball players had not examine their skin over the last year
    • 78% of kitesurfers had not examined their skin, however 54% had consulted a dermatologist[2]
    • Among Austria runners, 60% had never had their skin checked by a dermatologist
    • Approximately 61% of Spanish cyclists did not examine their skin regularly[20]
Moderate sunburn 3 days after an 8-h exposure to the sun.[21]
  • Knowledge, Attitudes and Reported Reasons for Safe vs Unsafe Behaviour
    • Behavior influenced by multiple factors including demographic, environmental and psychosocial[22]
      • This includes skin cancer risk perception, perceived barriers to sunscreen and protective clothing use, perceived benefits and norms
    • Intention to use sunscreen appears to be associated with more frequent use[23]
      • However, knowledge of sun safety does not always translate to behavior
      • Some studies reveal contradictory behaviors and opinions
    • In kite surfers, 80% worried about skin cancer, 70% worried about sunburn but 40% enjoyed sunbathing[2]
    • In paralympic sailors, 82% report concern about skin cancer, 42.9% enjoy sunbathing[14]
    • Individuals are often likely to underestimate risk of skin cancer or sunburn
    • They may not seek attention if feeling healthy, no obvious skin lesions
    • Stated reasons for not using sunscreen include forgetfulness, discomfort, greasy feel, burning of eyes, causing acne, time consuming, inconvenient, messy or hindering performance due to slippery hands
    • Sun protective clothing may be restrictive or uncomfortable

Terminology

  • Sunburn
    • Characterized by damage to epidermis and dermis to to prolonged exposure to UV light
    • Manifests as painful erythema and blisters
  • Ultraviolet (UV) Radiation
    • A form of non-ionizing radiation emitted by the sun and some artificial sources (tanning beds, black lights, etc)
    • UV light causes DNA damage, which manifests as suntans, sunburns and skin cancer in humans
    • Also responsible for the formation of Vitamin D in humans
    • Note that UV light is present even in cloud cover
  • SPF (Sun Protection Factor)
    • Measure of UVB protection
    • E.g. SPF 30 meaning it would take 30 times longer for erythema to develop vs unprotected skin, in a laboratory setting
First Degree Sunburn.[24]

Risk Factors

  • Sports
  • Occupation
    • Mountain Guide
    • Ski Guide
  • Environmental/ Geographic
    • Snow is reflective[25]
    • Elevation: thinner air, ozone increase peak UV index[26]
  • Training
    • Duration of exposure
    • Sweating (shifting wavelength of light absorbed decreases minimal erythema dose)
  • Medications
    • Tetracyclines
    • Sulfa medications
    • Phenothiazines
    • Multiple acne medications.
  • Noncancerous and Precancerous Lesions Risk
    • Outdoor sports[27]
    • Richtig et al study of Marathon runners[28]
      • Lentigines: Lifetime sunburn history, type of sports wear
      • Naevi: training parameters (heart rate, training velocity, physical strain)
    • Marathon runners[29]
    • Golf players[30]
  • Skin Cancer Risk
    • Increased level of physical activity[31]
    • Beach vacations, water sports[32]
      • Including swimming, surfing, sailing[33]
    • Outdoor sports/ recreational activities[34]
    • History of sunburn

Differential Diagnosis

Differential Diagnosis of Sunburns

  • Exaggerated sunburn reaction
    • Drug-induced phototoxic reactions
    • Phytophotodermatitis
    • Xeroderma pigmentosum
    • Erythropoietic protoporphyria
  • Non-sunburn reactions
    • Polymorphous light eruption
    • Solar urticaria
    • Chronic actinic dermatitis
    • Systemic lupus erythematosus

Differential Diagnosis Heat Illness

Clinical Features

  • Moderate to severe sunburn without blistering

    Moderate to severe sunburn without blistering

  • Diffuse erythema on sun exposed areas[35]

    Diffuse erythema on sun exposed areas[35]

  • Erythema, edema, and bullae are present on this child with a severe sunburn.[36]

