Case Study: Severe Solar Dermatitis in an Adolescent with Recent Isotretinoin Use

Case at a Glance

A 17-year-old female college student presented with severe pain, erythema, and sleep disturbance two days after extensive sun exposure. Her condition was significantly exacerbated by increased photosensitivity from a recently completed course of isotretinoin. The case highlights the challenges of managing an acute, painful dermatological condition with limited resources in a dormitory setting.

Patient's Story

The patient, a 17-year-old female of mixed Asian and Caucasian descent, sought advice for excruciating pain following a severe sunburn sustained 48 hours prior. She is a first-year college student living in a dormitory. She reported prolonged, unprotected sun exposure that resulted in a burn across her shoulders, posterior neck, and lower back. The pain had progressively worsened, preventing her from sleeping and causing significant distress. She described that she could 'barely move her arms' and that her skin was sticking to her bedsheets, causing excruciating pain upon movement. Her medical history was notable for completing a course of isotretinoin for acne two months prior.

Initial Assessment

The patient's initial consultation was conducted via a campus telehealth service due to her severe pain and limited mobility. She reported her symptoms clearly and was afebrile. Her chief complaint was uncontrolled pain rated at a 9/10. She had been applying a commercially available 'aloe-adjacent' gel with minimal relief and found cold showers impractical due to her dormitory's shared bathroom facilities. Based on her description and submitted images, the skin exhibited diffuse, intense erythema and edema consistent with a first-degree burn, with areas suggesting superficial second-degree involvement given the extreme pain and reported weeping or plasma leakage causing the skin to adhere to fabric.

The Diagnostic Journey

The diagnosis was made on a clinical basis, guided by the clear history of excessive UV exposure and the characteristic presentation of a severe sunburn. The patient's recent history of isotretinoin use was identified as a critical factor contributing to the severity of the phototoxic reaction. While isotretinoin is cleared from the system relatively quickly, heightened skin sensitivity can persist for several months post-treatment. The diagnostic challenge was not in identifying the condition but in assessing its severity remotely and providing an effective management plan that was feasible within the patient's environmental constraints (i.e., living in a dorm with access to only one small convenience store).

Final Diagnosis

Acute Solar Dermatitis (Severe Sunburn), with features of both First-Degree and Superficial Second-Degree Burns, secondary to excessive ultraviolet (UV) radiation exposure. The reaction was likely potentiated by increased photosensitivity from recent isotretinoin therapy.

Treatment Plan

The immediate goal was to manage pain, reduce inflammation, and prevent complications like infection or dehydration.

1. Systemic Analgesia: The patient was advised to immediately obtain and begin a course of over-the-counter NSAIDs, specifically Ibuprofen (400 mg every 6-8 hours with food), to target both pain and inflammation.
2. Topical Care: She was instructed to apply cool, damp compresses to the affected areas for 15 minutes several times a day. It was recommended she look for a bland, hydrating emollient or a pure aloe vera gel without alcohol or fragrance. Topical anesthetic sprays containing lidocaine were suggested for short-term, targeted pain relief, with a caution against widespread use on potentially broken skin.
3. Hydration: The importance of increasing oral fluid intake was emphasized to counteract dehydration from the burn.
4. General Measures: The patient was advised to wear loose-fitting, soft cotton clothing to minimize irritation and to avoid peeling any flaking skin to prevent scarring and infection.
5. Red Flag Warnings: She was instructed to seek immediate in-person medical evaluation at the campus health center or emergency department if she developed a fever, chills, large blisters, or any signs of systemic illness.

Outcome and Follow-up

The patient was able to obtain ibuprofen and a more suitable topical gel. Within 24 hours of starting the recommended treatment, her pain decreased significantly, allowing her to rest more comfortably. Over the next 72 hours, the acute erythema and edema began to subside. By the time she traveled home four days post-burn, the severe pain had resolved, and the desquamation (peeling) phase had begun. Follow-up advice included strict sun avoidance for the affected areas and a strong recommendation for diligent use of broad-spectrum SPF 50+ sunscreen in the future, with a reminder of her ongoing skin sensitivity post-isotretinoin.