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Barman-Aksözen J, Hentschel N, Pettersson M, Schupp E, Granata F, Dechant C, Aksözen MH, Falchetto R. Fair Funding Decisions: Consistency of the Time Horizons Used in the Calculation of Quality-Adjusted Life Years for Therapies for Very Rare Diseases by the National Institute for Health and Care Excellence in England. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:616. [PMID: 38791830 PMCID: PMC11121024 DOI: 10.3390/ijerph21050616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024]
Abstract
The National Institute for Health and Care Excellence (NICE) in England uses quality-adjusted life years (QALYs) to assess the cost-effectiveness of treatments. A QALY is a measure that combines the size of the clinical benefit of a treatment with the time the patient benefits from it, i.e., the time horizon. We wanted to know how consistently QALY gains are calculated at NICE. Therefore, we have analysed information on the time horizons used for the QALY calculations of the concluded evaluations conducted under the Highly Specialised Technologies programme for treatments of very rare diseases at NICE. For treatments with final guidance published by December 2023 (n = 29), a time horizon of median 97.5 years (range: 35 to 125 years) was used to calculate the QALY gains. For most QALY calculations, the accepted time horizon was longer than either the expected treatment duration or the estimated life expectancy. In contrast, for the only technology with a final negative funding decision, i.e., afamelanotide for treating the lifelong chronic disease erythropoietic protoporphyria, a time horizon that was shorter than the expected treatment duration was used. The fairness and consistency of the evaluation process of treatments for very rare diseases at NICE should be reviewed.
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Affiliation(s)
- Jasmin Barman-Aksözen
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Nicole Hentschel
- Independent Researcher, Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Mårten Pettersson
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Eva Schupp
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Francesca Granata
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, S.C Medicina ad Indirizzo Metabolico, 20122 Milano, Italy
| | - Cornelia Dechant
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Mehmet Hakan Aksözen
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Rocco Falchetto
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
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Dickey AK, Berkovich J, Leaf RK, Jiang PY, Lopez-Galmiche G, Rebeiz L, Wheeden K, Kochevar I, Savage W, Zhao S, Campisi E, Heo SY, Trueb J, LaRochelle EPM, Rogers J, Banks A, Chang JK. Observational pilot study of multi-wavelength wearable light dosimetry for erythropoietic protoporphyria. Int J Dermatol 2024. [PMID: 38602089 DOI: 10.1111/ijd.17166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) causes painful light sensitivity, limiting quality of life. Our objective was to develop and validate a wearable light exposure device and correlate measurements with light sensitivity in EPP to predict and prevent symptoms. METHODS A wearable light dosimeter was developed to capture light doses of UVA, blue, and red wavelengths. A prospective observational pilot study was performed in which five EPP patients wore two light dosimeters for 3 weeks, one as a watch, and one as a shirt clip. RESULTS Standard deviation (SD) increases from the mean in the daily blue light dose increased the odds ratio (OR) for symptom risk more than the self-reported outdoor time (OR 2.76 vs. 2.38) or other wavelengths, and a one SD increase from the mean in the daily blue light wristband device dose increased the OR for symptom risk more than the daily blue light shirt clip (OR 2.45 vs. 1.62). The area under the receiver operator curve for the blue light wristband dose was 0.78, suggesting 78% predictive accuracy. CONCLUSION These data demonstrate that wearable blue light dosimetry worn as a wristband is a promising method for measuring light exposure and predicting and preventing symptoms in EPP.
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Affiliation(s)
- Amy K Dickey
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Jaime Berkovich
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
- Northwestern University Department of Materials Science and Engineering, Evanston, IL, USA
| | - Rebecca K Leaf
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paul Y Jiang
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Lina Rebeiz
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Irene Kochevar
- Harvard Medical School, Boston, MA, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Seung Y Heo
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
| | - Jacob Trueb
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
| | | | - John Rogers
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
- Northwestern University Department of Materials Science and Engineering, Evanston, IL, USA
| | - Anthony Banks
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
| | - Jan-Kai Chang
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
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3
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Mathias SD, Burke L, Colwell HH, Mensing G, Savage W, Naik H. Development and Content Validation of Novel Patient-Reported Outcome Measures to Assess Disease Severity and Change in Patients with Erythropoietic Protoporphyria: The EPP Impact Questionnaire (EPIQ). Patient Relat Outcome Meas 2024; 15:17-30. [PMID: 38375415 PMCID: PMC10875163 DOI: 10.2147/prom.s438892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose Erythropoietic protoporphyria (EPP), a rare inherited disorder, presents in early childhood with severe, painful phototoxicity, with significant impacts on health-related quality of life (HRQoL). Previous studies have not captured all concepts important to patients. Therefore, this study sought to develop a novel, comprehensive, and content valid patient-reported outcome (PRO) measure to assess the efficacy of new therapies. Patients and Methods Qualitative interviews were conducted with EPP participants and clinical experts to obtain views on concepts relevant to patients. Results informed the development of novel PROs, which were debriefed during subsequent combined concept elicitation and cognitive debriefing interviews. Results Twenty-three interviews were conducted with 17 adults and 6 adolescents with EPP. Concept elicitation revealed that participants experienced many symptoms with significant variability. The most common were burning, pain, swelling, and tingling. Tingling was the most common prodromal symptom, while burning was the most bothersome, and pain was the worst full reaction symptom. Participants reported being negatively impacted in their ability to do daily activities, and social and emotional functioning. Many reported impacted ability to work and be productive at their job. Participants reviewed and completed the newly developed PRO measures assessing full reactions and ability to do activities, as well as items to assess severity and change in severity of prodromal symptoms, full reactions, and EPP overall. All measures were found to be comprehensive, clear, and relevant. Conclusion PRO measures are needed to assess important aspects of HRQoL and evaluate therapeutic response. These PRO measures are unique in assessing overall severity and change in EPP.
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Affiliation(s)
| | | | | | | | | | - Hetanshi Naik
- Department of Genetics, Stanford University School of Medicine, Palo Alto, CA, USA
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4
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Dickey AK, Naik H, Keel SB, Levy C, Beaven SW, Elmariah SB, Erwin AL, Goddu RJ, Hedstrom K, Leaf RK, Kazamel M, Mazepa M, Philpotts LL, Quigley J, Raef H, Rudnick SR, Saberi B, Thapar M, Ungar J, Wang B, Balwani M. Evidence-based consensus guidelines for the diagnosis and management of erythropoietic protoporphyria and X-linked protoporphyria. J Am Acad Dermatol 2023; 89:1227-1237. [PMID: 36041558 PMCID: PMC9968824 DOI: 10.1016/j.jaad.2022.08.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/07/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022]
Abstract
Erythropoietic protoporphyria and X-linked protoporphyria are rare genetic photodermatoses. Limited expertise with these disorders among physicians leads to diagnostic delays. Here, we present evidence-based consensus guidelines for the diagnosis, monitoring, and management of erythropoietic protoporphyria and X-linked protoporphyria. A systematic literature review was conducted, and reviewed among subcommittees of experts, divided by topic. Consensus on guidelines was reached within each subcommittee and then among all members of the committee. The appropriate biochemical and genetic testing to establish the diagnosis is reviewed in addition to the interpretation of results. Prevention of symptoms, management of acute phototoxicity, and pharmacologic and nonpharmacologic treatment options are discussed. The importance of ongoing monitoring for liver disease, iron deficiency, and vitamin D deficiency is discussed with management guidance. Finally, management of pregnancy and surgery and the safety of other therapies are summarized. We emphasize that these are multisystemic disorders that require longitudinal monitoring. These guidelines provide a structure for evidence-based diagnosis and management for practicing physicians. Early diagnosis and management of these disorders are essential, particularly given the availability of new and emerging therapies.
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Affiliation(s)
- Amy K Dickey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Siobán B Keel
- Division of Hematology, University of Washington School of Medicine, Seattle, Washington
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Simon W Beaven
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles Medical Center, Los Angeles, California
| | - Sarina B Elmariah
- Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Angelika L Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic, Cleveland, Ohio
| | - Robert J Goddu
- Division of Continuing Education, University of Colorado Boulder, Boulder, Colorado
| | - Karli Hedstrom
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rebecca K Leaf
- Harvard Medical School, Boston, Massachusetts; Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohamed Kazamel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marshall Mazepa
- Division of Hematology and Oncology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - John Quigley
- Division of Hematology/Oncology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Haya Raef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sean R Rudnick
- Department of Internal Medicine, Section on Gastroenterology and Hepatology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Behnam Saberi
- Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Manish Thapar
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jonathan Ungar
- Department of Dermatology, Mount Sinai Hospital, New York, New York
| | - Bruce Wang
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York.
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Tumminelli C, Burlo F, Pastore S, Severini GM, Berti I, Marchini S, Zanon D, De Martino E, Tommasini A. Erythropoietic protoporphyria: case reports for clinical and therapeutic hints. Ital J Pediatr 2023; 49:156. [PMID: 37996925 PMCID: PMC10668413 DOI: 10.1186/s13052-023-01544-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/03/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Erythropoietic protoporphyria is a rare disorder which represents an important health problem in children, causing painful photosensitivity. Little is known on the correlation between genetic profile and clinical manifestations. The standard of care for Erythropoietic protoporphyria is based on avoiding sun and using sun protections, but recent literature has suggested that cimetidine may have a role in improving sun sensitivity. Herein we report our case series describing the successful use of cimetidine and analyzing potential phenotype-genotype correlations. CASE PRESENTATION This case series describes five patients presented to our Rheumatology Service complaining sun sensitivity. Blood exams and genetic analysis were consistent with the diagnosis of erythropoietic protoporphyria. Four of 5 patients received cimetidine in addition to standard therapies and the effect of treatment was evaluated by Erythropoietic Protoporphyria - Quality of Life questionnaire. CONCLUSIONS Erythropoietic protoporphyria usually manifests in early childhood after a short sun exposure. Skin manifestations are the main reason for investigations, although sometimes they can be more subtle, leading to a significant diagnostic delay. Skin diseases in children can have profound effects on their family and social relationships. A treatment with cimetidine appears to be an excellent therapeutic option in children with Erythropoietic protoporphyria.
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Affiliation(s)
- Cristina Tumminelli
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Francesca Burlo
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Serena Pastore
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy.
| | - Giovanni Maria Severini
- Department of Medical Genetics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Irene Berti
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy
| | - Stefano Marchini
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41124, Italy
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Eleonora De Martino
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy
| | - Alberto Tommasini
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy
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6
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Mathias SD, Burke L, Colwell HH, Mensing G, Savage W, Naik H. Development and content validation of a sunlight exposure diary in patients with erythropoietic protoporphyria. J Patient Rep Outcomes 2023; 7:119. [PMID: 37982964 PMCID: PMC10660587 DOI: 10.1186/s41687-023-00655-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/10/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Erythropoietic protoporphyria is a rare, inherited disorder presenting in early childhood with severe, painful phototoxicity. EPP has significant impacts on health-related quality of life, though there is variable disease severity. Accurately capturing how much time individuals with EPP can spend outdoors before they develop symptoms is critical to understanding HRQoL and measuring therapeutic response. Therefore, the goal of this study was to develop a comprehensive and content valid sun exposure diary to assess the efficacy of new therapies in individuals with EPP. METHODS Qualitative interviews were conducted with adult and adolescent EPP participants, as well as five clinical experts, to obtain their input on the content of an existing sun exposure diary. Revisions to the diary were made based on evidence generated in cognitive debriefing interviews analyzed in eight consecutive groups of EPP participant. RESULTS Interviews were conducted with 17 adults and 6 adolescents with EPP. The average age of adults was 40 years and of adolescents was 14 years. Clinical experts thought the original diary needed clarification on the description of symptoms, how time outdoors was captured, and the distinction between direct vs. indirect sunlight. Participants with EPP also noted these items needed revision, and that the distinction between prodromal symptoms and full reaction symptoms should be clarified. In the final diary version, participants with EPP found most items to be clear and easy to complete/think about. Seventy-six percent of participants (13/17) asked thought the diary was easy to complete. The remainder thought the majority of the diary was easy to complete with the exception of select questions. CONCLUSIONS Evaluating a new treatment for EPP requires accurately capturing time in sunlight and symptoms in this unique disorder. The newly developed sun exposure diary is content valid and can be used to assess important aspects of symptoms and daily life and therefore evaluate clinically meaningful therapeutic response.
