The occurrence of sunburn in children is common. Sunburn is also common in adolescents, with 70% of 11- to 18-year-olds reporting at least one sunburn over a time period of 1 year.1 A detailed study of exposure among youth with at least one summer sunburn reported approximately only one-third using sunscreen with a sun protection factor (SPF) of 15 or higher.2
Risk Factors and Clinical Course
Sunburn occurs when the skin is exposed to ultraviolet radiation, with the highest risk from ultraviolet B (UVB) rays (wavelength of 280–320 nm).3 Ultraviolet A rays (wavelength of 320–400 nm) pose a lesser risk, requiring doses nearly 1,000 times more than UVB radiation.4 Susceptibility to sunburn is variable, with highest risk for those with fair skin, blue eyes, and red or blond hair.5 Some people can even develop sunburn with fewer than 15 minutes of sun exposure.6 It should be noted that susceptibility to sunburn is itself a marker of higher risk of melanoma throughout one's life.7 Geographical location is a risk factor for sunburn as well. Areas closest to the equator and at high altitudes are higher-risk locations for sunburn due to higher UVB intensity. An additional risk factor is the presence of reflective surfaces such as snow, sand, or water.8 Risk of sunburn is greater around 12 noon due to the angle of the sun's rays, and cloud cover does not necessarily offer complete protection from ultraviolet radiation.9
When skin is exposed to the sun, vasodilation, increased blood flow, formation of keratinocytes undergoing apoptosis, endothelial cell activation, and release of inflammatory mediators occurs.10 The keratinocytes undergoing apoptosis are called “sunburn cells” and can appear in the epidermis within a few hours of exposure.11 Numerous inflammatory markers have been identified in sunburn blisters, which occur within 24 to 48 hours and include several identifiable prostaglandins and cytokines.12 Changes in the dermis also occur, including endothelial cell swelling, edema, and appearance of degranulated mast cells.6 Monocytes can appear and may be present for 48 hours.
Sunburn may not be immediately evident; redness typically starts 3 to 5 hours after being in the sun. The condition is self-limiting, with redness peaking 12 to 24 hours after exposure and fading over the course of 3 to 7 days.6 Skin that has been sunburned is warm to the touch and has increased sensitivity to pressure and heat.6 More severe sunburn involves blistering of the skin, which is an indication of superficial partial thickness burns. These will heal without scarring in 7 to 10 days. Peeling skin can be noted 4 to 7 days after sun exposure. Severe sunburn may be accompanied by systemic symptoms of headache, fever, nausea, and vomiting.
Diagnosis and Medical Treatment
Diagnosis of sunburn is typically straightforward with history of sun exposure and clinical findings of erythematous skin and possible blisters. Other considerations in a child or teen who presents with findings typical for sunburn would be exposure to photosensitizing drugs or topical agents and use of indoor tanning beds or lights. Drugs that cause photosensitivity include doxycycline, sulfonamides, griseofulvin, amiodarone, and some nonsteroidal anti-inflammatory drugs.13,14 Topical exposure to some plants, vegetables, and fruits can cause an exaggerated sunburn-like reaction. The affected skin will be found in the area that has been in contact with the plant or fruit and may be painful. This can be seen in some children who have come into contact with celery, limes, lemons, dill, parsley, and the sap of fig trees.6
Treating sunburn usually can be done without the assistance of a medical provider. The parent should be instructed to have the child take a cool bath or use cool compresses on the sunburned area and to give acetaminophen or ibuprofen for discomfort. Use of a topical coolant agent such as aloe gel can be helpful. Use of topical steroids is not recommended as they do not relieve pain, redness, or speed healing.15 It is important not to break open blisters as this may introduce infection. Ruptured blisters should be cleansed gently with mild soap and water and covered with wet dressings. Parents should also be instructed to give their child extra fluids to avoid dehydration.
Children with extensive blistering sunburns and those with severe pain or systemic symptoms such as vomiting and dehydration may require hospitalization for pain control, intravenous hydration, and burn care.
