Professional Documents
Culture Documents
APPROACH TO A PATIENT WITH
PHOTOSENSITIVITY
PRESENTER ‐ DR PANKAJ CHATURVEDI
PRESENTER DR PANKAJ CHATURVEDI
MODERATOR‐ DR SOMESH GUPTA
ALL INDIA INSTITUTE OF MEDICAL SCIENCES (AIIMS)
ALL INDIA INSTITUTE OF MEDICAL SCIENCES (AIIMS)
Feedback will be appreciated
drpankaj4u@gmail.com
Photosensitivity
Abnormal cutaneous response to ordinary
light exposure .
Causes
1)Idiopathic photodermatoses 4)Photoexacerbated
) h b d dermatoses
d
Polymorphous light eruption Autoimmune diseases
(PMLE) Lupus erythematosus
Actinic prurigo Dermatomyositis
Hydroa vacciniforme Pemphigus
Chronic actinic dermatitis Bullous pemphigoid
Solar urticaria Pemphigus erythematosus
2)Secondary to exogenous Genodermatoses
agents Hailey‐Hailey disease
Photoallergy Darier,s disease
Phototoxicity Bloom syndrome
3)Secondary to endogenous
) y g Rothmund‐Thompson syndrome
p y
agents Kindler syndrome
Porphyrias Cockayne,s syndrome
Xeroderma pigmentosum
pg
Trichothiodystrophy
Hartnup disese
Causes
Infections Other dermatological disorders
Herpes simplex Atopic dermatitis
Viral exanthems
Viral exanthems Acne
Verruca plana Grover,s disease
Nutritional deficiencies Disseminated superficial actinic
porokeratoses
Pellagra
Lichen planus
Pyridoxine deficiency
Psoriasis
Reticular erythematous
m cinosis (REM) syndrome
mucinosis (REM) s ndrome
Rosacea
Cutaneous T‐cell lymphoma
Erythema
E th multiforme
ltif
Granuloma annulare
Jessner,s lymphocytic infiltrate
Pityriasis
Pi i i rubrab pilaris
il i
Seborrhoeic dermatitis
When to suspect a
photosensitive disorder?
photosensitive disorder?
Which sites are involved ?
Which sites are involved ?
Which sites are not involved ?
Which sites are not involved ?
History
Age of onset
Age of onset
IInfants and toddlers
f t d t ddl SSchool going children
h l i hild
Genodermatoses Polymorphous light
Erythropoietic eruption
porphyrias Hydroa vacciniforme
Neonatal/ Childhood
N t l/ Childh d Actinic prurigo (girls)
A ti i i ( il)
LE SLE
Juvenile
dermatomyositis
Age of onset
Age of onset
Adults
Ad lt Eld l
Elderly
Polymorphous light
eruption Chronic actinic
Solar urticaria dermatitis
Drug induced
D i d d Drug induced
D i d d
photosensitivity photosensitivity
Porphyria cutanea
P h i t
tarda
Lupus erythematous
Lupus erythematous
Symptoms
Itching
Burning pain
Burning pain ‐ Erythropoietic porphyria
Erythropoietic porphyria
Occular symptoms ‐ Actinic prurigo
‐ Hydroa vacciniforme
H d i if
Mucosal involvement ‐ Actinic prurigo
‐ Pellagra
‐ SLE
Systemic symptoms
Systemic symptoms ‐ Solar urticaria
Solar urticaria
‐ Porphyria
‐ SLE
‐ Pellagra
Relation to sun exposure
p
Latent interval between exposure and
eruption
Few minutes
Solar urticaria
Drug induced like amiodarone
Upto few hrs
PLE
Hydroa vacciniforme
Drug induced (thiazides)
Hydroa vacciniformis
EPP
SCLE
Relation to sun exposure
Relation to sun exposure
TType and amount of sunexposure
d f
Prolonged exposure after a long gap ‐ PMLE
Tanning beds (UVA)
Relation to season
Early part of the sunny season and becomes
less severe as the season progresses –
p g PMLE
Does rash comes in episodes?
Is patient completely asymptomatic in
between episodes?
Yes ‐ Photodermatoses
No ‐ Photo exacerbated dermatoses
Duration of the persistence of the lesions in the
absence of additional sunexposure
Subside in hours → solar urticaria
Subside in days to wks → PMLE
Persist wks to months/throughout the
season → CAD,
CAD PCT
Patient described morphology of the lesions
Patient described morphology of the lesions
Wheals
Erythema
Blisters
Papules
Scarring
Whether lesions occur by window glass
Whether lesions occur by window glass
filtered sunlight ?
