Chronic actinic dermatitis: an immunohistologic and photobiologic study

Primary Cutaneous CD30+ Anaplastic Large T Cell Lymphoma in a Patient Treated with Cyclosporine for Actinic Reticuloid

Actinic reticuloid (AR)—a subtype of chronic actinic dermatitis—clinically and histopathologically shows lymphoma-like features. We report a male patient initially diagnosed with erythrodermic cutaneous T cell lymphoma (CTCL) who developed severe broadband photosensitivity. Clinical evaluation, histopathology, and phototesting were consistent with AR. The patient was treated with cyclosporine 150–300 mg/d. Under this therapy, he developed several times primary cutaneous anaplastic large cell lymphomas (C-ALCL) which in part tended to regress spontaneously under cyclosporine reduction. The association between cyclosporine treatment and development of C-ALCL and other CD30+ lymphoproliferative disorders has previously been reported in patients with atopic dermatitis, psoriasis, and transplant patients. In conclusion, the present case highlights the difficulties arising in the distinction between AR and CTCL and shows that long-term cyclosporine treatment may cause C-ALCL development in AR as well.

The Successful Use of Topical Tacrolimus Treatment for a Chronic Actinic Dermatitis Patient with Complications of Idiopathic Leukopenia

Chronic actinic dermatitis (CAD) is a photosensitivity disorder marked by severe eczematous lesions on exposed areas. Although associations with contact dermatitis, atopic dermatitis, and human immunodeficiency virus (HIV) have been suggested, its pathogenesis remains unknown. CAD is often refractory, and systemic administration of cyclosporin A has been the treatment of choice. Recently, topical tacrolimus therapy has been reported to be effective. We report the efficacy of topical tacrolimus treatment in a CAD patient who also had the complication of idiopathic leukopenia. A phototest showed marked suppression of erythema formation in the skin pre-treated with tacrolimus before UVB radiation but not in the skin treated after the irradiation. Therefore, it is suggested that tacrolimus may prevent UV-B induced erythema by suppressing a very early phase of the inflammatory process in CAD.

Prevalence of photodermatosis in four regions at different altitudes in Yunnan province, China

Idiopathic photodermatoses are common diseases in dermatology clinics that are associated with ultraviolet (UV) irradiation. The group includes a few dermatoses such as polymorphous light eruption (PLE) and chronic actinic dermatitis (CAD). The prevalence of PLE and CAD in China has not been previously reported. To investigate the population-based prevalence of polymorphous light eruption (PLE) and chronic actinic dermatitis (CAD) in six minority groups living in four regions with significantly different altitudes in the Yunnan province, a questionnaire survey was administered to 4899 residents of random villages in Yuanjiang county (Dai and Hani minorities), Kunming city (Han people and Yi minority), Lijiang county (Naxi minority), and Shangri-La county (Zang minority). The altitudes of these counties are 380 m, 1870 m, 2410 m and 3280 m a.s.l., respectively. The results showed that, first, there were 2400 males (49.0%) and 2499 females (51.0%). The prevalence of PLE was 0.65% (32/4899), and the prevalence of CAD was 0.18% (9/4899). PLE was higher among females than males (3.8 vs 1, P < 0.01). The CAD prevalence was not significantly different between males and females (1.6 vs 1, P > 0.05). Second, the prevalence of PLE was increased in higher elevations regions compared to lower elevations (P < 0.01). However, the prevalence of CAD was not significantly different among the four regions (P > 0.05). Third, the mean times of sun exposure for PLE and CAD were 6.0 and 6.5 h/day, respectively. The mean durations of PLE and CAD were 5.8 years, and 6.6 years, respectively. The study demonstrated that the prevalence of PLE is higher than that of CAD in Yunnan, and that the prevalence of PLE is correlated with altitude.

A case of chronic actinic dermatitis treated with topical tacrolimus

INTRODUCTION

The treatment of chronic actinic dermatitis (CAD), a sun-induced disorder characterized by a persistent eczematous eruption, involves photoprotective measures, topical corticosteroid therapy and, in more severe cases, systemic immunosuppression. The potential side effects of systemic immunosuppressant drugs prompted us to evaluate the efficacy of topical tacrolimus for treatment of CAD. PATIENT AND TREATMENT: A 58-year-old man with CAD, resistant to previous treatment with topical and systemic corticosteroids, oral cyclosporine and PUVA-photochemotherapy, was treated with tacrolimus ointment 0.1% once a day.

RESULTS

Tacrolimus ointment led to significant improvement of pruritus and severe eczematous skin lesions after 20 days of treatment.

