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The evidence on how to best treat sunburn in children: a common treatment dilemma.

It is well documented that repeated sun exposure is linked to premature aging as well as an increased risk of skin cancer (Burns, Dunn, Brady, Starr, & Blosser, 2008; Schmitt, 1996; The Skin Cancer Foundation, 2008). In 2006, the St. Louis University School of Medicine reported that more than half of one's lifetime sun exposure occurs before 20 years of age, and developing skin cancer as an adult is a resultant of damage that occurred during childhood and/or adolescence. Between 1985 and 2005, the incidence of pediatric melanomas rose 103% (St. Louis University School of Medicine, 2006).

Sunburn occurs as an injury to the skin due to overexposure to ultraviolet rays by natural or artificial means. Three distinct types of ultraviolet (UV) rays are UVA, UVB, and UVC. UVA rays have the longest wavelength and are able to penetrate the dermis, causing premature aging of the skin. UVB rays are known as "the burning rays" and have a shorter wavelength. They are able to be absorbed in the upper layers of the skin and cause sunburn, freckles, thickening of the skin, and skin cancer. UVC rays have the shortest wavelength, and while they are the most damaging, they are filtered by the ozone layer surrounding the earth (Silverstone, 1997).

Symptoms of sunburn include erythema, pain, tenderness, swelling, itching, and blistering of the skin. These symptoms begin to manifest as soon as 3 to 5 hours after UVB exposure, peak at 12 to 24 hours, and subside at 72 hours following sunburn (Driscoll & Wagner, 2000). Both first and second-degree burns can occur as a result of sun overexposure. First-degree burns are manifested by pink or red skin, while second-degree burns result in blistering of the skin (The Skin Cancer Foundation, 2008).

Erythema and inflammation are biological responses due to overexposure to UVB rays. The exact mechanism of the resultant erythema is unknown, but it is thought that inflammatory mediators are responsible for the development of inflammation (Driscoll & Wagner, 2000). Research has been conducted to determine if suppressing these mediators by means of corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) will result in a decrease of symptoms and time until recovery (Driscoll & Wagner, 2000). Additional symptomatic treatments include cool compresses, elevation, cool baths, oatmeal soaks, use of moisturizers, analgesics, and increased fluid intake.

This article will review the evidence regarding the use of NSAIDs and corticosteroids in the treatment of sunburn, and will determine the best evidence-based approach to treatment. Therefore, the following PICO (P = patient population; 1 = intervention of interest; C = comparison intervention, O = outcome) question was formulated to drive the literature search and answer the clinical question, "Does the use of topical corticosteroids and/or NSAIDs (intervention) decrease symptoms associated with sunburn (outcome) in children and adults (patients)?" The focus was to identify the best treatment for sunburn, and randomized controlled trials (RCTs) with a control or comparison group were sought. Figure 1 lists common terms and definitions associated with this article.

Search Methods

CINAHL, Medline, and Pubmed databases were searched to locate published RCTs for review. Various search terms from the PICO question were used alone and in combination. Additional terms were used to assure a thorough search of the published literature, and they included sunburn, burn, therapeutics, treatment, child, UVB-induced inflammation, topical corticosteroids, and non-steroidal anti-inflammatory. Many of the articles located were in reference to sunburn prevention and were not treatment-focused. A number of articles were greater than 5 to 10 years old, and therefore, did not provide current research evidence. A total of six publications were retrieved and reviewed to answer the clinical question. These publications were either reviews of evidence (N = 3) or presentations of RCT treatment trials (N = 3). Unfortunately, no literature included large sample sizes or focused on children. Additionally, in the search for the best level I evidence, it was determined that there is no published systematic review (such as the Cochrane Review) regarding the treatment of sunburn.
Figure 1.
Glossary Terms

Exclusion Criteria--Investigator-identified characteristics
that are possessed by individuals that would exclude them
from participating in a study and specified to exclude studies
from a body of evidence (Melnyk & Fineout-Overholt, 2005).

