Induction of Light Tolerance Using Narrowband UV-B in Solar Urticaria. / Inducción de fototolerancia con ultravioleta B de banda estrecha en urticaria solar.

INTRODUCTION: Solar urticaria is an uncommon photodermatosis. First-line treatment is with antihistamines; second-line treatment includes induction of light tolerance using UV phototherapy. OBJECTIVES: We aimed to describe and evaluate the effectiveness of a desensitization protocol with narrowband UV-B in patients with solar urticaria. MATERIAL AND METHODS: We performed a retrospective study of patients with solar urticaria with an action spectrum in the UV-A range, the visible light range, or both who had received therapy with narrowband UV-B for induction of light tolerance. Short courses of treatment were administered (<20 sessions, 3 per week) during spring. The initial dose was determined according to the skin type. The Skindex-29 was administered before treatment and after summer; a nonvalidated questionnaire was also administered after summer to evaluate disease activity and satisfaction with treatment. RESULTS: We included 8 patients with an action spectrum (4 with visible light and 4 with UVA plus visible light). Seventeen courses (1-6 per patient) were administered per year. The number of sessions per year ranged from 11 to 20. The mean dose of narrowband UV-B per course was 7.45J/cm2. No patients experienced flares or adverse effects during treatment. The response was satisfactory in 6 patients. The improvement in the overall Skindex-29 score was greater than 20% in 78.6% of cases. The improvement in the function and symptoms subscales was over 20% in 71% and 64% of cases, respectively. CONCLUSION: Induction of light tolerance with narrowband UV-B in solar urticaria is safe and effective in a high percentage of patients.

Practice Models in Teledermatology in Spain: Longitudinal Study, 2009-2014. / Modelos de práctica de la teledermatología en España. Estudio longitudinal 2009-2014.

INTRODUCTION: Teledermatology is the most advanced clinical specialty in telemedicine. The development of teledermatology in specific countries has not been studied in depth. METHODS: Our objective was to analyze teledermatology models in clinical practice in Spain. We paid special attention to organization, technical aspects, training, and the advantages/disadvantages as seen by teledermatologists. Two surveys were carried out (2009 and 2014). RESULTS: Teledermatology was used at 25 centers in 2009 and at 70 in 2014. The extended survey was completed by 21 centers in 2009 and 41 in 2014. Store-and-forward teledermatology was the main technique (83%) in 2014. Only 12% of centers used the real-time method, and 5% used a hybrid modality. Patients lived less than 25km away in 75% of cases (urban teledermatology). Most centers used mid-range bridge cameras; only 12% used mobile phones. Teledermoscopy and tertiary teledermatology were each used in 15% of centers. Teledermatology was restricted to skin cancer in 25% of cases, and 66% of centers used it to train primary care physicians. The main advantages, assessed on a scale of 1 to 10, were prioritization in cancer screening (8.3), rapid emergency care (7.8), training of and communication with primary care physicians (7.6), screening for trivial conditions (7.6), and reduction in the number of face-to-face visits (7.6). The main disadvantages were poor image quality (6.3), fear of error (5.7), difficulty in coordinating with primary care physicians (3.8), and time commitment (3.3). Between 2009 and 2014, the number of centers using teledermatology and the number of teledermatologists increased, as did use of the store-and-forward and urban models. The technology used also improved. CONCLUSION: Teledermatology is an emerging technology that is becoming well established in Spain. More than 25% of dermatology centers in Spain have implemented a teledermatology model. Store-and-forward in an urban setting is the most widely used modality. Teledermatologists see this technology as an effective option with more advantages than disadvantages. General satisfaction is high, although there is room for significant improvement in some areas.

Determination of minimal erythema dose and anomalous reactions to UVA radiation by skin phototype.

BACKGROUND: Phototesting is a technique that assesses the skin's sensitivity to UV radiation by determining the smallest dose of radiation capable of inducing erythema (minimal erythema dose [MED]) and anomalous responses to UV-A radiation. No phototesting protocol guidelines have been published to date. METHODOLOGY: This was a multicenter prospective cohort study in which 232 healthy volunteers were recruited at 9 hospitals. Phototests were carried out with solar simulators or fluorescent broadband UV-B lamps. Each individual received a total of 5 or 6 incremental doses of erythemal radiation and 4 doses of UV-A radiation. The results were read at 24hours. RESULTS: At hospitals where solar simulators were used, the mean (SD) MED values were 23 (8), 28 (4), 35 (4), and 51 (6) mJ/cm(2) for skin phototypes i to iv, respectively. At hospitals where broadband UV-B lamps were used, these values were 28 (5), 32 (3), and 34 (5) mJ/cm(2) for phototypes ii to iv, respectively. MED values lower than 7, 19, 27, and 38 mJ/cm(2) obtained with solar simulators were considered to indicate a pathologic response for phototypes I to IV, respectively. MED values lower than 18, 24, and 24mJ/cm(2) obtained with broadband UV-B lamps were considered to indicate a pathologic response for phototypes ii to iv, respectively. No anomalous responses were observed at UV-A radiation doses of up to 20J/cm(2). CONCLUSIONS: Results were homogeneous across centers, making it possible to standardize diagnostic phototesting for the various skin phototypes and establish threshold doses that define anomalous responses to UV radiation.

