Fitofotodermatosis: el peligro del sol y las plantas para la piel / Phytofotodermatosis: the danger of the sun and plants for the skin

Presentamos el caso de un paciente que padeció una reacción cutánea intensa tras el contacto con los frutos y las hojas de una higuera y posterior exposición solar. Se trata de una reacción no inmunológica llamada fitofotodermatosis. Es una erupción inflamatoria de la piel que se produce tras el contacto con sustancias fototóxicas (furocumarinas o psoralenos) y que puede llegar a ser de gran intensidad. Por ello requiere una anamnesis exhaustiva y su conocimiento por parte del equipo médico de Atención Primaria y pediatría, ya que su diagnóstico diferencial puede ser muy complejo.(AU)

We report the case of a patient who developed an intense skin reaction after contact with the fruits and leaves of a fig tree and subsequent sun exposure. This is a non-immunological reaction called phytophotodermatosis. It is an inflammatory skin rash that occurs after contact with phototoxic substances (furocoumarins or psoralens) and could be very intense. That is why it requires an in-depth history; its knowledge by primary care physicians and paediatricians, is important because the differential diagnosis could be very complex.(AU)

Solar urticaria involves rapid mast cell STAT3 activation and neutrophil recruitment, with FcεRI as an upstream regulator.

BACKGROUND: Solar urticaria is a rare photodermatosis characterized by rapid-onset sunlight-induced urticaria, but its pathophysiology is not well understood. OBJECTIVE: We sought to define cutaneous cellular and molecular events in the evolution of solar urticaria following its initiation by solar-simulated UV radiation (SSR) and compare with healthy controls (HC). METHODS: Cutaneous biopsy specimens were taken from unexposed skin and skin exposed to a single low (physiologic) dose of SSR at 30 minutes, 3 hours, and 24 hours after exposure in 6 patients with solar urticaria and 6 HC. Biopsy specimens were assessed by immunohistochemistry and bulk RNA-sequencing analysis. RESULTS: In solar urticaria specimens, there was enrichment of several innate immune pathways, with striking early involvement of neutrophils, which was not observed in HC. Multiple proinflammatory cytokine and chemokine genes were upregulated (including IL20, IL6, and CXCL8) or identified as upstream regulators (including TNF, IL-1ß, and IFN-γ). IgE and FcεRI were identified as upstream regulators, and phosphorylated signal transducer and activator of transcription 3 expression in mast cells was increased in solar urticaria at 30 minutes and 3 hours after SSR exposure, suggesting a mechanism of mast cell activation. Clinical resolution of solar urticaria by 24 hours mirrored resolution of inflammatory gene signature profiles. Comparison with available datasets of chronic spontaneous urticaria showed transcriptomic similarities relating to immune activation, but several transcripts were identified solely in solar urticaria, including CXCL8 and CSF2/3. CONCLUSIONS: Solar urticaria is characterized by rapid signal transducer and activator of transcription 3 activation in mast cells and involvement of multiple chemotactic and innate inflammatory pathways, with FcεRI engagement indicated as an early event.

Fig Tree-Induced Phytophotodermatitis: A Case Report on the Perils of a Hobby.

Phytophotodermatitis, a condition that results from sequential skin exposure to phototoxic chemicals contained within plants, followed by exposure to solar ultraviolet radiation, has been described with several plants and plant-based foods, namely members of the Moraceaefamily, which include Ficus carica L. This tree's branches, leaves, and fruit skin exude a milky sap or latex containing proteolytic enzymes and furocoumarins known to be photoirritants, easily absorbed upon skin contact. Oxygen-dependent and independent toxic reactions subsequent to sun exposure promote cell membrane damage and oedema, consequently leading to cell death. The diagnosis is confirmed with a detailed anamnesis, and photopatch testing is often useful to rule out a differential diagnosis. It is typically a self-limited condition, with few cases requiring treatment with topical or systemic corticosteroids. We report on a 55-year-old male patient who, following picking figs and pruning a fig tree while exposed to sunlight, developed erythematous and pruritic maculopapular lesions that progressed to blisters with residual hyperpigmentation. The diagnosis was further corroborated through photopatch testing, and the patient was recommended to avoid this recreational activity without symptoms' relapse. This case highlights the importance of considering phytophotodermatitis as a differential diagnosis when evaluating cases of dermatitis on exposed body surfaces and the importance of an exhaustive anamnesis. Identification of specific plant triggers and the performance of photopatch tests are essential to help confirm the diagnosis and guide avoidance recommendations.