Generalizability--The extent to which the findings from a
study can be generalized or applied to a larger population
(Melnyk & Fineout-Overholt, 2005).

Inclusion Criteria--Essential characteristics specified by
investigator that potential participants must possess in order
to be considered for a study and studies must meet to be
included in a body of evidence (Melnyk & Fineout-Overholt,
2005).

PICO--A process in which clinical questions are phrased in
a manner that yields the most relevant information (P--Patient,
I--Intervention, C--Comparison, O--Outcome)
when searching research databases (Melnyk & Fineout-Overholt,
2005).

Randomized Controlled Trial--True experiment that
involves randomized placement of assigned subjects to an
experimental or controlled group. This is considered a strong
research design and will support cause and effect relationships
(Melnyk & Fineout-Overholt, 2005).

Type I Skin--Always burns and never tans (Burns, et al.,
2008; Silverstone, 1997).

Type II Skin--Burns easily and tans minimally (Burns, et al.,
2008; Silverstone, 1997).

Type III Skin--Sometimes burns and tans easily (Burns, et
al., 2008; Silverstone, 1997).

Type IV Skin--Rarely burns and tans well (Burn, et al., 2008;
Silverstone, 1997).

Validity--Whether or not the results of the study were
obtained via sound scientific methods (Melnyk & Fineout-Overholt,
2005).


Review #1: Management of Acute Sunburn--A Review of Evidence

Presentation of the evidence. Han and Mailbach (2004) published a review of studies regarding the management of acute sunburn. All published research articles from 1966-2001 related to sunburn or UV-induced erythema were retrieved via the Medline database and reviewed. The inclusion and exclusion criterion of the review were clearly stated. Studies were excluded if they did not involve the use of human subjects; this is important because clinicians are most concerned with the ability to treat their patients and must know if study results are applicable. Inclusion criteria included treatment with corticosteroids, antioxidants, emollients, antihistamines, and NSAIDs. Fourteen studies related to the treatment of sunburn were included in the Han and Mailbach review. Of the 14 studies reviewed, three were conducted using double-blind, randomized, and placebo-controlled designs and methodologies (level II evidence). Twelve of the studies used artificial means to induce erythema. Sample sizes of included studies ranged from 10 to 30 participants. The majority of evidence collected concluded that both NSAIDs and corticosteroids were not effective in decreasing healing time. Therefore, the authors suggested that the most effective management of sunburn may be symptomatic treatment (Han & Mailbach, 2004).

Appraisal of the evidence. While the process for the identification of research studies included in the review was well documented, included studies were not all similar in design, and there is a lack of precise and thorough appraisal of the presented evidence. These are essential components of a quality systematic review of evidence. The inclusion and exclusion criterion were clearly stated, which assists the reader in determining the validity of the review and its summative findings. The selection criteria of solely English-written and published studies, which is a strength of this review for English-speaking practitioners/patients, limits the generalizibility of the overall findings of this review of research literature. While this review of published research articles concludes by supporting symptomatic treatment of sunburn, practitioners should use caution applying the evidence reviewed because the presentation of evidence is not a level I systematic review, and therefore, it does not clearly support evidence-based best practices.

Review #2: Hot Advice for Managing Sunburn: Symptomatic Approach Is Best--A Review of Evidence

Presentation of the evidence. This review of evidence was completed to evaluate various treatments of sunburn, including the use of corticosteroids and NSAIDs. A total of 14 research studies were found, with publication dates ranging from 1966 to 1999. Regarding the use of corticosteroids, the reviewers concluded that the research evidence is vague and limited. One cited study resulted in a decrease of recovery time from 3 to 4 days to one week, although it was mentioned that this trial did not have a control group. Research involving the use NSAIDs resulted in equivocal outcomes as well. The authors of the review found in this search for best evidence that the majority of studies had vague and unclear results, often involved small sample sizes, and utilized artificially induced erythema. "A conservative approach is, therefore, advocated for the management of sunburn, including symptomatic relief with analgesics, emollients, cool compresses, and oatmeal soaks" (Adis International, Ltd., 2005, p. 6).

