Sunscreen use in patients with cutaneous lupus erythematosus

Epidermal ZBP1 stabilizes mitochondrial Z-DNA to drive UV-induced IFN signaling in autoimmune photosensitivity

Photosensitivity is observed in numerous autoimmune diseases and drives poor quality of life and disease flares. Elevated epidermal type I interferon (IFN) production primes for photosensitivity and enhanced inflammation, but the substrates that sustain and amplify this cycle remain undefined. Here, we show that IFN-induced Z-DNA binding protein 1 (ZBP1) stabilizes ultraviolet (UV)B-induced cytosolic Z-DNA derived from oxidized mitochondrial DNA. ZBP1 is significantly upregulated in the epidermis of adult and pediatric patients with autoimmune photosensitivity. Strikingly, lupus keratinocytes accumulate extensive cytosolic Z-DNA after UVB, and transfection of keratinocytes with Z-DNA results in stronger IFN production through cGAS-STING activation compared to B-DNA. ZBP1 knockdown abrogates UV-induced IFN responses, whereas overexpression results in a lupus-like phenotype with spontaneous Z-DNA accumulation and IFN production. Our results highlight Z-DNA and ZBP1 as critical mediators for UVB-induced inflammation and uncover how type I IFNs prime for cutaneous inflammation in photosensitivity.

Dermatologists Should Encourage and Resume Photoprotection in Patients with Photodermatoses and Melasma Following the COVID-19 Pandemic

Background

The COVID-19 pandemic may alter individuals' perspectives and behaviors regarding sun exposure and photoprotection. Presently, there is a paucity of information about how the pandemic influences photoprotection in photodermatoses and melasma.

Objective

To compare the photoprotection attitudes and behaviors of individuals with photodermatoses and melasma with those of a control group (other dermatologic patients) before and during the COVID-19 pandemic.

Methods

A questionnaire-based, cross-sectional study was conducted among Thai patients with photodermatoses, melasma, and other dermatological conditions between August 2021 and November 2022. Each of the three groups consisted of 35 patients.

Results

Among the 105 patients, 81.9% were female, and the mean age was 45.83 years. Over 80% of individuals who used surgical masks daily for 4 to 8 hours believed that these masks provided skin protection from the sun. The duration of sun exposure and the frequency of photoprotection practices decreased significantly in all groups during the COVID-19 pandemic compared to the pre-pandemic period. Sunscreen was the most prevalent form of photoprotection, but its usage declined considerably during the pandemic. Upon physical examination, the photodermatoses and control groups exhibited unchanged skin conditions, while the patients with melasma demonstrated improved skin conditions during the pandemic.

Conclusion

Owing to increased indoor activities and the perception that face masks could block sunlight, the COVID-19 pandemic led to notable reductions in sun exposure and photoprotective practices. Despite the absence of photodermatoses exacerbation and the observed improvements in patients with melasma, consistent and effective photoprotection must continue to be promoted.

Accuracy and adequacy of photoprotection in pediatric systemic lupus erythematosus patients, and the effect of education on photoprotection: a prospective study

BACKGROUND

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that is associated with multiple organ involvement and leads to significant morbidity and mortality. One of the important environmental factors that influences the exacerbation of preexisting SLE is ultraviolet (UV) radiation, so photoprotection is essential. The aims of this study were to evaluate the accuracy and adequacy of photoprotection in pediatric SLE patients, and to investigate the effect of education on photoprotection.

METHODS

SLE patients aged ≤ 18 years who attended pediatric outpatient clinics were prospectively enrolled. The accuracy and adequacy of photoprotection were assessed by the questionnaire, and compared between baseline and the ≥ 3-month follow-up timepoint. Comprehensive written and verbal photoprotection education was provided to all patients and parents/caregivers after the first assessment.

