Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use...

Ashley Feneran, DO

Jenifer Lloyd, DO

University Hospitals Regional Hospitals

AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY

Review key points of several photodermatoses

Update knowledge and treatment of photodermatoses

Discuss vitamin D levels in photodermatoses

Objectives

Types of photodermatoses

Immunologically mediated disorders

Defective DNA repair disorders

Photoaggravated dermatoses

Chemical- and drug-induced photosensitivity

Types of photodermatoses

Immunologically mediated disorders

Polymorphous light eruption

Actinic prurigo

Hydroa vacciniforme

Chronic actinic dermatitis

Solar urticaria

Polymorphous light eruption (PMLE)

Most common form of idiopathic

photodermatitis

Possibly due to delayed-type

hypersensitivity reaction to an

endogenous cutaneous photo-

induced antigen

Presents within minutes to

hours of UV exposure and lasts

several days

Superficial and deep lymphocytic infiltrate

Marked papillary dermal edema

Pathology

PMLE Treatment

Topical or oral corticosteroids

High SPF

Restriction of UV exposure

Hardening – natural, NBUVB,

PUVA

Antimalarial

PMLE updates

Study suggests topical vitamin D analogue

used prophylactically may provide

therapeutic benefit in PMLE

Gruber-Wackernagel A, Bambach FJ, Legat A, et al. Br J Dermatol, 2011.

PMLE updates

Study seeks to further elucidate the

pathogenesis of PMLE

Found a decrease in Langerhans cells and an

increase in mast cell density in lesional skin

Wolf P, Gruber-Wackernagel A, Bambach I, et al. Exp Dermatol, 2014.

Actinic prurigo

Similar to PMLE

Common in native American

children

Strong association with HLA

DR4 subtype DRB1*0407

Heals with scarring

Shallow ulcer, neutrophils, & fibrin deposits

Acanthosis, spongiosis, & superficial vessel

telangiectasias

Follicular chelitis

Pathology

Actinic prurigo treatment

Photoprotection

UV protective film on windows

Topical and oral steroids

NBUVB

Thalidomide

Pentoxifylline

Cyclosporine

Azathioprine

TNF-a inhibitors

Actinic prurigo updates

Study describes successful use of thalidomide

in 6 total adult and pediatric patients with

actinic prurigo

Regular nerve conduction studies performed

Crouch R, Foley P, Ng J, et al. Australas J Dermatol, 2002.

Hydroa vacciniforme (HV)

Rare, scarring photodermatosis

seen in early childhood

Some cases are associated

with latent EBV infection

Hemorrhagic bullae heal with

varioliform scars

Spongiosis & epidermal vesicles

Epidermal and upper dermis necrosis

Lymphocytic infiltrate of dermis

Pathology

Hydroa vacciniforme treatment

Refractory to treatment

Close monitoring for atypical

features

Photoprotection

NBUVB

Oral antimalarials

Azathioprine

Thalidomide

Cyclosporine

Beta carotene

Fish oil supplements

Hydroa vacciniforme updates

Recent case report illustrates adult-

onset HV with T-cell monoclonality with

a favorable course

Nomura H, Suzuki H, Egami S, et al. Br J Dermatol, 2015.

Chronic actinic dermatitis

Chronic eczema caused by UV

radiation and visible light

Tends to affect older men

Likely a delayed-type

hypersensitivity reaction

Often a pre-existing allergic or

photoallergic contact dermatitis

Spongiosis, acanthosis, superficial perivascular

infiltrate

Occasional apoptotic keratinocytes

Exocytosis of inflammatory cells

Pathology

Chronic actinic dermatitis treatment

Photoprotection

Topical steroids

Topical calcineurin inhibitors

NBUVB

PUVA

Azathioprine

Cyclosporine

Mycophenolate mofetil

Chronic actinic dermatitis updates

This study disproved the hypothesis that

the filaggrin gene plays a strong role in

the pathogenesis of chronic actinic

dermatitis

Harkins C, Waters A, Kerr A, et al. J Invest Dermatol, 2015.

Solar urticaria

Urticaria induced by sun

exposure

Appears within 5-10 minutes of

sun exposure & resolve over

1-2 hours

Most cases do not resolve

Risk of anaphylactic-type

response

Mild perivascular lymphocytic, mast cell, &

eosinophilic infiltrate

Mild dermal edema

Can see intraluminal neutrophils and

eosinophils

Pathology

Solar urticaria treatment

Photoprotection

Sunscreen is not particularly helpful

for those sensitive to visible light

Anti-histamines

Topical steroids

Graduated UV exposure

IVIG

Omalizumab

Plasmapheresis

Solar urticaria updates

This study showed promising results

with IVIG to treat solar urticaria,

however the duration of response was

not prolonged and adverse effects were

frequent

Aubin F, Porcher R, Jeanmougin M. J Am Acad Dermatol, 2014.

Solar urticaria updates

Case studies are conflicting on efficacy of

omalizumab in solar urticariaBaliu-Piqué C, Aquilera Peiró P. J Eur Acad Dermatol Venereol, 2015.

Müller S, Schempp C, Jakob T. J Eur Acad Dermatol Venereol, 2014.

Vitamin D levels

All of the discussed photodermatoses have the

recommendation for photoprotection, but what effect, if

any, does this have on vitamin D levels?

This prospective, longitudinal study

compared sunlight exposure,

photoprotective behavior, and vitamin D

levels in patients with photosensitivity

vs. healthy adults

Rhodes L, Webb A, Berry J, et al. Br J Dermatol, 2014.

Compared to healthy adults,

photosensitive patients had:

Lower weekend UVB doses

Smaller skin area exposure

Greater sunscreen use

Rhodes L, Webb A, Berry J, et al. Br J Dermatol, 2014.

Compared to healthy adults,

photosensitive patients had:

Lower vitamin D levels year-round

Year-round lows

Rhodes L, Webb A, Berry J, et al. Br J Dermatol, 2014.

Recommendation is to educate patients

on potential for year-round decreased

vitamin D levels and supplementation of

400IU daily

Program Director: Jenifer Lloyd, DO

PGY-3

Rosanne Paul, DO

Madeline Tarrillion, DO

PGY-2

Mathew Loesch, DO, PhD

Miesha Merati, DO

PGY-4

Aziza Wahby, DO

AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY

AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY

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