Roy A. Palmer

Erythrodermic chronic actinic dermatitis responding only to topical tacrolimus

Chronic actinic dermatitis (CAD) is a disorder characterized by an often severe persistent eczematous eruption induced by exposure to ultraviolet radiation. Treatment involves photoprotective measures and topical corticosteroid therapy and in more severe cases, systemic immunosuppression. Occasionally, however, the condition can prove very resistant to all therapy and be severely disabling. We report a patient with CAD who resisted standard topical and systemic treatments, but responded to topical tacrolimus ointment 0.1% (Protopic®).

Contact and photocontact sensitization in chronic actinic dermatitis: a changing picture

Background: Patients with chronic actinic dermatitis (CAD) frequently have positive patch or photopatch tests. In our previous study (period 1987–1992), the most prominent contact allergen was the sesquiterpene lactone mix (36% of patients with CAD).

Vertebral Morphometry: Repeat Scan Precision Using the Lunar Expert-XL and the Hologic 4500A. A Study for the “WISDOM” RCT of Hormone Replacement Therapy

Abstract: On radiation safety grounds there is concern about the morbidity attributable to routine radiographs of the spine for the identification of new fractures in large-scale trials of fracture prevention. However, the role of the potentially safer low-radiation-dose technique of vertebral morphometry performed by third generation dual-energy X-ray absorptiometry equipment requires evaluation for use in clinical trials. We have therefore investigated the short-term inter-scan imprecision as well as the imprecision attributable to different-day analyses by the same operator and differences in analyses by different operators. The volunteer subjects were participants in a pilot study for a randomized controlled trial of hormone replacement therapy (Women”s International Study of long Duration Oestrogen after Menopause, WISDOM). Each subject had two morphometric X-ray analysis scans separated by 2–4 weeks. Exclusions were women with densitometrically defined osteoporosis, as defined by the WHO criterion, and women with a body mass index exceeding 30.9 kg/m2. On average, the women were 58.7 years of age and had bone mineral density values in the lumbar spine which were about 0.7 SD units higher than a reference US female age-matched population. Scans were assessed from vertebrae T7 through L4. In the study there were no clinically significant differences in performance between the Hologic QDR 4500A and the Lunar Expert XL equipment. Between-scan imprecision was significantly worse than imprecision attributable to reanalysis of the same scan by a different operator or the same operator after an interval. Vertebral level had an effect on measurement uncertainty, especially at the level of the diaphragm and at T7. Coefficients of variation, expressed as percentages of mean values, were better for absolute height measurements than for height ratios, ranging from 1.75% to 3.40% for the three heights measured on three separate machines and from 2.34% to 4.11% for the two height ratios. These results compared favorably with the equivalent figures from a parallel study of morphometry precision undertaken using standard lateral radiographs of the thoracic and lumbar spine (3.1–3.6% and 3.8–3.9%, respectively). We conclude that in trials of prevention therapy in women (or men) selected for not having osteoporosis, low-dose vertebral morphometry using the Hologic 4500A, the Lunar Expert XL or similar equipment is preferable on safety grounds to the classical technique based on standard radiographs, although conventional radiology may still be required in those with prevalent or incident deformities to exclude causes other than osteoporosis. The place of this low-dose technique in trials performed on patients with osteoporosis requires further study.

A simple method to assess severity of polymorphic light eruption

Background  The severity of polymorphic light eruption (PLE) is highly variable. The results of studies of the prevalence, pathogenesis, provocation and treatment of PLE may be highly dependent on the severity of disease in the patients studied.

Persistent severe amiodarone-induced photosensitivity.

Amiodarone, a benzofuran derivative, has been used therapeutically as an antiarrhythmic and coronary vasodilator in Europe since 1964. One of its commoner side effects is cutaneous photosensitivity; more rarely, after ingestion of the drug for around 12 months, a slate‐grey or violaceous discoloration of sun‐exposed sites may gradually develop. Both of these side effects usually resolve within 2 years of discontinuation of the drug. We now present a woman who developed both photosensitivity and a slate‐grey discoloration whilst taking amiodarone; on discontinuation of the drug, the dyspigmentation gradually resolved, but the photosensitivity has persisted and the patient remains symptomatic more than 17 years later.

