Photocontact Reactions Research Articles

Throwing a Light on Photosensitivity in Atopic Dermatitis

Photosensitivity in atopic dermatitis (AD) is a well known but ill-defined phenomenon. To determine the prevalence of photosensitivity in patients with AD, define its clinical characteristics, and analyze the photo provocation test (phototest) results. A retrospective study of patients with AD who were phototested because of suspected photosensitivity at our department during the period 1994-2004. The total number of patients with AD seen in our department between 1994 and 2004 was 3804, of whom 145 patients (45 men and 100 women) were phototested. Photosensitivity was confirmed in 108 (74%) of these 145 patients (33 men and 75 women). The minimal erythema dose (MED) for UVB was decreased in eight of these 108 patients (7%) and the MED for UVA in five patients (5%). Two major clinical reaction patterns were observed: a polymorphic light eruption-type reaction in 51 patients (47%) and an eczematous reaction in 44 patients (41%). Seventy-two of the 108 patients (67%) had a pathologic reaction to UVA and UVB, 18 patients (17%) were only UVB sensitive, and 18 patients (17%) were only UVA sensitive. Photopatch tests were performed in 125 patients (86%). Twenty-nine patients (23%) had a positive photocontact reaction to one or more substances. Photosensitivity is found in approximately 3% of patients with AD and the majority are female. Photosensitivity in patients with AD consists of two clinical reaction patterns distinguishable by phototesting. Patients were diagnosed with either AD and co-existing polymorphic light eruption or photosensitive AD.

Photo Allergic Contact Dermatitis: The 15-Year Experience of a Tertiary Reference Center in a Sunny Mediterranean City

Photoallergic contact dermatitis (PACD) represents an important entity of photodermatoses while photopatch testing is the main diagnostic tool. The main goal of this study is to evaluate retrospectively the prevalence of photoallergic reactions and the offending agents in Athens during a 15-year period. The medical records of all patients with possible PACD between 1992 and 2006 were examined. All patients included in the analysis had undergone patch testing and photo-testing. Contact reactions were detected in 86 out of 207 participants (41.54%), while photocontact reactions were identified in 28/207 (13.52%) patients. The most common offending photoallergen was promethazine (25%), while chlorpromazine and oxybenzone were both detected in 12.5% of cases. PACD represents a unique proportion of photodermatoses in a sunny Mediterranean city such as Athens.

Allergic and photoallergic contact dermatitis from ketoprofen: results of (photo) patch testing and follow‐up of 42 patients*

Photoallergic contact dermatitis from topical ketoprofen (KP), a nonsteroidal anti-inflammatory agent, is a well-known side effect. To investigate photo-contact allergic reactions to KP and other nonsteroidal anti-inflammatory drugs (NSAIDs), sunscreens, and fragrance components as well as the presence of prolonged photosensitivity related to it. From June 1993 to June 2007, 42 patients were patch tested and photopatch tested with the ingredients of a KP preparation and other relevant substances. A questionnaire was performed in order to determine the importance of prolonged photosensitivity; 40/42 did respond. 38 patients showed photo-contact reaction, 1 photoaggravated reaction, and 3 contact allergic (CA) reaction to KP. Simultaneous photo-contact allergic reactions were frequently observed not only to structurally related but also to non-structurally related NSAIDs and sunscreens. Simultaneous CA to fragrance components was common. 1/3 of the patients reported prolonged photosensitivity, i.e. from 1 up to 14 years after having stopped KP application. The history is often not a good guidance to determine KP-related (photo) allergic contact dermatitis and the severe clinical symptoms sometimes require hospitalization, and/or systemic corticosteroids. As for the association between KP and sunscreen intolerance (being 1 of the possible causal factors for recurrent dermatitis), routine standard photopatch testing with KP might be indicated.

Positive photocontact responses are not elicited to sunscreen ingredients exposed to UVA prior to application onto the skin

Photocontact allergic reactions to sunscreen chemicals are investigated by photopatch testing. It has generally been assumed that for photocontact allergy to be shown, the putative pro-allergen must be in the skin at the time of ultraviolet A (UVA) exposure. However, this assumption has not, to our knowledge, been tested. The objective of this study was to determine whether positive photocontact responses can still be elicited when sunscreen chemicals are exposed to UVA prior to application onto the skin. 3 patients known to have positive photocontact reactions to a total of 6 sunscreen chemicals were studied. For conventional photopatch testing, patch test strips were applied onto the back and removed 1 D later, and the area was irradiated with UVA (5 J/cm(2)). For pre-irradiated testing, patches were exposed to the same dose of UVA immediately before application onto the back and then removed 1 D later. Skin responses were visually assessed by a blinded investigator 1 and 2 D after patch test removal. The same photocontact responses of the same magnitude, as previously documented for each patient, were seen at each of the conventional UVA-exposed patch test sites. However, in no patient was a positive response elicited at any of the sites where pre-irradiated patches had been applied. This study shows that positive photocontact responses to sunscreen chemicals do not occur when the putative pro-allergen is irradiated prior to application onto the skin. This suggests that for a photoallergic reaction to occur, the sunscreen chemical needs to be within the skin when activated by UVA.