CONCLUSIONS

Tacrolimus shows a beneficial effect on CAD; this could be attributed to the fact that CAD is characterized by a lymphohistiocytic infiltrate producing a chronic eczema and that tacrolimus blocks the activation of lymphocytes and other immune system cells, also inhibiting the release of mediators from cutaneous mast cells and basophils.

Benign summer light eruption and polymorphic light eruption: genetic and functional studies suggest that a revised nomenclature is required

New research indicates that polymorphic light eruption (PLE) is an autoimmune disease against an ultraviolet radiation-induced cutaneous antigen. PLE may even confer some protection against skin cancer later in life. This new information demands a reassessment of the precise nature and nomenclature of PLE. Benign summer light eruption (BSLE) (lucite estivale bénigne) is the name used in continental Europe, and particularly France, to describe a clinically short-lived, itchy, papular eruption particularly affecting young women after several hours of sunbathing at the beginning of summer or on sunny vacations. Clinically more prolonged forms of solar eruption, starting early in spring and persisting for long periods, have been known in France as polymorphic light eruption (PLE) (lucite polymorphe) ('European PLE'). Investigative studies, however, now suggest that BSLE and some cases of 'European PLE' are part of the same spectrum. In the Anglo-Saxon literature, they are lumped together as PLE ('Anglo-Saxon PLE'). The other cases of 'European PLE', which do not fall within the compass of 'Anglo-Saxon PLE', are, in the Anglo-Saxon literature, classified as either actinic prurigo (AP) (a genetically determined, prolonged, excoriated form of Anglo-Saxon PLE), or chronic actinic dermatitis (CAD) (a sunlight-induced eczema precisely resembling allergic contact dermatitis, apparently to an ultraviolet radiation-induced antigen). It is therefore proposed that: i. the European term BSLE be dropped and that these patients be reclassified within the spectrum of (Anglo-Saxon) PLE, ii. the European use of the term PLE ('European PLE') be discontinued, iii. those previously diagnosed as having 'European PLE' be reclassified as (Anglo-Saxon) PLE, AP or CAD, as appropriate. The benefits of such a change in nomenclature would be twofold, firstly a uniformity of terminology and secondly, and more importantly, terminology would then correlate better with our recently improved understanding of the pathogenesis of these disorders.

Mechanisms of phototherapy and photochemotherapy for photodermatoses

Most photodermatoses represent indications for preventive ultraviolet (UV) phototherapy and/or psoralen plus ultraviolet A (PUVA) photochemotherapy. The aim of treatment is to prevent the outbreak of disease by increasing the patient's tolerance to sunlight. The mechanisms by which ultraviolet B (UVB) and PUVA induce such tolerance are not completely understood. Pigmentation and skin thickening may be important factors in the protective effect, but they cannot sufficiently explain the degree of protection induced. Other mechanisms that may be of critical importance for the therapeutic efficacy encompass a variety of immunomodulatory effects on human skin known to be induced by UVA, UVB, and PUVA. Obviously the mechanisms of prophylactic phototherapy are strongly intertwined with the pathogenesis of the photodermatoses. The possible mechanisms of photoprevention are discussed for polymorphic light eruption (PMLE), actinic prurigo, chronic actinic dermatitis, and solar urticaria.

Photosensitivity: the 9-year experience at a Sydney contact dermatitis clinic

In this retrospective study, 81 patients with photosensitivity were referred to the Contact and Occupational Dermatitis Clinic at The Skin and Cancer Foundation Australia, in Sydney, between 1991 and 1999. Photoallergic contact dermatitis (PACD) was diagnosed in 39.5% of patients, with 87.5% of these reactions being to sunscreen chemicals. Polymorphic light eruption (PMLE) accounted for 19.7% of cases, drug photosensitivity 14.8%, and photoaggravated atopic dermatitis and chronic actinic dermatitis (CAD) each constituted 7.4%. Compared with overseas studies, there was a high incidence of PACD, possibly reflecting the referral bias and widespread use of sunscreens. The incidence of PMLE and CAD was less than studies from cooler climates overseas. No cause could be determined for three photosensitive patients.

Photosensitive mycosis fungoides or actinic reticuloid?

We report two patients who satisfied the diagnostic criteria for actinic reticuloid (AR) on initial presentation, in whom genotypic analysis of early skin biopsies failed to show T-cell gene receptor rearrangements. Both patients progressed to widespread skin involvement associated with histopathological and genotypic features of mycosis fungoides (MF). Arguably, these patients may have had photosensitive MF from the outset, but their clinical features, phototesting, and subsequent demonstration of a T-cell gene receptor rearrangement in the skin could also suggest progression of AR to MF.

