Photodermatitis from topical phenothiazines: A case series.

BACKGROUND: In Europe, contact photosensitivity to phenothiazines is well-known, particularly in southern countries. Topical phenothiazines are widely used and sold over-the-counter (OTC) for the treatment of mosquito bites and pruritus in France. OBJECTIVE: To report a series of cases with photodermatitis following use of topical phenothiazines. METHOD: A retrospective study of cases of contact dermatitis from phenothiazines seen in French photodermatology centers was performed. RESULTS: In all, 14 patients with a diagnosis of contact dermatitis from phenothiazines were included. These patients developed eczema on the application sites, and in 13 the eruption spread to photodistributed sites. Topical products containing isothipendyl were the most common cause of photodermatitis. One patient had photoaggravated eczema due to promethazine cream. All patients stopped using topical phenothiazines and were treated successfully with topical corticosteroids. One patient relapsed and developed persistent light eruption. In all of the nine cases tested, photopatch testing to the topical phenothiazine used "as is" was positive. Isothipendyl, chlorproethazine, and the excipients were not tested. Photopatch tests to chlorpromazine and promethazine were positive in 8 of 12 and 7 of 13 tested, respectively. CONCLUSION: Use of isothipendyl and promethazine as OTC (or even prescribed) drugs needs to be limited due to severe reactions and sensitization to other phenothiazines that consequently will have to be avoided.

Extracorporeal Photopheresis: An Efficacious and Well-Tolerated Treatment for Cutaneous and Oral Mucosal Chronic Graft-versus-Host Disease.

BACKGROUND: Extracorporeal photopheresis (ECP) is a second-line therapy for steroid-refractory chronic graft-versus-host disease (cGVHD). OBJECTIVE: We describe the long-term efficacy and tolerability of ECP according to the cutaneous phenotype of cGVHD and report on the reduced need for immunosuppressant drugs in this setting. PATIENTS AND METHODS: Fourteen patients (8 females) with cutaneous and/or mucosal cGVHD, treated with ECP between October 2010 and May 2016 within a single center, were included. Final analyses included patients who had received ECP for at least 12 months. We prospectively evaluated the efficacy of ECP using lesion-specific clinical scores and by recording changed doses of systemic immunosuppressants. RESULTS: Of the 14 patients, sclerotic skin lesions were present in 10 (71%). The mRODNAN score decreased in all patients from month 9 onwards, with 40 and 77% reductions at 12 and 36 months, respectively. Six patients (43%) presented with cutaneous lichenoid lesions: this score was reduced in all patients by month 3, reaching a 93% reduction by month 12. Five patients (36%) experienced oral mucosal lichenoid lesions: these scores were decreased by 55% at month 12 and by 100% by month 33. The use of systemic immunosuppressants was reduced in all patients; 4 patients could stop all immunosuppressant drugs after 2 years. ECP was stopped in 3 patients after a complete response. No major ECP-associated adverse effects were observed. DISCUSSION AND CONCLUSION: ECP was an effective long-term therapy for oral and cutaneous cGVHD: consequently, dose levels of therapeutic immunosuppression could be reduced.

Photoaggravated allergic contact dermatitis and transient photosensitivity caused by methylisothiazolinone.

BACKGROUND: Photoaggravated allergic contact dermatitis caused by methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI) and MI has been reported. OBJECTIVES: To describe the clinical characteristics and results of (photo)patch tests and photo-tests of 10 patients in Belgium and France suffering from photoaggravated contact dermatitis caused by MI. PATIENTS AND METHODS: Five men and five women, with a median age of 49.5 years, were investigated between January 2012 and February 2017 because of suspected photoaggravated contact dermatitis. Patch tests, photopatch tests and/or photo-tests were performed. RESULTS: Seven patients had positive patch test reactions to both MCI/MI and MI, whereas 3 patients had positive patch test reactions only to MI. In most cases, MI was the (strong) primary sensitizer. Photopatch tests with MCI/MI and/or MI gave stronger reactions than patch tests with these derivatives, indicating photoaggravation. Sensitization probably took place from cosmetics and work-related biocides, whereas elicitation of dermatitis was remarkably often related to airborne exposure to MI present in paints or industrial biocides. Four patients suffered from transient photosensitivity. CONCLUSION: Photoaggravated allergic contact dermatitis and transient photosensitivity caused by MI is a peculiar clinical presentation of allergic contact dermatitis caused by this preservative, and should be considered in daily clinical practice.

