Topical protection against long-wave A Michael Jarratt, M.D.,* Marcia Hill, R.N.,* and Kenneth Smiles, Ph.D.** Houston, TX, and BloomJirld, NJ

A PABA ester-oxybenzonepreparation is superiorto PABA or alone in protecting the skin from methoxsalen-inducedultraviolet A (UVA) phototoxicity after water substantivity challenge. Such a mixture would lx useful as a UVA screenfor uninvolved or actinically damagedskin in patients receiving psoralensand ultraviolet A (PUVA) therapy. An effective topical UVA screenalso may protect against UVA-induced diseaseslike solar urticaria, polymorphic light eruptions, drug-inducedphototoxicity or photoallergy, and possibly againstthe deepdegenerative changes of solar elastosis. (J AM ACAD DERMATOL 9:354-360, 1983.)

Long-wave ultraviolet radiation, 3 15-400 mm agents that protect against UVA. Conventional (UVA), constitutes a major component of solar containing para-aminobenzoic acid ultraviolet radiation incident on the skin. Although (PABA) do not block UVA. The following study UVA is less erythemogenic than middle range was designed to evaluate the UVA screening ca- UVB (280-3 15mm), because of the abundance of pacity of a new formulation. UVA in sunlight, UVA may well contribute sub- stantially to acute and chronic ultraviolet radiation METHODS damage. Ultraviolet A is responsible for inciting Test preparationsused were the following: the clinical symptoms of photosensitive diseases, 1. 5% para-aminobenzoic acid (PABA) in alcohol including the porphyrias, soIar urticaria,’ poly- 2. 10% 2-hydroxy-4-methoxybenzophenone-5-sulfonic morphic light eruptions,’ and drug-induced pho- acid (sulisobenzone) in lotion base totoxic and photoallergic reactions.Y Moreover, in 3. 7% N,N-dimethyl-2-erhylhexyl para-aminobenzoate recent years orally administered psoralens and (PABA ester) and 3% 2-hydroxy-4-methoxybenzo- phenone () in-an anionic emulsion vehicle UVA (PUVA) has gained popularity in clinical 4. Anionic emulsion vehicle alone dermatologic practice for the treatment of psoria- sis,’ vitiligo,j and mycosis fungoides.6 Long-term Ultraviolet A screening evaluation use of PUVA may contribute to cutaneous aging Twelve male subjects, 19 to 37 years of age, in- and induction of squamous cell carcinomas.’ gested%merhoxypsoralen, 0.5 mg/kg in a single dose. The recognition of UVA as a biologically im- Sixteentest sites (5.08~ 5.08 cm each)were outlined in portant component of solar ultraviolet radiation four vertical columns on the untanned back or chest of and the use of PUVA in clinical practice have skin type 2 or type 3 subjects.4 Each test preparation aroused interest in topical ultraviolet screening was applied to one vertical column of four test sites according to a randomized Latin-square design. A re- From the Department 07 Dermatology. Baylor College of Medicine. search associate applied the test preparations, 0.05 Housto>n/c and Schering-Plough Corporation, Bloomfield.** ml/site. Test preparations dried for 30 minutes, and the AcceptEd for publication Jan. 5, 1983. treatment sites were masked down to 2.54x2.54 cm Reprint requests to: Dr. K. Smiles, Schering-Plough Corp.. Bloom- with opaque tape. The three top horizontal rows of four field. NJ-07033. test sites were covered. Two hours after subjects in- 3;4 r ’ .1 . 1 ‘Ime 9 b .:nber 3 Topical protection against (/VA 355 Scpxmber, 1983

5 2.2 ‘ .I ; 1.8 g 1.4 1.0

w’ I I I I 74 10 Joules I cm2 UV-A Joules ‘1 cm2 “!-A

Fig. 1. UVA screeningwithout water wash off. Aver- Fig. 2. UVA screeningwithout water wash off. Average age erythema scoresat 48 hours. Erythema scoresare erythema scores at 72 hours. Without a water chal- comparablein sites treatedwith the PABA preparation lenge, the sulisobenzone-treatedsites (B) show slightly (C) or the emulsion vehicle (0). A, PABA ester- less erythemathan those treatedwith the PABA ester- oxybenzonepreparation; B, sulisobenzonepreparation; oxybenzonepreparation (A). A, PABA ester-oxyben- 7, PABA preparation;D, anionic emulsion vehicle. zone preparation; B, sulisobenzonepreparation; C, PABA preparation;D, anionic emulsion vehicle.