Chronic actinic dermatitis: A 5-year clinical analysis of 488 patients in China.

BACKGROUND/PURPOSE: Chronic actinic dermatitis (CAD) is a spectrum of diseases with chronic photosensitivity occurring mostly among middle-aged and older men. We seek to explore the characteristics and pathogenesis of CAD among the Chinese population. METHODS: The medical records of 488 CAD cases diagnosed by phototesting at Huashan Hospital, Fudan University from January 2014 to December 2018 were analyzed retrospectively. RESULTS: Among the 488 patients, 344 were male and 144 were female. 84.8% of the cases were over 40 years old at the age of onset, while the remaining with an early age of onset had a prevalence of atopic history of 21.6%. Up to 45.0% of the patients reported excessive sun exposure and outdoor activities before the initiation of symptoms. The typical skin lesions were erythema, papules and plaques laid predominantly in sun-exposed areas. 42.8% of the cases showed sensitivity to UVB only, 20.7% were both sensitive to UVA and UVB, and 18.2% had UVA sensitivity only. The most predominant photoallergens were chlorpromazine (80.1%), thimerosal (17.2%), potassium dichromate (12.7%), etc. The most prevalent patch test allergens were potassium dichromate (24.4%), thimerosal (20.5%), formaldehyde (16.8%), etc. CONCLUSIONS: CAD was more commonly seen in males over 40 years old. The action spectrum of Chinese patients is primarily in the UVB range. Exposure to excessive sunlight or contact allergens and photoallergens are important risk factors. Photobiology tests are essential in detecting photosensitivity and recognizing potential photosensitizers. Early avoidance of confirmed photoallergens and sun exposure may prevent photosensitive reactions from progressing into persistent photosensitivity.

Pediatric Cutaneous Oncology: Genodermatoses and Cancer Syndromes.

Skin cancers represent the most common malignancy worldwide. In children, the diagnosis of skin cancer is rare and raises the possibility of an underlying genetic predisposition. Recent molecular advances have increased understanding of certain genetically determined regulatory pathways that constantly protect the skin from atypical cell growth and cancer. Knowledge about these underlying gene defects aids a dermatologist's ability to recommend confirmatory genetic testing and provides potential targets for future therapies. In this review, we outline genetic conditions important to dermatologists that are associated with skin cancer development and review the current approaches to the management of these patients.

Review on photoprotection: a clinician's guide to the ingredients, characteristics, adverse effects, and disease-specific benefits of chemical and physical sunscreen compounds.

Photoprotection is a critical health prevention strategy to reduce the deleterious effects of ultraviolet radiation (UVR) and visible light (VL). Methods of photoprotection are reviewed in this paper, with an emphasis on sunscreen. The most appropriate sunscreen formulation for personal use depends on several factors. Active sunscreen ingredients vary in their protective effect over the UVR and VL spectrum. There are dermatologic diseases that cause photosensitivity or that are aggravated by a particular action spectrum. In these situations, sunscreen suggestions can address the specific concern. Sunscreen does not represent a single entity. Appropriate personalized sunscreen selection is critical to improve compliance and clinical outcomes. Health care providers can facilitate informed product selection with awareness of evolving sunscreen formulations and counseling patients on appropriate use. This review aims to summarize different forms of photoprotection, discuss absorption of sunscreen ingredients, possible adverse effects, and disease-specific preferences for chemical, physical or oral agents that may decrease UVR and VL harmful effects.

In vitro Effect of Photodynamic Therapy with Curcumin and Methylene Blue Photosensitizers on Staphylococcus Aureus.