Prevention is Best Medicine
A sunny day should not preclude a child from playing outdoors; however, parents should be advised to limit sun exposure during hours of peak intensity (10 am to 4 pm). If the child is younger than age 6 months, parents should keep their baby out of the sun entirely by keeping the baby in the shade as much as possible. Parents should be advised to create their own shade when none is available using an umbrella canopy or stroller cover. Babies should be dressed with long-sleeved and lightweight shirt and pants and a brimmed hat if possible. Sunscreen can be used on children younger than age 6 months if needed. For all children, the best choice is a water-resistant sunscreen with an SPF of 30. An SPF above 30 gives only negligibly more benefit.16 Sun blocks such as zinc oxide or titanium dioxide are safe and may be more hypoallergenic to a young child's skin. Placing sun block on areas of high sun exposure such as the forehead, cheeks, nose, and shoulders is recommended. For young children it is important to test the sunscreen on a small area of skin first to ensure that they do not develop a rash. When choosing a sunscreen, parents should look for the words “broad-spectrum” on the label, which means that the sunscreen will protect against UVB and ultraviolet A rays. It should be applied 30 minutes before going outdoors (it needs time to work on the skin), and every 2 hours it should be reapplied to areas of greatest sun exposure such as face and the back of the hands. It is best for parents to avoid sunscreens that have vitamin A, oxybenzone, dyes, fragrances, parabens, or other preservatives that could irritate young skin.16 Spray-on sunscreens, although convenient, can be dangerous if inhaled.
- Cokkinides V, Weinstock M, Glanz K, et al. Trends in sunburns, sun protection practices, and attitudes toward sun exposure, protection and tanning among US adolescents, 1998–2004. Pediatrics. 2006;118:853–864. doi:. doi:10.1542/peds.2005-3109 [CrossRef]
- Davis KJ, Cokkinides VE, Weinstock MA, O'Connell MC, Wingo PA. Summer sunburn and sun exposure among US youths ages 11 to 18: national prevalence and associated factors. Pediatrics. 2002;110:27–35. doi:10.1542/peds.110.1.27 [CrossRef]
- Young AR. Acute effects of UVR on human eyes and skin. Prog Biophys Mol Biol. 2006;92:80–85. doi:. doi:10.1016/j.pbiomolbio.2006.02.005 [CrossRef]
- Young AR, Chadwick CA, Harrison GI, et al. Sun exposure and melanoma risk at different latitudes: a pooled analysis of 5700 cases and 7216 controls. Int J Epidemiol. 2009;38:814–830. doi:. doi:10.1093/ije/dyp166 [CrossRef]
- Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869–871. doi:10.1001/archderm.1988.01670060015008 [CrossRef]
- Young AR, Tewari A. Sunburn. https://www.uptodate.com/contents/sunburn?search=sunburn&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed May 22, 2019.
- Dennis LK, Vanbeek MJ, Beane Freeman LE, et al. Sunburns and risk of cutaneous melanoma: does age matter? A comprehensive meta-analysis. Ann Epidemiol. 2008;18:614–627. doi:. doi:10.1016/j.annepidem.2008.04.006 [CrossRef]
- Diffey BL. Sources and measurement of ultraviolet radiation. Methods. 2002;28:4–13. doi:10.1016/S1046-2023(02)00204-9 [CrossRef]
- Diffey BL. What is light?Photodermatol Photoimmunol Photomed. 2002;18:68–74. doi:10.1034/j.1600-0781.2002.180203.x [CrossRef]
- Murphy G, Young AR, Wulf HC, et al. The molecular determinants of sunburn cell formation. Exp Dermatol. 2001;10:155–160. doi:10.1034/j.1600-0625.2001.010003155.x [CrossRef]
- Gilchrest BA, Soter NA, Stoff JS, Mihm MC Jr, . The human sunburn reaction: histologic and biochemical studies. J Am Acad Dermatol. 1981;5:411–422. doi:10.1016/S0190-9622(81)70103-8 [CrossRef]
- Rhodes LE, Lim HW. The acute effects of ultraviolet radiation on the skin. In: Lim HW, Honigsmann H, Hawk JL (eds). Photodermatology. New York, NY: Informa Healthcare USA; 2007:75.
- Gould JW, Mercurio MG, Elmets CA. Cutaneous photosensitivity diseases included by exogenous agents. J Am Acad Dermatol. 1995;33(4):551–573. doi:10.1016/0190-9622(95)91271-1 [CrossRef]
- Kim WB, Shelley AJ, Novice K, Joo J, Lim HW, Glassman SJ. Drug-induced phototoxicity: a systematic review. J Am Acad Dermatol. 2018;79(6):1069–1075. doi:. doi:10.1016/j.jaad.2018.06.061 [CrossRef]
- Russo PM, Schneiderman LJ. Effect of topical corticosteroids on symptoms of clinical sunburn. J Fam Pract.1978;7(6):1129–1132.
HealthyChildren.org. Sun Safety: Information for parents about sunburn & sunscreen. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Sun-Safety.aspx. Accessed May 20, 2019.