gestedmethoxsalen, the bottom horizontal row of four pool (25”-28” C) and swam slowly for 5 minutes. The uncovered sites received 2 joules/cm* ultraviolet A treatmentsites air-dried and were maskeddown to 2.54 radiation (320-390 mm) in a GTE Sylvania Photoche- to 2.54 cm with opaquetape. Ultraviolet A radiation B motherapyTreatment Unit.4 The horizontal row of sites was administeredaccording to the previously described superiorto the irradiated row was uncovered, and both procedure. openrows receivedanother 2 joules/cm*. The third row Both in the ultraviolet A screeningand in the sub- ,Nasexposed, and all three openrows received2 joules/ stantivity evaluations, erythema readings were exam- cm*. The top row was uncovered, and all sixteen sites ined with an analysis of variance for Latin-squarede- received an additional 4 joule&m?. Thus, each hori- sign for differences among the treatmentsand among zontal row from top to bottom received4, 6, 8, and 10 the UVA dosages.Duncan ’s multiple range test was joules/cm*, respectively. At 48 and 72 hours after ex- used to make all pairwise comparisons.Study subjects posure, the investigator, who was unaware of which had complete blood count, urinalysis, and blood treatments were applied to the various sites, graded chemistry determinationsdone before and 1 week after the severity of the phototoxic reaction on a five-point testing. scale: RESULTS 0 = No erythema Ultraviolet A screening evaluation I + = Slight erythema, just perceptible 2+ = Slight erythema, with definitemargins At 48 hours, sites treated with the anionic emul- 3f = Moderate erythema sion vehicle and irradiated with 4, 6, 8, and 10 4+ = Severe erythema joules/cm’ UVA showed l+ to 2+ erythema that Substantivity evaluation was significantly correlated with the dose of ultra- violet A radiation (p < 0.01) (Fig. 1). At 72 hours, Twelve male subjects22 to 37 years‘ of age ingested Y-methoxypsoralen,0.5 mg/kg, in a single dose. The erythema was more pronounced. Ten joules/cm2 four test preparations-wereapplied to sixteen sites in a UVA produced greater than 2+ erythema at 72 random Latin sq&e design as described previously. hours. Erythema in 5% PABA-treated sites was Test areas were left to dry for 30 minutes, and the comparable to that in vehicle-treated sites. These subjects entered.a fresh water, chlorinated swimming two treatments did not differ significantly from D Journalof the 356 Jarratt et al AmericanAcademy of Dermatology

4 j/cm*

6 j/cm*

8 j/cm*

10 j/cm2

Fig. 3. UVA screeningwithout water wash off. Photographat 72 hours. The two para- spinous columns treated with the PABA ester-oxybenzone preparation (A) or the sulisobenzonepreparation (B) show barely perceptible erythema even in sites radiated with 10 joules/cm* UVA. A, PABA ester-oxybenzonepreparation; B, sulisobenzone preparation; C, PABA preparation;D, anionic emulsion vehicle.