Statement of the Problem: Staphylococcus aureus (S.A) can colonize in the skin, nasal cavity, and oral cavity. In the oral cavity, it can cause dental caries and periodontal disease. Mouthwashes can be used as an adjunct to mechanical plaque control methods to decrease the load of oral microorganisms. Chlorhexidine (CHX) is a commonly used antimicrobial mouthwash with side effects such as changing the sense of taste, tooth discoloration, oral mucosal burning, allergy, and xerostomia. It also has adverse systemic effects, if swallowed. Purpose: This study aimed to assess the effect of photodynamic therapy (PDT) with curcumin and methylene blue (MB) photosensitizers and different laser parameters on S.A colony count. Materials and Method: In this in vitro experimental study, 99 samples of standard-strain S.A were subjected to PDT with curcumin and MB photosensitizers with/without irradiation of 660 and 445 nm laser with different exposure parameters, and CHX in 9 groups (n=11). The samples were cultured in microplates containing Mueller-Hinton agar, and the number of colony forming units (CFUs) was counted after 24 h of incubation at 37°C. Data were analyzed by the Kruskal-Wallis and Dunn tests. Results: The minimum colony count was noted in CHX group (CFUs=0) followed by MB and 660nm diode laser group irradiated for 100 s (CFUs=147.2727±169.35707). The difference in this respect was significant between MB+660nm diode laser for 100 s and other groups (p< 0.05) except for the MB + 660 nm diode laser for 60 s group. Conclusion: CHX is superior to laser for elimination of S.A. However, PDT with 660 nm diode laser + MB has considerable antimicrobial efficacy against S.A; increasing the duration of laser irradiation enhances the antimicrobial effect.

Pathogenesis of solar urticaria: Classic perspectives and emerging concepts.

Solar urticaria is a rare, immunologically mediated photodermatosis in which activation of cutaneous mast cells is triggered by specific wavelengths of solar electromagnetic radiation. This manifests clinically as the rapid development of cutaneous itch, erythema and wheal formation after several minutes of sun exposure. Disease mechanisms in solar urticaria remain incompletely elucidated and there have been few recent investigations of its pathobiology. Historic passive transfer experiments performed during the twentieth century provide support for a 'photoallergy' model of disease pathogenesis, wherein molecular alteration of a putative chromophore by solar electromagnetic radiation produces mast cell activation via an IgE-dependent mechanism. However, this model does not account for several observations made during passive transfer experiments nor does it explain a range of subsequent clinical and photobiological observations made in solar urticaria patients. Furthermore, increased understanding of the molecular dynamics underpinning cutaneous mast cell responses highlights the need to reformulate our understanding of solar urticaria pathogenesis in the context of this contemporary scientific landscape. In this review, we discuss the current understanding of solar urticaria pathogenesis and, by incorporating recent scientific and clinical observations, develop new hypotheses to drive future investigation into this intriguing disorder.

Actinic prurigo in a dermatological reference center in Colombia: 108 cases / Prurigo actínico en un centro dermatológico de referencia en Colombia: 108 casos.

Introduction: Actinic prurigo is a chronic photodermatosis. It affects the Latin American population more frequently, predominantly women, and involves the sun-exposed areas of the skin, conjunctiva, and lips. Objective: To update the information on the clinical-epidemiological characteristics and treatment of patients with actinic prurigo in Colombia. Materials and methods: We conducted a cross-sectional study including the medical records of patients with actinic prurigo treated in the Photodermatology Service of Hospital Universitario Centro Dermatológico Federico Lleras Acosta between 2011 and 2016. We described the demographic, clinical, histopathological, and treatment characteristics of the patients. Results: We included 108 patients, 77 (71.3%) were women and 31 (28.7%) men, mainly with phototypes III-IV (70%). The disease had begun during the first decade of life in 66.4% of the cases and 25% of the patients had a family history with the condition. The lesions predominated on the face (93.5%), forearms (79.6%), and back of the hands (70.4%). Ocular (87.9%) and lip (88.8%) involvement was also documented. A photo-provocation test with UVA was performed in 25% of the cases and skin biopsies in 19.4%. Physical and chemical photoprotection was indicated in all patients. Mild to moderate cases were treated with topical corticosteroids (91.7%) and calcineurin inhibitors (65.7%) while severe cases received thalidomide (33.3%) and pentoxifylline (14.8%). Conclusion: The characteristics of actinic prurigo patients in Colombia are similar to those reported in other Latin American countries: early onset of the disease, predominance in women, frequent involvement of conjunctiva and lips, and adequate response to topical and systemic treatment.

