Beach medicine pearls (and seashell lacerations)

Sunburn may require medical care and increases the risk for malignant melanoma.
Sunburn may require medical care and increases the risk for malignant melanoma.

Primary care usually addresses problems and illnesses associated with everyday life, but summer vacations and winter trips to the tropics expose our patients to potential injuries and illnesses that are more related to leisure than to daily life. 

I worked for years as a physician assistant at an urgent care center in a North Carolina beach community. On some days in August, the vast majority of patients presented with problems related in one way or another to the beach and their beach-related activities. In this article some of those problems, common and less common, will be reviewed.


Sunburn


Sunburn is a common and painful leisure-related injury that may require medical care, and it has long-term consequences, such as increasing the risk of malignant melanoma. Children and young adults are most commonly affected. Individuals vary widely in their susceptibility to sunburn, with light-skinned, red- and blonde-haired, and blue-eyed people at highest risk (Table 1).1

Risk is also higher with sun exposure in lower tropical and subtropical latitudes, during summer months when the sunlight is more direct, at high altitudes where there is less atmospheric filtering, and during the middle of the day when the sun is highest in the sky. Reflection from surfaces such as sand, water, and snow can also increase the risk of sunburn. Some medications, including tetracycline family and fluoroquinolone antibiotics, and certain plant components, including lime, can cause photosensitization and also increase the risk of sunburn.1

Although the pathophysiology of sunburn is not fully understood, ultraviolet exposure, especially ultraviolet B (UVB), triggers a sequence of inflammatory responses including vasodilatation, release of inflammatory mediators and cytokines, and keratinocyte apoptosis. These processes result first in erythema, then edema, and potentially in blisters and fluid loss. Most sunburns are first-degree burns and, in spite of being painful, are self-limited.2

Treatment of mild to moderate sunburn is symptomatic (see Table 2). Cool compresses of water or aluminum acetate (Burow's) solution provide cooling and pain relief. Nonsteroidal anti-inflammatory agents, especially given early, may decrease inflammation. They also provide appropriate analgesia, along with other nonprescription pain relievers such as acetaminophen.


In spite of their common use, topical anesthetics (including lidocaine, benzocaine, and pramoxine) have not been shown to be very effective and may cause sensitization and dermatitis, potentially worsening the problem. The same is true of topical antihistamines such as diphenhydramine. 

Topical steroids have been studied in the treatment of sunburn, but evidence does not support their use. Oral steroids, while sometimes given to patients with marked edema, also do not have good evidence for their use, neither improving symptoms nor speeding recovery. Other commonly used topical agents, such as aloe vera gel, may be cooling and help relieve discomfort for a short period of time, but they lack evidence of effectiveness.1

Blistering sunburns, superficial or deep partial thickness burns, can be severe enough to require fluid replacement (oral or IV), infection prevention with topical antibacterials (silver sulfadiazine or mupirocin), and pain control. When extensive areas of skin are involved, burn unit admission is appropriate.


Sunburn is clearly a problem for which prevention is the best "treatment." Risk should be minimized by generous and repeated use of broad-spectrum sunscreens, appropriate clothing (including hat) when sun exposure is expected, and limiting activities to less risky times of day.


TABLE 1. Sunburn risk factors

Type 1 or 2 (fair) skin
Location (higher risk at lower latitude and higher altitude)
Systemic photosensitizers (e.g., quinolones and tetracyclines, psoralens, and phenothiazines)
Topical photosensitizers (e.g., citrus oils, para-aminobenzoic acid, some dyes)

TABLE 2. Common beach-related conditions and treatment recommendations

Condition Treatment
Sunburn Symptomatic: cool compresses, nonsteroidal anti-inflammatory drugs, analgesia
Otitis externa Clear debris, topical antibacterial/antimicrobial
Jellyfish stings Nematocyst removal, heat, analgesia
Stingray envenomation Heat, wound care, analgesia

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