Mario Lecha

Photopatch testing: recommendations for a European photopatch test baseline series.

In order to establish a consensus recommendation for performing photopatch testing, a photopatch test taskforce group was established under the joint umbrella of the European Society for Contact Dermatitis and the European Society for Photodermatology in 2000. After proposing the most adequate methodology in 2004 and completing a European multicentre photopatch test study in 2011, this taskforce is recommending a list of photoallergens that should form part of a baseline series for photopatch testing in Europe. It contains mainly ultraviolet filters and drugs, mostly non‐steroidal anti‐inflammatory drugs. The choice of chemicals was based on the results of a recent multicentre study, previous published cases of photoallergy, and use of the substances in the European market.

Documento de consenso sobre fototerapia: terapias PUVA y UVB de banda estrecha

It is essential to develop a consensus document on phototherapy in order to adapt this procedure to the specific characteristics, needs and reality of our milieu. Using a review of existing literature on the subject and the experience of its own members as a reference, the Spanish Photobiology Group (GEF) of the Spanish Academy of Dermatology and Venereology (AEDV) has developed some therapeutic guidelines for the most widely used modes of phototherapy: PUVA therapy and narrow-band UVB (NBUVB) therapy. These guidelines deal with generalities about the equipment, calibration and regulation in phototherapy booths, and the concept and indications for these forms of treatment are reviewed. Recommendations are also proposed regarding patient selection, therapeutic procedures, associated pharmacological agents of interest and the prevention and management of adverse effects. The consensus document is designed as a flexible and practical instrument intended for use in daily clinical practice, aimed at optimizing the possibilities of phototherapy while reducing risks for patients and therapists.

Non-invasive management of non-melanoma skin cancer in patients with cancer predisposition genodermatosis: a role for confocal microscopy and photodynamic therapy

Background  Patients with genodermatosis such as Gorlin syndrome (GS) and Xeroderma pigmentosum (XP) require a close follow‐up for early diagnosis and treatment of skin cancer. We aimed to evaluate the efficacy of methyl‐aminolevulinate (MAL) photodynamic therapy (PDT) in basal cell carcinomas (BCCs) from patients with GS and XP, and to determine the utility of reflectance confocal microscopy (RCM) in the diagnosis and the evaluation of therapeutic response.

Immunopathologic study of skin lesions in dermatomyositis

To determine the phenotype of skin infiltrates in affected and uninvolved skin from patients with dermatomyositis, immunohistochemical studies with 10 murine monoclonal antibodies were carried out on 25 skin biopsy specimens. Dermal infiltrates consisted predominantly of HLA-DR-expressing macrophages and T lymphocytes, especially of the CD4 subset. B lymphocytes, as defined by positive staining for Leu-12, were absent. Epidermal Langerhans cells were absent or decreased in some areas of affected skin but the total number was normal. OKT6+ cells were present in some dermal mononuclear infiltrates in close contact with lymphocytes. We observed reduced HLA-DR positivity of dermal capillary endothelia. These findings are apparently different from dermatomyositis muscle infiltrates but are similar to those in skin affected by cutaneous lupus erythematosus. Our observations support the concept that, in autoimmune diseases, cellular infiltrates may be more organ-specific than disease-specific.

Benefits of oral Polypodium Leucotomos extract in MM high-risk patients

Background  UV radiation and the presence of melanocytic nevi are the main risk factors of sporadic melanoma (MM). Protection of skin by an oral photoprotective agent would have substantial benefits.

Flutamide photosensitivity : residual vitiliginous lesions

A case of flutamide photosensitivity is reported in a patient receiving treatment for prostate cancer. Photopatch testing with flutamide at 10 and 20% in acetone was positive and controls negative. Other reports in the literature indicate that flutamide photosensitivity can be produced either by UV‐A or UV‐B, but the small number of reports and the differences in the tests performed do not allow the specific characteristics of flutamide photosensitivity to be established. Presently it would be advisable, due to the frequent use of this drug, to include flutamide in the investigation of photosensitive patients.

An open-label, multicenter study of the combination of amorolfine nail lacquer and oral itraconazole compared with oral itraconazole alone in the treatment of severe toenail onychomycosis

Abstract Background: Data indicate that combination therapy may provide enhanced clinical and economic benefits over monotherapy in the treatment of onychomycosis. Objective: The aim of this study was to compare the efficacy of 2 topical amorolfine/oral itraconazole combination regimens with oral itraconazole alone in the treatment of severe toenail onychomycosis. Cost implications of all treatments were assessed in a pilot pharmacoeconomic analysis. Methods: In this multicenter, open-label, 24-week study, patients were randomized to 3 parallel treatment groups: 5% solution of amorolfine nail lacquer applied once weekly for 24 weeks plus itraconazole 200 mg once daily for either 6 weeks (group AI-6) or 12 weeks (group AI-12), or itraconazole alone for 12 weeks (group I-12). Results: Mycologic cure at week 12 was achieved in 93% of patients in group AI-6, 83% in group AI-12, and 41% in group I-12. Combination therapies were significantly more effective than itraconazole monotherapy ( P P Conclusions: Our results show that topical amorolfine combined with oral itraconazole was more effective in treating severe toenail onychomycosis than was itraconazole monotherapy. Combination with a short course of oral therapy had a marked pharmacoeconomic advantage over the other regimen, suggesting that switching from the current 12-week itraconazole monotherapy to the 6-week combination therapy would cure more patients for a lower cost.