Yes – UVA
Lesions occuring/worsening despite
sunscreen application
sunscreen application
Drug history
Drug history
History of drugs which pt has taken
Hi fd hi h h k
History of drugs which patient has applied
History of Desi/Homeopathic/Ayruvedic medication
eg Bagchi
History of other over the counter preparations
which patient may not consider medications/drugs
History of cosmetics/ perfumes
Photosensitizing Agents
Occupational history
Occupational history
Exposure to sun, artificial light sources
Handling of plants, drugs and chemicals
Handling of plants drugs and chemicals
Family history
Genodermatoses
Porphyria
PMLE (20%)
Actinic prurigo (20%)
p g ( )
Examination
Distribution of the lesions
IInvolvement of
l t f SSparing of
i f
Forehead Below the eyebrows
Bridge of nose
Bridge of nose under the hair fringe
under the hair fringe
Upper cheeks on the upper eyelids
Chin
Chin below the nose
below the nose
Helix of the ear Upper lip
Back and sides of the
Back and sides of the Behind the earlobes
Behind the earlobes
neck Distal phalynx &
V area of neck webspaces of the
Dorsa of the hands and
fingers
feet skin folds
Extensor extremities
Macules/Papules
PMLE
LE
AP
Drug eruption
AP AP AP
PMLE PMLE
Drug induced photosensitivity
Erythematous edematous plaques
edematous plaques
PMLE
LE
DM
Porphyria
PMLE PMLE PMLE
SLE Seb. Dermatitis
DM
DM
PCT
Eczematous plaques
Eczematous plaques
CAD
AIDS
Thiazides
Photosensitive atopic dermatitis
CAD Photoallergic CD
CAD HIV Pt with drug induced photosensitivity
Pellagra
Vesiculobullous
Hydroa vacciniforme
H d i if
Porphyria
Juvenile Spring Eruption
Phototoxic CD
Drugs (Frusemide, Nalidixic Acid, )
HV
Juvenile spring eruption
PCT
Phototoxic der. d/t topical
Psoralens
Phytophotodermatitis
Lichenoid lesions
CAD
Actinic Reticuloid
Actinic LP
Drugs (Thiazides)
AR
AR
Telangiectasias
Rosacea
R
XP
Ataxia telengiectasis
Bloom syndrome
SLE
DM
Drugs (ACE inhibitor, Nifedipine, Amlodipine)
Rosacea
Bloom syndrome
Hyperpigmentation
Melasma
M l
Berloque dermatitis
Pellagra
Melasma Berloque derm
Scarring
Porphyria
P h i
HV
Hypertrichosis
P h i
Porphyria
Investigations
Phototesting
Ph i
Photopatch
Histopathology
Other lab. Studies
Phototesting
Not required for diagnosis until diagnosis is
N i d f di i il di i i
uncertain
Primarily a research tool
l h l
Phototesting
Monochromatic phototesting
M h i h i
Photoprovocation
Phototesting
Monochromatic phototesting
Monochromatic phototesting
Wavelength dependency of the disorder & to elicit
the eruption when possible
the eruption when possible
Exposure (covered areas) to a series of doses of UVR
to determine the MED (Xenon arc irradiation
to determine the MED (Xenon arc irradiation
monochromator )
Comparison with the range of results for the normal
C i ith th f lt f th l
population (by MED chart)
MED below the lower limit of normal
MED b l th l li it f l
↓
Photosensitivity present
Monochromatic phototesting
p g
Phototesting
Photoprovocation testing
To induce the lesion for clinical diagnosis/biopsy
T i d th l i f li i l di i /bi
Solar stimulator (Xenon arc filtered)
Large areas of skin known to be succeptable
L f ki k t b t bl for
f
eruption
Irradiation for 2‐3 consecutive days may be reqd.