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Affiliation(s)
| | | | | | | | | | - Hetanshi Naik
- Department of Genetics, Stanford University School of Medicine, Palo Alto, CA, USA.
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7
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Portich JP, Ribeiro AS, Rodrigues Taniguchi AN, Backes A, de Souza CFM, Kieling CO, Scherer FF, de Oliveira Poswar F, Leipnitz I, Doederlein Schwartz IV, Sekine L, Rigoni LDC, Marquardt da Silveira L, de Almeida Furlanetto M, Adami MR, Breunig RC, Guedes RR, do Amaral SN, Gonçalves Vieira SM, de Brum Soares T, Silva TO, da Rocha Silla LM, Astigarraga CC, Paz AA, Daudt LE. Consecutive Liver and Bone Marrow Transplantation for Erythropoietic Protoporphyria: Case Report and Literature Review. J Pediatr Hematol Oncol 2023; 45:416-422. [PMID: 37539993 DOI: 10.1097/mph.0000000000002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited disease of heme biosynthesis resulting in the accumulation of protoporphyrin, characterized by liver failure in a minority of cases. Although liver transplant (LT) is the therapeutic strategy for advanced hepatic disease, it does not correct the primary defect, which leads to recurrence in liver graft. Thus, hematopoietic stem cell transplantation (HSCT) is an approach for treating EPP. METHODS We aim to describe the first sequential LT and HSCT for EPP performed in Latin America, besides reviewing the present-day literature. RESULTS The patient, a 13-year-old female with a history of photosensitivity, presented with symptoms of cholestatic and hepatopulmonary syndrome and was diagnosed with EPP. Liver biopsy demonstrated cirrhosis. She was submitted to a successful LT and showed improvement of respiratory symptoms. However, she had disease recurrence on the liver graft. She underwent a myeloablative HSCT using a matched unrelated donor, conditioning with BuCy (busulfan and cyclophosphamide), and GvHD (graft vs. host disease) prophylaxis with ATG (thymoglobulin), tacrolimus and methotrexate. Neutrophil engraftment occurred on D+18. She has presented mixed chimerism, but normalization of PP levels, being 300 days after HSCT, in good state of health and normal liver function. CONCLUSIONS Consecutive LT and HSCT for EPP is a procedure that has been described in 10 cases in the literature and, even though these patients are a highly diversified population, studies have shown favorable results. This concept of treatment should be considered in patients with established liver disease.
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Affiliation(s)
| | | | | | | | | | - Carlos Oscar Kieling
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | | | | | - Ian Leipnitz
- Hemotherapy
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | | | - Leo Sekine
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Luciana Marquardt da Silveira
- Departments of Bone Marrow Transplantation
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Marina Rossato Adami
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | - Raquel Cristine Breunig
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Renata Rostirola Guedes
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
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Hussain Z, Qi Q, Zhu J, Anderson KE, Ma X. Protoporphyrin IX-induced phototoxicity: Mechanisms and therapeutics. Pharmacol Ther 2023; 248:108487. [PMID: 37392940 PMCID: PMC10529234 DOI: 10.1016/j.pharmthera.2023.108487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/03/2023]
Abstract
Protoporphyrin IX (PPIX) is an intermediate in the heme biosynthesis pathway. Abnormal accumulation of PPIX due to certain pathological conditions such as erythropoietic protoporphyria and X-linked protoporphyria causes painful phototoxic reactions of the skin, which can significantly impact daily life. Endothelial cells in the skin have been proposed as the primary target for PPIX-induced phototoxicity through light-triggered generation of reactive oxygen species. Current approaches for the management of PPIX-induced phototoxicity include opaque clothing, sunscreens, phototherapy, blood therapy, antioxidants, bone marrow transplantation, and drugs that increase skin pigmentation. In this review, we discuss the present understanding of PPIX-induced phototoxicity including PPIX production and disposition, conditions that lead to PPIX accumulation, symptoms and individual differences, mechanisms, and therapeutics.
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Affiliation(s)
- Zahir Hussain
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Qian Qi
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Junjie Zhu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Xiaochao Ma
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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9
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Heerfordt IM, Philipsen PA, Lerche CM, Wulf HC. Phototesting in erythropoietic protoporphyria trials: A systematic review. Exp Dermatol 2023. [PMID: 37052136 DOI: 10.1111/exd.14809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Abstract
Severe skin pain when exposed to long wave ultraviolet radiation or visible light is the main symptom of erythropoietic protoporphyria (EPP). Treatment options for EPP are inadequate and new treatments are needed but hampered by the lack of valid efficacy outcomes. Phototesting with well-defined illumination of the skin can be performed reliably. We aimed to provide an overview of phototest procedures used to evaluate EPP treatments. Systematic searches of Embase, MEDLINE and the Cochrane Library were performed. Searches identified 11 studies using photosensitivity as efficacy outcome. The studies used eight different phototest protocols. Illuminations were performed with a filtered high-pressure mercury arc, or a xenon arc lamp equipped with monochromator or filters. Some used broadband, others narrowband illumination. In all protocols phototests were performed on the hands or the back. Endpoints were minimal dose required to induce either first symptom of discomfort, erythema, urticaria or intolerable pain. Other endpoints were change in erythema intensity or diameter of any type of flare after exposure compared to before. In conclusion, protocols displayed extensive variability in illumination set-up and evaluation of phototest reactions. Implementation of a standardized phototest method will allow more consistent and reliable outcome evaluation in future therapeutic research of protoporphyric photosensitivity.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
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10
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Balwani M, Bonkovsky HL, Levy C, Anderson KE, Bissell DM, Parker C, Takahashi F, Desnick RJ, Belongie K. Dersimelagon in Erythropoietic Protoporphyrias. N Engl J Med 2023; 388:1376-1385. [PMID: 37043653 DOI: 10.1056/nejmoa2208754] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Erythropoietic protoporphyria and X-linked protoporphyria are inborn errors of heme biosynthesis that cause elevated circulating levels of metal-free protoporphyrin and phototoxicity. Both disorders are characterized by excruciating phototoxic attacks after exposure to visible light. Dersimelagon is a new, orally administered, selective melanocortin 1 receptor agonist that increases levels of skin eumelanin. METHODS We conducted a randomized, placebo-controlled, phase 2 trial to investigate the efficacy and safety of dersimelagon with respect to the time to onset and the severity of symptoms associated with sunlight exposure in patients with erythropoietic protoporphyria or X-linked protoporphyria. Patients 18 to 75 years of age were randomly assigned in a 1:1:1 ratio to receive placebo or dersimelagon at a dose of 100 or 300 mg once daily for 16 weeks. The primary end point was the change from baseline to week 16 in the time to the first prodromal symptom associated with sunlight exposure. Patients recorded daily sunlight exposure and symptom data in an electronic diary. Quality of life and safety were also assessed. RESULTS Of the 102 patients (93 with erythropoietic protoporphyria and 9 with X-linked protoporphyria) who underwent randomization, 90% completed the treatment period. The mean daily time to the first prodromal symptom associated with sunlight exposure increased significantly with dersimelagon: the least-squares mean difference from placebo in the change from baseline to week 16 was 53.8 minutes in the 100-mg dersimelagon group (P = 0.008) and 62.5 minutes in the 300-mg dersimelagon group (P = 0.003). The results also suggest that quality of life improved in patients receiving dersimelagon as compared with placebo. The most common adverse events that occurred or worsened during treatment were nausea, freckles, headache, and skin hyperpigmentation. CONCLUSIONS At both doses evaluated, dersimelagon significantly increased the duration of symptom-free sunlight exposure in patients with erythropoietic protoporphyria or X-linked protoporphyria. (Funded by Mitsubishi Tanabe Pharma; Endeavor ClinicalTrials.gov number, NCT03520036.).
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Affiliation(s)
- Manisha Balwani
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Herbert L Bonkovsky
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Cynthia Levy
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Karl E Anderson
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - D Montgomery Bissell
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Charles Parker
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Fumihiro Takahashi
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Robert J Desnick
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Kirstine Belongie
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
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11
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Barman-Aksözen J, Minder AE, Granata F, Pettersson M, Dechant C, Aksözen MH, Falchetto R. Quality-Adjusted Life Years in Erythropoietic Protoporphyria and Other Rare Diseases: A Patient-Initiated EQ-5D Feasibility Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5296. [PMID: 37047912 PMCID: PMC10094018 DOI: 10.3390/ijerph20075296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 06/19/2023]
Abstract
Erythropoietic protoporphyria (EPP) is an ultra-rare inborn error of metabolism characterised by painful phototoxic burn injuries after short exposure times to visible light. Patients with EPP are highly adapted to their condition which makes the quantification of their health-related quality of life (QoL) challenging. In the presented patient-initiated feasibility study, we describe a new approach to assess treatment benefits in EPP by measuring QoL with the generic EQ-5D instrument in five patients under long-term (≥two years) treatment with afamelanotide, the first approved therapy for EPP. For the study, we selected patients with EPP who in addition were affected by an involuntary treatment interruption (caused by a temporary reimbursement suspension) because we hypothesized that individuals who had previously unlearned their adaptation are better able to assess their life without treatment than treatment-naïve patients. QoL under treatment was comparable to the age-matched population norm, and retrospective results for a treatment interruption and phototoxic reaction time point were comparable to the QoL of patients with chronic neuropathic pain and acute burn injuries, respectively. The results were accepted by the National Institute for Health and Care Excellence in England for their evaluation of the cost-effectiveness of afamelanotide, i.e., the calculation of quality-adjusted life years.
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Affiliation(s)
- Jasmin Barman-Aksözen
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
- Institute of Laboratory Medicine, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Anna-Elisabeth Minder
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
- Division for Endocrinology, Diabetology and Porphyria, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Francesca Granata
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, S.C Medicine and Metabolic Disorders, 20122 Milano, Italy
| | - Mårten Pettersson
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
| | - Cornelia Dechant
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
| | | | - Rocco Falchetto
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
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12
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Burfield L, Rutter KJ, Thompson B, Marjanovic EJ, Neale RE, Rhodes LE. Systematic review of the prevalence and incidence of the photodermatoses with meta-analysis of the prevalence of polymorphic light eruption. J Eur Acad Dermatol Venereol 2023; 37:511-520. [PMID: 36433668 DOI: 10.1111/jdv.18772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/10/2022] [Indexed: 11/27/2022]
Abstract
Information about the prevalence of photodermatoses is lacking, despite their substantial impact on life quality. Our objective was to systematically review the literature to establish what is known regarding prevalence and incidence of photodermatoses. We searched Medline, CINAHL and Embase from inception to 2021 to identify original population-based studies in English literature reporting the prevalence and/or incidence of photodermatoses. Information was extracted according to geographical location and risk of bias was assessed using a 10-point risk of bias tool for prevalence studies. Primary outcome was the population prevalence of photodermatoses. Prevalence data for polymorphic light eruption (PLE) were used to calculate the global pooled prevalence of PLE. Twenty-six studies were included; 15 reported prevalence of photodermatoses based on samples of the general population and 11 on prevalence and/or incidence from national and international registry data. The general population studies involved PLE (nine studies), unspecified photosensitivity (2), actinic prurigo (2), juvenile spring eruption (1), chronic actinic dermatitis (1) and variegate porphyria (1), while registry studies reported on cutaneous porphyrias and genophotodermatoses (nine and two studies, respectively). Worldwide the prevalence of PLE between countries ranged from 0.65% (China) to 21.4% (Ireland). The pooled estimated prevalence of PLE was 10% (95% CI 6%-15%) among the general population (n = 19,287), and PLE prevalence increased with distance from the equator (r = 0.78, p < 0.001). While several photodermatoses are rare, photosensitivity can be prevalent at wide-ranging world locations, including Egypt where photosensitivity was found in 4% of children and 10% of adults. This study showed that PLE is highly prevalent in many populations and that its prevalence shows a highly significant correlation with increasing northerly or southerly latitude. Available population-based studies for photodermatoses suggest they can be prevalent at a range of world locations; more attention is required to this area.
