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Cutaneous Drug Eruptions
Skin Cancer Prevention
Skin Disease in HIV
Sunburn results when the amount of exposure to UV rays exceeds the protective capability of the body's defense mechanism, the skin pigment called melanin. Shorter-wavelength UVB rays are the main culprits for the erythema (redness) that develops in sunburn, but UVA rays are much more abundant (about 95% to 98% at midday) and create most of the immediate and long-term damaging effects of UV light. UV radiation is the highest between 10 a.m. and 4 p.m. Even on cloudy days, UV radiation penetrates and can cause severe burns.
Although melanin does yield some protection, exposure to UV rays eventually causes damage to the skin. Severe sunburn is an acute inflammatory response of the body to this damage. First, blood vessels dilate, creating the erythematous rash that typically occurs in sunburned skin. Shortly after, the body reacts to the inflammation by releasing chemicals such as histamine and cytokines, creating edema and the beginning of blisters. Within a few hours of overexposure to the sun or other light sources, DNA damage and cell death are visible under a microscope. In severe sunburn, the damage to the skin goes beyond a first-degree burn, where only the outermost layer of the skin, or epidermis, is affected. Second-degree sunburn permeates the epidermis and the underlying dermis.
Anyone can experience severe sunburn. Those most at risk are children, older adults, and individuals with fair or freckled skin or pale white skin, blue/hazel eyes, and blond/red hair. Lighter-skinned individuals are affected more frequently and severely. Skin types are often described using the Fitzpatrick Classification Scale, which classifies individuals according to their tendency to tan, burn, or both (see Skin type and sunburn potential).
There are other factors that make a person prone to sunburn. People who want a tan from the sun or tanning salons are at risk for severe sunburn. People who live at higher altitudes tend to experience severe sunburn faster, as do people living closer to the equator, because UV radiation intensity increases with elevation. Environmental factors such as UV radiation caused by the reflection of sun by snow and ice can also cause severe sunburn. UV radiation may be transmitted through clothing, especially when wet, so sunburn may occur under clothed skin.
It's important to review your patient's medication history. Some medications can cause the skin to overreact to light sources, including the sun, photocopiers, fluorescent lighting, and other sources of indoor lighting, which can create sunburn with blistering. An overreaction of the skin to light sources related to medications is called drug-induced photosensitivity.
It's also important to assess your patient's general health status. Malnutrition and dehydration can sensitize the skin. Several diseases such as acne, systemic lupus erythematosus, rosacea, and herpes simplex virus decrease the resistance of the skin to damage from the sun and other light sources. Photosensitivity is increasingly recognized as a common development in HIV-positive patients.
Perform a head-to-toe assessment of your patient while you carefully inspect the skin for areas that are burned. Erythema and edema usually develop after 3 to 4 hours of exposure to the sun or other light sources, including indoor tanning equipment, and peak at 12 to 24 hours. Patients will have moderate-to-severe pain that's described as a burning, prickly, itchy, or warm-to-hot sensation. The skin will be very tender. Blistering of the skin is a sign of a second-degree burn, and skin peeling may last from days to weeks.
Your patient may experience systemic symptoms such as fever, chills, headache, nausea, and vomiting. In more superficial second-degree burns, the skin may be very painful; patients with deeper second-degree burns may have reduced sensation and permanent scarring may result. In severe cases, your patient may experience dehydration, electrolyte imbalances, secondary infection, shock, or even death. Don't forget to assess lab indicators of acute inflammation, including C-reactive protein, erythrocyte sedimentation rate, and elevated white blood cell count, especially when many areas of the body are involved.
Drinking plenty of water is important to prevent dehydration while a patient has severe sunburn. Severe sunburn increases the metabolic demands in the body, requiring more fluid and a nutritionally sound diet to prevent skin breakdown and secondary infection as the skin heals. Most severe sunburns can be managed by the patient at home.
Most severe sunburns, while painful, aren't life-threatening, and treatment is primarily symptomatic. However, when pain is severe and the patient has systemic symptoms, it may be necessary to seek medical care. I.V. fluid replacement may be necessary in the ED. Systemic steroids are sometimes used to shorten the course and reduce the pain of sunburn when given early. In extreme cases, patients may require care in a dedicated burn unit. Morbidity and mortality associated with long-term sun exposure is related primarily to the development of various forms of skin cancer, including basal cell carcinoma, squamous cell carcinoma, and malignant melanoma.
