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SEMINAR

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
ƒ Polymorphous light eruption  Autoimmune diseases
(PMLE) ƒ Lupus erythematosus
ƒ Actinic prurigo ƒ Dermatomyositis
ƒ Hydroa vacciniforme ƒ Pemphigus
ƒ Chronic actinic dermatitis ƒ Bullous pemphigoid
ƒ Solar urticaria ƒ Pemphigus erythematosus
2)Secondary to exogenous  Genodermatoses
agents ƒ Hailey‐Hailey disease
ƒ Photoallergy ƒ Darier,s disease
ƒ Phototoxicity ƒ Bloom syndrome
3)Secondary to endogenous 
) y g ƒ Rothmund‐Thompson syndrome
p y
agents ƒ Kindler syndrome
ƒ Porphyrias ƒ Cockayne,s syndrome
ƒ Xeroderma pigmentosum
pg
ƒ Trichothiodystrophy
ƒ Hartnup disese
Causes
Infections Other dermatological disorders
ƒ Herpes simplex ƒ Atopic dermatitis
ƒ Viral exanthems
Viral exanthems ƒ Acne
ƒ Verruca plana ƒ Grover,s disease
Nutritional deficiencies ƒ Disseminated superficial actinic 
porokeratoses
ƒ Pellagra
ƒ Lichen planus
ƒ Pyridoxine deficiency
ƒ Psoriasis
ƒ Reticular erythematous
m cinosis (REM) syndrome
mucinosis (REM) s ndrome
ƒ Rosacea
ƒ Cutaneous T‐cell lymphoma
ƒ Erythema
E th multiforme
ltif
ƒ Granuloma annulare
ƒ Jessner,s lymphocytic infiltrate
ƒ Pityriasis
Pi i i rubrab pilaris
il i
ƒ 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
ƒ Genodermatoses ƒ Polymorphous light 
ƒ Erythropoietic  eruption
porphyrias ƒ Hydroa vacciniforme
ƒ Neonatal/ Childhood 
N t l/ Childh d ƒ Actinic prurigo (girls)
A ti i i ( il)
LE ƒ SLE
ƒ Juvenile 
dermatomyositis
Age of onset
Age of onset

Adults
Ad lt Eld l
Elderly
ƒ Polymorphous light 
eruption ƒ Chronic actinic 
ƒ Solar urticaria dermatitis
ƒ Drug induced 
D i d d ƒ Drug induced
D i d d
photosensitivity photosensitivity 
ƒ Porphyria cutanea 
P h i t
tarda
ƒ Lupus erythematous
Lupus erythematous
Symptoms
ƒ Itching 
ƒ Burning pain                 
Burning pain ‐ Erythropoietic porphyria
Erythropoietic porphyria
ƒ Occular symptoms       ‐ Actinic prurigo
‐ Hydroa vacciniforme
H d i if
ƒ Mucosal involvement  ‐ Actinic prurigo
‐ Pellagra
‐ SLE
ƒ Systemic symptoms      
Systemic symptoms ‐ Solar urticaria
Solar urticaria
‐ Porphyria
‐ SLE
‐ Pellagra  
Relation to sun exposure
p
Latent interval between exposure and 
eruption
ƒ Few minutes
Solar urticaria
Drug induced like amiodarone
ƒ 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
ƒ Prolonged exposure after a long gap ‐ PMLE
ƒ Tanning beds (UVA)
Relation to season
ƒ 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?
ƒ Yes ‐ Photodermatoses
ƒ No ‐ Photo exacerbated dermatoses
Duration  of the persistence of the lesions in the 
absence of additional sunexposure
ƒ Subside in hours → solar urticaria
ƒ Subside in days to wks → PMLE
ƒ Persist wks to months/throughout the
season → CAD,
CAD PCT
Patient described morphology of the lesions
Patient described morphology of the lesions
ƒ Wheals

ƒ Erythema

ƒ Blisters

ƒ Papules

ƒ Scarring
ƒ Whether lesions occur by window glass 
Whether lesions occur by window glass
filtered sunlight ?
Yes – UVA
ƒ Lesions occuring/worsening despite 
sunscreen application
sunscreen application 
Drug history
Drug history

