LETTERS

CASE NOTES

Bullous rheumatoid neutrophilic dermatosis

To the Editor: Lu et al1 recently described the rarecase of a 35-year-old man presenting with rheuma-toid neutrophilic dermatosis (RND). As an uncom-mon clinical feature, skin lesions consisted ofsymmetrically grouped vesicles and tense bullae,mimicking dermatitis herpetiformis. To date, this isthe second published case of bullous RND since thefirst report by Lowe et al2 in 1992.We here add a thirdcase of bullous RND, clinically resembling bullouspemphigoid.

A 78-year-old female visited our clinic in March2004 for the first time with a 6-month history ofpruritic cutaneous lesions. She had suffered fromsevere seropositive rheumatoid arthritis (RA) for

Side effects of naltrexone observed in frequenttanners: Could frequent tanners haveultraviolet-induced high opioid levels?

To the Editor: The compulsion to tan in many peopleraises the question: Is tanning behavior driven by aphysiologic stimulus? We found that frequent tannerscould distinguish between ultraviolet (UV) and non-UV light beds and that they preferred the UV stim-ulus.1,2 UV radiation can induce keratinocytes toproduce endorphins, which raises the possibility thattanning behavior might be influenced by endoge-nous endorphins.3-6 In a first attempt to see if opioidblockade would prevent frequent tanners from be-ing able to distinguish UV from non-UV stimuli, wetreated 3 female frequent tanners with an endorphin-blocking agent (naltrexone, 50 mg) before UV andnon-UV exposures.

The first subject preferred the non-UV bed andreported no adverse effects from naltrexone. Thesecond subject reported a slight preference for thenon-UV bed. Shortly after being treated with nal-trexone, she felt ‘‘disoriented’’ and ‘‘unable to con-centrate.’’ The subject felt nauseated later in the day.The third subject also reported a slight preferencefor the non-UV bed. However, she felt ‘‘emotionallydrained’’ after being treated with naltrexone anddeveloped nausea and vomiting. These symptomsresolved by the next morning.

We expected the study participants to show astrong preference for the UV exposure stimulus. It isintriguing, though highly speculative with such asmall sample size, to suggest that by blocking opioideffects, naltrexone appeared to reduce these fre-quent tanners’ preference for UV exposure. Thedevelopment of adverse events in 2 of the 3 partici-pants was unexpected. When naltrexone is given toopioid-dependent individuals,withdrawal symptoms,including nausea, may occur. Is it possible that fre-quent tanners experience acute or chronic eleva-tions of opioid peptide levels and experience a formof opioid withdrawal in response to naltrexone? Fur-ther research is needed to explore these findings andthe role that opioids may play in the reinforcing prop-erties of UV radiation exposure.

Mandeep Kaur, MDa

Anthony Liguori, PhDb

Alan B. Fleischer, Jr, MDa

Steven R. Feldman, MD, PhDa

Departments of Dermatologya

916 MAY 2005

and Physiology and Pharmacologyb

Wake Forest University Health SciencesWinston-Salem, North Carolina

Funding source: The Center for DermatologyResearch is funded by a grant from

Galderma Laboratories, LP

Correspondence and reprint requests to:Steven R. Feldman, MD, PhD

Department of DermatologyWake Forest University School of Medicine

Medical Center BoulevardWinston-Salem, NC 27157-1071

E-mail: sfeldman@wfubmc.edu

REFERENCES

1. Scerra C. Addicted to the sun? Dermatol Times 2003;24:58.

2. Feldman SR, Liguori A, Kucenic M, Rapp SR, Fleischer AB,

Lang W, et al. UV exposure is a reinforcing stimulus in fre-

quent indoor tanners. J Am Acad Dermatol 2004;51:45-51.

3. Wintzen M, Yaar M, Burbach JP, Gilchrest BA. Proopiomelano-

cortin gene product regulation in keratinocytes. J Invest

Dermatol 1996;106:673-8.

4. Levins PC, Carr DB, Fisher JE, Momtaz K, Parrish JA. Plasma beta-

endorphin and beta-lipoprotein response to ultraviolet radia-

tion. Lancet 1983;2:166.

5. Wintzen M, Ostijn DM, Polderman MC, le Cessie S, Burbach JP,

Vermeer BJ. Total body exposure to ultraviolet radiation does

not influence plasma levels of immunoreactive beta-endorphin

in man. Photodermatol Photoimmunol Photomed 2001;17:

256-60.

6. Gambichler T, Bader A, Vojvodic M, Avermaete A, Schenk M,

Altmeyer P, et al. Plasma levels of opioid peptides after sunbed

exposures. Br J Dermatol 2002;147:1207-11.

doi:10.1016/j.jaad.2005.02.026

J AM ACAD DERMATOL