Severe sunburn is better prevented than treated!! Protection from the sun and other light sources is the best defense against the damaging effects of UV radiation on the skin. Teach these important points to your patient:
* Avoid sun exposure, especially between 10 a.m. and 4 p.m.
* Minimize overexposure to light sources, including photocopiers, indoor lighting, and computer screens.
* Wear protective clothing, including wide-brimmed hats.
* Apply sunscreen with an SPF of 30 or more every 4 hours to exposed skin.
* Wear sunglasses with UV protection. Remember that the mucous membranes in the eyes are prone to UV damage.
* Use lip balm with sunscreen every 4 hours.
* Drink plenty of fluids, especially during hot weather.
* Avoid drinking alcohol. Alcohol can cause dehydration and also impair a person's ability to discern how long he or she has been exposed to the sun.
* Avoid smoking cigarettes. Nicotine tends to decrease circulation to the skin and can make sunburn worse.
* Schedule outdoor activities carefully. Limit outdoor activities to morning and evening hours. Try to rest often in shady areas.
Encourage patients to know their skin type. Some people burn easier than others based on age, gender, ethnicity, skin type, and general physical health.
It's important for you to perform a comprehensive assessment of your patient's skin and degree of sunburn, and provide care as directed by the healthcare team. The most important intervention for you to implement is to teach patients how to prevent severe sunburn. Help them to "stay bright" and "think right" with the sun and other light sources.
* Drink plenty of water.
* Soak in a cool bath. It may help to add bath products containing oatmeal to decrease itching and burning sensations.
* Put cool, moist cloths on the sunburned skin several times a day.
* Take anti-inflammatory medications, such as aspirin, ibuprofen, or naproxen, to help ease the pain of the sunburn. These agents also lessen damage to the skin because they reduce the acute inflammatory effects of sunburn, especially when taken at the very beginning of the sunburn.
* Put 1% hydrocortisone cream or a moisturizing lotion on the skin three times a day for a few days. Aloe vera may sooth severely sunburned skin.
* Put calamine lotion on the skin to lessen itching.
* Take antihistamines. Keep in mind that these agents may cause drowsiness; don't drive or operate machinery or equipment when taking antihistamines.
* Don't try to open blisters. Let them open on their own, when the underlying skin can better protect itself from infection. Shallow blisters can be treated with an over-the-counter antibiotic ointment for a few days. However, these blisters need air from the environment to heal properly. Don't overuse antibiotic ointment. If blisters are red or look infected after a few days of topical antibiotic treatment, contact the healthcare provider.
The results of a new survey by the American Academy of Dermatology found that a troubling number of White teen girls and young women aren't being warned about the skin cancer dangers of indoor tanning beds by tanning salon employees. The 2011 Indoor Tanning: Teen and Young Adult Women Survey found that 43% of indoor tanners reported that they've never been warned about the dangers of tanning beds by tanning salon employees.
When asked if they were aware of any warning labels on tanning beds, 30% of indoor tanners said no. By age group, younger tanning bed users (ages 14 to 17) were more likely to be unaware of any warning labels on tanning beds than older tanners (ages 18 to 22)-42% versus 25%, respectively.
More than 3,800 White, non-Hispanic females ages 14 to 22 responded to a nationwide survey online to determine their tanning knowledge, attitudes, and behavior. For more on the survey, visit http://www.aad.org/stories-and-news/news-releases/new-survey-finds-tanning-salon.
CDC. Sunburn prevalence among adults-United States, 1999, 2003, and 2004. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5621a2.htm.
Land V, Small L. The evidence of how to best treat sunburn in children: a common treatment dilemma. Dermatol Nurs. 2009;21(3):126,133-137.
McStay CM, Elahi E. Sunburn treatment & management. http://emedicine.medscape.com/article/773203-treatment.
Patient education series: severe sunburn. Nursing. 2009;39(7):31.
Sarnoff DS, Saini R, Handel A. Photosensitivity: A reason to be even safer in the sun. http://www.roadtohealthyskin.org/photosensitivity-a-reason-to-be-even-safer-in-t.
U.S. Environmental Protection Agency. Sun exposure. http://www.epa.gov/radtown/sun-exposure.html.
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