Appraisal of the evidence. This published review of evidence is not considered to be systematic in nature, but instead, a narrative review. There was no mention of how referenced studies were included or excluded for review, which is critically important to convey to readers so that the validity of the review findings can be established. Additionally, the search strategies used to locate research articles were not outlined in the publication (another critical item by which to appraise research reviews). Only one of the referenced articles was a randomized double-blind, placebo-controlled trial; thus, there is an overall lack of high-level evidence brought to bear by this review to support a specific treatment of sunburn. Based on the quality of this published review, practitioners cannot be encouraqed to treat sunburn in specific evidence-based ways, but rather, should consider a symptomatic approach. This will allow patients to feel better as they recover from the immediate damaging and painful effects of sun overexposure because this review does not support care with high levels of evidence.

Review #3: Clinical Management of the Acute Sunburn Reaction--A Review of Evidence

Presentation of the evidence. In 2000, Driscoll and Wagner published a review of studies regarding the treatment and management of acute sunburn. Treatments reviewed included corticosteroids, NSAIDs, and combined corticosteroids and NSAIDs. The authors concluded that treatment outcomes resulting from the use of corticosteroids and NSAIDs were not clinically significant. "Although NSAIDs appear to have a slightly greater effect than corticosteroids when used at optimal anti-inflammatory dosages, almost all of the studies initiated reviewed therapy immediately after or before UVB exposure, which does not replicate the clinical situation in which these agents would be used" (Driscoll & Wagner, 2000, p. 58).

Appraisal of the evidence. While the authors suggested that this was a thorough review, it did not appear to be systematic, level I evidence, but rather, a narrative review since it serves as a general background discussion for the topic of interest (Melnyk & Fineout-Overholt, 2005). Quality systemic reviews are notable for meticulous search strategies and methods of appraisal. However, this published review lacked a description of the search strategies used to find studies included in the review. Additionally, the inclusion and exclusion criteria used to make decisions about the studies that were reviewed were not published. This information is critical because it allows the reader to appreciate the parameters used for the review, revealing any potential biases that may have been present when the authors' conclusions were reached. In addition, there was limited discussion regarding the individual study sample sizes, study methods, or identifying characteristics of study participants. This information is important to determine which patient populations study findings may be generalized. The similarity of the referenced studies and the level of the evidence presented was not evident, as some were double-blind and placebo-controlled, and others study designs are not mentioned. Outcome measures were similar regarding edema, tenderness, and erythema of the assessed sunburns, and this was a strength of this review. While this published review of literature serves as a general background, the quality of the review and conclusions are in question due to limited information provided; therefore, caution should be taken when considering use of this evidence in practice.

Review #4: A Randomized, Controlled Study of the Safety and Efficacy of Topical Corticosteroid Treatments of Sunburn in Healthy Volunteers (RCT)

Presentation of the evidence. A randomized, controlled, intra-individual study in which participants were treated with both treatments and served as their own control was conducted by Duteil, Queille-Roussel, Lorenz, Thieroff-Ekerdt, and Ortonne (2002) to determine the safety and efficacy of topical corticosteroid use to treat UV-induced erythema (see Table 1). Twenty-four Caucasian participants between the ages of 19 to 61 years, all of whom had skin type III (skin that sometimes burns and tans easily) (Burns et al., 2008; Silverstone, 1997), enrolled and completed the study. Prior to study initiation, volunteers were given physical examinations, and laboratory tests and drug screens were collected. It was not reported if there were any significant baseline health or physical differences in study volunteers. Both 0.1% methylprednisolone aceponate milk (MPA) and 0.1% hydrocortisone 17-butyrate emulsion (HCB) were used as treatments. Similar areas were irradiated by simulated sunlight at a dose three times the minimal erythema dose (MED). The topical treatments were randomly applied in a double-blind manner. Primary outcome measures included erythema, edema, burning, and itching. The reported results suggested that both preparations decreased the primary outcome measures significantly at the end of treatment (p = 0.001 MPA; p = 0.005 HCB). Based on the results of this study, the authors concluded that 0.1% MPA and 0.1% HCB lotions are safe and effective in the treatment of sunburn (Duteil et al., 2002).