each other (p < 0.1) (Fig. 2). Thus, 5% PABA apparent, with erythema in the vehicle, 10% sul- offered no better protection than vehicle. isobenzone, and 5% PABA-treated sites averaging Both the P!IBA ester-oxybenzone preparation 2.4 at 10 joules/cm” compared to the 0.75 at and the 10% sulisobenzone lotion offered sub- the PABA ester-oxybenzone-treated sites (p < stantial protection with l+ or less erythema at 72 0.01). Again, no significant differences were seen hours (Fig. 2). Both of these treatments were sta- among sites treated with vehicle, 10% sulisoben- tistically and visibly better than vehicle or 5% zone, or 5% PABA (p < 0.1) (Fig. 5). The PABA PABA (p < 0.01) (Fig. 3). Ten percent suliso- ester-oxybenzone protected column of sites was benzone was more protective than the PABA easily identified on visual inspection (Fig. 6). ester-oxybenzone preparation at 72 hours and at Pre- and postlaboratory tests showed scattered ultraviolet A dosages of 8 and 10 joules/cm2 at 48 small excursions of isolated values outside the hours (p C 0.01). normal range. These abnormalities were not con- sistent among subjects and thus were not consid- Substantivity evaluation ered indicative of a toxic effect associated with At 48 hours, erythema was comparable in sites methoxsalen ingestion. treated with vehicle alone, 10% sulisobenzone, or 5% PABA. Erythema scores averaged I .7 at IO DISCUSSION joules/cm’ for the three former test preparations Solar ultraviolet radiation is divided into three compared to the PABA ester-oxybenzone-treated spectra: short wavelength UVC (200-280 nm), sites that averaged 0.5, with most sites showing mid-range UVB (280-315 nm), and long wave- barely perckptibb erythema. This difference was length UVA (315-400 nm).a Short wave-length significant (p < 0.01). No significant differences UVC from artificial light sources induces brisk were se&r among the 10% sulisobenzone, 5% cutaneous erythema with subsequent desquama- PABA, and vehicle-treated sites (p C 0.1) (Fig. tion, but naturally occurring solar UVC does not 4). At 72 hours, these same results were more reach the earth’s surface because of atmospheric h‘...:lber 3 Topical protection against WA 357 September1983,

AVERAGEERYTHEMA SCORES AT 48 HOURS 3.0 r 3.0 2.6 Q)

I I J ’ ’ ’ 0 4 10 0 -4 10 Joules6 I cm2 !V-A Joules61 cm2 Ut-A Fig. 5. UVA screeninga fter water wash off. Average Fig. 4. UVA screening after water wash off. Average erythemascores a t 72 hours. After water wash off, the erythemascores a t 48 hours. After washoff, the PABA sulisobenzoneprepara tion (B) offers no better UVA ester-oxybenzoneprepara tion (A) offers substantial protectiont han the PABA (C) or emulsion vehicle (0). UVA protection. PreparationsB , C, and D do not. A, A, PABA ester-oxybenzoneprepara tion;B , sulisoben- PABA ester-oxybenzoneprepara tion;B , sulisobenzone zone preparation; C, PABA preparation; D, anionic preparation;C , PABA preparation;D , anionic emul- emulsion vehicle. sion vehicle.

absorption and scattering.g Ultraviolet C, there- UVA, like UVB, induces erythema and sub- fore, does not contribute to the physiologic pro- sequent melanogenesis. l6 UVA radiant energy

) cesses of UV-induced cutaneous disease. adds to, or perhaps even augments, erythema in- Ultraviolet A, on the other hand, penetrates the duced by UVB. l7 Preradiation of the skin with earth’s atmosphere more readily than UVC or UVA enhances the subsequent erythemogenic re- UVB.‘O Ultraviolet A constitutes the major com- sponse of a given dose of UVB.‘* Despite this ponent of ultraviolet radiation incident on the skin evidence for the erythema-enhancing effects of at earth’s surface. Solar UVA spectral u-radiance UVA, experiments with albino mice have not at noon is 100 times that of UVB; in mid morning shown that UVA enhances the carcinogenic effect and mid afternoon, it is 500 times greater.” Al- of UVB.rg s though UVB is one thousand times more erythem- Until recently, topical sunscreening prepara- ogenic than UVA, UVA may account for 10% of a tions were formulated primarily to protect against noonday because of substantially higher UVB (290-320 nm). Para-aminobenzoic acid. doses of UVA incidence?on the skin.r2 (PABA) absorbs ultraviolet radiation in the 29O- Ultraviolet ‘A penetrates not only the atmo- 320 nm range. *OConsequen tly, PABA and its es- sphere, but also the skin, more efficiently than ters have enjoyed the sunscreen spotlight for the does UVB. Ultraviolet B is reflected, scattered, last 10 years. PABA is a better UVB screen than and absorbed by the epidermis, but approximately its esters, but PABA stains clothing. 50% of incident UVA is transmitted through Increased awareness of the pathophysiologic Caucasian epidermis. l3 Ultraviolet. A penetrates action of UVA stirred interest in broadening the into the reticular dermis where the histologic protective effect of topical sunscreens to include changes of solar e!a,stosis are seen. Ultraviolet B long-wave UVA radiation (320-400 nm). The ben- does not.14 Thus; it is reasonable to assume that zophenones, ultraviolet screening agents first used UVA may play a role in causing the deep changes in the paint industry, absorb a broad band of ul- _- Do f solar elasto2is.‘5 - traviolet radiation between 200 and 380 nm.** Journal of the American Academy of Dermatology