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Affiliation(s)
- Laura Burfield
- Centre for Dermatology Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.,Dermatology Department, Royal Alexandra Hospital, Paisley, UK
| | - Kirsty J Rutter
- Centre for Dermatology Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.,Photobiology Unit, Dermatology Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Bridie Thompson
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Elizabeth J Marjanovic
- Centre for Dermatology Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.,Photobiology Unit, Dermatology Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Rachel E Neale
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.,School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Lesley E Rhodes
- Centre for Dermatology Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK.,Photobiology Unit, Dermatology Centre, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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13
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An Enigmatic Case of Jaundice and Photosensitivity in an Adolescent. ACG Case Rep J 2023; 10:e00996. [PMID: 36891180 PMCID: PMC9988325 DOI: 10.14309/crj.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/30/2023] [Indexed: 03/06/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) presents with nonblistering photosensitivity. Hepatobiliary manifestations are seen in around 5% cases and include cholelithiasis, elevations in liver enzymes, progressive jaundice, and end-stage liver disease. The diagnosis is suspected based on clinical features and elevated erythrocyte metal-free protoporphyrin and confirmed by genetic analysis showing loss-of-function mutations in the ferrochelatase (FECH) gene. We present an adolescent boy who presented with jaundice and photosensitivity with the liver biopsy showing deposition of brown pigments within the canaliculi and hepatocytes. This pigment showed Maltese cross birefringence on polarizing microscopy and Medusa-head appearance on electron microscopy. Genetic analysis revealed loss-of-function mutations in FECH. Introduction of EPP is an inborn error of heme biosynthesis caused by mutations in FECH with a prevalence of 1:75,000 to 1:200,000. We present a case of a 16-year-old adolescent boy with photosensitivity, abdominal pain, and jaundice with protoporphyrin deposition in the liver who was ultimately diagnosed with EPP based on genetic analysis.
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14
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Experimental and approved treatments for skin photosensitivity in individuals with erythropoietic protoporphyria or X-linked protoporphyria: A systematic review. Biomed Pharmacother 2023; 158:114132. [PMID: 36525819 DOI: 10.1016/j.biopha.2022.114132] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are characterized by skin photosensitivity caused by accumulation of protoporphyrin IX. We aimed to review the clinical evidence of efficacy and safety of skin photosensitivity treatments in individuals with EPP or XLP. We systematically searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov. A total of 40 studies with data on 18 treatment modalities were included. Comprehensive treatment safety data were obtained from the European Medicines Agency and the United States Food and Drug Administration. The studies used different outcome measures to evaluate the sensitivity without a generally accepted method to assess treatment effect on skin photosensitivity. Of the included studies, 13 were controlled trials. Gathered, the trials showed moderate positive effect of inorganic sunscreen application and subcutaneous implant of afamelanotide and no effect of organic sunscreen application, or oral treatment with beta-carotene, cysteine, N-acetylcysteine, vitamin C, or warfarin. Studies without control groups suggested treatment effect of foundation cream, dihydroxyacetone/lawsone cream, narrow-band ultraviolet B phototherapy, erythrocyte transfusion, extracorporeal erythrocyte photodynamic therapy, or oral treatment with zinc sulphate, terfenadine, cimetidine, or canthaxanthin, but the real effect is uncertain. Assessment of treatment effect on photosensitivity in patients with EPP or XLP carries a high risk of bias since experienced photosensitivity varies with both weather conditions, exposure pattern, and pigmentation. Controlled trials of promising treatment options are important although challenging in this small patient population.
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15
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Heerfordt IM, Philipsen PA, Lerche CM, Wulf HC. Protection against visible light by dihydroxyacetone in erythropoietic protoporphyria. Photodiagnosis Photodyn Ther 2023; 41:103302. [PMID: 36690194 DOI: 10.1016/j.pdpdt.2023.103302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with erythropoietic protoporphyria (EPP) are hypersensitive to long wave ultraviolet (UVA) radiation and visible light and they experience severe skin pain by light exposure. The patients have very limited treatment options. Sunless skin tanning with dihydroxyacetone (DHA) is now being investigated as a possible treatment modality of skin photosensitivity in EPP. METHODS We simulated the theoretical light protection factor provided by DHA application. In addition, we present 19 cases with EPP who were treated at our department with DHA weekly during spring and summer from 2018 to 2021 inclusive. RESULTS The protection factor against UVA and visible light was estimated to approximately two. Out of the 19 patients with EPP who were treated with DHA in 2018, 11 patients experienced a sustained good effect and continued to use the treatment on a weekly basis in the spring and summer of 2019, 2020, and 2021. CONCLUSION AND PERSPECTIVES Both the theoretical estimates and the uncontrolled study suggest that sunless tanning with DHA reduces photosensitivity in patients with EPP. Our hypothesis is that skin treated with DHA can tolerate twice the daylight dose compared to untreated skin before onset of skin symptoms. To validate this conclusion, we plan a randomized clinical trial to determine the effect of DHA application to reduce photosensitivity in patients with EPP under controlled clinical conditions. The study protocol for this trial is presented in the paper.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark.
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark; Department of Pharmacy, University of Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
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16
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Shizuku M, Kurata N, Jobara K, Tanaka T, Fukuta A, Hatanaka (Iwata) M, Hara K, Katsuno M, Nakano H, Ogura Y. Recovery From Severe Systemic Peripheral Neuropathy Secondary to Erythropoietic Protoporphyria by Liver Transplant: A Case Report. EXP CLIN TRANSPLANT 2022; 20:954-958. [DOI: 10.6002/ect.2022.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Porphyrias are disorders of the haem biosynthesis which are encountered infrequently and which often present themselves atypically as a combination of gastrointestinal, neurologic and/or dermatologic symptoms. Although they are primarily caused by enzyme defects, inheritance patterns are mostly not evident. Considering all of these characteristics, it is not surprising that there is a long delay between the onset of symptoms and the diagnosis of the disease, with as possible consequences impaired quality of life, irreversible neurologic damage and even death. This review aims to increase the clinical suspicion of the three most common porphyrias in adults: acute intermittent porphyria (AIP), porphyria cutanea tarda (PCT) and protoporphyria. Their relevant pathophysiology, clinical manifestations, diagnosis and treatment are discussed aiming at increasing the awareness of these diseases among physicians.
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Affiliation(s)
- Benjamin Heymans
- Department of General Internal Medicine, KU Leuven, Leuven, Belgium
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18
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Endo Y, Hibi T, Shinoda M, Obara H, Kitago M, Yagi H, Abe Y, Hasegawa Y, Matsubara K, Hori S, Tanaka M, Makiuchi S, Nakano Y, Itano O, Kuroda T, Kitagawa Y. Reappraisal of liver transplantation for erythropoietic protoporphyria: A deadly combination of disease recurrence and biliary complication. Pediatr Transplant 2022; 26:e14261. [PMID: 35225415 DOI: 10.1111/petr.14261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/23/2022] [Accepted: 02/17/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited disorder that causes the accumulation of protoporphyrin in the erythrocytes, skin, and liver. Severe protoporphyric hepatopathy results in liver failure, requiring both liver and bone marrow transplantation as a life-saving procedure and to correct the underlying enzymatic defect, respectively. CASE PRESENTATION We report a 20-year-old man who underwent split liver transplantation using a right trisegment and caudate lobe graft for EPP-induced liver failure, but succumbed to a deadly combination of early relapse of EPP and subsequent, intractable, late-onset bile leakage from the cut surface of segment 4. EPP recurrence most likely created a high-risk situation for bile leakage from the non-communicating bile ducts of segment 4; therefore, this case shed light on the potential relationship between EPP recurrence and biliary complications. CONCLUSION Physicians should recognize the potentially rapid and life-threatening progression of protoporphyric hepatopathy that leads to liver failure. For young patients with EPP, LT and sequential BMT should thoroughly be considered by a multidisciplinary team as soon as hepatic reserve deterioration becomes evident. Split liver transplantation should preferably be avoided and appropriate post-transplant management is critical before protoporphyrin depositions to the bile duct and hepatocyte causes irreversible damage to the liver graft.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.,Department of Digestive Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masayuki Tanaka
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satomi Makiuchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yutaka Nakano
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Itano
- Department of Gastrointestinal Surgery, International University of Health and Welfare, Chiba, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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19
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Obi CD, Bhuiyan T, Dailey HA, Medlock AE. Ferrochelatase: Mapping the Intersection of Iron and Porphyrin Metabolism in the Mitochondria. Front Cell Dev Biol 2022; 10:894591. [PMID: 35646904 PMCID: PMC9133952 DOI: 10.3389/fcell.2022.894591] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022] Open
Abstract
Porphyrin and iron are ubiquitous and essential for sustaining life in virtually all living organisms. Unlike iron, which exists in many forms, porphyrin macrocycles are mostly functional as metal complexes. The iron-containing porphyrin, heme, serves as a prosthetic group in a wide array of metabolic pathways; including respiratory cytochromes, hemoglobin, cytochrome P450s, catalases, and other hemoproteins. Despite playing crucial roles in many biological processes, heme, iron, and porphyrin intermediates are potentially cytotoxic. Thus, the intersection of porphyrin and iron metabolism at heme synthesis, and intracellular trafficking of heme and its porphyrin precursors are tightly regulated processes. In this review, we discuss recent advances in understanding the physiological dynamics of eukaryotic ferrochelatase, a mitochondrially localized metalloenzyme. Ferrochelatase catalyzes the terminal step of heme biosynthesis, the insertion of ferrous iron into protoporphyrin IX to produce heme. In most eukaryotes, except plants, ferrochelatase is localized to the mitochondrial matrix, where substrates are delivered and heme is synthesized for trafficking to multiple cellular locales. Herein, we delve into the structural and functional features of ferrochelatase, as well as its metabolic regulation in the mitochondria. We discuss the regulation of ferrochelatase via post-translational modifications, transportation of substrates and product across the mitochondrial membrane, protein-protein interactions, inhibition by small-molecule inhibitors, and ferrochelatase in protozoal parasites. Overall, this review presents insight on mitochondrial heme homeostasis from the perspective of ferrochelatase.
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Affiliation(s)
- Chibuike David Obi
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, United States
| | - Tawhid Bhuiyan
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, United States
| | - Harry A. Dailey
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, United States
- Department of Microbiology, University of Georgia, Athens, GA, United States
| | - Amy E. Medlock
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, United States
- Augusta University/University of Georgia Medical Partnership, University of Georgia, Athens, GA, United States
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20
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Wensink D, Coenen S, Wilson JHP, Wagenmakers MAEM, Langendonk JG. Liver involvement in patients with erythropoietic protoporphyria. Dig Liver Dis 2022; 54:515-520. [PMID: 34475006 DOI: 10.1016/j.dld.2021.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND In erythropoietic protoporphyria (EPP), which presents with severe painful phototoxicity, progressive deposition of protoporphyrins in hepatocytes and bile canaliculi may result in liver disease. Clinically EPP related liver disease ranges from mildly elevated liver enzymes to cirrhosis and acute cholestatic hepatic failure. The prevalence of liver disease in EPP, and factors predicting the risk of developing liver disease, have not been defined in a large series of unselected EPP patients. AIM To determine the prevalence of liver disease in EPP-patients. METHODS A single-center prospective unselected cohort study of 114 adult EPP patients, who underwent routine laboratory testing, abdominal ultrasonography and transient elastography to assess the presence of steatosis (controlled attenuation parameter,dB/m) and liver stiffness (kPa). RESULTS 114 adult EPP patients were included. Elevated liver enzymes were found in 6.2% of the patients. Liver steatosis was detected in 29.0%, and significant fibrosis as assessed with liver stiffness measurements was present in 9.6% of patients. BMI positively predicted CAP-values (p = 0.026); and protoporphyrin IX levels (p = 0.043) positively predicted liver stiffness. CONCLUSIONS This study demonstrates a prevalence of hepatic steatosis and fibrosis in adult EPP-patients comparable to that found in the general population. Protoporphyrin IX levels correlate with increased liver stiffness in EPP.