    Erythema, edema, and bullae are present on this child with a severe sunburn.[36]

  • Numerous small solar lentigines on the photodamaged skin of the upper chest.[37]

    Numerous small solar lentigines on the photodamaged skin of the upper chest.[37]

  • History
    • Patient should have a clear history of sun or outdoor exposure
    • Symptoms range from mild to highly painful, burning rash on sun exposed areas
    • Severe cases may also include headache, fever, nausea and vomiting
  • Physical Exam
    • Rash is typically erythematous, lasting 4-7 days
    • As severity increases, edema, vesiculation and blistering may be present and last up to 10 days
    • Desquamation can occur about 4 to 7 days after exposure
    • Note that dark complexion patients may not have erythema and sunburn may manifest as skin peeling

Evaluation

  • Clinical diagnosis, no workup or evaluation is required

Classification

  • No widely accepted classification of sunburns exist, however:
    • Mild-to-moderate sunburns are classified as superficial (1st degree)
    • Severe sunburns are classified superficial partial thickness (2nd degree)

Management

Treatment

  • General
    • Primarily a self limited condition that requires symptomatic management
    • Prevention is the best treatment
    • Symptoms resolve in 3 to 7 days
    • Blisters will heal without scarring in 7-10 days
    • Oral hydration to help alleviate increased third spacing and fluid loss
  • Topical treatment for pain relief and discomfort
  • Oral medications
  • Other options
    • Cool showers or baths can help relieve the pain
    • Moisturizers that contain aloe vera or soy
    • Increase oral hydration
  • Blisters
    • Do not manually rupture, leave roof on if they rupture as a protective barrier
    • Ruptured blisters can be gently cleansed with soap and water
    • Covered with wet dressing
    • Topical Antibiotics can be considered to prevent superinfection
  • Topical corticosteroids
    • Generally not indicated
    • Small studies have shown no benefit[38]
  • Hospitalization
    • In Severe sunburn these patients may require hospitalizing for fluid replacement and parenteral analgesia

Individual Prevention

  • General
    • Photoprotection should be practiced by all athletes of all skin types
    • Apply sunscreen irrespective of the UV index (UVI).
    • Avoid training between 10 am and 2 pm when possible to avoid mid-day exposure
    • Avoid photosensitising agents
  • Clothing
    • Clothes provide good, broad-spectrum UV and visible light protection[39]
    • Take advantage of sport-specific clothes, such as rash vests for surfing when possible
    • Protective hats or caps
    • Efficient UV-filtering sunglasses, when possible
  • Sunscreen
    • Sunscreen should be at least SPF 30.
    • Should be broad-spectrum to include balanced UVA protection.
    • Higher SPFs, e.g. SPF 50 and up to 100, are likely to be beneficial for snow sports and water sports
      • This is especially true in spring and summer when the UVI is high or very high[40]
    • Apply in sufficient amounts (approximately 2 mg/cm2), at least 30 min before exposure
    • Reapply every 2–3 h of exposure
      • Reapplication is particularly important in water sports.
    • Ideal sunscreen is easy to spread, non-greasy, non-sticky, suitable for use on wet skin, non-irritating to the eyes, sweat resistant, and not causing loss of grip
  • Skin examination
    • Routine self-examination of the skin and consultation at least once a year[41]
  • Antioxidants
    • Oral supplementation with antioxidants should be considered[42]
    • Benefit is not immediate
    • Not a substitute for sunscreen, consider as adjunct
  • Indicators
    • UV detection stickers or phone apps can increase awareness[43]
    • May increase sunscreen use

Organizational Prevention

  • Clothing
    • Uniform and clothing policies should ensure skin coverage
    • Eye protection should be worn
  • Sunscreen
    • Visual and verbal reminders to athletes to use, reapply sunscreen
    • Sunscreen should be easily accessible (locker room, sideline, etc)
  • Coaching/ Leadership
    • Should actively encourage athletes to wear sun protective clothing and sunscreen
  • Fans/ Attendees
    • Event and team organizers can send reminders to bring sunscreen and wear protective clothing
    • This can occur via text message, email
    • Sunscreen advertising to inform attendees how to apply sunscreen correctly[44]
  • Other
    • Elite athletes should act as role models for others[45]