The idiopathic photodermatoses

The idiopathic photodermatoses present a challenge for dermatologists. Although, as in other specialty areas, the classical clinical presentation produces few problems, it is the severe forms and overlap cases that cause the most difficulty. It is fortunate that the semi-objective investigation of phototesting is available, which, when conducted carefully, reveals so much about the nature of this group of conditions. This essential investigation not only helps achieve a diagnosis, but also affords material for study and a means of monitoring therapy response or progress towards spontaneous resolution. Although these conditions are grouped together, throughout this century we have seen a continuing process of distinct diseases emerging as a consequence of careful clinical observation and investigation.

The role of interleukins 1, 6 and 8 as lymphocyte attractants in the photodermatoses polymorphic light eruption and chronic actinic dermatitis

The two photodermatoses, polymorphic light eruption (PLE) and chronic actinic dermatitis (CAD), are characterized by lymphocyte-rich inflammatory infiltrates, the pathogeneses of which are not fully understood. We have therefore studied suction blister fluid (SBF) samples from patients with these conditions before and at two time points after the induction of experimental lesions by means of a solar simulator; this SBF was then tested for the presence of selected cytokines known to induce peripheral blood lymphocyte (PBL) migration in vitro. A specific EL-4 NOB-1 bioassay was used to detect interleukin (IL)-1 activity, which has already been noted in normal skin and this was found in pre-irradiation control samples as well as 1-3 h and 24 h post-irradiation in both patient groups, but at levels not significantly different from those of controls. Use of a B9 cell proliferation assay showed no detectable IL-6-like activity pre-irradiation, but there was substantial activity in samples at both post-irradiation time points in both patient groups. Further, in other experiments, retained SBF samples were tested in an in vitro PBL migration assay in the presence and absence of neutralizing antibodies against IL-1 alpha, IL-1 beta, IL-6 and IL-8; considerable PBL attractant activity was noted in the pre-irradiation SBF from both patient groups; a finding consistent with previous reports of such activity in samples from normal skin, and at least in CAD patients, a proportion of this activity appeared to be due to IL-1, pre-incubation of SBF with neutralizing antibodies against IL-1 alpha and IL-1 beta reducing the effect significantly. Substantial PBL attractant activity was present also in the SBF from 1-3 h and 24 h post-irradiation samples in both patient groups and again, IL-1 neutralizing antibodies reduced this in the 1-3 h and 24 h CAD samples. In addition, neutralizing antibodies against IL-6 and IL-8 reduced the activity in the 24 h PLE samples significantly and although not fully conclusive in the case of IL-1, these data suggest that IL-6, IL-8 and possibly IL-1 may be involved in the induction of PBL infiltrates, and perhaps other events, in both PLE and CAD.

Cutaneous pseudolymphomas

Cutaneous pseudolymphoma refers to a heterogeneous group of benign reactive T- or B-cell lymphoproliferative processes of diverse causes that simulate cutaneous lymphomas clinically and/or histologically. The inflammatory infiltrate is bandlike, nodular, or diffuse and is composed predominantly of lymphocytes with or without other inflammatory cells. Depending on the predominant cell type in the infiltrate, cutaneous pseudolymphomas are divided into T- and B-cell pseudolymphomas. Cutaneous T-cell pseudolymphomas include idiopathic cutaneous T-cell pseudolymphoma, lymphomatoid drug reactions, lymphomatoid contact dermatitis, persistent nodular arthropod-bite reactions, nodular scabies, actinic reticuloid, and lymphomatoid papulosis. Cutaneous B-cell pseudolymphomas include idiopathic lymphocytoma cutis, borrelial lymphocytoma cutis, tattoo-induced lymphocytoma cutis, post-zoster scar lymphocytoma cutis, and some persistent nodular arthropod-bite reactions. This review attempts to discuss current aspects of the classification, pathogenesis, clinical spectrum, histopathologic and immunohistochemical diagnosis, and laboratory investigations for clonality in the various types of cutaneous pseudolymphomas.