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Affiliation(s)
- Debby Wensink
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
| | - Sandra Coenen
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
| | - J H Paul Wilson
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
| | - Margreet A E M Wagenmakers
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
| | - Janneke G Langendonk
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, the Netherlands.
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21
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Wensink D, Wagenmakers MAEM, Qi H, Wilson JHP, Langendonk JG. Objective light exposure measurements and circadian rhythm in patients with erythropoietic protoporphyria: A case-control study. Mol Genet Metab 2022; 135:215-220. [PMID: 35034844 DOI: 10.1016/j.ymgme.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/26/2021] [Accepted: 12/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) patients suffer from painful phototoxicity. Sunlight-avoiding behaviour has not yet been quantified objectively in EPP patients. OBJECTIVE To study total white light exposure obtained with an actigraph device, before and during afamelanotide treatment, in EPP patients compared to healthy controls. Effects on circadian rhythm, pain and sleep were also investigated. METHODS Adult EPP patients visiting the Porphyria Center Rotterdam of the Erasmus MC were included in this single-center longitudinal case-control open-label intervention study. Controls were age and place of residence matched. Participants wore an actigraph (Actiwatch Pro) during two weeks for multiple periods. Afamelanotide was given to EPP patients as part of standard care. RESULTS Twenty-six EPP patients and 23 matched controls participated. Controls were statistically significantly more exposed to white light than EPP patients off treatment during autumn (95.4%), spring (69.9%), and summer (105.4%; p = 0.01). EPP patients on afamelanotide treatment had 71.6% more light exposure during spring compared to EPP patients off treatment (p < 0.01). Afamelanotide treatment resulted in a reduction of painful moments in the morning (6.5% decrease) and the evening (8.1% decrease; p < 0.05). Bedtime differed between EPP patients off treatment, controls and EPP patients on treatment (23:45 h ± 1:51 versus 23:02 ± 1:41 and 23:14 ± 1:29, respectively; p < 0.0001). CONCLUSION Actigraphy is a useful method to objectively measure white light exposure and treatment effects in EPP. In EPP patients afamelanotide treatment is associated with increased white light exposure during spring, and overall less pain. Treatment with afamelanotide is also associated with normalization of circadian rhythm.
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Affiliation(s)
- Debby Wensink
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - Margreet A E M Wagenmakers
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - Hongchao Qi
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - J H Paul Wilson
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - Janneke G Langendonk
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
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22
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Di Pierro E, Granata F, De Canio M, Rossi M, Ricci A, Marcacci M, De Luca G, Sarno L, Barbieri L, Ventura P, Graziadei G. Recognized and Emerging Features of Erythropoietic and X-Linked Protoporphyria. Diagnostics (Basel) 2022; 12:diagnostics12010151. [PMID: 35054318 PMCID: PMC8775248 DOI: 10.3390/diagnostics12010151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are inherited disorders resulting from defects in two different enzymes of the heme biosynthetic pathway, i.e., ferrochelatase (FECH) and delta-aminolevulinic acid synthase-2 (ALAS2), respectively. The ubiquitous FECH catalyzes the insertion of iron into the protoporphyrin ring to generate the final product, heme. After hemoglobinization, FECH can utilize other metals like zinc to bind the remainder of the protoporphyrin molecules, leading to the formation of zinc protoporphyrin. Therefore, FECH deficiency in EPP limits the formation of both heme and zinc protoporphyrin molecules. The erythroid-specific ALAS2 catalyses the synthesis of delta-aminolevulinic acid (ALA), from the union of glycine and succinyl-coenzyme A, in the first step of the pathway in the erythron. In XLP, ALAS2 activity increases, resulting in the amplified formation of ALA, and iron becomes the rate-limiting factor for heme synthesis in the erythroid tissue. Both EPP and XLP lead to the systemic accumulation of protoporphyrin IX (PPIX) in blood, erythrocytes, and tissues causing the major symptom of cutaneous photosensitivity and several other less recognized signs that need to be considered. Although significant advances have been made in our understanding of EPP and XLP in recent years, a complete understanding of the factors governing the variability in clinical expression and the severity (progression) of the disease remains elusive. The present review provides an overview of both well-established facts and the latest findings regarding these rare diseases.
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Affiliation(s)
- Elena Di Pierro
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
- Correspondence: or ; Tel.: +39-0255036155
| | - Francesca Granata
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Michele De Canio
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Mariateresa Rossi
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Andrea Ricci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Matteo Marcacci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giacomo De Luca
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Luisa Sarno
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Luca Barbieri
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Paolo Ventura
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giovanna Graziadei
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
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23
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Sernicola A, Cama E, Pelizzo MG, Tessarolo E, Nicolli A, Viero G, Alaibac M. In vitro Assessment of Solar Filters for Erythropoietic Protoporphyria in the Action Spectrum of Protoporphyrin IX. Front Med (Lausanne) 2021; 8:796884. [PMID: 34988101 PMCID: PMC8720878 DOI: 10.3389/fmed.2021.796884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/03/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Subjects with erythropoietic protoporphyria rely on broad-spectrum sunscreens with high sun protection factor, which is not informative on efficacy in the absorption spectrum of protoporphyrin IX, spanning visible radiation and peaking around 408 nm. Photoactivation of protoporphyrin IX is responsible for painful skin photosensitivity in erythropoietic protoporphyria. The authors assessed the protective efficacy of six sunscreens in vitro in the absorption spectrum of protoporphyrin IX. Method: Transmittance measurements were performed in the 300-850 nm wavelengths on samples of six photoprotective products applied to polymethyl methacrylate plates. Porphyrin protection factor was calculated in the 300-700 nm region to provide a measurement for the efficacy of each product based on the action spectrum of protoporphyrin IX. Results: Product A showed the highest porphyrin protection factor among tested products with a median value of 4.22. Product A is a sunscreen containing organic filters, titanium dioxide and synthetic iron oxides, pigmentary grade active ingredients that absorb visible radiation. Other products showed inefficient protection in the visible, with transmittance between 75 and 95% at 500 nm. The low porphyrin protection factor of inorganic filter product B was attributed to particle micronization, as declared by the manufacturer. Conclusion: Adding porphyrin protection factor to sunscreen labeling could help patients with erythropoietic protoporphyria and other photosensitivity disorders identify products tailored on their specific needs. The development of sunscreens providing protection from visible radiation and excellent cosmetical tolerability could improve the lifestyle of patients with erythropoietic protoporphyria.
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Affiliation(s)
- Alvise Sernicola
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Elena Cama
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Maria Guglielmina Pelizzo
- Department of Information Engineering, University of Padova, Padua, Italy
- Institute for Photonics and Nanotechnologies, National Research Council of Italy, Padua, Italy
| | - Enrico Tessarolo
- Institute for Photonics and Nanotechnologies, National Research Council of Italy, Padua, Italy
| | - Annamaria Nicolli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health (DCTV), University of Padova, Padua, Italy
| | - Giulia Viero
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
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24
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Heerfordt IM, Lerche CM, Philipsen PA, Wulf HC. The effect of vitamin D recommendations on serum 25-hydroxyvitamin D level in patients with erythropoietic protoporphyria. Nutrition 2021; 93:111477. [PMID: 34763310 DOI: 10.1016/j.nut.2021.111477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/19/2021] [Accepted: 08/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Patients with erythropoietic protoporphyria (EPP) avoid sun exposure owing to photosensitivity. For decades, sun-avoiding Danes have been recommended daily vitamin D supplements all year. We offered our EPP patients serum 25-hydroxyvitamin D (25(OH)D) monitoring, and counseling if their level was low. We aimed to investigate the effect of the general recommendation and counseling on 25(OH)D status in patients attending our clinic. Additionally, the 25(OH)D status of our EPP patients was compared to that of British patients with EPP not taking vitamin D supplements and with that of the general Danish population. METHODS Forty-six Danish patients with EPP had 25(OH)D measured in 721 blood samples collected between 2003 and 2021. Dates of individual counseling were noted. Data on British patients with EPP and the general Danish population were extracted from previous publications. RESULTS Our patients had higher 25(OH)D levels than British patients with EPP not taking vitamin D supplements, but the recommendations did not elevate their 25(OH)D levels to that of the general Danish population. Overall, 17.5% of the 25(OH)D measurements in our EPP patients were below 30 nmol/L (deficiency) and 29.4% were between 30 and 50 nmol/L (insufficiency). Patients were monitored for a median of 11 y. Thirty-one patients had a total of 74 vitamin D counseling sessions, providing an increase in 25(OH)D of about 18 nmol/L the year after. However, many patients repeatedly developed insufficiency. CONCLUSIONS This study documents the positive effect of vitamin D recommendations on serum 25(OH)D in patients with EPP. Follow-up on vitamin D status and recommendations is essential to increase 25(OH)D levels.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Denmark.
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Denmark
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Denmark
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25
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Lanzafame M, Branca G, Landi C, Qiang M, Vaz B, Nardo T, Ferri D, Mura M, Iben S, Stefanini M, Peverali FA, Bini L, Orioli D. Cockayne syndrome group A and ferrochelatase finely tune ribosomal gene transcription and its response to UV irradiation. Nucleic Acids Res 2021; 49:10911-10930. [PMID: 34581821 PMCID: PMC8565352 DOI: 10.1093/nar/gkab819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/10/2021] [Accepted: 09/12/2021] [Indexed: 11/14/2022] Open
Abstract
CSA and CSB proteins are key players in transcription-coupled nucleotide excision repair (TC-NER) pathway that removes UV-induced DNA lesions from the transcribed strands of expressed genes. Additionally, CS proteins play relevant but still elusive roles in other cellular pathways whose alteration may explain neurodegeneration and progeroid features in Cockayne syndrome (CS). Here we identify a CS-containing chromatin-associated protein complex that modulates rRNA transcription. Besides RNA polymerase I (RNAP1) and specific ribosomal proteins (RPs), the complex includes ferrochelatase (FECH), a well-known mitochondrial enzyme whose deficiency causes erythropoietic protoporphyria (EPP). Impairment of either CSA or FECH functionality leads to reduced RNAP1 occupancy on rDNA promoter that is associated to reduced 47S pre-rRNA transcription. In addition, reduced FECH expression leads to an abnormal accumulation of 18S rRNA that in primary dermal fibroblasts from CS and EPP patients results in opposed rRNA amounts. After cell irradiation with UV light, CSA triggers the dissociation of the CSA–FECH–CSB–RNAP1–RPs complex from the chromatin while it stabilizes its binding to FECH. Besides disclosing a function for FECH within nucleoli, this study sheds light on the still unknown mechanisms through which CSA modulates rRNA transcription.