Appraisal of the evidence. A major strength of this study was the randomization of treatments, thus providing the highest level of evidence possible for an individual study. Additionally, it was a double-blind study, lessening any possibility of bias. While the sample size was small (N = 24), all volunteers did complete the study, further reducing the potential of group bias. Furthermore, there were no adverse reactions to either treatment. One significant limitation of this study was the pharmaceutical company funding for the project, which casts suspicion on study findings. Additionally, the "sunlight exposure" was not natural. While this controls for the variable effects of natural sun exposure on two different people as well as for the potential overexposure (an ethical concern), it is unclear what effects this may have on outcomes of interest. It is unknown if these results with participants having skin type III are applicable to all patient populations. Additionally, differences in volunteer data were not referenced; therefore, limited information is known about the sample (mean age). This study has shown topical corticosteroids to be safe in the treatment of sunburn and decrease the primary outcomes of erythema, edema, burning, and itching; however, additional research with this treatment following naturally acquired sunburn is suggested. This would enable researchers to further evaluate the treatment efficacy in a natural, uncontrolled environment. Using symptomatic treatment in one group would also provide guidance to health care providers and parents regarding the best treatment.

Review #5: Synergistic Effects of Oral Nonsteroidal Drugs and Topical Corticosteroids In the Therapy of Sunburn in Humans (RCT)

Presentation of the evidence. An RCT was conducted to determine the possible synergistic effects of oral NSAIDs and topical corticosteroids in treating sunburn (Hughes et al., 1992). A total of 24 individuals, 14 male and 10 female, with skin type II or III, participated in this study. Type II skin type is defined as skin that burns easily and tans minimally (Burns et al., 2008; Silverstone, 1997). The range of participant ages was 18 to 57 years. Baseline data were collected on participants, including physical examination, medical history, EKG, and blood and urine tests. Treatments included ibuprofen (IB), indomethacine (IN), and topical betamethasone dipropionate (BD). Outcome measures consisted of skin blood flow, skin biopsy, and minimal erythema dose (MED). Participants were exposed to UVB to induce erythema and determine the MED. Group 1 participants were randomized to IB, BD, IB+BD, or control, and Group 2 participants were randomized to IN, BD, IN+BD, or control. Each treatment phase (IB, BD, IN, or combinations) lasted five days, with a two-day washout period (no treatment for two days). IB and IN were given at -2 (2 hours prior to exposure), 2, 6, and 10 hours relative to exposure of UVB. BD was applied to the exposed area at 10 minutes and 12 hours after UVB exposure. The same dosages were utilized in all phases of the study. It was reported that there were no statistical differences in outcomes as a result of the different treatments. The greatest reduction in skin blood flow occurred when NSAIDs and topical corticosteroids were used. "The skin biopsy results revealed subtle differences between the treated groups and the UVB control, but these were not readily quantifiable" (Hughes et al., 1992, p. 57).

Appraisal of the evidence. The randomized controlled design was a major strength of this study because it eliminated bias from study findings, thus supporting the highest level of evidence. Additionally, there were no reported baseline differences between participants, and treatments were the same for all phases, limiting confounders of study findings. It was not stated if both participants and investigators were blinded, and lack of blinding may lead to potential bias. A limitation of this study is that the erythema was artificially induced, and treatment with NSAIDs began before UVB induced erythema. It was reported that prior studies have shown reduction in erythema when NSAIDs are given early or before exposure (Hughes et al., 1992). This does not mimic both exposure and treatment in natural settings. With the small sample size used in this investigation, study findings are unable to be generalized to other populations and limit the researchers' ability to detect significant differences between the two study groups (type II error). Unfortunately, effect sizes were not reported. It is suggested that additional research with a larger sample and natural sun exposure be conducted. Until then, practitioners might not elect to suggest NSAIDs combined with corticosteroids due to their limited demonstrated effects.