RESULTS

One hundred patients were included (mean age 13.6 ± 2.5, 92% female). At the first assessment, 79% of patients used sunscreen with a sunburn protection factor ≥ 30 (77%) and protection grade of ultraviolet A +  +  + (63%). Fifty-two percent of patients applied sunscreen every day. A minority of patients applied an adequate amount of sunscreen (32%), used water-resistant sunscreen (34%), used lip balm with sunscreen (23%) and reapplied sunscreen when sweating (13%). The most commonly missed areas when applying sunscreen were the ears and dorsum of the feet. The least often practiced sun protection behavior was wearing sunglasses. The most often reported activities during the peak UV index, were playing with friends and walking to the cafeterias. At the second assessment, the majority of photoprotection practices were improved in all aspects except using water-resistant sunscreen, reapplying sunscreen when sweating, applying sunscreen on the ears and dorsum of feet, and wearing sunglasses. The main reason for not using sunscreen switched from thinking it was unnecessary at the first assessment to disliking its texture at the second assessment.

CONCLUSIONS

Education on photoprotection was effective in improving photoprotection practices. The photoprotection practices that need to be specifically emphasized are applying an adequate amount of sunscreen and using lip balm with sunscreen. The photoprotection which were least practiced at both the first and seconds assessments were reapplying sunscreen when sweating, applying sunscreen on the ears and dorsum of the feet, and wearing sunglasses.

An update on the management of refractory cutaneous lupus erythematosus

Management of cutaneous lupus erythematosus (CLE) involves a combination of preventive measures, topical and systemic drugs, fairly similar for the different subtypes. Although guidelines exist, to date, no specific drugs have been specifically licensed for CLE. Antimalarials remain the first-line systemic treatment, but many patients do not respond, making refractory lupus a challenge for clinicians. The choice of alternative medication should be based on effectiveness, safety and cost. Most of the available drugs for CLE have been adapted from systemic lupus erythematosus (SLE) treatment but the existing literature is limited to small studies and evidence often lacks. As knowledge of pathogenesis of both CLE and SLE is improving, promising new therapies are emerging. In this review, we discuss the available medications, focusing on the novelties under development for CLE.

'More extraordinary than mundane … ' A phenomenological analysis of the experiences of individuals living with CLE and their taking care in the sun

Introduction

CLE is a chronic inflammatory autoimmune condition of which photosensitivity is a major symptom. Individuals living with CLE are advised to practice photoprotection. Despite the benefits for disease control, many individuals living with CLE do not practice optimal photoprotection. The aim of this study was to gain a deep insight into the lived experiences of individuals with CLE and their photoprotective practices.

Methods

A qualitative study approach was conducted, using Hermeneutic phenomenology. Individuals living with CLE were recruited and interviewed. Rich pictures were used to enrich the interviews. Interviews were transcribed and analysed using Template Analysis.

Results

Analysis revealed four themes: ‘Much more than just a photosensitive skin condition’, ‘The impact of sun on CLE and social dynamics’, ‘Drifting to the sun: personal transitions and social norms’ and ‘Taking care in the sun: easier said than done’.

Discussion and conclusion

This study provides a nuanced insight into the lived experiences of individuals with CLE and their photoprotective practices. Taking care in the sun is not a simplistic process. Beyond the biomedical model of illness, the social impact that CLE has on individuals has a dominant influence on their photoprotective behaviours. Such insights could help healthcare professionals tailor photoprotective advice.

The behavior, attitude, and knowledge towards photoprotection in patients with cutaneous/systemic lupus erythematosus: a comparative study with 526 patients and healthy controls

OBJECTIVE

To evaluate the attitude, knowledge, and behavior towards the sun protection in systemic lupus erythematosus (SLE) patients with and without cutaneous involvement (CLE) compared to non-photosensitive controls and to determine influential factors for photoprotective practices in SLE patients.

METHODS

A case-control study was performed. Patients and controls completed a self-reported questionnaire. For SLE patients, the presence of organ involvement, disease activity and laboratory data were acquired from their physical examination and medical records.