Rehab and Return to Play

Rehabilitation

  • Not applicable

Return to Play/ Work

  • No specific guidelines
  • RTP is driven by symptom control

Complications and Prognosis

Prognosis

  • Sunburn is generally a self limited condition which will resolve with symptomatic management

Complications

  • With cumulative exposure[46]
    • Skin cancer
    • Melanoma
    • Keratinocyte carcinoma including basal cell and squamous cell
      • Risk correlates more with chronic exposure than with burn episodes[47]

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 De Castro-Maqueda G, Gutierrez-Manzanedo JV, Ponce-Gonzalez JG, Fernandez-Santos JR, Linares-Barrios M, De Troya-Martin M. Sun protection habits and sunburn in elite aquatics athletes: surfers, windsurfers and Olympic sailors. J Cancer Educ. 2020;35(2):312–20.
  2. ↑ 2.0 2.1 2.2 de Castro MG, Gutierrez-Manzanedo JV, Gonzalez-Montesinos JL, Vaz Pardal C, Rivas Ruiz F, de Troya MM. Sun exposure and photoprotection: habits, knowledge and attitudes among elite kitesurfers. J Cancer Educ. 2020;27:1–7.
  3. ↑ 3.0 3.1 Duarte AF, Nagore E, Silva JNM, Picoto A, Pereira AC, Correia OJC. Sun protection behaviour and skin cancer literacy among outdoor runners. Eur J Dermatol. 2018;28(6):803–8.
  4. ↑ 4.0 4.1 4.2 Purim KS, Leite N. Sports-related dermatoses among road runners in Southern Brazil. An Bras Dermatol. 2014;89(4):587–92.
  5. ↑ 5.0 5.1 Fernandez-Morano T, de Troya-Martin M, Rivas-Ruiz F, et al. Sun exposure habits and sun protection practices of skaters. J Cancer Educ. 2017;32(4):734–9.
  6. ↑ 6.0 6.1 6.2 Wysong A, Gladstone H, Kim D, Lingala B, Copeland J, Tang JY. Sunscreen use in NCAA collegiate athletes: identifying targets for intervention and barriers to use. Prev Med. 2012;55(5):493–6.
  7. ↑ Berndt NC, O’Riordan DL, Winkler E, McDermott L, Spathonis K, Owen N. Social cognitive correlates of young adult sport competitors’ sunscreen use. Health Educ Behav. 2011;38(1):6–14.
  8. ↑ Lawler S, McDermott L, O’Riordan D, et al. Relationships of sun-protection habit strength with sunscreen use during outdoor sport and physical activity. Int J Environ Res Public Health. 2012;9(3):916–23.
  9. ↑ Walker N, Love TD, Baker DF, et al. Knowledge and attitudes to vitamin D and sun exposure in elite New Zealand athletes: a cross-sectional study. J Int Soc Sports Nutr. 2014;11(1):47.
  10. ↑ De Castro-Maqueda G, Gutierrez-Manzanedo JV, Lagares-Franco C, Linares-Barrios M, de Troya-Martin M. Photoprotection practices, knowledge and sun-related skin damage in Spanish beach handball players. PeerJ. 2019;7:e7030.
  11. ↑ 11.0 11.1 Zink A, Koch E, Seifert F, Rotter M, Spinner CD, Biedermann T. Nonmelanoma skin cancer in mountain guides: high prevalence and lack of awareness warrant development of evidence-based prevention tools. Swiss Med Wkly. 2016.
  12. ↑ Noble-Jerks J, Weatherby RP, Meir R. Self-reported skin cancer protection strategies and location of skin cancer in retired cricketers: a case study from membership of the Emu Cricket Club. J Sci Med Sport. 2006;9(6):441–5.
  13. ↑ Rivas-Ruiz F, Fernandez-Morano T, Gilaberte Y, Garcia-Montero P, Blazquez-Sanchez N, de Troya-Martin M. Sun exposure and long-distance runners on the Spanish Costa del Sol: habits, attitudes, and knowledge. Actas Dermosifiliogr. 2021;112(6):541–5.
