Guideline:
Evaluation, management and treatment of sunburn in adults
Bibliographic Source(s)
- University of Texas School of Nursing Family Nurse Practitioner Program. Evaluation management and treatment of sunburn in adults. Austin (TX): University of Texas School of Nursing; 2007. 24 p. [20 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Evaluation
Management
Treatment
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
- To provide specific recommendations for the evaluation management and treatment of sunburns for adult patients
- To offer evidence-based step-by-step decision protocols for the evaluation management and treatment of sunburn
Target Population
Adults with sunburn in ambulatory outpatient settings
Interventions and Practices Considered
Evaluation
- Evaluation of persons presenting with sunburn
- Pain assessment including patient's self-report use of pain assessment tools (Numeric Rating Scale [NRS] Faces Scale); and assessment for physiological and behavioral indicators of pain
- Evaluation and documentation of skin pathology
- Communicating findings of skin pathology and pain assessment with the patient patient's family and the healthcare team
Management/Treatment
- Establishing a plan for sunburn management
- Pharmacological management of tissue destruction and pain
- Selecting appropriate analgesics
- Analgesics such as acetaminophen nonsteroidal anti-inflammatory drugs (NSAID's) such as ibuprofen; or opioids such as meperidine
- Use of the World Health Organization's (WHO) step-wise approach to pain relief
- Selecting appropriate anti-infectives
- Monitoring for safety efficacy side effects and toxicities of medications
- Anticipation and prevention of common side effects of opioids
- Patient and family education regarding pain prevention and treatment of medication side effects
- Effective documentation
- Referral to another healthcare provider for complicated patients
- Non-pharmacological management of tissue destruction and pain (e.g. superficial cold compresses topical aloe vera relaxation imagery)
- Education for prevention and recognition of infection
Major Outcomes Considered
- Effectiveness of sunburn management strategies
- Safety and side effects of medications/treatments used to manage sunburn
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
A systematic literature search in addition to a structured Internet search yielded supportive evidence in the form of grade A B C D and I recommendations. After a quality appraisal was completed (see "Methods Used to Assess Quality and Strength of the Evidence" and "Rating Scheme for the Strength of the Evidence" fields) 18 documents were identified as high quality relevant guidelines appropriate for use in the development of this best practice guideline. The articles were written in the English language had reported a controlled trial or randomized trial. When articles on the specific topic did not meet the above criteria they were evaluated with regard to rigor context and content which the panel identified as being important in terms of the data they required.
Number of Source Documents
18 documents were reviewed
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Quality of Evidence (Based on the U.S. Preventive Services Task Force Ratings)
- Good: Evidence includes consistent results from well-designed well-conducted studies in representative populations that directly assess effects on health outcomes.
- Fair: Evidence is sufficient to determine effects on health outcomes but the strength of the evidence is limited by the number quality or consistency of the individual studies generalizability to routine practice or indirect nature of the evidence on health outcomes.
- Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies important flaws in their design or conduct gaps in the chain of evidence or lack of information on important health outcomes.
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
The panel reviewed all relevant literature from printed sources as well as electronic sources within the last 6 years that contained the keyword sunburn. Each of the 18 source documents were reviewed with and compared to each other with regard to quality of the study content of material and reputation/reliability of the originating source. Preference was given to high quality systematic reviews and clinical trials published since 2000. Consensus of the panel members then included or excluded the source. In addition reviews of articles in alternative medicine journals were considered if the content would not induce harm to tissues if the methods used were employed by a person of normal intelligence.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The panel proceeded to develop an algorithm of the recommendations from the 2 selected clinical practice guidelines. Practice recommendations were extracted or adapted from those guidelines that ranked the highest in rigor context content and application. The panel adapted practice recommendations within these guidelines in order to ensure their applicability to best clinical practice. Systematic and narrative reviews of the literature were used in the development of practice recommendations that could not be extracted from existing guidelines. Panel consensus was obtained for each recommendation.
Rating Scheme for the Strength of the Recommendations
Strength of Recommendations (Based on the U.S. Preventive Services Task Force Ratings)
A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.
B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.
C. There is at least fair evidence that the recommendations can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.
D There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.
I. Evidence that the recommendation is effective is lacking of poor quality or conflicting and the balance of benefits and harms can not be determined.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
A draft guideline was submitted to Dr. D. Schaefer Board Certified Dermatologist for review. The feedback received was reviewed and incorporated into the final draft guideline.
