Chronic actinic dermatitis

Published on 18/03/2015 by admin

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[level-membership-for-dermatology-category]

Chronic actinic dermatitis

Sally H. Ibbotson and Robert S. Dawe

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Chronic actinic dermatitis (CAD), previously photosensitivity dermatitis/actinic reticuloid (PD/AR) syndrome, is a chronic dermatitis (sometimes with pseudoreticuloid features) predominantly of photo-exposed sites. Objective abnormal photosensitivity (to ultraviolet B [UVB] and often UVA and visible light) is an essential component of the syndrome. It usually arises on a background of a preceding dermatitis, whether endogenous or exogenous. It always involves photoexposed sites, but half the cases also report covered site involvement. More than three-quarters have contact allergens, often multiple. It typically presents in men over the age of 50 years, but it can occur in younger patients and women. All skin phototypes can be affected.

Management strategy

Phototesting investigations are essential. Without investigation, definitive distinction between photoaggravated eczemas, drug-induced photosensitivity, and CAD is not possible.

Photoprotection advice should include environmental measures (use of window film to prevent UVA transmission and avoidance of single envelope compact fluorescent lamps for those with extreme UVA and visible light sensitivity), behavioral measures (including avoidance of sunlight in the middle of the day), clothing measures (tightly woven clothing, dark colors for those with visible wavelength sensitivity), and topical sunscreens. Patient education to reduce exposure to their contact allergens is necessary. Contact allergy tends to persist indefinitely, whereas photosensitivity can eventually resolve.

For active disease, use of emollients and potent/very potent topical corticosteroids is also required. Inpatient admission, with nursing behind photoprotective screens, may be necessary for acute flares, especially if causing erythroderma. Systemic corticosteroids can be used for acute flares and reduced over weeks, with continued use of topical steroids for maintenance control. If these measures do not suffice and if the patient is not too UVA sensitive, controlled use of PUVA may be appropriate. UVB phototherapy is an alternative, although in our experience patients are usually too UVB-sensitive to tolerate this. For others a variety of systemic immunosuppressants can be tried.

Specific investigations

First-line therapies

imagePhotoprotective measures C
imageAvoidance of relevant contact allergens C
imageTopical corticosteroids C
imageTopical emollients C

Second-line therapies

imageAzathioprine A
imageCyclosporine E
imageMycophenolate E
imageHydroxycarbamide E
imagePUVA D
imageUVB D
imageTopical calcineurin inhibitors B

Third-line therapies

imageHydroxychloroquine D
imageEtretinate E
imageDanazol E
imageThalidomide E
imageInterferon E
imageInfliximab E

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Chronic actinic dermatitis

Sally H. Ibbotson and Robert S. Dawe

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Chronic actinic dermatitis (CAD), previously photosensitivity dermatitis/actinic reticuloid (PD/AR) syndrome, is a chronic dermatitis (sometimes with pseudoreticuloid features) predominantly of photo-exposed sites. Objective abnormal photosensitivity (to ultraviolet B [UVB] and often UVA and visible light) is an essential component of the syndrome. It usually arises on a background of a preceding dermatitis, whether endogenous or exogenous. It always involves photoexposed sites, but half the cases also report covered site involvement. More than three-quarters have contact allergens, often multiple. It typically presents in men over the age of 50 years, but it can occur in younger patients and women. All skin phototypes can be affected.

Management strategy

Phototesting investigations are essential. Without investigation, definitive distinction between photoaggravated eczemas, drug-induced photosensitivity, and CAD is not possible.

Photoprotection advice should include environmental measures (use of window film to prevent UVA transmission and avoidance of single envelope compact fluorescent lamps for those with extreme UVA and visible light sensitivity), behavioral measures (including avoidance of sunlight in the middle of the day), clothing measures (tightly woven clothing, dark colors for those with visible wavelength sensitivity), and topical sunscreens. Patient education to reduce exposure to their contact allergens is necessary. Contact allergy tends to persist indefinitely, whereas photosensitivity can eventually resolve.

For active disease, use of emollients and potent/very potent topical corticosteroids is also required. Inpatient admission, with nursing behind photoprotective screens, may be necessary for acute flares, especially if causing erythroderma. Systemic corticosteroids can be used for acute flares and reduced over weeks, with continued use of topical steroids for maintenance control. If these measures do not suffice and if the patient is not too UVA sensitive, controlled use of PUVA may be appropriate. UVB phototherapy is an alternative, although in our experience patients are usually too UVB-sensitive to tolerate this. For others a variety of systemic immunosuppressants can be tried.

Specific investigations