Chronic actinic dermatitis: A retrospective analysis of 44 cases referred to an Australian photobiology clinic

A retrospective study was performed to analyse the clinical and photobiological features and therapeutic outcomes of 44 patients with chronic actinic dermatitis who were evaluated over an 8.3-year period. The study population comprised 37 men and seven women with a mean age of 62.7 years (range 26-85 years). The most common abnormal phototest results were decreased minimal erythema doses to both UVA and -B (73.8%), and to UVA alone (14.3%). Twenty-six patients (78.8%) had at least one allergic, photoallergic or combined allergic/photoallergic reaction. A total of 139 positive contact or photocontact reactions were recorded (mean 4.2 per patient). Most commonly, treatment consisted of photoprotection, topical corticosteroids and episodic use of systemic agents, in particular azathioprine.

Analysis of patients with suspected photosensitivity referred for investigation to an Australian photodermatology clinic

Background: Australia's first dedicated photodermatology clinic was established at St Vincent's Hospital Melbourne in 1993. Objective: We sought to review clinical diagnoses and results of investigations performed on patients seen at this institution. Methods: A database was created to enable a retrospective and prospective analysis of all patients attending for evaluation of suspected photosensitivity from April 1993 to October 2000. Results: A total of 513 patients were seen, 289 (56.3%) female and 224 (43.7%) male, with a mean age of 45.2 years (range: 2.6-85.9). A photosensitive disorder was diagnosed in 397 patients (77.4%), with the acquired idiopathic photodermatoses accounting for diagnoses in 215 (41.9%) of all patients seen. The most common diagnosis was polymorphous light eruption. Reduced minimal erythema doses were seen in 25.3% of all patients light tested. In those photopatch tested, 23.3% had at least 1 photocontact reaction. Allergic contact dermatitis in a photosensitive distribution was diagnosed in 7.4% of the clinic population. Conclusion: A large proportion of referrals to a photodermatology clinic comprise people with acquired idiopathic photodermatoses, with other common diagnoses that may mimic photosensitivity including allergic contact dermatitis, atopic dermatitis, and rosacea. (J Am Acad Dermatol 2003;48:714-20.)

Evaluation of the role of contact sensitization and photosensitivity in the pathogenesis of poikiloderma of Civatte.

Poikiloderma of the face and neck (Civatte) is a rather common, indolent, chronic dermatosis, most often affecting menopausal females. Cumulative excessive sun exposure, a phototoxic or a photoallergic reaction, hormonal changes of menopause and genetic factors have all been incriminated in its obscure aetiopathogenesis. To evaluate the role of contact sensitization and photosensitivity in the pathogenesis of poikiloderma of Civatte (PC). Thirty-two patients (24 females and eight males, age range 38-74 years) with PC were patch tested with the European standard series and the fragrance series, and were photopatch tested with the photoallergens series. Additionally, photo-testing with a monochromator was performed. Thirteen of 32 patients (40.62%) had one or more positive reactions to allergens of the standard series. Eight patients (25%) had positive reactions to fragrance mix and/or Balsam of Peru, which are included in the standard series, or to allergens of the fragrance series. Nickel sulphate was the single most common cause of contact sensitization (18.75%) among our patients. Ninety-seven subjects, who were patch tested with the standard series for suspected allergic contact dermatitis of the face and/or neck, served as age, sex and site controls. Of these, nine (9.27%) had one or more positive reactions to fragrance compounds. Statistical analysis showed a statistically significant difference in the frequency of positive reactions to fragrances between the PC group and the control group (chi2 value = 3.91, P < 0.05). In contrast, none of the PC patients had a positive photopatch test for the allergens included in the photoallergens series. The estimated minimal erythemal dose for the PC group was in all cases within normal limits for all wavelengths of ultraviolet (UV) radiation examined. Contact sensitization, mostly to perfume ingredients, may develop in PC, possibly playing a pathogenetic part, at least in a subset of patients. Despite negative results of photopatch testing, an allergic photo-contact reaction cannot be definitely excluded. PC seems not to be a photosensitivity disorder of the type of chronic actinic dermatitis. UV radiation-induced dermal connective tissue changes are the predominant histological feature of PC, leading to telangiectasia due to loss of vascular support. Reticular pigmentation may result from a delayed hypersensitivity reaction to perfume and/or cosmetic ingredients. Patch testing with the standard series and avoidance of documented allergens may be of value in patients with PC.