6 j/cm2

8 j/cm2

10 j/cm2

Fig. 6. UVA screening after water wash off. Photograph at 72 hours. After water wash off, only the column of sites treated with the PABA ester-oxybenzone preparation (A) were protected from UVA. A, PABA ester-oxybenzone preparation; B, sulisobenzone prepara- tion; C, PABA preparation; D, anionic emulsion vehicle.

Their protective effect in the UVB range is completely blocked UVA phototoxicity that was roughly comparable to that of the PABA esters,“O otherwise manifest as 4+ erythema at 72 hours in but because of their long wavelength absorption radiated sites treated with 5% PABA or vehicle capacity, they also protect against UVA.” A dis- base. In outdoor sunlight studies with human sub- advantage of-the benzophenones is lack of sub- jects, Sayre et al a6 showed the PABA ester-oxy- stantivity.2” They sweat off and wash off more benzone preparation to be superior to five other readily than PABA. Sulisobenzone (2-hydroxy-4- commercially available sunscreens both in sun methoxybenzophenone-5sulfonic acid), the ac- protective factor scores and in substantivity after tive agent in Uval, is readily washed off the skin swimming. because of its water solubility (Figs. 4 and 5). In this study, human volunteers were sen- An improved topical sunscreen formulation sitivzed to UVA with orally administered 8-meth- would block both UVB and UVA, would not wash oxypsoralen (methoxsalen) and exposed to artifi- off readily with water immersion, and would be cial UVA from a fluorescent lamp source. nonstaining and cosmetically acceptable. The Methoxsalen induces sensitivity to ultraviolet combination of a nonstaining PABA ester (NJ- radiation in the 320-380 nm range.“-a8 A PABA dimethyl-2-ethylhexyl para-aminobenzoate) and a ester-oxybenzone mixture in an anionic emulsion less water-soluble benzophenone (2-hydroxy-4- vehicle was compared with 5% PABA in alcohol, methoxybenzophenone or oxybenzone) in a non- 10% sulisobenzone lotion, and emulsion vehicle ionic emulsion vehicle satisfies the criteria for an alone for capacity to block methoxsalen-induced improved sunscreen. The absorption curve of the UVA phototoxicity. preparation peaks at 310 nm and extends into the Sites treated with 5% PABA or vehicle alone UVA range beyond 370 nm.‘)’ (Fig. 7). To dem- showed marked erythema at 72 hours after irradi- onstrate topical .UVA screening efficacy, Akin ation. Sites treated with the PABA ester-oxyben- et al’” sensitized animals with 8methoxypsoralen zone preparation or the sulisobenzone lotion and exposed them to fluorescent black light (320- showed minimal erythema at 72 hours (Fig. 2). 400 nm) or to sunlight filtered through window The UVA screening capacity of the PABA ester- glass. The PABA ester-oxybenzone preparation oxybenzone preparation and the sulisobenzone lo- Topical protection against UVA 359

tion were comparable without a water washoff substantivity challenge (Figs. 1 and 2). However, 21 after test subjects swam in a pool for 5 minutes, the sulisobenzone-treated sites showed erythema 18 ccmparable to that in sites treated with vehicle or 15 with 5% PABA, i.e., no apparent protection. After a swimming challenge, the PABA ester- oxybenzone treated sites showed significantly less erythema than other test sites treated with 5% PABA, 10% sulisobenzone, or vehicle (p < 0.01) (Figs. 4 and 5). 6