Photoinduced lichenoid reaction by thioridazine

Photosensitivity reactions to the phenotiazine derivates are well known, but they are infrequent in patients treated with thioridazine. Three patients treated with thioridazine for several years visited our clinic with a photoinduced lichenoid reaction while under treatment with this antipsychotic drug. The first case, a 72-year-old woman who was being treated with thioridazine (Meleril; Novartis Farmaceutica, Barcelona, Spain) for 4 years, presented with well-delimited hyperpigmented papular lesions on exposed areas, mainly on face and neck. Phototest revealed a diminished minimal erythema dose (MED) to ultraviolet B (UVB) light. A skin biopsy showed residual incontinentia pigmenti. Suggested diagnosis was photoinduced reaction by thioridazine. After withdrawal of this medication, the lesions disappeared progressively during the next 6 years. The second case, a 63-year-old woman treated with thioridazine (Meleril) for several years, also showed maculo-papular pigmented skin lesions on face, neck and forearms. In this case phototesting was not performed and the histological study of lesions demonstrated a lichenoid dermatitis. The diagnosis of photoinduced lichenoid reaction by thioridazine was considered. Treatment was withdrawn and after 8 years skin lesions had completely disappeared. The third case, a 72-year-old women treated with thioridazine (Meleril) consulted us because she presented papular pigmented skin lesions on the face, neck and back of hands since last summer. Phototesting did not show alterations of MED to UVB or UVA and the skin biopsy revealed a lichenoid reaction. In this case thioridazine was also withdrawn and we have observed a slight progressive improvement of lesions. In summary these three patients under treatment with thioridazine, presented with identical appearing photo-distributed skin lesions that showed a lichenoid dermatitis pattern by histological examination and could be related to the thioridazine treatment. Thioridazine is an antipsychotic drug that belongs to the phenothiazine group. This pharmacologic group also includes promazine, chlorpromazine, perphenazine and fluphenazine. It is well known that all these drugs show photosensitizing capacity and it is accepted that thioridazine does so. Since 1967, when Satanove published the first case of photoallergy caused by thioridazine (1), only few cases of this adverse event have been reported (2–4). This fact could be considered as surprising if we take into account that this drug has been widely used. Therefore a low photosensitizing potential should be considered for thioridazine. Moreover, in a recent article, Elisei et al. (5) studied the mechanism by which three phenothiazine derivates (perphenazine, fluphenazine and thioridazine) may induce skin photosensitization. They estimate that the action spectrum of these drugs photosensitization is situated in the UVB band, although wavelengths higher than 400 nm also may be implicated. We consider that this fact can really be significant because it might explain that patients may not experience clearly photosensitivity and the development of the lesions is initially unnoticed by the patient. We think that although photoinduced lichenoid reactions by thioridazine are infrequent, its extremely characteristic clinical features make it easy to diagnose, despite the low frequency of these patients. So, the presence of an hyperpigmented papular eruption in a patient treated with thioridazine developing progressively without clear evidence of objective photosensitivity, must lead us to suspect the possibility of a photoinduced reaction by this drug.

Why do melanomas ulcerate

Ulceration is an indicator of unfavourable prognosis in malignant melanoma (MM). But why do melanomas ulcerate?. Possible causes of ulecration were investigated in a group of 69 ulcerated and 69 non‐ulcerated malignant melanomas. A significant correlation (P < 0.001) between ulceration and mitotic index was found. In a group of 69 ulcerated malignant melanomas, 49 had over 7. 15 had 4–6, and only 5 had 0–3 mitotic figures per 10 high‐power fields. Among 69 non‐ulcerated melanomas, 28 had more than 7, 24 had 4–6, and 17 had 0–3 mitotic figures per 10 high‐power fields. This study supports the hypothesis that ulceration of melanomas is usually the result of the destruction of the epidermis by the proliferating neoplastic cells or modification of blood supply due to the expansile activity of the tumor. The relationship between ulceration and mitotic activity helps clarify the prognostic significance of ulceration.

Impact of Sunscreens on Preventing UVR-Induced Effects in Nevi: In Vivo Study Comparing Protection Using a Physical Barrier vs Sunscreen

IMPORTANCE Sun damage is the most important environmental factor associated with malignant melanoma. To address the health threat, as well as the economic burden, primary prevention and early detection are crucial. OBJECTIVE To test the efficacy of a topical sunscreen in the prevention of UV-induced effects in nevi. DESIGN Prospective study of nevi protected by sunscreen vs a physical barrier. SETTING AND PATIENTS Twenty-three nevi from 20 patients attending a referral hospital. INTERVENTION Half of each nevus was protected by either a physical barrier or a sunscreen. Lesions were completely irradiated by a single dose of UV-B. MAIN OUTCOMES AND MEASURES In vivo examination before and 7 days after irradiation and histopathologic-immunopathologic evaluation after excision on the seventh day. RESULTS The most frequent clinical changes after UV radiation were pigmentation, scaling, and erythema; the most frequent dermoscopic changes were increased globules/dots, blurred network, regression, and dotted vessels. Both physical barrier- and sunscreen-protected areas showed some degree of these changes. More than 30% (7) of nevi did not show any change on clinical examination, and 18% (4) had no dermoscopic change. Immunohistopathologic differences between the halves of each nevus were demonstrable even when in vivo examination detected nothing. Parakeratotic scale, increased number and activation of superficial melanocytes, and keratinocyte proliferation were the most remarkable features. The only difference between both barriers was more enhanced melanocytic activation and regression features in the sunscreen group. No phenotypic features were found to predict a specific UV-B response. CONCLUSIONS AND RELEVANCE Both physical barriers and sunscreens can partially prevent UV-B effects on nevi. Subclinical UV radiation effects, not always associated with visible changes, can develop even after protection. Sunscreens are not quite as effective as physical barriers in the prevention of inflammatory UV-B-induced effects.