Major Recommendations
Strength of recommendations (A B C D I) and quality of evidence (good fair poor) are defined at the end of "Major Recommendations" field.
Practice Recommendations - Part A: Evaluation and Treatment
Recommendation 1
Methods to Reduce Inflammation
- Cooling ice packs (Han 2004)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) acetaminophen (Morgan 2000)
- Topical corticosteroids (Duteil et al. 2002; Han 2004)
- Systemic corticosteroids (not recommended) (Han 2004)
(Grade of recommendation = A; Quality of Evidence = Good)
Recommendation 2
Methods to Prevent Infection in Sunburn
- Diligent wound care with mild soap and water (Hudspith & Rayatt 2004; Morgan 2000)
- Application of non-adherent dressings if open areas present (Dowsett 2002)
- Sterile saline soaks (Dowsett 2002)
- Care of blisters blebs (keep intact if possible and cover open wounds with sterile dressings) (Dowsett 2002; Morgan 2000)
- Tetanus prophylaxis for burns deeper than superficial partial thickness (Kagan 2002; Morgan 2000)
- Topical antibiotics such as Bacitracin or Silvadene (Kagan 2002; Morgan 2000)
- Simple dressings such as Telfa Duoderm Granuflex Mepitel (Hudspith & Rayatt 2004)
- Oral or injectable antibiotics (not recommended) (Dowsett 2002)
- Chlorhexidine povidone iodine (not recommended) (Morgan 2000)
- Biologic dressings such as Burnsheild or Rescue Derm (Hudspith & Rayatt 2004; Martineau & Dosch 2006)
(Grade of Recommendation = B; Quality of Evidence= Good)
Recommendation 3
Comprehensive Pain Assessment
Methods to Evaluate Pain
- Location of pain
- Effect of pain on function and activities of daily living (i.e. work interference with usual activities etc.)
- Level of pain at rest and during activity
- Medication usage
- P - provoking or precipitating factors
- Q - quality of pain (what words does the person use to describe pain? - aching throbbing)
- R - radiation of pain (does the pain extend from the site?)
- S - severity of pain (intensity 0-10 scale)
- T - timing (occasional intermittent constant)
(Grade of Recommendation = C; Quality of Evidence= Good)
A standardized tool with established validity is used to assess the intensity of pain.
- Visual Analogue Scale (VAS)
- Numeric Rating Scale (NRS)
- Verbal Scale
- Faces Scale
- Behavioral Scale
(Grade of Recommendation = C; Quality of Evidence= Good)
Pharmacological Management of Pain: Selecting Appropriate Analgesics
Using the WHO (World Health Organization) Stepwise Approach to Pain
Ensure that the selection of analgesics is individualized to the person taking into account:
- The type of pain (acute or chronic nociceptive and/or neuropathic)
- Intensity of pain
- Potential for analgesic toxicity (age renal impairment peptic ulcer disease thrombocytopenia)
- General condition of the person
- Concurrent medical conditions
- Response to prior or present medications
- Cost to the person and family
- The setting of care
(Grade of Recommendation = A; Quality of Evidence = Good)
Recognize that acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are used for the treatment of mild pain and for specific types of pain as adjuvant analgesics unless contraindicated.
(Grade of Recommendation = A; Quality of Evidence = Good)
Recognize that opioids are used for the treatment of moderate to severe pain unless contraindicated taking into consideration:
- Previous dose of analgesics
- Prior opioid history
- Frequency of administration
- Route of administration
- Incidence and severity of side effects
- Potential for age related adverse effects
- Renal function
(Grade of Recommendation = A; Quality of Evidence = Good)
Consider the following pharmacological principles in the use of opioids for the treatment of severe pain:
- Mixed agonist-antagonists (e.g. pentazocine) are not administered with opioids because the combination may precipitate a withdrawal syndrome and increase pain.
- The elderly generally receive greater peak and longer duration of action from analgesics than younger individuals thus dosing should be initiated at lower doses and increased more slowly ("careful titration").