Photo-induced graft-versus-host disease.

Overlap chronic graft-versus-host disease (GVHD) associates both features of acute and chronic GVHD. Trigger factors for chronic GVHD are unclear. We describe two patients who received allogenic haematopoietic stem-cell transplantation, and who later developed overlap chronic GVHD after sun exposure. Available data from in vivo investigations suggest ultraviolet B radiation (UVB) has a beneficial effect on acute and chronic GVHD. The role of sun irradiation as a trigger for isomorphic cutaneous GVHD has been rarely reported in the literature. Herein, we demonstrate for the first time, using repetitive broadband phototesting, that UVB triggers chronic GVHD.

Severe and refractory solar urticaria treated with intravenous immunoglobulins: a phase II multicenter study.

BACKGROUND: Retrospective data have suggested the effectiveness of intravenous immunoglobulins (IVIG) for solar urticaria (SU). OBJECTIVE: We sought to prospectively assess the efficacy of IVIG for SU. METHODS: We conducted a multicentric phase II study to test the efficacy of a single course of IVIG (2 g/kg) in patients with severe and refractory SU. The primary outcome was remission of SU on phototesting at 12 weeks after IVIG treatment. Secondary objectives included clinical remission, improved quality of life, and 50% improvement in disease intensity as measured on a visual analog scale. RESULTS: Of the 9 patients who received IVIG injection, 2 showed remission of SU on phototesting, corresponding to a response rate of 22.2% (95% confidence interval 2.8%-60.0%). In all, 6 patients (67%) showed at least 1 response criterion after 4 weeks and 5 (56%) after 12 weeks. Response was maintained after 24 weeks for 2 patients and after 48 weeks for 1 patient. About half of the patients (56%) had moderate to severe headache. LIMITATIONS: Lack of control arm and small number of patients are limitations. CONCLUSION: A single course of IVIG appears insufficient to obtain prolonged significant control of SU; future evaluation of different schedules of IVIG administration is warranted.

Purpuric lesions induced by UVA1 spectrum (340-400 nm) phototesting in an adult with persistent and severe hydroa vacciniforme.

A 28-year-old man had presented a severe photosensitivity since his infancy. In March 2008, the clinical examination showed large crusts on the dorsum of his hands, on the edge of his ears with destruction of the underlying cartilage, and on his nose and cheeks. He also presented erythematosus fibrous scars on the temples. The diagnosis of hydroa vaccinforme was made. Phototesting including repeated UVA1 phototest was strongly positive with purpuric lesions from day 7 to day 10 and hypertrophic scars at day 67. A sequential histological study of the UVA1 triggered lesions was performed and showed bullous cleavage, dense inflammatory infiltrate in the whole dermis with numerous neutrophilic cells, nuclear dusts, superficial focal thrombosis of small blood vessels at day 10. We report an unusual case of hydroa vaccinforme with purpuric lesions leading to fibrous scars and with important infiltration of neutrophils in the dermis of the photoinduced lesions.

Milia complicating bullous polymorphic light eruption.

Polymorphic light eruption (PLE) is the most common photosensitivity disorder. Typically, PLE manifests in the spring or summer months as a recurrent pruritic papular and/or vesicular eruption occurring on photoexposed skin areas following sun exposure. The milia are caused by proliferative tendencies of the epithelium after injury. These may occur in areas of subepidermal bullous eruption. We report an original case of bullous PLE complicated by milia. Such association has not been reported previously.

Photodistribution of blue-gray hyperpigmentation after amiodarone treatment: molecular characterization of amiodarone in the skin.

BACKGROUND: For decades, the photodistributed blue-gray skin hyperpigmentation observed after amiodarone therapy was presumably attributed to dermal lipofuscinosis. Using electron microscopy and high-performance liquid chromatography, we identified amiodarone deposits in the hyperpigmented skin sample from a patient treated with this antiarrhythmic agent. Our findings therefore indicate that the hypothesis relating the blue-gray hyperpigmentation to lipofuscin should be challenged. OBSERVATIONS: A 64-year-old man, skin phototype III, presented with asymptomatic skin hyperpigmentation that had been slowly developing on sun-exposed areas since April 2004. He had been taking amiodarone for 4 years (cumulative dose, 277 g). Electron microscopy did not show lipofuscin pigments in his skin. Conversely, abundant electron-dense membrane-bound granule deposits were observed in most of the dermal cells (fibroblasts, macrophages, pericytes, Schwann cells, and endothelial cells), especially in photoexposed skin. High-performance liquid chromatography confirmed that the skin deposits were composed of amiodarone. These results demonstrate that amiodarone hyperpigmentation is related to drug deposition on photoexposed skin. CONCLUSION: Amiodarone-related hyperpigmentation should be considered a skin storage disease that is secondary to drug deposition.

