Photoaggravated disorders

Sunscreens in pigmentary disorders: time to revise the message

Current sunscreen messaging centres around skin cancer prevention, with an emphasis on mitigating the damaging effects of ultraviolet B (UVB) radiation. Darker skin is believed to be better protected against UVB owing to its higher melanin content, and therefore, this messaging has been largely targeted at people with lighter skin tones. This is reflected by low sunscreen use by people of darker skin types. However, visible light (VL) is now being appreciated as a culprit behind exacerbation of disorders of hyperpigmentation such as melasma and post-inflammatory hyperpigmentation (PIH) which is known to significantly impair quality of life (QoL) of those affected. The role of VL in melanogenesis is not well known to patients nor to dermatologists and is a missed opportunity in the management of pigmentary disorders. We propose that changing the terminology from 'sunscreen' to 'light protection' acknowledges the central role of VL in melanogenesis, underlining the importance of VL protection and making the messaging more inclusive for people of all skin colours.

Continuum of light sensitivity in atopic dermatitis: A retrospective analysis of 139 cases in Scotland

BACKGROUND

Previous reports have characterized photosensitivity in atopic dermatitis (AD), but with differences in terminology and criteria.

OBJECTIVE

This study aims to assess outcomes in 139 patients with AD referred for photodiagnostic testing and to establish diagnostic criteria for photosensitivity in AD.

METHODS

Clinical and photodiagnostic data were reviewed, categorizing photosensitivity into photoexacerbated AD, photosensitive AD, and chronic actinic dermatitis.

RESULTS

Of the patient cohort, the mean age was 42.6 ± 16.7 years, and 61.9% were men. In total, 51.1% of the patients with photoexacerbated AD had normal monochromator phototesting, and 7.9% of the patients with photosensitive AD displayed slight-to-moderate ultraviolet (UV)-A sensitivity (≥30% of normal minimal erythema dose [MED]) and mostly normal or slightly reduced UV-B MEDs (≥80% of normal MED). Conversely, 41% of the patients had chronic actinic dermatitis, and 93% of this group demonstrated significant UV-B sensitivity, with very low UV-B MEDs (<80% of normal MED) and/or very low UV-A MEDs (<30% of normal MED). No significant differences in sex, age, or skin phototype were observed between the groups. Serial phototesting revealed changes in photosensitivity status over time in 8 patients.

LIMITATIONS

A small sample size and retrospective design.

CONCLUSIONS

This study highlights the heterogeneity of photosensitivity patterns in patients with AD and the importance of follow-up assessments due to potential shifts in disease spectrum over time.

The essential role of combined calcium and vitamin D supplementation in the osteoporosis scenario in italy: Expert opinion paper

An Italian multidisciplinary working group discussed the current Italian scenario of osteoporosis management during a meeting and highlighted the essential role of calcium and vitamin D supplementation in the prevention of fragility fractures.

PURPOSE

This paper aims to review and discuss data on calcium and vitamin D requirements and the role of combined calcium and vitamin D supplementation in the treatment of patients with osteoporosis.

METHODS

The discussion of the experts covered literature data on calcium and vitamin D supplementation, gaps in the diagnosis and treatment of osteoporosis, and the role of the primary care physician in identifying and treating patients with osteoporosis. Articles for consideration were identified through PubMed searches using different combinations of pertinent keywords.

RESULTS

The discussion highlighted that insufficient calcium or vitamin D intake increases the risk of fragility fractures. The experts also drew attention to the essential role of calcium and vitamin D supplementation in achieving an anti-fracture effect and supporting the efficacy of anti-osteoporotic agents without increasing nephrolithiasis and cardiovascular risks. In addition, the discussion underlined the role of the primary care physician in the initial clinical approach to patients with osteoporosis.

CONCLUSIONS

The experts believe that efficient treatment for patients with osteoporosis should include calcium and vitamin D supplementation to achieve adequate levels that are able to inhibit the parathyroid hormone and bone resorption.

Contribution of phototesting in the diagnosis of photodermatoses: Retrospective study of 100 cases

BACKGROUND

Photodermatoses are sun-related inflammatory skin diseases. They usually require phototesting in diagnosis. However, fewer and fewer medical centers in France are equipped with photobiological equipment.

OBJECTIVES

The main purpose was to evaluate the relevance of phototesting in photodermatosis diagnosis. The second goal was to study the proportions of the different kinds of photodermatosis found in this particular study.

METHODS

This study was descriptive, retrospective, and mono-centric. It was based on 100 consecutive patients, who have been phototested in a French University Hospital from 2014 to 2018. Phototesting included determination of the minimal erythematous dose (MED), UVA and UVB phototests, and photopatch testing.

RESULTS

The use of phototesting led to 60% of photodermatosis diagnosis and formally eliminated the latter in 13% of the cases. The diagnosis remained undetermined in 27% of the cases. Nineteen cases of polymorphous light eruption (PLE), 14 cases of photocontact dermatitis (PCD), 10 cases of solar urticaria, 8 cases of photo-aggravated atopic eczema, 5 cases of chronic actinic dermatitis, and 2 cases of systemic photosensitization were diagnosed. The allergens involved in PCD were topical non-steroidal anti-inflammatory drug (NSAID) in 9 cases, sunscreens in 3 cases, and fragrance in 2 cases. The average amount of time between the first symptoms and actual phototesting was about 7,5 years.