(Grade of Recommendation = B; Quality of Evidence = Good)
Recommendation 4
Methods to Treat Pain/Discomfort
- Non-steroidal anti-inflammatory drugs acetaminophen (Morgan 2000)
- Aspirin (Morgan 2000)
- Topical anesthetics analgesics such as Propolis Solarcaine or Witch Hazel (Ackerson 2004; "Sunburn" 2006; Gregory et al. 2002)
- Short course of codeine or oxycodone (Hudspith & Rayatt 2004; Oldfield & Perry 2006; Brown 2004)
- Anti-pruritics; Benadryl Periactin Atarax (Han 2004)
- Bicarbonate of soda baths Calamine lotion (Morgan 2000)
- Green tea cucumber Echinaea Mimosa tenuiflora (Duke 2002; Schar & Altshul 2003)
- General comfort measures; emollients cool compresses oatmeal soaks (Ackerson 2004; "Sunburn" 2006; Perez 2006)
- Relaxation and imagery (Kagen 2002)
- Petroleum jelly benzocaine lidocaine butter or greasy ointments (not recommended) (Perez 2006)
(Grade of Recommendations = B; Quality of Evidence = Good)
Recommendation 5
Methods to Promote Healing
- Healthy diet with adequate protein (Johns Hopkins 2006)
- Adequate hydration (Kagen 2002)
- Rest (Johns Hopkins 2006)
- Avoidance of alcohol (Johns Hopkins 2006)
- Use of non-perfumed moisturizing lotions once epithelialization occurs to promote natural lubricating mechanisms (Perez 2006)
- Avoidance of direct intense sun exposure (Perez 2006)
- Loose comfortable clothing (Johns Hopkins 2006)
(Grade of Recommendation = C; Quality of Evidence = Fair)
Recommendation 6
Alternative Therapies
- Vitamin C E (Kagen 2002)
- Aloe Vera (Ackerson 2004)
- Oatmeal baths (Ackerson 2004 Perez 2006)
- Antioxidants (not recommended) (Han 2004)
- Topical melatonin (not recommended) (Han 2004)
- Milk ("Post-sunburn soothers" 2005)
(Grade of Recommendation = C; Quality of Evidence = Fair)
Practice Recommendations- Part B- Management
Follow-up
- Follow-up one day after initial visit
- Weekly until wound epithelialization begins
- Concurrent evaluation for infection/complications
Patient Teaching
- General care to promote healing and prevent infection
- Signs and symptoms of infection/complications
- Medication/wound care
- When to follow-up
- Sunburn protection
(Grade of Recommendation = C; Quality of Evidence = Good)
Definitions:
Quality of Evidence (Based on U.S. Preventative Services Task Force Ratings)
- Good: Evidence includes consistent results from well-designed well-conducted studies in representative populations that directly assess effects on health outcomes.
- Fair: Evidence is sufficient to determine effects on health outcomes but the strength of the evidence is limited by the number quality or consistency of the individual studies generalizability to routine practice or indirect nature of the evidence on health outcomes.
- Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies important flaws in their design or conduct gaps in the chain of evidence or lack of information on important health outcomes.
Strength of Recommendations (Based on the U.S. Preventive Services Task Force Ratings)
A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.
B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.
C. There is at least fair evidence that the recommendations can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.
D There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.
I. Evidence that the recommendation is effective is lacking of poor quality or conflicting and the balance of benefits and harms can not be determined.
Clinical Algorithm(s)
An algorithm is provided in the original guideline document for "Depth assessed (appearance bleeding blistering capillary refill sensation)."
References Supporting the Recommendations
- Ackerson A. Natural alternatives to mass meds. Better Nutr 2004;66(6) [1 reference]
- Brown A. Advances in acute pain management. Patient Care 2004 Sep;:23-9.
- Dowsett C. The assessment and management of burns. Br J Community Nurs 2002 May;7(5):230-9. [20 references] PubMed
- Duke J. Soothe sunburn with nature's pharmacy. Mother Earth News 2002 Aug-Sep;(193)
- Duteil L Queille-Roussel C Lorenz B Thieroff-Ekerdt R Ortonne JP. A randomized controlled study of the safety and efficacy of topical corticosteroid treatments of sunburn in healthy volunteers. Clin Exp Dermatol 2002 Jun;27(4):314-8. PubMed
- Gregory SR Piccolo N Piccolo MT Piccolo MS Heggers JP. Comparison of propolis skin cream to silver sulfadiazine: a naturopathic alternative to antibiotics in treatment of minor burns. J Altern Complement Med 2002 Feb;8(1):77-83.
- Han A Maibach HI. Management of acute sunburn. Am J Clin Dermatol 2004;5(1):39-47. [43 references] PubMed
- Hudspith J Rayatt S. First aid and treatment of minor burns. BMJ 2004 Jun 19;328(7454):1487-9. PubMed
- Johns Hopkins Medicine. Wound healing and post burn care. Baltimore (MD): Johns Hopkins Hospital; 2006.
