Hell’s itch due to sunburn

Sun damage is amongst the leading causes of skin problems in travellers.¹ In a study in kite-surfers, 74% had at least one sunburn during the last 6 months.² Sunburns are caused by overexposure to ultraviolet (UV) rays, and the degree of burn can vary from mild to severe depending on the skin type and the amount of sun exposure. However, a specific acute phenomenon related to sunburn called ‘hell’s itch’, also described as ‘suicide itch’, is often not mentioned in the scientific literature; a PubMed search did not show any results. In comparison, a Google search yielded 158 000 results. A Scopus search yielded one unrelated Book Chapter. As I was unfortunate enough to experience hell’s itch first-hand, I would like to describe this phenomenon in order to raise medical awareness.

A Caucasian fair-skinned male in my 20s, I had a severe sunburn on the Galapagos Islands after falling asleep in the sun without sun protection during mid-day. Not unexpectedly, severe erythema developed that the same evening in the sun-exposed areas, as is well described in the sunburn literature. My self-management included immediately applying aloe-vera containing skin lotions, wearing loose clothing and staying hydrated.

However, 3 days after the onset of the sunburn, triggered by a shower, the most intense itch developed that was more painful than anything I have experienced in my life. It felt as if needles were stabbing deep into the epidermis. The pain was so unbearable that I did not know what to do. I was in a frenzy state, irritable and restless, wringing on the floor, with an intense urge to scratch which made it even worse. It felt like hell. It seemed that I was going insane. Applying aloe-vera skin lotions further worsened the symptoms. The painful itch was so unbearable that I was given benzodiazepines to calm down the uncontrollable urge to scratch, in addition to oral antihistamines, and non-steroidal anti-inflammatory medication.

Much of what has been written about hell’s itch comes from people on the Internet relaying their own experiences with this painful condition. Online sufferers have described their experiences as feeling ‘like fire ants are biting you under your skin’, ‘wanting to rip your skin off’ or ‘an uncontrollable itch that, when scratched, causes stabbing pain’ (https://health.clevelandclinic.org/what-the-heck-is-hells-itch/). Interestingly, showers often seem to be a trigger, and skin lotions do not alleviate pain. Hell’s itch seem to start at least 48 h after the onset of the sunburn and is mainly reported by fair-skinned persons.

My symptoms came in waves but then disappeared after 48 h. Interestingly, the itch also affected areas which did not have a sunburn, though to a much lesser extent. Four days later, my skin was peeling, not only on the areas where I had the sun exposure but also on the pads of my fingers, palms of my hands and especially on the soles of my feet, perhaps due to the Skin Stress Response System.³

What is the pathophysiology of hell’s itch? Given the absence of hell’s itch in the scientific literature, we can only speculate. Based on a sunburn model, a sensitized pain response to bradykinin release after sunburn was reported.⁴ An endogenous origin of the peripheral mediators causing the nociceptor discharge was postulated. A large area of secondary mechanical hyperalgesia to pin prick was found in a study to investigate the central origin of sunburn related pain.⁵ It appears that the peripheral nociceptive afferent input of inflamed skin enhances central hypersensitivity of mechanosensitive nociceptors in a larger receptive field far beyond the inflamed skin.

Apart from the immediate physical problems, like many other online users, I am now psychologically permanently scarred to avoid such a situation of sunburn again, and now often appear to ‘over-do’ sun protection. Many people doubt the authenticity of hell’s itch, unless they have lived through it themselves or witnessed it and maybe that is the reason why it has not been covered in the scientific literature. Because of lack of healthcare knowledge in this area, a layman’s guide to hell’s itch has been produced on Reddit.com via the collection of personal experiences shared through Internet forums (https://www.reddit.com/r/HellsItch/). Healthcare researchers should follow suit and provide evidence-based, not merely anecdotal, advice. Furthermore, scientific documentation of the frequency, risk factors and management of hell’s itch is required. Lastly, travel medicine practitioners and primary healthcare physicians should counsel at-risk travellers about photo-protection and self-management.⁶