Ashley Feneran, DO Jenifer Lloyd, DO University Hospitals Regional Hospitals AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY Objectives Review key points of several photodermatoses Update knowledge and treatment of photodermatoses Discuss vitamin D levels in photodermatoses 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 Pathology Superficial and deep lymphocytic infiltrate Marked papillary dermal edema 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 Pathology Shallow ulcer, neutrophils, & fibrin deposits Acanthosis, spongiosis, & superficial vessel telangiectasias Follicular chelitis 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 Pathology Spongiosis & epidermal vesicles Epidermal and upper dermis necrosis Lymphocytic infiltrate of dermis Hydroa vacciniforme treatment Refractory to treatment Azathioprine Close monitoring for atypical Thalidomide features Cyclosporine Photoprotection Beta carotene NBUVB Fish oil supplements Oral antimalarials 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 Pathology Spongiosis, acanthosis, superficial perivascular infiltrate Occasional apoptotic keratinocytes Exocytosis of inflammatory cells 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 Pathology Mild perivascular lymphocytic, mast cell, & eosinophilic infiltrate Mild dermal edema Can see intraluminal neutrophils and eosinophils 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 urticaria Baliu-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 PGY-2 PGY-4 Rosanne Paul, DO Mathew Loesch, DO, PhD Aziza Wahby, DO Madeline Tarrillion, DO Miesha Merati, DO AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY References 1. Aubin F, Porcher R, Jeanmougin M. Severe and refractory solar urticarial treated with intravenous immunoglobulins: A phase II multicenter study. J Am Acad Dermatol. 2014; 71(5): 948-953. 2. Baliu-Piqué C, Aquilera Peiró P. Three cases of solar urticaria successfully treated with omalizumab. J Eur Acad Dermatol Venereol. 2015. Epub ahead of print. 3. Bruderer P, Shahabpour M, Christoffersen S, Andre J, Ledoux M. Hydroa vacciniforme treated by a combination of beta-carotene and canthaxanthin. Dermatology. 1995;190:343-345. 4. Collins P, Ferguson J. Narrow-band UVB (TL-01) phototherapy: an effective preventative treatment for the photodermatoses. Br J Dermatol. 1995;132:956-963. 5. Crouch R, Foley P, Ng J, et al. Thalidomide experience of a major Australian teaching hospital. Australas J Dermatol. 2002; 43(4): 278-284. 6. Durbec F, Regulai Z, Leonard F, Pluot M, Bernard P. Efficacy of v-3 polyunsaturated fatty acids for the treatment of refractory hydroa vacciniforme. Pediatr Dermatol. 2012;29: 118-119. 7. Gruber-Wackernagel A, Bambach I, Legat FJ. Randomized double-blinded placebo-controlled intra-individual trial on topical treatment with a 1,25-dihydroxyvitamin D₃ analogue in polymorphic light eruption. Br J Dermatol 2011; 165(1): 152-63. 8. Hall L, Eminger L, Hesterman K. Epstein-Barr virus: Dermatologic associations and implications: part I. Mucocutaneous manifestations of Epstein-Barr virus and nonmalignant disorders. J Am Acad Dermatol. 2015; 72(1): 1-19. 9. Harkins C, Waters A, Kerr A, et al. Loss-of-function mutations in the gene encoding filaggrin are not strongly associated with chronic actinic dermatitis. J Invest Dermatol. 2015; 135(7): 1919-1921. 10. Kutlubay Z, Sevim A, Engin B, et al. Photodermatoses, including phototoxic and photoallergic reactions (internal and external). Clin Dermatol. 2014; 32: 73-79. 11. Lim H, Snauwaert J. Vitamin D and photodermatoses. Br J Dermatol. 2014; 171(6): 1297-1298. 12. Müller S, Schempp C, Jakob T. Failure of omalizumab in the treatment of solar urticarial. J Eur Acad Dermatol Venereol. 2014. Epub ahead of print. 13. Nitiyarom R, Wongpraparut C. Hydroa vacciniforme and solar urticaria. Dermatol Clin. 2014; 32(3): 345-353. 14. Nomura H, Suzuki H, Egami S, et al. A patient with elderly-onset atypical hydroa vacciniforme with an indolent clinical course. Br J Dermatol. 2015. Epub ahead of print. 15. Rhodes L, Durham B, Fraser W, et al. Dietary fish oil reduces basal and ultraviolet B-generated PGE2 levels in skin and increases the threshold to provocation of polymorphic light eruption. J Invest Dermatol. 1995; 105: 532-535. 16. Rhodes L, Webb A, Berry J, et al. Sunlight exposure behaviour and vitamin D status in photosensitive patients: Longitudinal comparative study with healthy individuals at U.K. latitude. Br J Dermatol. 2014; 171(6): 1478-1486. 17. Rhodes L, White S. Dietary fish oil as a photoprotective agent in hydroa vacciniforme. Br J Dermatol. 1998; 138: 173-178. 18. Valbuena M, Muvdi S, Lim H. Actinic prurigo. Dermatol Clin. 2014; 32(3): 335-344. 19. Wolf P, Gruber-Wackernagel A, Bambach I, et al. Photohardening of polymorphic light eruption patients decreases baseline epidermal Langerhans cell density while increasing mast cell numbers in the papillary dermis. Exp Dermatol. 2014; 23: 424-448..