Review #6: Effect of Topical Corticosteroids On Symptoms of Clinical Sunburn (RCT)

Presentation of the evidence. Russo and Schneiderman (1978) performed a randomized, double-blind study to determine the effect of topical corticosteroids in the treatment of naturally acquired sunburn. Participants in this study were recruited by means of a newspaper ad and in person recruitment at San Diego, CA, beaches. Inclusion criteria for this study included that subjects be healthy, Caucasian, young, and had been sunburned either the same or previous day. Subjects were excluded from the study if they had a history of dermatologic problems or if they appeared to need further medical care based on the severity of their sunburn. Forty-two participants began the study on the day of sun overexposure, and an additional eight began the study the day after their exposure. Subjects were given two identical jars of topical cream (fluocinolone topical corticosteroid and an inactive control cream) as a method of blinding to one of two treatment groups. After being asked to treat two symmetrical sun-exposed skin areas similarly, a questionnaire was used to evaluate outcomes. An analysis was completed on the data from the 23 subjects who completed treatment and returned the correctly completed form. There were limited positive outcome effects reported for swelling, blistering, and peeling due to reported scoring issues, and no significant differences were noted in pain relief or redness between the steroid-treated and inert cream-treated (placebo) sun-exposed areas (Russo & Schneiderman, 1978).

Appraisal of the evidence. While this study is older, it does provide the highest level of evidence for an individual research trial. Additionally, it is the only RCT found from the identified search strategies that involved naturally acquired sunburn rather than laboratory UVB induced exposure. While laboratory-controlled UVB-induced exposure causes skin to be exposed to a similar amount of damaging rays, it may not be similar to the damage occurring with natural exposure; therefore, a study such as this was sought for this review. The lack of studies using natural sun exposure may also be related to potential ethical concerns for study participants because of the overwhelming evidence linking sun damage to skin cancer. A great strength of this study is that subjects served as their own control, thus eliminating the potential for bias that could be caused from having different study participants with different skin types acting as control group members. There were no reported differences in outcomes between subjects in experimental or control groups, and with the exception of pruritus in two subjects, no other adverse affects were reported. One limitation of the study is the high attrition rate; approximately half of the initial subjects did not finish the study or complete the post-test questionnaire correctly. A high attrition rate may result in certain types of individuals remaining in the study; thereby limiting the generalizability of study findings. Follow-up data collection occurred via letters and telephone calls two weeks after subjects initially entered study, causing outcome measures to be self-disclosed data, which may not be similarly reported. The results of this study can more easily be applied to individuals affected by sunburn rather than laboratory-induced skin damage by artificial UV rays; however, there were a number of study limitations. Based on this level of evidence, it is recommended that practitioners not use topical corticosteroids in the treatment of sunburn because it was not shown to be more effective for pain, swelling, blistering, redness, and peeling than emollient (control) cream.

Summary of the Evidence with Clinical Practice Recommendations

Based on the above review of evidence, there is a lack of RCTs and quality evidence reviews supporting the effectiveness of corticosteroids and NSAIDs in the treatment of sunburn. Although some RCTs conducted concluded that treatments were safe, sample sizes were small, and findings were not statistically significant. The small convenience samples prevent the reader from generalizing findings to larger populations or specific patient populations (for example, children). Additionally, all but one study involved sunburn treatment of UVB-induced erythema in comparison to natural sun overexposure. It is thought that UVB-induced erythema may not replicate natural sunburn, especially with current changes to the earth's ozone layer (Han & Mailbach, 2004). However, by utilizing artificial means, the same exposure and skin damage was attained. Another limitation of studies using UVB-induced erythema was that treatment is initiated immediately after, and sometimes before, skin exposure to damaging rays. Pretreatment conditions would be difficult to test in the natural setting. The lack of studies in a natural setting may be the result of the questionable ethics of intentional sun overexposure to UV rays because skin damage has been linked with cancer (Burns et al., 2008).