  14. ↑ 14.0 14.1 14.2 Gutiérrez-Manzanedo JV, De Castro-Maqueda G, Caraballo Vidal I, et al. Sun-related behaviors, attitudes and knowledge among Paralympic sailors. Disabil Health J. 2021;14(3):101095.
  15. ↑ Buller DB, Andersen PA, Walkosz BJ, et al. Compliance with sunscreen advice in a survey of adults engaged in outdoor winter recreation at high-elevation ski areas. J Am Acad Dermatol. 2012;66(1):63–70.
  16. ↑ Zink A, Thome F, Schielein M, Spinner CD, Biedermann T, Tizek L. Primary and secondary prevention of skin cancer in mountain guides: attitude and motivation for or against participation. J Eur Acad Dermatol Venereol. 2018;32(12):2153–61.
  17. ↑ Holman DM, Berkowitz Z, Guy GP Jr, Hartman AM, Perna FM. The association between demographic and behavioral characteristics and sunburn among US adults—National Health Interview Survey, 2010. Prev Med. 2014;63:6–12.
  18. ↑ Siddoo-Atwal, Chanda. "Genes That Can Cause Cancer." Gene Expression Profiling in Cancer. IntechOpen, 2019.
  19. ↑ Petersen B, Thieden E, Lerche CM, Wulf HC. Validation of self-reported erythema: comparison of self-reports, researcher assessment and objective measurements in sun worshippers and skiers. J Eur Acad Dermatol Venereol. 2013;27(2):214–9.
  20. ↑ Doncel Molinero D, Ruiz Paulano M, Rivas Ruiz F, et al. Sun protection behaviour and sunburns in Spanish cyclists. J Cancer Educ. 2020;27:1–8.
  21. ↑ Tanaka, Yohei, Kiyoshi Matsuo, and Shunsuke Yuzuriha. "Near-infrared irradiation nonthermally induces long-lasting vasodilation by causing apoptosis of vascular smooth muscle cells." Eplasty 11 (2011).
  22. ↑ Janssen E, van Kann D, de Vries H, Lechner L, van Osch L. Sun protection during snow sports: an analysis of behavior and psychosocial determinants. Health Educ Res. 2015;30(3):380–7.
  23. ↑ Petty KN, Knee CR, Joseph AK. Sunscreen use among recreational cyclists: how intentions predict reported behavior. J Health Psychol. 2013;18(3):439–47.
  24. ↑ Arrangoiz, Rodrigo, et al. "Melanoma review: epidemiology, risk factors, diagnosis and staging." Journal of Cancer Treatment and Research 4.1 (2016): 1-15.
  25. ↑ Price J, Ness A, Leary S, Kennedy C. Sun-safety behaviors of skiers and snowboarders on the South Island of New Zealand. J Cosmet Dermatol. 2006;5(1):39–47.
  26. ↑ Allen M, McKenzie R. Enhanced UV exposure on a ski-field compared with exposures at sea level. Photochem Photobiol Sci. 2005;4(5):429–37.
  27. ↑ Mahé E, Beauchet A, de Paula CM, et al. Outdoor sports and risk of ultraviolet radiation-related skin lesions in children: evaluation of risks and prevention. Br J Dermatol. 2011;165(2):360–7.
  28. ↑ Richtig E, Ambros-Rudolph CM, Trapp M, et al. Melanoma markers in marathon runners: increase with sun exposure and physical strain. Dermatology. 2008;217(1):38–44.
  29. ↑ Ambros-Rudolph CM, Hofmann-Wellenhof R, Richtig E, Müller-Fürstner M, Soyer HP, Kerl H. Malignant melanoma in marathon runners. Arch Dermatol. 2006;142(11):1471–4.