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Affiliation(s)
- Manuela Lanzafame
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Giulia Branca
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Claudia Landi
- Department of Life Sciences, University of Siena, 53100 Siena, Italy
| | - Mingyue Qiang
- Department of Dermatology and Allergic Diseases, Ulm University, Albert-Einstein Allee 23, 89081 Ulm, Germany
| | - Bruno Vaz
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Tiziana Nardo
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Debora Ferri
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Manuela Mura
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Sebastian Iben
- Department of Dermatology and Allergic Diseases, Ulm University, Albert-Einstein Allee 23, 89081 Ulm, Germany
| | - Miria Stefanini
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Fiorenzo A Peverali
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
| | - Luca Bini
- Department of Life Sciences, University of Siena, 53100 Siena, Italy
| | - Donata Orioli
- Institute of Molecular Genetics -L.L. Cavalli Sforza, CNR, 27100 Pavia, Italy
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26
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Noyman Y, Edel Y, Snast I, Sherman S, Kaftory R, Lapidoth M, Mimouni D, Hodak E, Levi A. Inherited genetic late-onset erythropoietic protoporphyria: A systematic review of the literature. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2021; 37:374-379. [PMID: 33556208 DOI: 10.1111/phpp.12667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/18/2021] [Accepted: 02/04/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Inherited genetic erythropoietic protoporphyria (EPP) is characterized by a photosensitive rash that emerges during infancy or early childhood. Acquired EPP can erupt at any age, even during adulthood, and is associated with hematological disorders. A third, less-studied type of EPP is also inherited but appears later in life (during adulthood). PURPOSE To evaluate the characteristics of inherited genetic late-onset (IGLO) EPP. METHODS A systematic comprehensive search of the literature was conducted using PubMed, Google Scholar, ScienceDirect, and clinicaltrials.gov databases. Studies describing patients with IGLO EPP were included. Additionally, we present an index case of a patient, treated at our clinic in whom inherited genetic EPP was diagnosed at age 21 years. RESULTS The search yielded 1514 citations. Five publications were eligible for review. Along with our case, 7 patients (4 males) were included in the analysis. Mean age at disease onset was 34.2 years (range 18-69, median 30). Most patients presented with mild pruritus and rash in a photosensitive distribution. Mean level of free erythrocyte protoporphyrin IX (FEP) was 8.6 μmol/L. A mutant ferrochelatase gene (FECH) in trans to a hypomorphic FECH allele was found in 3 of the 4 patients who underwent genetic testing. CONCLUSION We describe the distinct features of IGLO EPP. This work emphasizes that a diagnosis of inherited genetic EPP should not be ruled out in adults with new-onset photosensitive manifestations.
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Affiliation(s)
- Yehonatan Noyman
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Edel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Porphyria Center, Rabin Medical Center - Beilnson Hospital, Petah Tikva, Israel
- Rheumatology Unit, Rabin Medical Center - Beilnson Hospital, Petah Tikva, Israel
| | - Igor Snast
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shany Sherman
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assi Levi
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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27
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Genovese G, Maronese CA, Moltrasio C, Piccinno R, Marletta DA, De Luca G, Graziadei G, Granata F, Di Pierro E, Cappellini MD, Marzano AV. Ultraviolet A phototest positivity is associated with higher free erythrocyte protoporphyrin IX concentration and lower transferrin saturation values in erythropoietic protoporphyria. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2021; 38:141-149. [PMID: 34420239 PMCID: PMC9291137 DOI: 10.1111/phpp.12727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/15/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare disorder of heme biosynthesis hallmarked by early-onset photosensitivity and mainly due to defective ferrochelatase activity leading to increased erythrocyte protoporphyrin IX (PPIX) levels. Evidence regarding the relationship between erythrocyte PPIX concentration and photosensitivity is limited. METHODS To investigate the relationship between free erythrocyte PPIX (FEP) concentration; routine laboratory tests, particularly iron metabolism biomarkers; and ultraviolet (UV) A/visible light phototesting findings, 20 genetically confirmed EPP and one XLPP treatment-naive patients were included in our study. They underwent UVA and visible light phototesting. On the same day, blood samples were collected for measurement of FEP, serum iron, transferrin, transferrin saturation, and ferritin, 25-hydroxyvitamin D, and liver enzyme levels. RESULTS Median FEP concentration at the time of phototesting was 57.50 (IQR: 34.58-102.70) μg/g of Hb. UVA and visible light phototesting were positive in 9 (42.9%) and 8 (38.1%) patients, respectively. Median FEP concentration was significantly higher in UVA phototest-positive patients than in those negative (64.37 [IQR: 57.45-121.82] vs 45.35 [IQR: 24.53-74.61] μg/g of Hb, respectively; P = .04486). Similarly, UVA photosensitive individuals had significantly lower median serum iron levels (61.5 [IQR: 33.5-84] μg/dL vs 109 [IQR: 63.25-154] μg/dL, respectively; P = .01862) and transferrin saturation values (15.005 [IQR: 7.0775-18.41] % vs 29.645 [IQR: 17.8225-34.3575] %; P = .0109) than those negative. CONCLUSIONS Our study demonstrates that UVA phototest positivity is associated with higher FEP concentration and lower transferrin saturation and serum iron concentration in EPP.
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Affiliation(s)
- Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Carlo Alberto Maronese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Roberta Piccinno
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Antonio Marletta
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giacomo De Luca
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Graziadei
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Granata
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Di Pierro
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Biolcati G, Hanneken S, Minder EI, Neumann NJ, Wilson JHP, Wolgen PJ, Wright DJ, Lloyd AJ. Validation of a novel patient reported tool to assess the impact of treatment in erythropoietic protoporphyria: the EPP-QoL. J Patient Rep Outcomes 2021; 5:65. [PMID: 34342778 PMCID: PMC8333176 DOI: 10.1186/s41687-021-00345-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 07/15/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND A novel treatment has been developed for erythropoietic protoporphyria (EPP) (a rare condition that leaves patients highly sensitive to light). To fully understand the burden of EPP and the benefit of treatment, a novel patient reported outcome (PRO) measure was developed called the EPP-QoL. This report describes work to support the validation of this measure. METHODS Secondary analysis of trial data was undertaken. These analyses explored the underlying factor structure of the measure. This supported the deletion of some items. Further work then explored the reliability of these factors, their construct validity and estimates of meaningful change. RESULTS The factor analyses indicated that the items could be summarised in terms of two factors. One of these was labelled EPP Symptoms and the other EPP Wellbeing, based on the items included in the domain. EPP Symptoms had evidence to support its reliability and validity. EPP Wellbeing had poor psychometric properties. CONCLUSIONS Based on the analysis it was recommended to drop the EPP Wellbeing domain (and associated items). EPP Symptoms, despite limitations in the development of items, showed evidence of validity. This work is consistent with the recommendations of a task force that provided recommendations regarding the development, modification and use of PROs in rare diseases.
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Affiliation(s)
- G Biolcati
- Centre for Porphyrias, Istituto Dermatologico S. Gallicano - Istituti Fisioterapici Ospitalieri, Rome, Italy
| | - S Hanneken
- Private Practice Empoderm, Düsseldorf, Germany
| | - E I Minder
- Stadtspital Triemli, Porphyria Outpatient Clinics, Zurich, Switzerland
| | - N J Neumann
- Department of Dermatology, Heinrich Heine University, Duesseldorf, Germany
| | - J H P Wilson
- The Department of Internal Medicine, Center of Lysosomal and Metabolic Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - P J Wolgen
- Clinuvel Pharmaceuticals Limited, Melbourne, Australia
| | - D J Wright
- Clinuvel Pharmaceuticals Limited, Melbourne, Australia
| | - A J Lloyd
- Acaster Lloyd Consulting Ltd, London, UK.
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Snast I, Kaftory R, Lapidoth M, Mamet R, Hodak E, Edel Y, Levi A. Clinical features of genetic cutaneous porphyrias in Israel: A nationwide survey. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2021; 37:236-242. [PMID: 33306200 DOI: 10.1111/phpp.12641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/20/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are three major types of genetic cutaneous porphyrias (GCP): erythropoietic protoporphyria (EPP), variegate porphyria (VP), and hereditary coproporphyria (HCP). Scarce data are available regarding their impact on patients' quality of life in the Mediterranean region. PURPOSE To describe the cutaneous features of GCP in Israel. METHODS An established nationwide cohort of patients with GCP diagnosed during 1988-2019 was surveyed by telephone for cutaneous features of GCP. Impact on quality of life was assessed using the Dermatology Life Quality Index. RESULTS Of the 95 patients with GCP, 71 (75%) completed the survey (21 HCP; 40 VP; 10 EPP). All EPP patients reported cutaneous symptoms compared with 58% of VP and 5% of HCP (P < .001). Mean age at symptom onset was 7 ± 6 years in EPP and 25 ± 15 years in VP (P < .001). Photosensitivity was the most common symptom in EPP (90%). In VP photosensitivity (52%), blistering (52%) and scarring (74%) were all common symptoms. In both VP and EPP, the dorsal hands/forearms were the most affected regions (≥96%), and in ≥ 78%, symptoms occurred on an almost daily basis. All EPP patients changed their lifestyle due to cutaneous symptoms vs 57% in VP. Major effect on quality of life was observed among EPP patients compared with a moderate effect in VP. No treatment was effective in EPP, while phototherapy and moisturizers were effective in 5 of 7 (71%) VP patients. CONCLUSION This study sheds light on the cutaneous features of the GCP, which have a substantial effect on patients' quality of life.
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Affiliation(s)
- Igor Snast
- Division of Dermatology, Photodermatosis Service, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Division of Dermatology, Photodermatosis Service, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rivka Mamet
- National Service for the Biochemical Diagnoses of Porphyrias, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Emmilia Hodak
- Division of Dermatology, Photodermatosis Service, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Edel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,National Service for the Biochemical Diagnoses of Porphyrias, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Department "C" of internal Medicine, Beilinson Hospital, Petah Tikva, Israel
| | - Assi Levi
- Division of Dermatology, Photodermatosis Service, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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30
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Wensink D, Wagenmakers MAEM, Langendonk JG. Afamelanotide for prevention of phototoxicity in erythropoietic protoporphyria. Expert Rev Clin Pharmacol 2021; 14:151-160. [PMID: 33507118 DOI: 10.1080/17512433.2021.1879638] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: In erythropoietic protoporphyria (EPP), an inherited disorder of heme biosynthesis, accumulation of protoporphyrin IX results in acute phototoxicity. EPP patients experience severe burning pain after light exposure, which results in a markedly reduced quality of life. Afamelanotide is the first effective approved medical treatment for EPP, acting on melanocortin-1 receptors. This article aims to review afamelanotide.Areas covered: This review summarizes the chemical properties, pharmacokinetics, safety, preclinical and clinical data on afamelanotide in EPP, and post-marketing surveillance. PubMed search, manufacturers' websites, and relevant articles used for approval by authorities were used for the literature search.Expert opinion: Afamelanotide is an α-melanocyte-stimulating hormone analog. It can activate eumelanogenesis without exposure to UV radiation. Clinical studies in EPP showed that afamelanotide treatment significantly increased exposure to sunlight and QoL. In our clinical experience afamelanotide treatment is much more effective in clinical practice than demonstrated in clinical trials and should be made available for all EPP patients meeting inclusion criteria. The 60-day interval period was not based on effectiveness studies, and therefore for some of the patients the maximum of four implants per year with the 60-day interval is insufficient. Afamelanotide is well tolerated; common adverse events were headache, fatigue, and nausea.
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Affiliation(s)
- Debby Wensink
- Porphyria Centre Rotterdam, Centre for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus University Medical Centre Rotterdam, The Netherlands
| | - Margreet A E M Wagenmakers
- Porphyria Centre Rotterdam, Centre for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus University Medical Centre Rotterdam, The Netherlands
| | - Janneke G Langendonk
- Porphyria Centre Rotterdam, Centre for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus University Medical Centre Rotterdam, The Netherlands
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31
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McGlacken-Byrne SM, Dann L, Murphy A, Moylett E. Pain, swelling and irritability in the sun: what is the diagnosis? Arch Dis Child Educ Pract Ed 2021; 106:102-106. [PMID: 31434640 DOI: 10.1136/archdischild-2019-317384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/30/2019] [Indexed: 11/03/2022]
Abstract
A 7-year-old boy presented with a 24-hour history of severe burning pain affecting both hands that had started within minutes of playing outdoors. His mother reported that he had been running his hands under cold water and shaking his hands and head to try and relieve the pain. On examination, there was swelling of his hands, eyelids and cheeks. His parents mentioned that his hands and face had 'swollen in the sun' every summer from the age of 2 years.A 3-year-old girl presented with a 2-day history of left upper limb swelling following a day of prolonged sun exposure. Examination revealed non-pitting oedema extending from her left shoulder to hand with no associated tenderness, erythema or rash. Her mother reported six previous episodes of irritability following sun exposure during which she would cry and flap her hands 'for hours'.Oral steroids and antihistamines were prescribed in both cases with little effect. Findings of routine baseline investigations were normal in both cases. A radiograph of the upper limb in the second patient disclosed nothing abnormal.
