What are the clinical signs, systemic symptoms, and recommended management of sun poisoning (severe sunburn)?

Sun Poisoning: Clinical Signs and Management

Sun poisoning (severe sunburn) presents with intense erythema, edema, and blister formation that peaks 12-24 hours after UV exposure, accompanied by systemic symptoms including fever, malaise, myalgias, and skin pain resembling a burn. 1

Clinical Signs

Cutaneous Manifestations

• Erythema develops within hours and peaks at 24 hours, though may continue progressing up to 96 hours or later 2
• Edema of affected skin areas 1
• Blister formation in severe cases 1
• Skin pain described as burning or stinging sensation, similar to thermal burns 3, 1
• Subsequent hyperpigmentation and peeling follow as the acute phase resolves 1

Systemic Symptoms

• Fever indicating systemic inflammatory response 3
• Malaise and myalgias reflecting systemic involvement 3
• Arthralgias may occur 3
• Abdominal pain in severe cases 3
• Ocular discomfort or photophobia if periorbital areas affected 3

Timeline of Presentation

• Visible erythema typically peaks at 24 hours but may develop up to 96 hours post-exposure 2
• Greatest increase in visible erythema occurs 4-8 hours after UVB exposure 2
• Pain and systemic symptoms develop concurrently with erythema 1

Grading Severity

Assess body surface area (BSA) involved, presence of blisters, and systemic symptoms to determine severity: 3

• Mild (<10% BSA): Erythema with minimal symptoms, no blisters
• Moderate (10-30% BSA): Erythema with pruritus, burning, or tightness; may have scattered blisters
• Severe (>30% BSA): Extensive erythema with moderate-to-severe symptoms, widespread blistering, systemic symptoms present
• Life-threatening: Requires hospitalization, severe systemic involvement 3

Management Approach

Immediate Assessment

• Physical examination documenting BSA involved, blister formation, and oral mucosa examination 3
• Review medication list to identify photosensitizing drugs (tetracyclines, fluoroquinolones, NSAIDs) 4, 5
• Rule out infection or other drug-induced causes 3
• Obtain CBC and comprehensive metabolic panel if systemic symptoms present 3

Symptomatic Treatment

The most effective approach is symptomatic management, as no treatment convincingly reduces recovery time: 6

Mild Cases (<10% BSA)

• Topical emollients for skin hydration 3
• Mild-to-moderate potency topical corticosteroids (though evidence shows limited benefit when applied >6 hours post-exposure) 3, 7
• Oral antihistamines for pruritus 3
• Cool compresses for symptomatic relief 6
• Counsel to avoid further sun exposure and skin irritants 3

Moderate Cases (10-30% BSA)

• Medium-to-high potency topical corticosteroids 3
• Oral antihistamines for pruritus 3
• Consider oral prednisone 0.5-1 mg/kg daily, tapering over 4 weeks 3
• Topical anti-itch remedies (refrigerated menthol and pramoxine) for pruritus without rash 3
• Monitor weekly for improvement 3

Severe Cases (>30% BSA with systemic symptoms)

• Oral prednisone 1 mg/kg daily, tapering over at least 4 weeks 3
• High-potency topical corticosteroids 3
• Oral antihistamines 3
• Consider phototherapy for severe pruritus once acute phase resolves 3
• For refractory pruritus: gabapentin, pregabalin, or aprepitant 3

Life-Threatening Cases

• Immediate hospitalization 3
• IV methylprednisolone 1-2 mg/kg with slow taper 3
• Dermatology consultation urgently 3
• Monitor for progression to severe cutaneous adverse reactions (SCAR) 3

Critical Caveats

Topical corticosteroids have minimal clinical benefit when applied ≥6 hours after UV exposure 7. Only high-potency corticosteroids applied 30 minutes before exposure showed clinically relevant protection (not applicable to treatment scenarios) 7.

NSAIDs, antioxidants, and most pharmacologic agents lack convincing evidence for reducing recovery time 6. The damage to epidermal cells remains unchanged regardless of treatment modality 6.

Prevention Counseling

• Apply broad-spectrum sunscreen SPF ≥30 before UV exposure to prevent both vasodilatory response and erythema 2, 8
• Limit sun exposure during peak hours (10 AM-4 PM, especially 11 AM-1 PM) 2
• Wear protective clothing and seek shade 9
• Avoid photosensitizing medications when possible (tetracyclines, fluoroquinolones) 4, 5
• For patients on photosensitizing drugs: use UVA-absorbing sunscreens and take medication in evening 4

Special Considerations

Patients with recurrent severe sunburns have significantly increased risk for melanoma and basal cell carcinoma 3. Document history of severe sunburns, especially those occurring in childhood or adolescence, as these confer higher cancer risk 3.

Consider dermatology referral if: 3

• Autoimmune skin disease suspected
• Atypical presentation
• Failure to improve within expected timeframe
• Recurrent severe photosensitivity reactions suggesting underlying photodermatosis 9