Comparison of histopathologic-clinical characteristics of Jessner's lymphocytic infiltration of the skin and lupus erythematosus tumidus: Multicenter study of 46 cases.

OBJECTIVE: We sought to identify criteria able to distinguish between Jessner's lymphocytic infiltration of the skin (JLIS) and lupus erythematosus tumidus (LET). METHODS: The following characteristics were recorded in a retrospective, multicenter analysis of patients with JLIS and LET: clinical features (number, size, type, and localization of lesions; photosensitivity; extracutaneous signs), histologic findings, phototesting, lupus serology, treatment, and outcome. Available histologic slides were reviewed blinded to the initial diagnosis using a pre-established grid. RESULTS: Univariate analysis of data from patients with JLIS (15 women, 17 men; mean age: 35 years) and LET (13 women, one man; mean age: 31 years) showed the following significant (P < .05) differences: more frequent back involvement and annular lesions in JLIS, as opposed to female predominance, more frequent face involvement, and plaques in LET. Phototesting, especially ultraviolet B, induced lesions in 18 of 26 patients with JLIS and all 4 with LET. The blinded histologic review (33 samples) only found slight epidermal atrophy and focal thickened dermoepidermal junction more frequent and perivascular lymphocyte infiltrations less dense in LET. The two groups of patients reclassified according histopathologic features (18 LET and 11 JLIS) showed only slight clinical differences (more frequent nasal bridge lesions in LET and annular lesions in JLIS). LIMITATION: The retrospective nature of the study is a limitation. CONCLUSION: JLIS and LET in this population showed more similarities than differences, supporting a continuous spectrum covering these two entities.

Photoprotection in teenagers.

BACKGROUND: It is very common to apply a 'template photoprotection' without taking into consideration the background of a specific population. In Lebanon, so far, no preliminary survey has been conducted before launching an educational photoprotection campaign, revealing the need of the people according to their background. MATERIALS AND METHODS: In April 2004, a specific questionnaire was administered to 940 adolescents, aged from 14 to 18 years. The questionnaire comprised 18 multiple-choice questions that established the approximate phototype of teenagers, awareness of ultraviolet (UV) hazard, presence of sufficient information regarding the risk of sun exposure (school, doctor, media) and the use of measures of photoprotection (clothes, sunscreens). RESULTS: The incidence of sunburn in teenagers was high (85.42%) despite their awareness of the risks of unprotected sun exposure. The information regarding sun damage seems to be insufficiently delivered at school and by doctors. The main source of information was television. It was obvious that our adolescents underestimated the value of clothing to protect themselves. The use of clothing comes at the second place after sunscreens. However, the application of sunscreen seems to be inadequate. CONCLUSIONS: While solar protection has become part of routine beach behavior for adolescents, there is room for improvement with better application of sunscreen and more use of clothing, especially wearing hats, and seeking shade. However, it is difficult to appreciate the impact of publicity campaigns on the risks of sun exposure in reducing the incidence of melanoma.

[Necrolytic migratory erythema revealing glucagonoma without diabetes]. / Erythème nécrolytique migrateur révélateur d'un glucagonome sans diabète.

We report a case of glucagonoma syndrome, revealed by a necrolytic migratory erythema that had developed for four Years, associated with anorexia, severe weight loss, anemia, hypoprotidemia, and hypoaminoacidemia. The fasting blood glucose level tended paradoxically to be low (0.6 g/l). Elevated plasma glucagon levels confirmed our diagnosis. The absence of diabetes was explained by an independent insulin secretion derived from this composite pancreatic tumor, authenticated by the histological analysis and the proinsulin level. This level was similar to those typically observed in insulinomas. Six Months after a complete surgical exeresis, symptoms disappeared and biological results returned to normal values.