CONCLUSION 3 Methoxsalen-induced photosensitivity to UVA 0 - I I , may be prevented by the use of either a sulisoben- zone or a PABA ester-oxyhenzone sunscreen. 250 270 290 310 330 350 370 390400 However, a bathing test of substantivity showed WAVELENGTH NM that for practical purposes the PABA ester-oxy- benzone preparation is more effective. Fig. 7. Ultraviolet absorption characteristics. The PABA ester-oxybenzone preparation (A) absorbs max- XEFERENCES imally at 310 nm and into the UVA range beyond 370 1. Ive H, Lloyd J, Magnus IA: Action spectra in idiopathic nm. A, PABA ester-oxybenzone preparation; B, suliso- solar urticaria. Br J Dermatol 77:229-243. 1965. benzone; C, PABA. 2. Frain-Bell W, Dickson A, Herd J, Sturrock I: The action spectrum in polymorphic light eruption. Br J Dermatol Eisen AZ, Wolff K, et al, editors: Dermatology in gen- 89~243-249, 1973. eral medicine, ed. 2. New York, 1979, McGraw-Hill 3. Epstein JH: Phototoxicity and photoallergy, in Fitzpat- Book Co., p. 953. rick TB, Pathak MA, Harber LC. et al, editors: Sunlight 13. Everett MA, Yeargers E, Sayer RM, Olson RL: Penetra- and man. Tokyo, 1974, University of Tokyo Press, pp. tion of epidermis by ultraviolet rays. Photochem Pho- 459-478. tobiol 5:533-542. 1966. 4. Parrish JA, Fitzpatrick TB, Tanenbaum L, Pathak MA: 14. Parrish JA, Anderson RR, Urbach F, Pitts D: UVA: Photochemotherapy of psoriasis with oral methoxsalen Biological effects of ultraviolet radiation. New York, and longwave ultraviolet light. N Engl J Med 291: 1978, Plenum Publishing Corp., pp. 62-77. 1207-1212, 1974. 15. Kligman AM: Solar elastosis in relation to pigmentation, 5. Parrish JA, Fitzpatrick TB, Shea C, Pathak MA: Pho- in Fitzpatrick TB. Pathak MA, Harber LC, et al, editors: tochemotherapy of vitiligo with oral psoralen and a new Sunlight and man. Tokyo, 1974, University of Tokyo high-intensity longwave ultraviolet light system. Arch Press, pp. 157-163. Dermatol 112:1531-1534, 1976. 16. Kaidbey KH, Kligman AM: The acute effects of long- 6. Gilchrest BA, Parrish JA. Tanenbaum L, et al: Oral wave ultraviolet radiation of human skin. J Invest Der- methoxsalen photochemotherapy of mycosis fungoides. matol72:253-256, 1978. Cancer 38:683-689, 1976, 17. Ying CY, Parrish JA, Pathak MA: Additive erythem- 7. Stem R, Thibodeau L, gleinerman R, et al: Risk of ogenic effects of middle- (280-320 mm) and long- (320- cutaneous carcinoma in patients treated with oral me- 400 mm) wave ultraviolet light. J Invest Dermatol 63: thoxsalen photochemotherapy for psoriasis. N Engl J 273-278, 1974. Med 300:809-813, 1979. 18. Willis I, Kligman A, Epstein J: Effects of long ultraviolet 8. Henderson ST: Daylight and its spectrum. New York, rays on human skin: Photoprotective or photoaugmenta- 1970, American Elsevier Publishers Inc. tive? J Invest Dermatol 59:416-420. 1972. 9. Environmental impact of stratospheric flight. Washing- 19. Parrish JA, Anderson RR, Urbach F, Pitts D: UVA: Bio- ton, DC, 1975, National Academy of Sciences. logical effects of ultraviolet radiation. New York, 1978, 10. Magnus IA: Dermatological photobicjlogy. London, Plenum Publishing Corp., pp. 166-168. 1976, Blackwell Scientific Publications, pp. 35- 20. Willis I, Kligman AM: Aminobenzoic acid and its esters. 38. Arch Dermatol 102:405-417. 1970 11. Parrish JA, Andersolr’RR. Urbach F, Pitts D: UVA: Bio- 21. Knox JM, Guin J, Cockereil EG: Benzophenones: Ul- logical effects of ;Itraviolet radiation. New York, 1978, traviolet light absorbing agents. J Invest Dermatol Plenum Publishing Corp., p. 12. 29:435-444, 1957. - --.12 ^Parrich -._.I.. I.IA ., White...... - ---HAT) .-, -Pathak ---_--_ _.__MA: _._._In _Firznatrick ---=- _____. TB..-, 22. Parrish JA, Pathak MA, Fitzpatrick TB: Prevention of D Journal of the Jarratt et al American Academy of Dermatology