Introducción. El prurigo actínico es una fotodermatosis crónica. Afecta con mayor frecuencia a la población latinoamericana, predomina en mujeres y compromete la piel expuesta al sol, las conjuntivas y los labios. Objetivo. Actualizar la información sobre las características clínico-epidemiológicas y el tratamiento de pacientes con prurigo actínico en Colombia. Materiales y métodos. Se hizo un estudio de corte transversal que incluyó los registros clínicos de pacientes con prurigo actínico atendidos en el Servicio de Fotodermatología del Hospital Universitario Centro Dermatológico Federico Lleras Acosta entre el 2011 y el 2016, y se describieron sus características demográficas, clínicas e histopatológicas, así como su tratamiento. Resultados. Se incluyeron 108 pacientes, el 71,3 % de ellos mujeres y el 28,7% hombres, con predominio de los fototipos III-IV (70 %). La enfermedad se había iniciado durante la primera década de vida en el 66,4% de los casos y el 25 % de los pacientes tenía antecedentes familiares de la enfermedad. Las lesiones predominaban en el rostro (93,5 %), los antebrazos (79,6 %) y el dorso de las manos (70,4 %). También, se documentó compromiso ocular (87,9 %) y de los labios (88,8 %). Se hizo la prueba de fotoprovocación con radiación ultravioleta A en el 25 % de los casos y biopsia cutánea en el 19,4 %. Todos los pacientes se trataron con protección solar química y física. En los casos leves a moderados, se formularon corticoides tópicos (91,7 %) e inhibidores de la calcineurina (65,7 %), y en los graves, talidomida (33,3 %) y pentoxifilina (14,8 %). Conclusión. Las características de los pacientes colombianos con prurigo actínico son similares a las reportadas en otros países latinoamericanos: inicio temprano de la enfermedad, predominio en mujeres, compromiso frecuente de conjuntivas y labios, y adecuada respuesta al tratamiento tópico y sistémico.

Prurigo actínico en un centro dermatológico de referencia en Colombia: 108 casos / Actinic prurigo in a dermatological reference center in Colombia: 108 cases

Introducción. El prurigo actínico es una fotodermatosis crónica. Afecta con mayor frecuencia a la población latinoamericana, predomina en mujeres y compromete la piel expuesta al sol, las conjuntivas y los labios. Objetivo. Actualizar la información sobre las características clínico-epidemiológicas y el tratamiento de pacientes con prurigo actínico en Colombia. Materiales y métodos. Se hizo un estudio de corte transversal que incluyó los registros clínicos de pacientes con prurigo actínico atendidos en el Servicio de Fotodermatología del Hospital Universitario Centro Dermatológico Federico Lleras Acosta entre el 2011 y el 2016, y se describieron sus características demográficas, clínicas e histopatológicas, así como su tratamiento. Resultados. Se incluyeron 108 pacientes, el 71,3 % de ellos mujeres y el 28,7% hombres, con predominio de los fototipos III-IV (70 %). La enfermedad se había iniciado durante la primera década de vida en el 66,4% de los casos y el 25 % de los pacientes tenía antecedentes familiares de la enfermedad. Las lesiones predominaban en el rostro (93,5 %), los antebrazos (79,6 %) y el dorso de las manos (70,4 %). También, se documentó compromiso ocular (87,9 %) y de los labios (88,8 %). Se hizo la prueba de fotoprovocación con radiación ultravioleta A en el 25 % de los casos y biopsia cutánea en el 19,4 %. Todos los pacientes se trataron con protección solar química y física. En los casos leves a moderados, se formularon corticoides tópicos (91,7 %) e inhibidores de la calcineurina (65,7 %), y en los graves, talidomida (33,3 %) y pentoxifilina (14,8 %). Conclusión. Las características de los pacientes colombianos con prurigo actínico son similares a las reportadas en otros países latinoamericanos: inicio temprano de la enfermedad, predominio en mujeres, compromiso frecuente de conjuntivas y labios, y adecuada respuesta al tratamiento tópico y sistémico.