[Zosteriform cutaneous leiomyoma. Satisfactory treatment with oral doxazosin]. / Leiomioma cutáneo zosteriforme. Tratamiento satisfactorio con doxazosina oral.

We report a 50-year-old man that presented a zosteriform cutaneous leiomyoma in the left facial region, intensely painful, that showed great improvement after the administration of a daily dose of 4 mg of oral doxasozin. The therapy was well tolerated and did not present any associated adverse effect. In the English medical literature only two cases successfully treated with doxasozin have been reported.

Erbium:Yag laser therapy of lichenoid red tattoo reaction.

Delayed reactions caused by red tattoo pigments are often difficult to treat. We report a 31-year-old female patient with a lichenoid reaction to a red tattoo on the right ankle who was successfully treated with five sessions of a surgical Erbium:Yag laser, using several passes in each session. Our work leads us to consider that Er:Yag laser therapy may be an effective and safe treatment for these therapeutically challenging reactions.

Cheilitis granulomatosa of Melkersson-Rosenthal syndrome: treatment with intralesional corticosteroid injections.

BACKGROUND: Melkersson-Rosenthal syndrome may manifest as the classical triad (orofacial edema, facial nerve palsy and stable lingua plicata) but monosymptomatic manifestations or combinations of typical symptoms are not infrequent. The available therapeutic options provide only limited success or temporary benefit. CASE REPORT: A 20-year-old man presented with a 7-month history of recurrent episodes of swelling of the upper lip without pain, burning or local pruritus. No causative factors, such as food, drugs or latex, or physical, chemical or emotional conditions could be identified. The patient had been treated with oral antihistamines and corticosteroids with no clinical improvement. Physical examination showed firm edema without fovea, limited to the central area of the upper lip without epidermal changes or symptoms on palpation. The patient had a previous history of facial palsy 6 years previously and recurrent episodes of herpes simplex labialis. Skin prick tests with inhalant aeroallergens, food, latex and Anisakis allergens were negative. Laboratory investigation revealed normal complete blood count, erythrocyte sedimentation rate, thyroid hormones, biochemistry, complement components (C3, C4 and C1-esterase inhibitor) and CH50, rheumatoid factor, antinuclear antibodies, immune complexes, protein electrophoresis and immunoglobulins. Thorax and paranasal sinus radiographs were clear. Biopsy of the involved area of the lip showed edema with lymphocytic and plasma cell infiltration and mononuclear perivascular infiltrates without granulomas, suggesting initial granulomatous cheilitis. Because the patient showed lack of response and/or poor tolerance to prior treatments (deflazacort, clofazimine and metronidazole), intralesional triamcinolone injections were administered with satisfactory response from the first session. CONCLUSIONS: Response to available treatments for Melkersson-Rosenthal syndrome is highly variable. In the present case, intralesional triamcinolone injections were effective.

Erythrodermia to pseudoephedrine in a patient with contact allergy to phenylephrine.

BACKGROUND: Phenylephrine and pseudoephedrine are sympathomimetic drugs belonging to the phenylamine family. Adverse cutaneous effects associated with these drugs have been reported but, in view of their frequent use, appear to be rare. The very close chemical structures of these drugs could explain potential cross-reactions among them but the results reported in the literature are controversial. CASE REPORT: An 18-year-old woman developed blepharoconjunctivitis after application of phenylephrine and tropicamide eye drops. Four years after this reaction, she took 1 tablet of Narine (pseudoephedrine and loratadine) and 3-4 hours later developed a generalized erythrodermic reaction. Cutaneous biopsy revealed hydropic changes in the basal layer and, in the dermis, moderate edema with slight perivascular lymphocyte and eosinophil infiltrates. Patch tests with European standard series, commercial eye drops, tropicamide, phenylephrine, pseudoephedrine and other sympathomimetic agents were applied to the patient's back. After 47 and 96 hours, only the patches with pseudoephedrine and phenylephrine were positive. CONCLUSIONS: We believe that our patient has presented two different reactions with different clinical outcome and histopathology, which are unlikely to be due to cross-reactivity between the drugs involved. We have found no similar coincidences reported int the literature.

[Atrial fibrillation and the Wolff-Parkinson_White syndrome in a 68-year-old patient with tuberous sclerosis]. / Fibrilación auricular y síndrome de Wolf-Parkinson-White en un paciente de 68 años con esclerosis tuberosa.

Tuberous sclerosis is an autosomal-dominant disease with involvement of several organs, the heart included. The cardiac anomaly most frequently found is the rhabdomyoma association. However, WPW association has also been encountered more common than usual. In the majority of the published related-series, infant or adolescent patients are described. We report the case of a 68-year-old patient with tuberous sclerosis whose first cardiac manifestation was a pre-excited atrial fibrillation. This association is reviewed and the consideration of accessory pathways is highlighted as the first mechanism to take into account when arrhythmias are present in these patients even in adult age.

Isolated lichen planus of the lip successfully treated with chloroquine phosphate.

Solitary lesions of lichen planus (LP) are often confused with other inflammatory or malignant epithelial lesions. We describe a 51-year-old woman who had had an LP of the lower lip for 11 years. She had undergone several oral and topical therapies with little improvement. The patient had an excellent response to chloroquine phosphate within 3 months. This report represents the third case of LP exclusively localized on the lower lip.