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Affiliation(s)
- Sinead Mary McGlacken-Byrne
- Department of Paediatrics, Clinical Science Institute, National University of Ireland Galway, Galway, Ireland
| | - Lisa Dann
- Department of Paediatrics, Clinical Science Institute, National University of Ireland Galway, Galway, Ireland
| | - Annette Murphy
- Department of Dermatology, Galway University Hospital, Galway, Ireland
| | - Edina Moylett
- Department of Paediatrics, Clinical Science Institute, National University of Ireland Galway, Galway, Ireland
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32
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Granata F, Duca L, Brancaleoni V, Fustinoni S, De Luca G, Motta I, Graziadei G, Di Pierro E. Alternative Pathway Involvement in Protoporphyria Patients Related to Sun Exposure. Front Immunol 2021; 12:615620. [PMID: 33664746 PMCID: PMC7921788 DOI: 10.3389/fimmu.2021.615620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/25/2021] [Indexed: 11/17/2022] Open
Abstract
The homeostasis of tissues in a chronic disease is an essential function of the alternative pathway (AP) of the complement system (CS). However, if not controlled, it may also be detrimental to healthy cells with a consequent aggravation of symptoms. The protoporphyria (PP) is a rare chronic disease that causes phototoxicity in visible light with local skin pain and general malaise. In order to establish if there is a systemic involvement of the CS during sun exposure, we designed a non-invasive method with a serum collection in winter and summer from 19 PP and 13 controls to detect the levels of CS protein: Properdin, Factor H (FH), and C5. Moreover, the global radiation data were collected from the regional agency of environmental protection (ARPA). The results show growing values for every protein in patients with PP, compared to control, in both seasons, in particular in summer compared to winter. To reinforce the evidence, we have estimated the personal exposure of patients based on the global radiation data. The main factors of the AP increased over the season, confirming the involvement of the AP in relation to light exposure. The systemic response could justify the general malaise of patients after long light exposure and can be exploited to elucidate new therapeutic approaches.
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Affiliation(s)
- Francesca Granata
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milan, Italy
| | - Lorena Duca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milan, Italy
| | - Valentina Brancaleoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milan, Italy
| | - Silvia Fustinoni
- EPIGET - Epidemiology, Epigenetics, and Toxicology Lab, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.,Environmental and Industrial Toxicology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo De Luca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milan, Italy
| | - Irene Motta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giovanna Graziadei
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milan, Italy
| | - Elena Di Pierro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, U.O.C. Medicina Generale, Milan, Italy
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33
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Wensink D, Wagenmakers MAEM, Barman-Aksözen J, Friesema ECH, Wilson JHP, van Rosmalen J, Langendonk JG. Association of Afamelanotide With Improved Outcomes in Patients With Erythropoietic Protoporphyria in Clinical Practice. JAMA Dermatol 2020; 156:570-575. [PMID: 32186677 DOI: 10.1001/jamadermatol.2020.0352] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The effectiveness of afamelanotide treatment in patients with erythropoietic protoporphyria (EPP) in clinical practice who experience pain after light exposure that substantially impairs quality of life is unknown. Objective To evaluate the association of afamelanotide treatment with outcomes in patients with EPP in regular practice during longer-term follow-up. Design, Setting, and Participants This single-center, prospective postauthorization safety and efficacy cohort study was directed and approved by the European Medicines Agency. Data were collected from patients with EPP treated with afamelanotide at Erasmus MC between June 2016 and September 2018. Analysis began October 2018. Main Outcomes and Measures Time spent outside during treatment, number of phototoxic reactions, disease-specific quality of life, usage of protective clothing, and adverse events. Results A total of 117 patients with EPP (59 women [50.4%]; mean [SD] age, 43.0 [15.5] years) were treated with afamelanotide. Nearly all patients continued treatment (115 [98%]) with a median (interquartile range) follow-up of 2.0 (1.3-2.1) years. Compared with baseline, mean time spent outside during treatment increased significantly by an added 6.1 hours per week (95% CI, 3.62-8.67; P < .001). Mean quality of life score improved significantly by 14.01% (95% CI, 4.53%-23.50%; P < .001). Phototoxic reactions were less painful (β, -0.85; 95% CI, -1.43 to -0.26; P < .001), but there was no significant difference in number or duration of reactions. Minor self-limiting adverse events occurred, such as nausea, fatigue, and headache. Conclusions and Relevance This cohort study found that afamelanotide treatment was associated with improved clinical outcomes and a good safety profile for patients with EPP. The treatment has clinically significant, sustained positive associations with quality of life, is associated with increased duration of sun exposure, and is associated with less severe phototoxic reactions.
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Affiliation(s)
- Debby Wensink
- Porphyria Center Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Margreet A E M Wagenmakers
- Porphyria Center Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Edith C H Friesema
- Porphyria Center Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - J H Paul Wilson
- Porphyria Center Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Janneke G Langendonk
- Porphyria Center Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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34
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Heerfordt IM, Heydenreich J, Philipsen PA, Lerche CM, Wulf HC. Light-provoked skin symptoms on the hands of erythropoietic protoporphyria patients related to personal dosimeter measurements, skin symptoms, light protection and priming. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2020; 213:112054. [PMID: 33075648 DOI: 10.1016/j.jphotobiol.2020.112054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/08/2020] [Indexed: 12/29/2022]
Abstract
Erythropoietic protoporphyria (EPP) is characterised by accumulation of protoporphyrin IX (PpIX) in erythrocytes. Upon illumination PpIX is released to the skin. Activation of the photoactive substance PpIX causes painful skin symptoms. This study aimed to objectively quantify individual light exposure of EPP patients in their everyday lives through spring and summer. We further aimed to establish the associations between daily symptoms and light exposure dose to photoprimed and non-photoprimed skin, use of gloves, and erythrocyte PpIX concentration. 14 Danish EPP patients participated from April through June, the period when symptoms are most frequent. Light exposure was measured using personal electronic dosimeters with sensor sensitivity comparable to the absorption spectrum of PpIX, measuring the biological effect of the light in this disease. Concurrently participants reported symptoms and use of protective gloves in a diary. Patients had a blood sample analysed for erythrocyte PpIX. The median patient was exposed to an average daily PpIX-weighted light dose of 3.8 J/cm2 corresponding to approximately 15 min in the midday sun during summer in Denmark. The median patient reported symptoms on 29% and wore gloves on 11% of study days. There was a significant positive correlation between erythrocyte PpIX concentration and percentage of days wearing gloves (r = 0.65, p = 0.011), and a significant negative correlation between erythrocyte PpIX concentration and mean daily light dose on days not wearing gloves (r = -0.53, p = 0.049). Photosensitivity was strongly dependent on photopriming.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Jakob Heydenreich
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Peter A Philipsen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Catharina M Lerche
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Hans Christian Wulf
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
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Barman-Aksözen J, Nydegger M, Schneider-Yin X, Minder AE. Increased phototoxic burn tolerance time and quality of life in patients with erythropoietic protoporphyria treated with afamelanotide - a three years observational study. Orphanet J Rare Dis 2020; 15:213. [PMID: 32811524 PMCID: PMC7437008 DOI: 10.1186/s13023-020-01505-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is an ultra-rare genetic disorder (prevalence 1:150`000) characterized by instant painful phototoxic burn reactions in skin exposed to visible light. Afamelanotide is the first clinically tested therapy effectively increasing the time EPP patients can spend in direct sunlight without developing symptoms and reducing the number and severity of phototoxic reactions. OBJECTIVES We report our data on real-world effectiveness of afamelanotide treatment in EPP and its phototoxic burn protection factor (PBPF). METHODS We analysed clinical data collected between 2016 and 2018 in the Swiss EPP cohort (n = 39) on maximum phototoxic burn tolerance time (PBTT), i.e., maximum time spent in sunlight without phototoxic reaction, severity of phototoxic reactions as assessed by an 11-point Likert-type visual analogue scale (VAS), with 0 being no pain and 10 being the worst possible pain, and Quality of Life (QoL), as assessed with an EPP-specific instrument. RESULTS Before treatment, the PBTT was median 10 min (IQR 5-20). Under treatment, PBTT increased to median 180 min (IQR 120-240). Individual PBPF increased 1.8- to 180-fold (full range, median 15). The pain severity of the worst phototoxic reaction before treatment was median 10 and under treatment median 6 (IQR 3-7). QoL at the end of the observation period in 2018 (with all the assessed patients under treatment) was 81.4% (IQR 69.4-93.4, n = 34). A 97.4% treatment adherence rate was observed. CONCLUSION Treatment of EPP patients with afamelanotide is highly effective under real-world conditions. We suggest PBTT as a clinical meaningful endpoint in further clinical trials.
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Affiliation(s)
| | - Michèle Nydegger
- Institute of Anesthesia and Intensive Medicine, Stadtspital Waid und Triemli, Zurich, Switzerland
| | - Xiaoye Schneider-Yin
- Institute of Laboratory Medicine, Stadtspital Waid und Triemli, Zurich, Switzerland
| | - Anna-Elisabeth Minder
- Department for Endocrinology, Diabetology, Porphyria, Stadtspital Waid und Triemli, Zurich, Switzerland.
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36
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Heerfordt IM, Lerche CM, Wulf HC. Trends in erythrocyte protoporphyrin IX concentration by age, sex and season among patients with erythropoietic protoporphyria-20 years of follow-up. Photodiagnosis Photodyn Ther 2020; 32:101928. [PMID: 32717453 DOI: 10.1016/j.pdpdt.2020.101928] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is an inherited disorder leading to an increased concentration of the photoactive protoporphyrin IX (PpIX) in erythrocytes. Upon photoactivation in the dermal blood vessels and release to the skin, it causes painful skin symptoms when illuminated, depending on PpIX concentration. The present study aimed to investigate if erythrocyte PpIX concentration changes with age in patients with EPP. In addition, we tested gender differences and seasonal variation in erythrocyte PpIX concentration. METHODS 53 EPP patients aged 0-90 years were included in this retrospective observational study. A total of 751 blood samples were routinely analyzed for erythrocyte PpIX between 2000 and 2020. Trends in erythrocyte protoporphyrin IX concentration depending on age, sex and season were investigated. RESULTS Erythrocyte PpIX levels increased during childhood and youth (median annual increase of 2.7 μmol/L) to reach a stable level in adults though, with a decrease in concentration of about 8% in summer. On average the PpIX level was higher in men (mean of 56 μmol/L, range: 6-139) than women (mean of 38 μmol/L, range: 6-82). CONCLUSION We hope that our results can contribute to finding a physiological explanation for the changes in erythrocyte PpIX observed throughout the lives of patients with EPP.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Denmark.
| | - Catharina M Lerche
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Denmark
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37
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Phillips JD. Heme biosynthesis and the porphyrias. Mol Genet Metab 2019; 128:164-177. [PMID: 31326287 PMCID: PMC7252266 DOI: 10.1016/j.ymgme.2019.04.008] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 04/10/2019] [Accepted: 04/18/2019] [Indexed: 01/08/2023]
Abstract
Porphyrias, is a general term for a group of metabolic diseases that are genetic in nature. In each specific porphyria the activity of specific enzymes in the heme biosynthetic pathway is defective and leads to accumulation of pathway intermediates. Phenotypically, each disease leads to either neurologic and/or photocutaneous symptoms based on the metabolic intermediate that accumulates. In each porphyria the distinct patterns of these substances in plasma, erythrocytes, urine and feces are the basis for diagnostically defining the metabolic defect underlying the clinical observations. Porphyrias may also be classified as either erythropoietic or hepatic, depending on the principal site of accumulation of pathway intermediates. The erythropoietic porphyrias are congenital erythropoietic porphyria (CEP), and erythropoietic protoporphyria (EPP). The acute hepatic porphyrias include ALA dehydratase deficiency porphyria, acute intermittent porphyria (AIP), hereditary coproporphyria (HCP) and variegate porphyria (VP). Porphyria cutanea tarda (PCT) is the only porphyria that has both genetic and/or environmental factors that lead to reduced activity of uroporphyrinogen decarboxylase in the liver. Each of the 8 enzymes in the heme biosynthetic pathway have been associated with a specific porphyria (Table 1). Mutations affecting the erythroid form of ALA synthase (ALAS2) are most commonly associated with X-linked sideroblastic anemia, however, gain-of-function mutations of ALAS2 have also been associated with a variant form of EPP. This overview does not describe the full clinical spectrum of the porphyrias, but is meant to be an overview of the biochemical steps that are required to make heme in both erythroid and non-erythroid cells.