unintentional overexposure in topical psoralen treatment 26. Sayre RM, Marlowe E, Agin PP, et al: Performance of of vitiligo. Arch Dermatol 104:281-283, 1971. six sunscreen formulations on human skin. Arch Der- 23. Pathak MA, Fitzpatrick TB, Frank E: Evaluation of topi- matol 115:46-49, 1980. cal agents rhat prevent sunburn. N Engl J Med 280: 27. Pathak MA: Mechanism of psoralen photosensitization 1459-1463, 1969. and in vivo biological action spectrum of %methoxypso- 24. Sayre RM, Agin PP, Levee GJ, Marlowe E: A compari- ralen. J Invest Dermatol 37:397-407, 1961. son of in vivo and in vitro testing of sunscreening formu- 28. Owens DW, Glicksman JM, Freeman RG. et al: Biologic las. Photochem Photobiol 29:559-566, 1979. action ‘spectra of 8-methoxypsoralen determined by 25. Akin FJ, Rose AP, Chamness TW, Marlowe E: Sun- monochromatic light. J Invest Dermatol 51:435-440, screen protection against drug-induced phototoxicity in 1968. animal models. Toxic01 Appl Pharmacol 49:219-224, 1979.

Fibrous papule: An immunohistochemical study with an antibody to S- 100 protein

Joan Spiegel, M.D .,* Mehrdad Nadji, M.D.,** and Neal S. Penneys, M.D., Ph.D.* Miami, FL

We studied twenty biopsies taken from fibrous papules which were located in the central part of the face. The lesions, which were characteristic histologically, did not contain S-100 protein within the stellate cells in the paallary dermis, nor was this substance found in mesenchymal cells with some features of nevus cells. In control studies, S-100 protein was found using an unlabeled antibody peroxidase-antiperoxiclase technic within nevus cells composing junctional, intradermal, and compound nevi, Spitz nevi, and halo nevi. It therefore seems unlikely that fibrous papule represents a form of degenerated nevus as some investigators have proposed. (J AM ACAD DERMATOL 9:360-362, 1983.)

The S-100 protein is a highly acidic protein uted mainly in astrocytes, oligodendrocytes, and which is calcium-binding and is widely distributed Schwann cells.6-8 Nakajima et al9 demonstrated throughout the central and peripheral nervous sys- this substance in nevus cells and in malignant tems of vertebrates.ld5 The protein received its melanoma. name because of its solubility in 100% saturated Using S- 100 protein as a marker for nevus cells, ammonium sulfate. It is now generally accepted we sought to evaluate fibrous papule of the nose that S-100 protein is a glial protein and is distrib- for the presence of nevus cells. This lesion has been considered by some to be derived from nevus From the Departments of Dermatology* and Pathology.** University cell nevi.*O*ll of Miami School of&4edicine. Supported by a grant from the National InStiNteS of Health, AM MATERIALS AND METHODS 28166, and by the Dermatology Foundation of Miami. Accepted d publication Jan. 7. 1983. An unlabeled antibody peroxidase-antiperoxidase Reprint requests to: Dr. Neal S. Penneys. Department of Dermatol- (PAP) technic was carried out, as previously de- ogy (R-11). Box 016940, Miami, FL 33101. scribed,‘* in the following manner: (1) Paraffin sections