This review of the evidence suggests that a symptomatic approach to treatment of sunburns may be a better choice than recommendations to use NSAIDs or corticosteroid treatments at this time. Symptomatic treatments may include cool water or saline compresses, ice packs, local anesthetic sprays or creams, skin emollients, and extra fluids to compensate for any dehydration (Burns et al., 2008). Practitioners and parents should be educated regarding these review findings to provide the best care for children. While education campaigns exist with a goal of preventing sun overexposure, sunburns still occur, and the incidence continues to increase. Therefore, it is suggested that further research involving randomized controlled trials with larger sample sizes be conducted. Additionally, research should be conducted with volunteers after sun exposure to avoid ethical dilemmas involving induced sun overexposure. Until such research has been conducted and shown to result in statistically significant changes in symptoms or recovery time, sunburns should be treated in a symptomatic manner with the goal of relieving the associated pain and discomfort.

References

Adis International, Ltd. (2005), Hot advice for managing sunburn: Symptomatic approach is the best. Drugs & Therapy Perspective, 21(4), 6-9.

Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B., & Blosser, C.G. (2008). Pediatric primary care: A handbook for nurse practitioners. Philadelphia: Saunders.

Centers for Disease Control and Prevention (CDC). (2007). Sunburn prevalence among adults- United States, 1999, 2003, and 2004. Retrieved from June 23, 2008, from http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5621a2.htm

Driscoll, MS., & Wagner, R.F. (2000). Clinical management of the acute sunburn reaction. Cutis, 66, 53-58.

Duteil, L., Queille-Roussel, C., Lorenz, B., Thieroff-Ekerdt, R., & Ortonne, J.P. (2002). A randomized, controlled study of the safety and efficacy of topical corticosteroid treatments of sunburn in healthy volunteer. Clinical and Experimental Dermatology, 27, 314-318.

Han, A., & Maibach, H.I. (2004). Management of acute sunburn. American Journal of Dermatology, 5(1), 39-47.

Hughes, G.S., Francom, S.E, Means, L.K., Bohan, D.E, Caruana, C., & Holland, M. (1992). Synergistic effects of oral nonsteroidal drugs and topical corticosteroids in the therapy of sunburn in humans. Pharmacology and Treatment, 184, 54-58.

Melnyk, B.M., & Fineout-Overhold, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams and Wilkins.

Russo, P.M., & Schneiderman, L.J. (1978). Effect of topical corticosteroids on symptoms of clinical sunburn. The Journal of Family Practice, 7(6), 1129-1132.

Schmitt, B.D. (1996). How to treat and prevent sunburn. Contemporary Pediatrics 13(5), 57-59.

Silverstone, T. (1997). Sunburn--Don't do it. Professional Care of Mother and Child, 7(3), 79-81.

St. Louis University School of Medicine. (2006). Statistics and facts on skin cancer. Retrieved June 23, 2008, from http:// dermatology.slu.edu

The Skin Cancer Foundation (2008). The truth about tanning. Retrieved June 23, 2008, from http://www.skincancer.org/content/view/307/70

Victoria Land, MS, RN, PNP, is a Staff Nurse, St. Joseph Medical Center, Phoenix, AZ.

Leigh Small, PhD, RN, CPNP-PC, is an Assistant Professor and Coordinator, PNP Program, Arizona State University, College of Nursing and Healthcare Innovation, Phoenix, AZ.
Table 1.
Evidence Table of Randomized Controlled Trials
Involving Sunburn Treatment Interventions

Author, Location,
Title, Design, and               Purpose, Sample,
Intervention                     and Setting

Authors: Duteil, Queille-        Purpose: Investigate the
Roussel, Lorenz, Thieroff-       efficacy and tolerability of
Ekerdt, & Ortonne                stated treatments in
                                 sunburned adults.
Location: Not stated
                                 Sample: N = 24 (10
Title: A randomized,             females and 14 males);
controlled study of the          Caucasian; 18 to 65 years
safety and efficacy of           of age with either type II
topical corticosteroid           or III skin.
treatments of sunburn in
healthy volunteers               Setting: Not stated.