Introduction: Actinic prurigo is a chronic photodermatosis. It affects the Latin American population more frequently, predominantly women, and involves the sun-exposed areas of the skin, conjunctiva, and lips. Objective: To update the information on the clinical-epidemiological characteristics and treatment of patients with actinic prurigo in Colombia. Materials and methods: We conducted a cross-sectional study including the medical records of patients with actinic prurigo treated in the Photodermatology Service of Hospital Universitario Centro Dermatológico Federico Lleras Acosta between 2011 and 2016. We described the demographic, clinical, histopathological, and treatment characteristics of the patients. Results: We included 108 patients, 77 (71.3%) were women and 31 (28.7%) men, mainly with phototypes III-IV (70%). The disease had begun during the first decade of life in 66.4% of the cases and 25% of the patients had a family history with the condition. The lesions predominated on the face (93.5%), forearms (79.6%), and back of the hands (70.4%). Ocular (87.9%) and lip (88.8%) involvement was also documented. A photo-provocation test with UVA was performed in 25% of the cases and skin biopsies in 19.4%. Physical and chemical photoprotection was indicated in all patients. Mild to moderate cases were treated with topical corticosteroids (91.7%) and calcineurin inhibitors (65.7%) while severe cases received thalidomide (33.3%) and pentoxifylline (14.8%). Conclusion: The characteristics of actinic prurigo patients in Colombia are similar to those reported in other Latin American countries: early onset of the disease, predominance in women, frequent involvement of conjunctiva and lips, and adequate response to topical and systemic treatment.

A qualitative study of knowledge, behaviour and attitudes regarding vitamin D acquisition among patients with photosensitivity disorders.

BACKGROUND: Cutaneous exposure to sunlight is a major source of vitamin D. Individuals with photosensitivity disorders have symptoms provoked by sunlight and may not achieve the brief sunlight exposures that convey vitamin D acquisition. OBJECTIVE: To explore knowledge, behaviour and attitudes towards vitamin D and its acquisition in patients with photosensitivity. METHODS: Patients (n = 19) diagnosed with solar urticaria, erythropoietic protoporphyria or polymorphic light eruption at a specialist photoinvestigation centre participated in semi-structured focus groups to discuss vitamin D knowledge, acquisition behaviours and attitudes towards vitamin D acquisition through sunlight and diet. Discussions were analysed by thematic analysis using MAXQDA11. RESULTS: Knowledge of vitamin D was variable. There was good awareness that sunlight exposure is an important source but knowledge of dietary sources was poor. Patients had little concern for their own vitamin D status prior to attending the photoinvestigation centre. Most patients avoided sunlight exposure, were unable to achieve the guidance on sun exposure for healthy individuals and were aware this could affect their vitamin D status. Use of oral vitamin D supplements was common, and all were willing to consider supplements if required. Patients recommended improving education of clinicians to increase patient awareness of vitamin D, CONCLUSIONS: More targeted guidance is required on acquisition of vitamin D for patients with photosensitivity, supported by increased patient and clinician education.

Dermatological and Epidemiological Profiles of Patients with Albinism in São Paulo, Brazil, between 2010 and 2017: A Cross-Sectional Study.