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Affiliation(s)
- John D Phillips
- Division of Hematology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States of America.
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38
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Weiss Y, Balwani M, Chen B, Yasuda M, Nazarenko I, Desnick RJ. Congenital erythropoietic porphyria and erythropoietic protoporphyria: Identification of 7 uroporphyrinogen III synthase and 20 ferrochelatase novel mutations. Mol Genet Metab 2019; 128:358-362. [PMID: 30454868 DOI: 10.1016/j.ymgme.2018.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 12/16/2022]
Abstract
The erythropoietic porphyrias are inborn errors of heme biosynthesis with prominent cutaneous manifestations. They include autosomal recessive Congenital Erythropoietic Porphyria (CEP) due to loss-of-function (LOF) mutations in the Uroporphyrinogen III Synthase (UROS) gene, Erythropoietic Protoporphyria (EPP) due to LOF mutations in the ferrochelatase (FECH) gene, and X-Linked Protoporphyria (XLP) due to gain-of-function mutations in the terminal exon of the Aminolevulinic Acid Synthase 2 (ALAS2) gene. During the 11-year period from 01/01/2007 through 12/31/2017, the Mount Sinai Porphyrias Diagnostic Laboratory provided molecular diagnostic testing for one or more of these disorders in 628 individuals, including 413 unrelated individuals. Of these 628, 120 patients were tested for CEP, 483 for EPP, and 331 for XLP, for a total of 934 tests. For CEP, 24 of 78 (31%) unrelated individuals tested had UROS mutations, including seven novel mutations. For EPP, 239 of 362 (66%) unrelated individuals tested had pathogenic FECH mutations, including twenty novel mutations. The IVS3-48 T > C low-expression allele was present in 231 (97%) of 239 mutation-positive EPP probands with a pathogenic FECH mutation. In the remaining 3%, three patients with two different FECH mutations in trans were identified. For XLP, 24 of 250 (10%) unrelated individuals tested had ALAS2 exon 11 mutations. No novel ALAS2 mutations were identified. Among family members referred for testing, 33 of 42 (79%) CEP, 62 of 121 (51%) EPP, and 31 of 81 (38%) XLP family members had the respective family mutation. Mutation-positive CEP, EPP, and XLP patients who had been biochemically tested had marked elevations of the disease-appropriate porphyrin intermediates. These results expand the molecular heterogeneity of the erythropoietic porphyrias by adding a total of 27 novel mutations. The results document the usefulness of molecular testing to confirm the positive biochemical findings in these patients and to identify heterozygous family members.
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Affiliation(s)
- Yedidyah Weiss
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Brenden Chen
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Irina Nazarenko
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Naik H, Shenbagam S, Go AM, Balwani M. Psychosocial issues in erythropoietic protoporphyria - the perspective of parents, children, and young adults: A qualitative study. Mol Genet Metab 2019; 128:314-319. [PMID: 30711301 PMCID: PMC6660424 DOI: 10.1016/j.ymgme.2019.01.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/21/2022]
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are rare photodermatoses, generally presenting in childhood with severe and painful phototoxicity. EPP has been reported to negatively affect quality of life (QoL), but there is limited information on the psychosocial issues faced by patients and families. To address this, an online focus group study was conducted to explore the perspective of parents of children with EPP, and young adults and children with EPP. Five focus groups were conducted in a semi-structured format, with moderator-led discussions exploring the impact on QoL. Three focus groups included parents of children with EPP, one with children aged 10-11 years, and another with young adults aged 24-25 years, for a total of 24 participants. Thematic data analysis showed that parents experience guilt for being unable to protect their children and frustration with the current state of knowledge of EPP. Parents also admitted that the disease can lead to stress within family members which is difficult to manage. Young adults expressed embarrassment over having to explain the disease to others. They reported that the teenage years were the most difficult to navigate; however, they learned to adapt to their disease as they grew older. Children expressed that they had limited understanding of their disease and wished they were told what symptoms to expect by physicians earlier in life. Our findings emphasize the significant impact on QoL for these families and a lack of age appropriate information for children with EPP. These findings can help improve counseling and support resources for patients and caregivers.
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Affiliation(s)
- Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
| | - Shruti Shenbagam
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Allysa Marie Go
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
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Naik H, Overbey JR, Desnick RJ, Anderson KE, Bissell DM, Bloomer J, Bonkovsky HL, Phillips JD, Wang B, Singal A, Balwani M. Evaluating quality of life tools in North American patients with erythropoietic protoporphyria and X-linked protoporphyria. JIMD Rep 2019; 50:9-19. [PMID: 31741822 PMCID: PMC6850979 DOI: 10.1002/jmd2.12052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) and X-linked Protoporphyria (XLP) are rare photodermatoses presenting with severe phototoxicity. Although anecdotally, providers who treat EPP patients acknowledge their life-altering effects, tools that fully capture their impact on quality of life (QoL) are lacking. METHODS Adult patients with EPP/XLP were given four validated QoL tools: the Patient Reported Outcomes Measurement Information System 57 (PROMIS-57), the Hospital Anxiety and Depression Scale (HADS), the Illness Perception Questionnaire Revised (IPQR), and an EPP-Specific tool. All patients received the PROMIS-57 while the HADS, IPQR, and EPP-Specific tools were introduced at a later date. Associations between responses and clinical phenotypes were explored. RESULTS Two hundred and two patients were included; 193 completed PROMIS-57, 104 completed IPQR, 103 completed HADS, and 107 completed the EPP-Specific tool. The IPQR showed that patients strongly believed EPP/XLP had a negative impact on their lives. Mean scores in anxiety and depression domains of both HADS and PROMIS-57 were normal; however, anxiety scores from HADS were borderline/abnormal in 20% of patients. The EPP-Specific tool revealed a decreased QoL in most patients. The PROMIS-57 showed that 21.8% of patients have clinically significant pain interference. Several tool domains correlated with measures of disease severity, most being from the PROMIS-57. CONCLUSIONS Impaired QoL is an important consequence of EPP/XLP. PROMIS-57 was most sensitive in evaluating impaired QoL in EPP/XLP. Further research is needed to compare the effectiveness of it for assessing response to treatment.
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Affiliation(s)
- Hetanshi Naik
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNew York
| | - Jessica R. Overbey
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew York
| | - Robert J. Desnick
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNew York
| | - Karl E. Anderson
- Department of Preventive Medicine and Community HealthUniversity of Texas Medical BranchGalvestonTexas
| | - D. Montgomery Bissell
- Department of Medicine and Liver CenterUniversity of CaliforniaSan FranciscoCalifornia
| | - Joseph Bloomer
- Department of MedicineUniversity of AlabamaBirminghamAlabama
| | - Herbert L. Bonkovsky
- Department of Medicine (Section on Gastroenterology & Hepatology)Wake Forest NC Baptist Medical CenterWinston‐SalemNorth Carolina
| | - John D. Phillips
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtah
| | - Bruce Wang
- Department of Medicine and Liver CenterUniversity of CaliforniaSan FranciscoCalifornia
| | - Ashwani Singal
- Department of MedicineUniversity of AlabamaBirminghamAlabama
| | - Manisha Balwani
- Department of Genetics and Genomic SciencesIcahn School of Medicine at Mount SinaiNew YorkNew York
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Ardalan ZS, Chandran S, Vasudevan A, Angus PW, Grigg A, He S, Macdonald GA, Strasser SI, Tate CJ, Kennedy GA, Testro AG, Gow PJ. Management of Patients With Erythropoietic Protoporphyria-Related Progressive Liver Disease. Liver Transpl 2019; 25:1620-1633. [PMID: 31469227 DOI: 10.1002/lt.25632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/10/2019] [Indexed: 12/23/2022]
Abstract
Erythropoietic protoporphyria (EPP) is an inherited metabolic disorder of heme synthesis resulting from overproduction of protoporphyrin IX (PPIX), which can lead to progressive liver disease characterized by recurrent EPP crises and end-stage liver disease. We used the Australian Transplant Registry to identify 5 patients referred for liver transplantation between 2008 and 2017. A total of 4 patients had EPP secondary to ferrochelatase deficiency, and 1 patient had X-linked EPP. No patient had follow-up with a specialist prior to the diagnosis of progressive liver disease. There were 3 patients who underwent orthotopic liver transplantation, whereas 2 died while on the transplant waiting list. Parenteral PPIX-lowering therapy was used in 4 patients and was effective in 3 patients, although 2 of these had rebound porphyria and worsening liver function following a decrease in the intensity of therapy. Early disease recurrence in the allograft following transplantation occurred in 2 patients requiring red cell exchange (RCE) to successfully attain and maintain low PPIX levels, but RCE was associated with hemosiderosis in 1 patient. Allogeneic stem cell transplantation (AlloSCT) was performed in 2 patients. One failed engraftment twice, whereas the second rejected the first graft but achieved full donor chimerism with a second graft and increased immunosuppression. In conclusion, our observations suggest that progressive liver disease needs parenteral PPIX-lowering treatment with the intensity adjusted to achieve a target Erc-PPIX level. Because EPP liver disease is universally recurrent, AlloSCT should be considered in all patients with adequate immunosuppression to facilitate engraftment. RCE appears to be effective for recurrent EPP liver disease but is associated with an increased risk of iron overload.
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Affiliation(s)
- Zaid S Ardalan
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia.,Department of Gastroenterology, Alfred Hospital, Melbourne, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Peter W Angus
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia.,Melbourne University, Melbourne, Australia
| | - Andrew Grigg
- Department of Clinical Hematology, Austin Hospital, Melbourne, Australia
| | - Simon He
- Department of Clinical Hematology, Austin Hospital, Melbourne, Australia
| | - Graeme A Macdonald
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Courtney J Tate
- Department of Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Glen A Kennedy
- Department of Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Adam G Testro
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia
| | - Paul J Gow
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia
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Rutter KJ, Ashraf I, Cordingley L, Rhodes LE. Quality of life and psychological impact in the photodermatoses: a systematic review. Br J Dermatol 2019; 182:1092-1102. [PMID: 31278744 DOI: 10.1111/bjd.18326] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The photodermatoses affect large proportions of the population but their impact on quality of life (QoL) and psychological health has not been reviewed. Several tools are available to evaluate QoL and psychological impacts. OBJECTIVES To systematically review current literature to identify tools used to assess QoL and psychological impacts in patients with photodermatoses, and to summarize the reported findings. METHODS A systematic search of PubMed, OVID Medline, PsycInfo and CINAHL was performed for articles investigating QoL and/or psychological impact in patients with photodermatoses, published between 1960 and September 2018. RESULTS Twenty studies were included: 19 incorporated QoL assessment while three evaluated psychological morbidity. Six QoL tools were found to be used: Dermatology Life Quality Index (DLQI), Children's DLQI, Family DLQI, Skindex (16- and 29-item versions), Erythropoietic Protoporphyria Quality of Life (EPP-QoL) and EuroQol. Between 31% and 39% of photosensitive patients reported a very large impact on QoL (DLQI > 10). Employment and education, social and leisure activities, and clothing choices were particularly affected. Only one tool was specifically designed for a photodermatosis (EPP-QoL). Four tools were used to evaluate psychological impact: the Hospital Anxiety and Depression Scale, Fear of Negative Evaluation, brief COPE and Illness Perception Questionnaire-Revised. Levels of anxiety and depression were approximately double British population data. Patients with facial involvement, female gender and younger age at onset showed more psychological morbidity. CONCLUSIONS Several tools have been used to assess QoL in the photodermatoses, and confirm substantial impact on QoL. Development of specific, validated QoL measures would address their unique impacts. Research delineating their psychological comorbidity is sparse and requires further exploration. What's already known about this topic? The photodermatoses negatively impact quality of life (QoL) and cause psychological distress, but no reviews of this area appear in the literature. What does this study add? Few studies have explored the psychological and social impacts of the photodermatoses. There are no fully validated QoL tools specific to the photodermatoses. Around one-third of adult and child patients with photosensitivity experience very or extremely large impact on QoL, with particular effect on clothing choices, employment and social and leisure activities. Studies suggest anxiety and depression levels in these patients are around double those in the U.K. general population. More attention is required on these 'hidden' conditions.