  30. ↑ del Boz J, Fernandez-Morano T, Padilla-Espana L, Aguilar-Bernier M, Rivas-Ruiz F, de Troya-Martin M. Skin cancer prevention and detection campaign at golf courses on Spain’s Costa del Sol. Actas Dermosifiliogr. 2015;106(1):51–60.
  31. ↑ Moore SC, Lee IM, Weiderpass E, et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med. 2016;176(6):816–25.
  32. ↑ Rosso S, Zanetti R, Martinez C, et al. The multicentre south European study “Helios”. II: Different sun exposure patterns in the aetiology of basal cell and squamous cell carcinomas of the skin. Br J Cancer. 1996;73(11):1447–54.
  33. ↑ Dozier S, Wagner RF Jr, Black SA, Terracina J. Beachfront screening for skin cancer in Texas Gulf coast surfers. South Med J. 1997;90(1):55–8.
  34. ↑ Rosso S, Joris F, Zanetti R. Risk of basal and squamous cell carcinomas of the skin in Sion, Switzerland: a case-control study. Tumori. 1999;85(6):435–42.
  35. ↑ Stedman's Medical Dictionary. Copyright © 2008 Lippincott Williams & Wilkins.
  36. ↑ Fleisher GR, Ludwig S, Baskin MN. Atlas of Pediatric Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia 2004.
  37. ↑ Image courtesy of uptodate.com, "Sunburn"
  38. ↑ Russo, P. M., and L. J. Schneiderman. "Effect of topical corticosteroids on symptoms of clinical sunburn." The Journal of Family Practice 7.6 (1978): 1129-1132.
  39. ↑ Ghazi S, Couteau C, Coiffard LJ. How to guarantee adequate sun protection for a young sportsperson. J Dtsch Dermatol Ges. 2011;9(6):470–4.
  40. ↑ Williams JD, Maitra P, Atillasoy E, Wu MM, Farberg AS, Rigel DS. SPF 100+ sunscreen is more protective against sunburn than SPF 50+ in actual use: results of a randomized, double-blind, split-face, natural sunlight exposure clinical trial. J Am Acad Dermatol. 2018;78(5):902-10.e2.
  41. ↑ De Castro-Maqueda G, Gutierrez-Manzanedo JV, Ponce-Gonzalez JG, Fernandez-Santos JR, Linares-Barrios M, De Troya-Martin M. Sun protection habits and sunburn in elite aquatics athletes: surfers, windsurfers and Olympic sailors. J Cancer Educ. 2020;35(2):312–20.
  42. ↑ De Gálvez MV. Antioxidants in photoprotection: do they really work? Actas Dermosifiliogr. 2010;101(3):197–200.
  43. ↑ Snyder A, Valdebran M, Terrero D, Amber KT, Kelly KM. Solar ultraviolet exposure in individuals who perform outdoor sport activities. Sports Med Open. 2020;6(1):42.
  44. ↑ Lynch BM, Dunn J. Scoreboard advertising at sporting events as a health promotion medium. Health Educ Res. 2003;18(4):488–92.
  45. ↑ Downs NJ, Axelsen T, Schouten P, Igoe DP, Parisi AV, Vanos J. Biologically effective solar ultraviolet exposures and the potential skin cancer risk for individual gold medalists of the 2020 Tokyo Summer Olympic Games. Temperature (Austin). 2020;7(1):89–108.
  46. ↑ Christoph S, Cazzaniga S, Hunger RE, Naldi L, Borradori L, Oberholzer PA. Ultraviolet radiation protection and skin cancer awareness in recreational athletes: a survey among participants in a running event. Swiss Med Wkly. 2016;146:w14297.
  47. ↑ Zanetti R, Rosso S, Martinez C, et al. Comparison of risk patterns in carcinoma and melanoma of the skin in men: a multi-centre case-case-control study. Br J Cancer. 2006;94(5):743–51.
Created by:
John Kiel on 30 June 2019 22:48:45
Last edited:
9 September 2022 20:09:03
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