Phototoxic and Photoallergic Reactions

Phototoxic and photoallergic reactions may be induced by the topical application of a compound followed by irradiation — phototoxic and photoallergic contact reactions. Alternatively, reactions may be induced after the systemic absorption of a compound followed by irradiation. Most of these latter reactions are probably phototoxic in nature, there being scanty evidence for photoallergy.

Case 4 - Pagetoid reticulosis (Woringer-Kolopp type) or unilesional mycosis fungoides (MF)

A 43-year-old man presented with a 12-year-history of a pruritic lesion on his left foot, which had slowly increased in size. It had been treated with calcipotriol and tar, with no benefit. His general health was good. Examination revealed a large erythematous welldemarcated plaque with an irregular edge and a little scale, located on the lateral aspect of his left foot, extending onto the sole (Fig 1).

Validation of the ‘Polymorphic Light Eruption Severity Index’

SIR, Polymorphic light eruption (PLE) is a very common condition, affecting 10–21% of the population in temperate climates. Within the spectrum of the disease there is wide variation in disease severity, with some patients experiencing frequent attacks throughout summer in temperate climates while others only rarely experience attacks on holidays to sunny climates. In patients’ reports of their symptoms, the extent of most of the features of PLE (such as time to the rash after exposure, number of episodes per year, severity of itch, extent of body surface that can be affected etc.) correlate with each other. For example, those who develop the rash after short exposures tend to be affected over a large surface area. These features, at least in part, reflect the ease of provocation of the eruption by natural sunlight. Interestingly, they do not correlate with the duration of persistence of the eruption after cessation of sun exposure. The fact that these features correlate with each other provides evidence that disease severity in PLE can be summarized in a single score, and that ‘benign summer light eruption’, allegedly a distinct condition with features similar to those of ‘mild PLE’, does not exist as a discrete entity. Because of the great variation in PLE severity, the outcome of research studies is likely to depend on the severity of the condition in participating subjects. However, until recently there has not been a validated method of assessing the severity of the disease. Successful experimental provocation of the eruption by ultraviolet (UV) radiation usually requires repeated exposures; the ease of provocation by such exposures can be regarded, not unreasonably, as a reflection of disease severity in a patient. Reflecting this, attempts to provoke PLE have had variable success rates (0–100%, reviewed by van de Pas et al.), partly because of variations in disease severity between patient cohorts. However, success rates also vary due to seasonal variation, and to large variations in provocation protocols between centres. Therefore, artificial provocation is not truly a ‘gold standard’ measure of severity, and it is also a time-consuming procedure. The lack of a valid, objective and simple method of assessing severity has been a major impediment in the study of the condition, whether we are concerned with its prevalence, pathogenesis, provocation or treatment. The ‘Polymorphic Light Eruption Severity Index’ (PLESI) is a recently described standardized interview that provides an assessment of PLE severity on a scale of 2–100. It was shown to be reproducible, and evidence for its validity was provided by demonstrating that the 10 items of which it is composed are highly correlated with each other (‘internal validity’), and that it correlated with the ease of experimental provocation among nine subjects. In the present study, we modelled the relationship between the PLESI score and the outcome of attempted provocation among 36 patients. The study was conducted between February 2002 and November 2004, was approved by the Local Research Ethics Committee and was conducted according to Declaration of Helsinki principles. Patients had a clinical diagnosis of PLE, with relevant negative porphyrin and immunological investigations, and met the inclusion criteria given in the footnote to Table 1. Exclusion criteria included phototherapy or use of a sunbed during the 6 months prior to the study, and photosensitizing medication. Thirty-six patients were recruited (30 women and six men; skin types I–IV; age range 19–76 years, mean 41). Patients had had PLE for a mean of 15 years (range 3–39), and 20 gave a history of PLE in a first-degree relative. The PLESI was determined as described in the footnote to Table 1, immediately prior to attempted provocation in 26 subjects and within 12 months afterwards in the remaining 10 subjects. Solar-simulated radiation (SSR) was generated by a 1-kW xenon arc solar simulator (Oriel, Stratford, CT, U.S.A.) as described previously (‘filter 2’), with irradiance defined according to the UVB component. The minimal erythema dose (MED) was the dose that resulted in just-perceptible erythema, assessed by visual inspection at 24 h after exposure to eight doses with 25% increments administered to areas measuring 1 cm; it ranged from 260 to 980 mJ cm UVB. Patients received one of two provocation protocols, for reasons not affecting the current report. Seventeen subjects were participating in a pilot study using a range of doses (protocol A) to determine an optimal provocation method, the results of which have been previously described, and the PLESI scores of nine of these were published. Briefly, these 17 patients were exposed to 0Æ25, 0Æ5, 0Æ75, 1Æ0, 1Æ25 and 1Æ5 multiples of the buttock MED at 24-h intervals on three occasions, on the buttock and either the arm or back. Each site measured 16 cm. The results of this study were used to develop protocol B, which was used in 19 subjects. These patients had their MED assessed on the upper outer arm, and were then exposed to a dose equal to their MED on an adjacent area measuring 60 cm, at 24-h intervals on three occasions. The provocation rates of protocols A and B were similar, with nine of 17 (53%) and 13 of 19 (68%) subjects, respectively, being provoked (v 1⁄4 0Æ91, d.f. 1⁄4 1, P 1⁄4 0Æ34). In 33 of the 36 subjects provocation was attempted between October and May, because attempts at provocation in summer months are less likely to succeed. Successful provocation was defined as the presence of papules or papulovesicles 24 h after any of the three exposures. PLESI scores had a normal distribution (confirmed with the Kolmogorov–Smirnov test, Z 1⁄4 0Æ44, P 1⁄4 0Æ99) with a mean ± SD of 56Æ6 ± 18Æ4 (range 22–92Æ5). Considering the success of attempted provocation as a dichotomous outcome (successful vs. unsuccessful), provocation was accomplished in 22 of 36 (61%) subjects. The mean ± SD PLESI score of successfully provoked patients was 63Æ2 ± 16Æ5 and of patients not provoked was 46Æ5 ± 16Æ5: this difference was statistically significant (t 1⁄4 2Æ96, d.f. 1⁄4 34, P 1⁄4 0Æ006, 95% confidence interval of difference 5Æ2–28Æ2). Grouping the patients into four categories according to PLESI score, namely 20–39,