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Affiliation(s)
- K J Rutter
- Centre for Dermatology Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - I Ashraf
- Centre for Dermatology Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - L Cordingley
- Health Psychology, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - L E Rhodes
- Centre for Dermatology Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester and Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
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43
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Collier V, Danford B, Boyd A. Erythema and blistering after sun exposure in a 12-year-old boy. Pediatr Dermatol 2019; 36:e83-e85. [PMID: 31290603 DOI: 10.1111/pde.13853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Victoria Collier
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brandon Danford
- Department of Dermatology, Vanderbilt University Hospital, Nashville, Tennessee
| | - Alan Boyd
- Department of Dermatology, Vanderbilt University Hospital, Nashville, Tennessee
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Juengling AM, Boulter EL, Kava MP. Erythropoietic protoporphyria: A rare cause of painful hands and feet. J Paediatr Child Health 2019; 55:236-238. [PMID: 30288822 DOI: 10.1111/jpc.14244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 08/12/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Anne-Marie Juengling
- Rheumatology Department, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Emily L Boulter
- Rheumatology Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Department of General Paediatrics, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Maina P Kava
- Neurology Department, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
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45
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Lala SM, Naik H, Balwani M. Diagnostic Delay in Erythropoietic Protoporphyria. J Pediatr 2018; 202:320-323.e2. [PMID: 30041937 PMCID: PMC6203604 DOI: 10.1016/j.jpeds.2018.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/09/2018] [Accepted: 06/01/2018] [Indexed: 12/15/2022]
Abstract
Erythropoietic protoporphyria is a photodermatosis presenting in childhood with severe pain on sun exposure. The diagnosis is often delayed because of the lack of awareness among pediatricians. We describe the diagnostic odyssey of 2 children presenting with symptoms of erythropoietic protoporphyria and report results of a survey of 129 affected individuals.
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Affiliation(s)
- Sajel M Lala
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY.
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46
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Gou E, Weng C, Greene T, Anderson KE, Phillips JD. Longitudinal Analysis of Erythrocyte and Plasma Protoporphyrin Levels in Patients with Protoporphyria. J Appl Lab Med 2018; 3:213-221. [DOI: 10.1373/jalm.2017.025874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 03/26/2018] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are inherited cutaneous porphyrias resulting from decreased activity of ferrochelatase and gain-of-function mutations of δ-aminolevulinic acid synthase-2, respectively. Both of these protoporphyrias cause increased protoporphyrin levels that cause photosensitivity and may lead to hepatopathy and further increases in erythrocyte and plasma porphyrin levels.
Methods
We evaluated erythrocyte protoporphyrin and plasma porphyrin levels in all subjects with EPP (83 subjects) or XLP (9 subjects) without evidence of liver disease tested repeatedly at a single laboratory over 25 years.
Results
Intersubject variation contributed more than intrasubject variation (78.86% vs 21.14%) to overall variability, and longitudinal variability, estimated by CV, averaged 26%. Erythrocyte total protoporphyrin levels were similar in males and females with EPP (ratio, 0.99; 95% CI, 0.82–1.21; P = 0.96) but were higher in males than females with XLP, although this difference was not statistically significant (ratio, 0.76; 95% CI, 0.43–1.36; P = 0.35). Analysis of 20 subjects from 9 separate families showed significant effects of family compared with effects of individual variation on total variance (50% vs 25%; P < 0.0001).
Conclusion
Variation of erythrocyte total protoporphyrin up to 25% is expected in patients with protoporphyria, whereas greater increases might raise concern for protoporphyric hepatopathy.
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Affiliation(s)
- Eric Gou
- University of Texas Medical Branch, Galveston, TX
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Coffey A, Leung DH, Quintanilla NM. Erythropoietic Protoporphyria: Initial Diagnosis With Cholestatic Liver Disease. Pediatrics 2018; 141:S445-S450. [PMID: 29610169 DOI: 10.1542/peds.2016-1625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2017] [Indexed: 11/24/2022] Open
Abstract
The porphyrias are a group of rare metabolic disorders that result from defects in heme biosynthesis. Erythropoietic protoporphyria (EPP) is the most common inherited porphyria in children and is diagnosed in most individuals after the onset of cutaneous manifestations. Hepatobiliary disease affects the minority of individuals with EPP and usually manifests in patients with an established diagnosis of EPP. We report on a classic but rare case of EPP that masqueraded as cholestasis. An 8-year-old boy was referred to the Hepatology Clinic after an abrupt onset of jaundice with a longstanding history of dermatitis. The diagnosis of EPP was established with liver biopsy, which revealed dense, dark-brown pigment in hepatocytes and Kupffer cells that, on polarization, displayed bright-red birefringence and centrally located Maltese crosses. Plasma total porphyrins and erythrocyte protoporphyrin were elevated and confirmed a diagnosis of EPP. We hope to raise awareness of this diagnosis among pediatricians, hepatologists, and pathologists and increase the consideration of EPP in patients with cholestatic liver disease and chronic dermatitis.
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Affiliation(s)
- Amy Coffey
- Departments of Pathology and Immunology and.,Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Daniel H Leung
- Pediatrics, Baylor College of Medicine, Houston, Texas; and.,Division of Pediatric Gastroenterology, Hepatology, and Nutrition and
| | - Norma M Quintanilla
- Departments of Pathology and Immunology and .,Department of Pathology, Texas Children's Hospital, Houston, Texas
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Suijker I, Savas M, van Rossum EFC, Langendonk JG. Hair cortisol is elevated in patients with erythropoietic protoporphyria and correlates with body mass index and quality of life. Br J Dermatol 2018; 178:1209-1210. [PMID: 29341104 DOI: 10.1111/bjd.16341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- I Suijker
- Porphyria Center, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - M Savas
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - E F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - J G Langendonk
- Porphyria Center, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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49
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Biewenga M, Matawlie RHS, Friesema ECH, Koole-Lesuis H, Langeveld M, Wilson JHP, Langendonk JG. Osteoporosis in patients with erythropoietic protoporphyria. Br J Dermatol 2017; 177:1693-1698. [PMID: 28815553 DOI: 10.1111/bjd.15893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare metabolic disease with painful photosensitivity due to protoporphyrin IX accumulation. OBJECTIVES To evaluate bone mineral density (BMD) and known osteoporosis risk factors in patients with EPP. METHODS Patients with EPP attending the Erasmus MC outpatient clinic who had undergone BMD measurements were included. Plasma 25 hydroxy (OH) vitamin D, alkaline phosphatase, parathyroid hormone and total protoporphyrin IX levels were measured; information on lifestyle, sunlight exposure and a bone-relevant physical exercise index [Bone Physical Activity Questionnaire (BPAQ) score] was obtained via questionnaires. BMD scores and the prevalence of osteopenia and osteoporosis in the EPP population were compared with a reference population. RESULTS Forty-four patients with EPP (23 female, 21 male; mean age 37·6 years) were included. The mean SDs of the T-scores were -1·12 for the lumbar spine and -0·82 for the femoral neck (both P < 0·001). Osteopenia was present in 36%; osteoporosis in 23%. Based on the reference population the expected prevalence was 15% and 1%, respectively. Prevalence of vitamin D deficiency was 50% (defined as a 25-OH vitamin D level < 50 nmol L-1 ). Mean self-reported BPAQ score was 19·4 units (reference interval 19-24). Multiple linear regression analysis showed a significant influence of vitamin D deficiency and bone-relevant physical exercise score on BMD in patients with EPP. CONCLUSIONS The prevalence of osteoporosis and osteopenia is greatly increased in patients with EPP. Alkaline phosphatase (related to vitamin D deficiency) and amount of weight-bearing exercise are significantly correlated with low BMD in this population.
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Affiliation(s)
- M Biewenga
- Department of Internal Medicine, Porphyria Centre, Centre for Lysosomal and Metabolic Diseases, Erasmus MC, PO Box 2040, 3000, CA Rotterdam, the Netherlands
| | - R H S Matawlie
- Department of Internal Medicine, Porphyria Centre, Centre for Lysosomal and Metabolic Diseases, Erasmus MC, PO Box 2040, 3000, CA Rotterdam, the Netherlands
| | - E C H Friesema
- Department of Internal Medicine, Porphyria Centre, Centre for Lysosomal and Metabolic Diseases, Erasmus MC, PO Box 2040, 3000, CA Rotterdam, the Netherlands
| | - H Koole-Lesuis
- Department of Internal Medicine, Porphyria Centre, Centre for Lysosomal and Metabolic Diseases, Erasmus MC, PO Box 2040, 3000, CA Rotterdam, the Netherlands
| | - M Langeveld
- Department of Internal Medicine, Porphyria Centre, Centre for Lysosomal and Metabolic Diseases, Erasmus MC, PO Box 2040, 3000, CA Rotterdam, the Netherlands
| | - J H P Wilson
- Department of Internal Medicine, Porphyria Centre, Centre for Lysosomal and Metabolic Diseases, Erasmus MC, PO Box 2040, 3000, CA Rotterdam, the Netherlands
| | - J G Langendonk
- Department of Internal Medicine, Porphyria Centre, Centre for Lysosomal and Metabolic Diseases, Erasmus MC, PO Box 2040, 3000, CA Rotterdam, the Netherlands
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Abstract
This is an overview of the cutaneous porphyrias. It is a narrative review based on the published literature and my personal experience; it is not based on a formal systematic search of the literature. The cutaneous porphyrias are a diverse group of conditions due to inherited or acquired enzyme defects in the porphyrin-haem biosynthetic pathway. All the cutaneous porphyrias can have (either as a consequence of the porphyria or as part of the cause of the porphyria) involvement of other organs as well as the skin. The single commonest cutaneous porphyria in most parts of the world is acquired porphyria cutanea tarda, which is usually due to chronic liver disease and liver iron overload. The next most common cutaneous porphyria, erythropoietic protoporphyria, is an inherited disorder in which the accumulation of bile-excreted protoporphyrin can cause gallstones and, rarely, liver disease. Some of the porphyrias that cause blistering (usually bullae) and fragility (clinically and histologically identical to porphyria cutanea tarda) can also be associated with acute neurovisceral porphyria attacks, particularly variegate porphyria and hereditary coproporphyria. Management of porphyria cutanea tarda mainly consists of visible-light photoprotection measures while awaiting the effects of treating the underlying liver disease (if possible) and treatments to reduce serum iron and porphyrin levels. In erythropoietic protoporphyria, the underlying cause can be resolved only with a bone marrow transplant (which is rarely justifiable in this condition), so management consists particularly of visible-light photoprotection and, in some countries, narrowband ultraviolet B phototherapy. Afamelanotide is a promising and newly available treatment for erythropoietic protoporphyria and has been approved in Europe since 2014.
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Affiliation(s)
- Robert Dawe
- Scottish Cutaneous Porphyria Service, Scottish Photodiagnostic Unit, Department of Dermatology, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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