CONCLUSION

This study confirms phototesting is truly useful. PLE was the most common form of photodermatosis, followed by PCD and solar urticaria. As photodermatosis could imply severe diseases sometimes requiring hospitalization, it is critical to maintain this expertise.

Flare management in atopic dermatitis: from definition to treatment

Atopic dermatitis (AD) is a skin immune-mediated inflammatory disease with a chronic-recurrent course. Acute exacerbations or flares are an integral part of the AD course and are generally defined as disease worsening, requiring escalation/intensification of treatment. Management of flares is crucial since their prevention is a key aim of long-term disease control. Nevertheless, difficulties related to this aspect are several, starting from the definition of flare itself, which is not always satisfactory or unambiguous, and needs clarification. Indeed, this hurdle may reduce clarity on treatment choice and generate difficulties when comparing data between studies. Deepening our knowledge on flares could be highly relevant to both clinicians and patients to provide adequate control of the disease through patient education and appropriate treatment. This review aims to summarize current knowledge on the management of AD flares from definition to treatment, highlighting aspects that are still unclear, and identifying any necessary unmet needs to better manage AD.

Photoprotection according to skin phototype and dermatoses: practical recommendations from an expert panel

Increasing evidence on the impact of the different wavelengths of sunlight on the skin demonstrates the need for tailored recommendations of sunscreen according to skin phototype and dermatoses, which is now possible due to advances in the filters and formulations of sunscreens. A selective literature search was performed by an international expert panel, focusing on the type of sunscreen to recommend for photoaging, skin cancers, photodermatoses, pigmentary disorders and skin inflammatory disorders. Protection against ultraviolet (UV)B is especially important for light skin as there is a high risk of sunburn, DNA damage and skin cancers. Darker skin may be naturally better protected against UVB but is more prone to hyperpigmentation induced by visible light (VL) and UVA. Protection against UVA, VL and infrared A can be helpful for all skin phototypes as they penetrate deeply and cause photoaging. Long‐wave UVA1 plays a critical role in pigmentation, photoaging, skin cancer, DNA damage and photodermatoses. Adapting the formulation and texture of the sunscreen to the type of skin and dermatoses is also essential. Practical recommendations on the type of sunscreen to prescribe are provided to support the clinician in daily practice.

Approach to Cutaneous Lymphoid Infiltrates: When to Consider Lymphoma?

Cutaneous lymphoid infiltrates (CLIs) are common in routine dermatopathology. However, differentiating a reactive CLI from a malignant lymphocytic infiltrate is often a significant challenge since many inflammatory dermatoses can clinically and/or histopathologically mimic cutaneous lymphomas, coined pseudolymphomas. We conducted a literature review from 1966 to July 1, 2015, at PubMed.gov using the search terms: Cutaneous lymphoma, cutaneous pseudolymphoma, cutaneous lymphoid hyperplasia, simulants/mimics/imitators of cutaneous lymphomas, and cutaneous lymphoid infiltrates. The diagnostic approach to CLIs and the most common differential imitators of lymphoma is discussed herein based on six predominant morphologic and immunophenotypic, histopathologic patterns: (1) Superficial dermal T-cell infiltrates (2) superficial and deep dermal perivascular and/or nodular natural killer/T-cell infiltrates (3) pan-dermal diffuse T-cell infiltrates (4) panniculitic T-cell infiltrates (5) small cell predominant B-cell infiltrates, and (6) large-cell predominant B-cell infiltrates. Since no single histopathological feature is sufficient to discern between a benign and a malignant CLI, the overall balance of clinical, histopathological, immunophenotypic, and molecular features should be considered carefully to establish a diagnosis. Despite advances in ancillary studies such as immunohistochemistry and molecular clonality, these studies often display specificity and sensitivity limitations. Therefore, proper clinicopathological correlation still remains the gold standard for the precise diagnosis of CLIs.

Polymorphous light eruption: a common skin disease uncommonly recognized in the Hispanic population

Polymorphous light eruption (PMLE) is a common acquired disease entity belonging to the idiopathic photodermatoses that is uncommonly considered in the Hispanic population. The pathogenesis of the disease and the mechanism of adaptation in skin (hardening phenomenon) have yet to be elucidated. PMLE is characterized by recurrent abnormal delayed reactions to sunlight ranging from pruritic erythematous papules, papulovesicles and plaques to erythema multiforme. It commonly occurs in the spring or early summer with a predilection for females. A Pubmed review of the literature shows no case reports or literature regarding PMLE in Hispanics. To the best of our knowledge, we report the first case of a 41-year-old Hispanic female diagnosed with PMLE. A high index of suspicion must remain in this group. Additional studies reviewing epidemiology in this group and detailing similar cases may be suggested.