Exacerbation of presumed chronic actinic dermatitis by cockpit visible light in an airline pilot with atopic eczema.

Chronic actinic dermatitis (CAD) is a persistent ultraviolet radiation‐ or visible light‐induced eczema of predominantly the exposed areas of usually elderly people. We now present the case of a young pilot with atopic eczema who developed CAD, regularly exacerbated by exposure to visible light through his aircraft cockpit window.

Aberrant gene expression with deficient apoptotic keratinocyte clearance may predispose to polymorphic light eruption.

Polymorphic light eruption (PLE) is the commonest photodermatosis, demonstrating intermittently appearing non-scarring pruritic, erythematous papules, vesicles or plaques on patient skin within hours of ultraviolet radiation (UVR) exposure. It depends on genetic susceptibility as well as environmental UVR exposure and is apparently a failure of normal UVR-induced immunosuppression in the presence of simultaneously produced skin photoneoantigens1,2, with a resulting increased immune response. Reduced TNF-α, IL-4 and IL-10 expression, a lack of neutrophils, reduced T-helper-1/T-helper-2 skewing and reduced Langerhans cell migration have also been demonstrated in UVB-irradiated PLE skin3. Bead-array immunoassay studies have further revealed significantly higher PLE baseline IL-1β and CCL11 (eotaxin) spring plasma levels4, while decreased TGFs1, IL-10 and receptor activator of nuclear factor kappa-B ligand (RANKL) epidermal and dermal expression, and reduced T-reg cells occur in UVA-1-irradiated patients5, as well as decreased T-reg cell function in all PLE patients, irradiated or not6. This article is protected by copyright. All rights reserved.