- Kagan RJ Smith SC. Evaluation and treatment of thermal injuries. Dermatol Nurs 2000 Oct;12(5):334-5 338-44 347-50. [29 references] PubMed
- Loyola University Health System. Sunburn. Maywood (IL): Loyola University Health System; 2006.
- Martineau L Dosch HM. In vitro bactericidal efficacy of a new sun- and heat burn gel. Burns 2006 Sep;32(6):748-54. PubMed
- Morgan ED Bledsoe SC Barker J. Ambulatory management of burns. Am Fam Physician 2000 Nov 1;62(9):2015-26 2029-30 2032. [35 references] PubMed
- Oldfield V Perry CM. Oxycodone/Ibuprofen combination tablet: a review of its use in the management of acute pain. Drugs 2005;65(16):2337-54. [63 references] PubMed
- Perez E. Sunburn first aid. In: MedlinePlus [internet]. Bethesda (MD): National Library of Medicine; 2006
- Post-sunburn soothers. Redbook 2005 Aug;205(2)
- Schar D Altshul S. Sunburn first-aid kit. Prevention 2003 Jun;55(6)
Type of Evidence supporting the Recommendations
These recommendations were based primarily on sources such as national guidelines meta-analysis review and evidenced-based randomized controlled research studies. Guidelines and statements are synthesized to make them applicable to the treatment of sunburn.
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Potential Benefits
- This best practice guideline is intended to provide direction to practicing physicians physician assistants nurse practitioners nurses and healthcare workers in all care settings both institutional and community in the assessment and management of sunburn including treatment.
- Guideline implementation is intended to help relieve patients' pain promote healing of tissue increase patient satisfaction and improve quality of life.
- Nurse practitioners nurses physicians physician assistants and other healthcare professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies procedures protocols educational programs assessment and documentation tools etc.
Potential Harms
Side Effects and Toxicities of Medications Used to Manage Sunburn
- Common side effects of opioids include nausea and vomiting constipation and drowsiness. Persons with acute pain may be at particular risk for respiratory depression depending on the dose of opioid prescribed. Caution should be taken with the elderly as drug interactions occur more frequently.
- Non-steroidal anti-inflammatory drugs should be used with caution for persons with a history of peptic ulcer disease bleeding disorders abnormal and/or diminished renal function and concomitant use of steroids and anticoagulants. Extra precautions are required in the long-term use of nonsteroidal anti-inflammatory drugs in the elderly.
- Persons who are sensitive or allergic to the recommended topical medications may experience adverse skin reactions such as increased erythema swelling pain and delayed healing. Caution should be taken with persons with multiple existing allergies.
Contraindications
Co-morbidities or medication allergies/sensitivities that may preclude treatment (see "Major Recommendations" field).
Qualifying Statements
- This guideline is to be used in the care of healthy adults without extensive co-morbid complications. Physicians advanced practice registered nurses and physician assistants working in specialty areas such as pediatrics should use further practice direction from clinical practice guidelines in their unique area of focus.
- Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
- This guideline is to be used for the care of the healthy adult with a superficial epidermal or superficial partial thickness burn from exposure to ultraviolet (UV) light. It is not intended for use with patients who have deep partial thickness or full thickness burns from ultraviolet exposure or from other thermal burn injury chemical burn injury electrical burn injury intense cold burn injury or hot liquid injuries. It is expected that the advanced practice registered nurses (APRNs) and physician assistants will seek appropriate consultation in instances where the patient's care needs surpass the ability of the individual practitioner to act independently. It is acknowledged that effective patient care depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and patients ever mindful of the personal preferences and unique needs of each individual patient.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- University of Texas School of Nursing Family Nurse Practitioner Program. Evaluation management and treatment of sunburn in adults. Austin (TX): University of Texas School of Nursing; 2007. 24 p. [20 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
University of Texas at Austin School of Nursing Family Nurse Practitioner Program
Guideline Committee
Practice Guidelines Committee
Composition of Group that Authored the Guideline
Guideline Development Panel Members: Vicki Greene RN MSN FNP; Patricia Roberts RN MSN FNP; Beth Weidner RN MSN FNP
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: None available
Print copies: Available from the University of Texas at Austin School of Nursing. 1700 Red River Austin Texas 78701-1499
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI Institute on August 23 2007. The information was verified by the guideline developer on November 9 2007. This summary was updated by ECRI Institute on March 10 2009 following the U.S. Food and Drug Administration advisory on Topical Anesthetics.
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