Design: RCT

Intervention: Treatment
with 0.1%
methylprednisolone
aceponate milk (MPA) &
0.1 % hydrocortisone
17-butyrate emulsion
(HCB)

Authors: Hughes,                 Purpose: To examine the
Francom, Means, Bohan,           ability of oral NSAIDs and
Caruana, & Holland               topical corticosteroids to
                                 improve UVB-induced
Location: United States          injury.

Title: Synergistic Effects of    Sample: N= 24; 18 to 57
Oral Nonsteroidal Drugs          years of age; type I or II
and Topical                      skin.

Corticosteroids in the           Setting: Upjohn Research
Therapy of Sunburn in            Clinics.
Humans

Design: RCT

Intervention: Group 1)
Ibuprofen (IB), topical
betamethasone i
dipropionate (BD),
combined above
treatment and control.
Group 2) Indomethoacine
(IN), topical betamethasone
diproprionate combined
treatment and control.

Authors: Russo &                 Purpose: Evaluate effect
Schneiderman                     of topical corticosteroid
                                 treatment in relieving
Location: United States          sunburn symptoms in a
                                 natural setting.
Title: Effect of Topical
Corticosteroids on               Sample: N= 50;
Symptoms of Clinical             23 completed.
Sunburn
                                 Setting: Beach recruits
Design: RCT double blind         and those solicited in alocal ad.
                                 newspaper
Intervention: Application of
flurocinolone cream and
an inactive cream twice a
day for 5 hours to
sun-exposed area.

Author, Location,                Intervention Period,
Title, Design, and               Outcome Measures, and
lIntervention                    Follow Up

Authors: Duteil, Queille-        Intervention period:
Roussel, Lorenz, Thieroff-       Treatments lasted 7 days
Ekerdt, & Ortonne                with follow up on day 8.

Location: Not stated             Outcome measures: Sun
                                 scores, including
Title: A randomized,             erythema, burning, g, itching, g,
controlled study of the          and oedema. Global
safety and efficacy of           assessment of therapeutic
topical corticosteroid           effect and colorimetry
treatments of sunburn in         were also measured.
healthy volunteers
                                 Follow up: Day 8 of study.
Design: RCT

Intervention: Treatment
with 0.1%
methylprednisolone
aceponate milk (MPA) &
0.1 % hydrocortisone
17-butyrate emulsion
(HCB)

Authors: Hughes,                 Intervention period. 5 days
Francom, Means, Bohan,           for each treatment.
Caruana, & Holland
                                 Outcome measures:
Location: United States          Minimal erythema dose
                                 (MED), skin blood flow,
Title: Synergistic Effects of    and skin biopsy.
Oral Nonsteroidal Drugs
and Topical                      Follow up: None reported.

Corticosteroids in the
Therapy of Sunburn in
Humans

Design: RCT

Intervention: Group 1)
Ibuprofen (IB), topical
betamethasone i
dipropionate (BD),
combined above
treatment and control.
Group 2) Indomethoacine
(IN), topical betamethasone
diproprionate combined
treatment and control.

Authors: Russo &                 Intervention period:
Schneiderman                     5 days.

Location: United States          Outcomes measures:
                                 Redness, pain, blisters,
Title: Effect of Topical         peeling, and swelling.
Corticosteroids on
Symptoms of Clinical             Follow up: None stated.
Sunburn

Design: RCT double blind

Intervention: Application of
flurocinolone cream and
an inactive cream twice a
day for 5 hours to
sun-exposed area.

Author, Location,
Title, Design, and               Findings and
Intervention                     Conclusions

Authors: Duteil, Queille-        Findings: On days 3 and
Roussel, Lorenz, Thieroff-       4, differences in sun
Ekerdt, & Ortonne                scores were noted and
                                 significant on days 4 and
Location: Not stated             5 for treatment areas.
                                 Sunburn reaction was
Title: A randomized,             lower in treated areas.
controlled study of the
safety and efficacy of           No difference was noted
topical corticosteroid           between treatments. No
treatments of sunburn in         adverse reactions related
healthy volunteers               to treatments.