Irradiation for 2 3 consecutive days may be reqd
Almost always +ve in solar urticaria, in minutes
Variable +ve
Variable +ve in PMLE (upto
in PMLE (upto 50% +ve
50% +ve if consecutive
if consecutive
for 2‐3 days)
Cant discriminate from other photodermatoses
Cant discriminate from other photodermatoses
Photoprovocation
p testingg
Photopatch
IIndication
di ti
Eczematous eruption in photodistribution
Photoallergic dermatitis
CAD (Photosensitivity dermatitis/ Actinic
reticuloid syndrome)
reticuloid syndrome)
(phototests also positive)
Photopatch series
5‐Bromo‐4
5 Bromo 4’chlorosalicylanilide 1%
chlorosalicylanilide 1% Camphor 10%
Camphor 10%
Hexachlorophene 1% 2‐phenyl‐5‐benzimidazolsulphonic
Bithionol 1% acid 10%
Sulfanilamide 1% Oxybenzone 10%
Promethazine hydrochloride 1% Thiourea 0.1%
Quinidine sulphate 1% Olaquindox 1%
Fragrance mix 1% Parthenium 1:100,1:200
(acetone)
para‐Aminobenzoic acid 10%
Xanthium (Aq)
2‐Ethylhexyl‐p‐
2 Ethylhexyl p
Dimethylaminobenzoate 10% Chrysanthemum (Aq)
Benzophenone‐4 10% Fentichlor
4‐tert‐butyl‐4’‐Methoxy‐
4 tert butyl 4 Methoxy 6‐methyl coumarin
Dibenzoylmethane Benzophenone
Isoamyl p‐methoxycinnamate Parthenium hysterophorus
10% Paraphenylenedimaine
2‐Ethylhexyl‐p‐methoxycinnamate Petrolatum (control
10%
Day 1
Day 1 –Perform
Perform MED testing. Apply duplicate sets of
MED testing Apply duplicate sets of
photoallergens on left and right back
Day 2
Day 2 – Read MEDs. Irradiate one set of allergens with UVA
Read MEDs Irradiate one set of allergens with UVA
(10 mJ/cm2 or 50% of MED‐A,
whichever is less), covering the other with an opaque
material
Day 5 – Perform second reading of reactions to both sets of
f f b h f
photoallergens
International Contact Dermatitis Research Group
Scoring System
± DDoubtful reaction (faint erythema only)
bf l i (f i h l )
+ Weak positive reaction (erythema, infiltration,
possibly papules)
bl l )
++ Strong positive reaction (erythema, infiltration,
papules, vesicles)
+++ Extreme positive reaction (intense erythema,
infiltration, coalescing vesicles or bulla
IR Irritant reaction
NT Not tested
German/ Swiss / Austrian
0 no erythema
1+ erythema
2+ erythema, infiltration,
2 erythema, infiltration, +/‐papule
/ papule
3+ erythema, papule, vesicle
4+ erythema blister erosion
4+ erythema,blister, erosion
Result
Reading of the photopatch test
Reading of the photopatch
Diagnosis Irradiated site Unirradiated
g site
No sensitivity ‐ ‐
Photocontact allergy + ‐
Contact allergy
Contact allergy + +
+ +
Photocontact & contact allergy ++ +
Results in CAD
Results in CAD
Phototests Photopatch
Phototests Photopatch
Persistent light reactors UVB+UVA+/‐VR PCD
Photosensitive eczema UVB ‐
Photosensitivity Dermatitis UVB+UVA+/‐VR +/‐
Histopathology
PMLE
9 +/‐
+/ spongiosis, dyskeratosis,
spongiosis dyskeratosis
exocytosis, basal cell
vacuolization
9 Tight perivascular infiltrate in
upper dermis and middermis (T
cells)
ll )
9 Upper dermal and perivascular
edema
9 Endothelial cell
Endothelial cell swelling
Actinic prurigo
Actinic prurigo
Acanthosis,exocytosis
A th i t i
spongiosis
Lymphohistiocytic
dermal perivascular
dermal perivascular
infiltration
Hydroa vacciniforme
Intraepidermal vesicle
I id l i l
Focal keratinocyte necrosis
Spongiosis
Dermal perivascular neutrophilic and
lymphocytic infiltration
Vasculitis+/‐
Solar urticaria
Solar urticaria
Dermal vasodilation
Dermal vasodilation
and edema
Mild interstitial and
P/V inflammatory cell
infiltrate of L & E
infiltrate of L & E
Chronic actinic dermatitis
Chronic actinic dermatitis
Epidermal spongiosis,
E id l i i
acanthosis
Perivascular
lymphocytic cellular
lymphocytic cellular
infiltrate , confined to
the upper dermis
pp
Actinic reticuloid
Actinic reticuloid
Marked acanthosis
Marked acanthosis
Mimic cutaneous T‐cell
l
lymphoma
h
¾ Pautrier‐like microabscesses
(rare)
¾ Dense epidermotropic
infiltrate
¾ Sometimes hyperchromatic
convoluted nuclei and giant
convoluted nuclei and giant
cells
¾ No marked increase in
mitoses
Phototoxic reactions
Phototoxic reactions
Necrosis of keratinocytes
N i f k ti t
Intraepidermal
I t id l blister
bli t
Epidermal necrosis
Epidermal necrosis
Spongiosis
Sparse dermal infiltrate.
Sparse dermal infiltrate
Porphyria cutanea tarda
Subepidermal blister
S b id l bli t
with minimal or no
infiltrate
Festooning
Other lab. Tests
Other lab. Tests
ANA If clinical suspicion of LE
Anti Ro/Ssa
Anti La/SSb
Urine, stool, blood porphyrin estimation
Blood film fluorescence
RBC protoporphyrin
Control Positive
¾ Autologus serum test in SU
Autologus serum test in SU
¾ Drug and chemical phototoxicity studies
Treatment
Photoprotection –
Ph i Cl hi H
Clothing, Hats
AND
Sunscreens
Symptomatic treatment
PMLE
Actinic Prurigo
Actinic Prurigo
Hydroa vacciniforme
Solar urticaria
Solar urticaria
CAD