INTRODUCTION: Oculocutaneous albinism is an autosomal recessive disease caused by complete absence of or decrease in melanin biosynthesis in melanocytes. Due to the reduction or absence of melanin, albinos are highly susceptible to the harmful effects of ultraviolet radiation and are at greater risk of actinic damage and skin cancer. There are no epidemiological data on the incidence of albinism in Brazil. OBJECTIVE: To analyze the clinical and epidemiological profile of patients with albinism treated by the Pró-Albino Program of the Dermatology Clinic of Santa Casa de Misericórdia from its beginning in 2010 until 2017. METHODS: In this cross-sectional study, the records of all consecutive albino patients admitted to the service in the study period were reviewed. Sociodemographic data, family history, and dermatological clinical data were collected. RESULTS: Between March 2010 and April 2017, 191 patients were admitted, of whom 109 were female (57.07%) and the age range was 0-92 years, with >30% under the age of 18 years. Consanguinity among the parents was confirmed by 26% of the patients. Unprotected sun exposure was reported by 109 (57.07%), and 138 (72.25%) had a history of sunburn. Of the 146 records with information, 38 had skin cancer (26%), with a mean age of 47.4 (p < 0.0001); the youngest patient diagnosed with a cutaneous tumor was 23 years old. The prevalence of actinic damage was high. There was information on solar elastosis and actinic keratosis in 148 medical records, of which 96 (64.8%) patients had elastosis and 75 (50.67%) keratoses. Elastosis, keratosis, and skin cancer were significantly associated with age, unprotected sun exposure, and sunburn (p < 0.05). Of the 37 (26% of the sample of 146) patients with a previous or current history of skin cancer, it was possible to identify the histological type in 29 (13 men and 16 women); of these, 18 (62%) were basal cell carcinomas (BCC), 15 (51%) were squamous cell carcinomas (SCC), and 2 (7%) were melanomas. Of these, 4 cases (14%) presented the 2 types of carcinoma (BCC and SCC), and the 2 that had a diagnosis of melanoma also had BCC. Some patients had multiple ulcerated tumors. The tumor site was preferentially in the head and neck (43%), trunk (37%) and limbs (20%). CONCLUSIONS: Albinos represent a risk group for skin cancer and other actinic lesions. These lesions were found to be prevalent in the albinos seen by the program and probably reflect the characteristics found in the Brazilian albino population. Access to health care, especially through multidisciplinary programs that enable the diagnosis and early treatment of these lesions, health education, and the use of photoprotective measures can reduce morbidity and mortality and improve the quality of life of patients with this rare genetic condition.

Delayed-Onset Transient Light Sensitivity Syndrome after Corneal Collagen Cross-Linking: A Case Series.

In this case series, we report a potentially novel association of corneal collagen crosslinking (CCL) with the development of photophobia symptoms in a series of patients at a tertiary ophthalmology clinic and describe their clinical course. Photosensitivity is a rare and seemingly unpredictable complication of refractive surgery but can present as a disabling, bilateral ocular pain that requires immediate treatment. This complication, termed transient light-sensitivity syndrome (TLSS), can have a substantially delayed presentation after ocular procedures and is associated with inflammation of structures in the anterior chamber that can be imperceptible on slit-lamp examination. Traditionally, exposure to high-energy femtosecond lasers is hypothesized to create stromal gas bubbles powering postoperative inflammatory reactions. TLSS-like symptoms after CCL may be due to a secondary inflammatory response involving activated keratocytes and cytokine release. However, free radical damage from the interaction of riboflavin and ultraviolet in CCL may also drive this inflammatory process.

Porphyrias: A clinically based approach.

BACKGROUND: Porphyrias are a group of metabolic diseases, individually rare but with an important combined prevalence. Because of their pathological complexity and clinical heterogeneity, they present a challenging diagnosis. The present review aims to provide a clinically based approach to the recognition and treatment of these disorders. METHODS: We carried out a search in PubMed, with the keyword "porphyria", for reviews published in English from 2010 until 2017. RESULTS: The research yielded 196 papers, of which 64 were included in the final narrative review. CONCLUSIONS: Porphyrias can be divided based on clinical presentation in acute neurovisceral, chronic cutaneous bullous, chronic cutaneous non-bullous and acute neurovisceral/chronic cutaneous bullous. Each individual porphyria presents a characteristic pattern of porphyrins in plasma, urine, stool and red blood cells. As such, diagnosis is easily obtained by following a simple diagnostic algorithm. Early recognition is key in managing these diseases. Neurovisceral porphyrias require acute support therapy and chronic eviction of precipitating factors. Cutaneous prophyrias, as photosensitivity disorders, rely on sunlight avoidance and, in some cases, specific therapeutic interventions. Given the rarity of these conditions, physician awareness is crucial.

Incapacitating solar urticaria: successful treatment with omalizumab

Abstract: Solar urticaria is a rare form of physical urticaria mediated by immunoglobulin E. The lesions appear immediately after the sun exposure, interfering with the patient's normal daily life. Omalizumab, a monoclonal anti-IgE antibody, has been recently approved for the treatment of chronic spontaneous urticaria, and the latest reports support its role also in the treatment of solar urticaria. Hereby, we report a case of solar urticaria refractory to conventional treatment strategies, with an excellent response to treatment with omalizumab and phototesting normalization.