Design: RCT                      Conclusion: Both MPA
                                 and HCB are safe and
Intervention: Treatment          effective in the treatment
with 0.1%                        of sunburn.
methylprednisolone
aceponate milk (MPA) &
0.1 % hydrocortisone
17-butyrate emulsion
(HCB)

Authors: Hughes,                 Findings: MED
Francom, Means, Bohan,           measurements reported
Caruana, & Holland               similar in both groups.
                                 Subtle differences in skin
Location: United States          biopsy results.

Title: Synergistic Effects of    Combination of NSAID
Oral Nonsteroidal Drugs          and topical corticosteroid
and Topical                      provided greatest
                                 decrease in skin blood
Corticosteroids in the           8 to 12 hours after
Therapy of Sunburn in            exposure.
Humans
                                 Conclusion: Synergistic
Design: RCT                      effect with combined
                                 topical corticosteroids and
Intervention: Group 1)           NSAIDs.
Ibuprofen (IB), topical
betamethasone i
dipropionate (BD),
combined above
treatment and control.
Group 2) Indomethoacine
(IN), topical betamethasone
diproprionate combined
treatment and control.

Authors: Russo &                 Findings:
Schneiderman                     * Symptoms of sunburn
                                   resolved within 3 to 5
Location: United States            days.
                                 * Swelling, blistering,
Title: Effect of Topical           and peeling were
Corticosteroids on                 minimal with most
Symptoms of Clinical               participants.
Sunburn                          * Both mean tenderness
                                   and erythema score
Design: RCT double blind           showed no statistical
                                   difference.
Intervention: Application of
flurocinolone cream and          Conclusion: No statistical
an inactive cream twice a        support for the use of
day for 5 hours to               topical corticosteroids in
sun-exposed area.                the treatment of sunburn.

Author, Location,
Title, Design, and               Study Strengths and
lIntervention                    Limitations

Authors: Duteil, Queille-        Strengths:
Roussel, Lorenz, Thieroff-       * RCT
Ekerdt, & Ortonne                * Easily replicated
                                 * Volunteers served as
Location: Not stated               own control

Title: A randomized,             Limitations:
controlled study of the          * Small sample size
safety and efficacy of           * Unique sample
topical corticosteroid           * Artificial induced
treatments of sunburn in           erythema
healthy volunteers               * Funded by
                                   pharmaceutical
Design: RCT                        company
                                 * No theoretical
Intervention: Treatment            framework
with 0.1%
methylprednisolone
aceponate milk (MPA) &
0.1 % hydrocortisone
17-butyrate emulsion
(HCB)

Authors: Hughes,                 Strengths:
Francom, Means, Bohan,           * RCT
Caruana, & Holland               * Easily replicated
                                 * Volunteers served as
Location: United States            own control

Title: Synergistic Effects of    Limitations:
Oral Nonsteroidal Drugs          * Artificial induced
and Topical                        erythema
                                 * Small sample size
Corticosteroids in the           * No theoretical
Therapy of Sunburn in              framework
Humans

Design: RCT

Intervention: Group 1)
Ibuprofen (IB), topical
betamethasone i
dipropionate (BD),
combined above
treatment and control.
Group 2) Indomethoacine
(IN), topical betamethasone
diproprionate combined
treatment and control.

Authors: Russo &                 Strengths:
Schneiderman                     RCT
                                 * Double blind
Location: United States          * Natural erythema
                                 * Easily replicated
Title: Effect of Topical
Corticosteroids on               Limitations:
Symptoms of Clinical             * Attrition (54%)
Sunburn                          * Lack of follow up
                                 * Self-reported findings
Design: RCT double blind         * Small sample size

Intervention: Application of
flurocinolone cream and
an inactive cream twice a
day for 5 hours to
sun-exposed area.
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Title Annotation:Evidence-Based Practice
Author:Land, Victoria; Small, Leigh
Publication:Pediatric Nursing
Geographic Code:1USA
Date:Jul 1, 2008
Words:5211
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