ƒ History of drugs which pt has taken
Hi fd hi h h k
ƒ History of drugs which patient has applied
ƒ History of Desi/Homeopathic/Ayruvedic medication 
eg Bagchi
ƒ History of other over the counter preparations 
which patient may not consider medications/drugs
ƒ History of cosmetics/ perfumes
Photosensitizing Agents
Occupational history
Occupational history
ƒ Exposure to sun, artificial light sources 
ƒ Handling of plants, drugs and chemicals
Handling of plants drugs and chemicals
Family history
ƒ Genodermatoses
ƒ Porphyria
ƒ PMLE (20%)
ƒ Actinic prurigo (20%)
p g ( )
Examination
Distribution of the lesions
IInvolvement of 
l t f SSparing of
i f
ƒ Forehead ƒ Below  the eyebrows
ƒ Bridge  of nose
Bridge of nose ƒ under the hair fringe
under the hair fringe
ƒ Upper cheeks ƒ on the upper eyelids 
ƒ Chin 
Chin below the nose
below the nose
ƒ Helix of the ear ƒ Upper lip  
ƒ Back  and sides of the 
Back and sides of the ƒ Behind  the earlobes
Behind the earlobes
neck ƒ Distal phalynx & 
ƒ V area of neck webspaces of the 
ƒ Dorsa  of the hands and 
fingers
feet ƒ skin folds
ƒ Extensor extremities
Macules/Papules

ƒ PMLE
ƒ LE
ƒ AP
ƒ Drug eruption
AP AP AP

PMLE PMLE
Drug induced photosensitivity
Erythematous edematous plaques
edematous plaques

ƒ PMLE
ƒ LE
ƒ DM
ƒ Porphyria
PMLE PMLE PMLE

SLE Seb. Dermatitis
DM

DM

PCT
Eczematous plaques
Eczematous plaques

ƒ CAD
ƒ AIDS
ƒ Thiazides
ƒ Photosensitive atopic dermatitis
CAD Photoallergic  CD

CAD HIV Pt with drug induced photosensitivity
Pellagra
Vesiculobullous

ƒ Hydroa vacciniforme
H d i if
ƒ Porphyria
ƒ Juvenile Spring Eruption
ƒ Phototoxic CD
ƒ Drugs (Frusemide, Nalidixic Acid, )
HV

Juvenile spring eruption
PCT
Phototoxic der. d/t topical 
Psoralens

Phytophotodermatitis
Lichenoid lesions

ƒ CAD
ƒ Actinic Reticuloid
ƒ Actinic LP
ƒ Drugs (Thiazides)
AR
AR
Telangiectasias

ƒ Rosacea
R
ƒ XP
ƒ Ataxia telengiectasis
ƒ Bloom syndrome
ƒ SLE
ƒ DM
ƒ Drugs (ACE inhibitor, Nifedipine, Amlodipine)
Rosacea

Bloom syndrome
Hyperpigmentation

ƒ Melasma
M l
ƒ Berloque dermatitis
ƒ Pellagra 

Melasma Berloque derm
Scarring

ƒ Porphyria
P h i
ƒ HV
Hypertrichosis

P h i
Porphyria
Investigations
ƒ Phototesting
Ph i
ƒ Photopatch
ƒ Histopathology
ƒ Other lab. Studies
Phototesting

ƒ Not  required for diagnosis until diagnosis is 
N i d f di i il di i i
uncertain
ƒ Primarily a research tool
l h l
Phototesting

ƒ Monochromatic phototesting
M h i h i
ƒ Photoprovocation
Phototesting
Monochromatic phototesting
Monochromatic phototesting
ƒ Wavelength  dependency of the disorder & to elicit 
the eruption when possible
the eruption when possible 
ƒ 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 )
ƒ Comparison  with the range of results for the normal 
C i ith th f lt f th l
population (by MED chart)
ƒ 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
ƒ To induce the lesion for clinical diagnosis/biopsy
T i d th l i f li i l di i /bi
ƒ Solar stimulator (Xenon arc filtered)
ƒ Large areas of skin known to be succeptable
L f ki k t b t bl for 
f
eruption
ƒ Irradiation for 2‐3 consecutive days may be reqd.
Irradiation for 2 3 consecutive days may be reqd
ƒ Almost always +ve in solar urticaria, in minutes
ƒ Variable +ve
Variable +ve in PMLE (upto
in PMLE (upto 50% +ve
50% +ve if consecutive 
if consecutive
for 2‐3 days)
ƒ Cant discriminate from other photodermatoses
Cant discriminate from other photodermatoses
Photoprovocation
p testingg
Photopatch