RESULTS

A total of 263 SLE patients and 263 healthy controls were recruited. SLE patients had statistically significant better photoprotective practices than controls, i.e. exposure to sunlight <1 hour per day (76.1% vs. 48.3%, OR, 3.40; 95% CI, 2.34-4.93, p < 0.001), less outdoor activities (9.8% vs. 19.1%, OR, 0.44; 95% CI, 0.26-0.71, p = 0.003), wore long-sleeved shirts (57.0% vs. 32.7%, OR, 2.73; 95% CI, 1.92-3.89, p < 0.001) and hats (43.8% vs. 26.6%, OR 2.14; 95% CI, 1.49-3.09, p < 0.001). SLE with CLE subgroup had the highest percentage for regular practice in almost all sun protective means compared to SLE without CLE and controls. SLE with CLE patients had more diligent sunscreen application with higher percentage of consistent use (93.7% vs. 59.3%, OR, 11.66; 95% CI, 2.57-52.89, p = 0.001) and adequate application (58.1% vs. 24.6%, OR, 4.24; 95% CI, 1.93-9.30, p < 0.001) compared to those without CLE. Previous and current CLE were influential factors for adherence to photoprotective methods, while the extracutaneous involvement was not. The majority of SLE patients were well acquainted with the harm of sunlight to their diseases (91.6%). However, 40.1% of them did not perceive that sunlight could escalate their internal flare, which may have led to inferior photoprotective practices in patients with extracutaneous involvement.

CONCLUSION

SLE patients had good awareness and practiced better photoprotection than controls. The cutaneous sign is a predictor for superior photoprotective behavior. Education regarding the harms of sunlight and the importance of appropriate photoprotection should be emphasized, especially in SLE cases without cutaneous involvement.

A review of the evidence and cost of therapies for cutaneous lupus erythematosus

Cutaneous lupus erythematosus (CLE)-a common presentation of lupus erythematosus-may exist independently or as a part of the systemic manifestations of systemic lupus erythematosus. The effects of living with and treating a chronic condition such as CLE can be debilitating to a patient's health and finances. The management of patients with CLE is made particularly challenging by poor compliance, limited therapeutic options, scarcity of evidence supporting their use, and significant differences in costs of medications. Effective management of CLE should center on prevention, individualized treatment regimens, and a mutual understanding of the challenges that patients with CLE face. This article seeks to provide an overview of the efficacy, safety, and cost of therapeutic options for CLE.

Therapeutic options for cutaneous lupus erythematosus: recent advances and future prospects

INTRODUCTION

Treatment and prevention are of critical importance in patients with cutaneous lupus erythematosus (CLE), as the disease can have a devastating effect on patient well-being and quality of life.

AREAS COVERED

We conducted a selective search of the PubMed database for articles published between December 2010 and November 2015. This review encompasses both non-pharmaceutical (photoprotection, smoking cessation, drug withdrawal, and vitamin D replacement) and pharmaceutical (topicals, antimalarials, immunosuppressives, biologics, etc.) interventions used in the treatment of CLE. Expert Commentary: Recent work has expanded our understanding of established therapies as well as introduced new treatments for consideration, though existing medications still prove inadequate for a subset of patients. Changes in trial design may help to alleviate this issue.

Adherence to Oral and Topical Medications in Cutaneous Lupus Erythematosus is not Well Characterized

INTRODUCTION

Treatment adherence plays a large role in chronic dermatologic diseases and may play an important role in the outcomes of patients with cutaneous lupus erythematosus (CLE). We sought to gauge what is currently known about adherence to topical and oral medications in patients with CLE.

METHODS

A review of MEDLINE was performed using a combination of the phrases "adherence", "compliance", "lupus", and "cutaneous". Studies were hand searched and prospective and cross-sectional studies evaluating medication adherence in patients with CLE and systemic lupus erythematosus (SLE) were included.

RESULTS

Only two articles explored adherence in patients with CLE, while 17 articles discussed treatment adherence in patients with SLE. Depression was consistently cited as detrimental to adherence. The impact that race, ethnicity, and education has on adherence is unclear. Three studies noted a clear connection between adherence and disease activity, while two others did not. Few studies investigated methods that have improved adherence to treatment which have showed promise.

CONCLUSION

Much of what we know about adherence to medication in patients with lupus is limited to SLE. Although cutaneous symptoms are among the most common manifestations of SLE, cutaneous disease is often managed at least in part with topical agents, and adherence to topical treatment was not assessed in any of the articles, though one study investigated sunscreen usage in patients with CLE. Understanding adherence in patients with CLE may help contribute to better CLE treatment outcomes.