Potent T cell stimulatory material with antigenic properties in stratum corneum of normal human skin

T cell mediated autoimmunity may be important in inflammatory skin disease, but target autoantigens have not previously been described. In studies aimed at defining T cell epitopes, aqueous extracts of normal facial and plantar stratum corneum have consistently been found to induce potent proliferation of peripheral blood mononuclear cells from normal donors and patients with inflammatory skin disease, giving stimulation indices up to 80. Potent stimulation was seen with both autologous and allogeneic stratum corneum extracts. Because of the presence of inhibitory material, demonstration of the stimulatory activity was critically dependent on extract concentration, and was facilitated by short-term pulsing of cultures with extract. The proliferation of cells purified from peripheral blood mononuclear cells by immunomagnetic beads and immunophenotyping of cell lines generated from peripheral blood mononuclear cells, confirmed the T cell nature of the response to stratum corneum extracts. The activity was inhibited by HLA-DR monoclonal antibody, indicating the presence of antigen or superantigen. Tetanus toxoid reactive clones and a purified protein derivative reactive line failed to respond to the stratum corneum extracts, indicating that the active material is not a nonspecific T cell stimulant such as a cytokine or mitogen. This and the failure of recombinant interleukin-1alpha to stimulate peripheral blood mononuclear cells in concentrations up to 1000 U per ml, indicate that the activity is not due to interleukin-1. We propose the hypothesis that antigenic or superantigenic material is normally sequestered from the immune system in the epidermis, but induces T cell activation when released following wounding and in disease, and that this represents an important and previously unrecognized pathogenic mechanism.

Immunoperoxidase techniques in the evaluation of cutaneous lymphocytic infiltrates

The widespread availability of immunoperoxidase technology and antibody probes over the past 15 years has changed the discipline of dermatopathology. In no aspect is this more evident than in the microscopic study of cutaneous lymphoid infiltrates. In the following review, the discussion focuses on some of the ways in which immunophenotyping is used to enhance the diagnosis of cutaneous lymphoproliferative disorders. A strategy for the use of immunophenotyping in some common clinical situations is forwarded. The immunopathologic findings can be helpful in resolving problems in the differential diagnosis of lymphoma and mimics of lymphoma.

Photoaccentuated erythroderma associated with CD4+ T lymphocytopenia: successful treatment with 5-methoxypsoralen and UVA, interferon alfa-2b, and extracorporeal photopheresis

We describe a 53-year-old HIV-negative white man who had chronic CD4+ T lymphocytopenia and photoaccentuated erythroderma with lymphoma-like histologic changes. The erythroderma completely responded to 5-methoxypsoralen and UVA (PUVA), interferon alfa-2b, and extracorporeal photopheresis. During therapy opportunistic skin infections, including tinea corporis, warts, and disseminated molluscum contagiosum, developed. Although the patient met the current definition of idiopathic CD4+ T lymphocytopenia (ICTL), we cannot rule out the possibility that this peripheral CD4+ T lymphocytopenia resulted from sequestration of CD4+ T lymphocytes in erythrodermic skin.

The action spectrum for induction of chronic actinic dermatitis is similar to that for sunburn inflammation

The action spectrum for induction of the abnormal cutaneous response at 24 h in the photosensitivity disorder chronic actinic dermatitis (CAD) was determined in 15 patients and found to be the same in shape as that for normal sunburn in fair-skinned individuals at 24 h, as determined for 47 control volunteers, although displaced in magnitude. This suggests that an endogenous chromophore(s), the same as or similar to that/those responsible for human sunburn, may be responsible for initiation of the abnormal reaction to irradiation in CAD, and that the putative antigen associated with the CAD reaction may be derived from that/those or associated molecules.

Chronic actinic dermatitis

Chronic actinic dermatitis (CAD) is one of the most frequently encountered photodermatoses in patients older than 50 years of age. It is characterized by persistent redness of the face and other exposed areas. CAD can become so severe that even nonexposed parts of the body develop eczematous lesions and the disease persists during winter. The diagnosis must be confirmed by phototests that show a broad action spectrum with low threshold doses. CAD must be differentiated from photocontact allergy and airborne dermatitis. The histopathologic features in the early stages are comparable to contact dermatitis, whereas in the later stages they may be those of pseudolymphoma. The most popular treatments are azathioprine and PUVA.

Chronic actinic dermatitis with vitiligo-like depigmentation

This report describes two patients suffering from severe chronic actinic dermatitis. Unusual widespread vitiligo-like depigmentation occurred during the course of the disease. The progression of these lesions was triggered by the chronic actinic dermatitis. Loss of pigment and complete absence of tyrosinase positive melanocytes were found in depigmented skin of both cases. Immunohistological investigation of the inflammatory infiltrate in case 2 revealed a predominance of CD-8 positive cytotoxic/-suppressor lymphocytes. Analysing the adjacent pigmented epidermis of progressive depigmenting lesions a dense exocytosis of CD-8 T-cells was notable. This distribution suggests cytotoxic destruction of melanocytes as the cause for the vitiligo-like depigmentation.