IIndication
di ti
Eczematous eruption in photodistribution

ƒ Photoallergic dermatitis

ƒ CAD (Photosensitivity dermatitis/ Actinic 
reticuloid syndrome)
reticuloid syndrome)
(phototests also positive)
Photopatch series
ƒ 5‐Bromo‐4
5 Bromo 4’chlorosalicylanilide 1% ƒ
chlorosalicylanilide 1% Camphor 10%
Camphor 10%
ƒ Hexachlorophene 1% ƒ 2‐phenyl‐5‐benzimidazolsulphonic 
ƒ Bithionol 1% acid 10%
ƒ Sulfanilamide 1% ƒ Oxybenzone 10%
ƒ Promethazine hydrochloride 1% ƒ Thiourea 0.1%
ƒ Quinidine sulphate 1% ƒ Olaquindox 1%
ƒ Fragrance mix 1% ƒ Parthenium 1:100,1:200 
(acetone)
ƒ para‐Aminobenzoic acid 10%
ƒ Xanthium (Aq)
ƒ 2‐Ethylhexyl‐p‐
2 Ethylhexyl p
Dimethylaminobenzoate 10% ƒ Chrysanthemum (Aq)
ƒ Benzophenone‐4 10% ƒ Fentichlor
ƒ 4‐tert‐butyl‐4’‐Methoxy‐
4 tert butyl 4 Methoxy ƒ 6‐methyl coumarin
Dibenzoylmethane ƒ Benzophenone
ƒ Isoamyl p‐methoxycinnamate ƒ Parthenium hysterophorus
10% ƒ Paraphenylenedimaine
ƒ 2‐Ethylhexyl‐p‐methoxycinnamate ƒ Petrolatum (control
10%
ƒ Day 1
Day 1 –Perform
Perform MED testing. Apply duplicate sets of 
MED testing Apply duplicate sets of
photoallergens on left and right back

ƒ 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

ƒ Day 3 –Remove nonirradiated patches and perform first 


reading of reactions to both sets of photoallergens
reading of reactions to both sets of photoallergens
(both sites)

ƒ 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
ƒ IR Irritant reaction
ƒ NT Not tested
German/ Swiss / Austrian
ƒ 0   no erythema
ƒ 1+ erythema
ƒ 2+ erythema, infiltration, 
2 erythema, infiltration, +/‐papule
/ papule
ƒ 3+ erythema, papule, vesicle
ƒ 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

ƒ Acanthosis,exocytosis 
A th i t i
spongiosis

ƒ Lymphohistiocytic 
dermal perivascular 
dermal perivascular
infiltration 
Hydroa vacciniforme

ƒ Intraepidermal vesicle 
I id l i l
ƒ Focal keratinocyte necrosis 
ƒ Spongiosis
ƒ Dermal perivascular neutrophilic and 
lymphocytic infiltration
ƒ Vasculitis+/‐
Solar urticaria
Solar urticaria

ƒ Dermal vasodilation 
Dermal vasodilation
and edema

ƒ Mild  interstitial and 
P/V inflammatory cell 
infiltrate of L & E
infiltrate of L & E
Chronic actinic dermatitis
Chronic actinic dermatitis

ƒ Epidermal spongiosis, 
E id l i i
acanthosis

ƒ Perivascular 
lymphocytic cellular 
lymphocytic cellular
infiltrate , confined to 
the upper dermis 
pp
Actinic reticuloid
Actinic reticuloid
ƒ Marked acanthosis
Marked acanthosis

ƒ 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

ƒ Necrosis of keratinocytes
N i f k ti t

ƒ Intraepidermal
I t id l blister
bli t

ƒ Epidermal necrosis
Epidermal necrosis

ƒ Spongiosis

ƒ Sparse dermal infiltrate.
Sparse dermal infiltrate
Porphyria cutanea tarda

ƒ Subepidermal blister 
S b id l bli t
with minimal or no 
infiltrate

ƒ 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 HLA typing(HLA DR4, HLA


HLA‐typing(HLA‐DR4, HLA‐DRB1*407
DRB1 407 in actinic 
in actinic
prurigo)
¾ DNA repair studies in fibroblast culture

¾ Drug and chemical phototoxicity studies
Treatment

ƒ Photoprotection –
Ph i Cl hi H
Clothing, Hats
AND
Sunscreens
ƒ Symptomatic treatment
PMLE
Actinic Prurigo
Actinic Prurigo
Hydroa vacciniforme
Solar urticaria
Solar urticaria
CAD