Consultation with the Specialist: Contact Dermatitis

1. Sheila Fallon Friedlander, MD* 1. 2. *Assistant Professor, Departments of Pediatrics and Medicine, UCSD School of Medicine; Division of Pediatric Dermatology, Children’s Hospital, San Diego, CA. Some physicians believe that contact dermatitis is a rather esoteric topic with little relevance to the daily practice of general pediatrics. In reality, contact dermatitis is an extremely common occurrence in the pediatric age group. Some authors estimate that it accounts for approximately 20% of all dermatitis seen in childhood. Although many forms, such as Rhus dermatitis (poison ivy/oak) and diaper dermatitis, are easily recognized and treated, even “diaper rash” occasionally can present a therapeutic challenge and cause significant discomfort to the infant. Other forms of contact dermatitis may be more difficult to diagnose. A photocontact reaction from the juice or rind of lemons and limes termed phytophotodermatitis causes an eruption that often is misdiagnosed as a burn or occasionally even as child abuse. This can lead to inappropriate and costly evaluations. Of greater concern, contact reactions sometimes can lead to life-threatening situations. Latex, a product of the rubber tree, can cause reactions ranging from mild contact dermatitis to anaphylaxis. Children who have spina bifida or congenital urologic anomalies are at increased risk for this allergy because of increased exposure to latex in catheters or gloves. Therefore, primary care clinicians must be familiar with the basic concepts relating to contact dermatitis. Reasonable queries that might arise, which are addressed in the following discussion, include: The exact incidence of contact dermatitis is unknown. However, two studies evaluating healthy children showed a 20% incidence of positive reactions to one or more patch tests. Almost 50% of infants develop diaper dermatitis, most …

7 years experience of photopatch testing with sunscreen allergens in Sweden.

Since 1990 7 sunscreen allergens have been included in the standard photopatch protocol at 2 Swedish dermatology clinics. 355 consecutive patients with suspected photosensitivity were tested, and in 28 of these (7.9%), a total of 42 allergic reactions were found. 80% of the reactions were of photocontact origin. The most common allergen was benzophenone-3 (Eusolex 4360), with 15 photocontact and 1 contact allergic reactions, followed by isopropyl dibenzoylmethane (Eusolex 8020) (8 photocontact, 4 contact) and butyl methoxydibenzoylmethane (Parsol 1789), with 6 photocontact reactions. There were 2 cases of photocontact allergy to phenylbenzimidazole sulfonic acid (Eusolex 232), which has not been reported previously. 1 case of contact urticaria from benzophenone-3 was accidentally found. In addition, 21 + reactions of doubtful relevance were noted in 14 patients: 16 on irradiated and 5 on non-irradiated test sites. Among these, irritant and phototoxic reactions may be included. These results indicate that the inclusion of UV filters in the standard photopatch protocol is important. Immediate-type testing for urticaria could also be of value.

C052 Drug and chemical photosensitivity

Photopatch testing was performed on 274 patients who had history of photosensitivity at the Institute of Dermatology Thailand from 1987 through 1989. A total of 92 positive photocontact reactions and 71 positive contact reactions were seen. The most frequent positive photopatch test reactions were to sulfanilamide (18.2%) followed by Jadit (4.4%) chlorpromazine (3.6%) promethazine (3.6%) and fenticlor (3.2%). The most common photodermatoses was polymorphous light eruption (60.9%). Photocontact dermatitis was established in 28 patients (10.2%) while other skin diseases aggravated by sunlight were seen in 47 patients (17.2%).

Photopatch test reactivity: effect of photoallergen concentration and UVA dosaging.

We have studied the influence of variations in allergen concentration and UVA dosaging on the results of photopatch testing with the Scandinavian standard photopatch series in 29 patients with photocontact and/or contact allergy to 1 or several of the allergens in that series. Photocontact test reactions were more sensitive to allergen dilution than plain contact test reactions. Even dilution from the standard 5% to 2.5% significantly reduced para-aminobenzoic acid photocontact test reactions. Reducing the UVA dose from the standard 5 J/cm2 to 2.5 or 1 J/cm2 in 2 out of 5 cases turned a significant (++) reaction into a doubtful one (+). Increasing the standard UVA dose of 5 J/ cm2 to 20-40 J/cm2 turned a single + photocontact reaction to trichlorcarbanilide and a single 1 + plain contact reaction to chlorhexidine into ++ reactions. In the majority of cases, however, neither photocontact nor plain contact test reactions were augemented by UVA doses up to 80 J/cm2. We conclude that a UVA dose of 5 J/cm2 is sufficient for eliciting photocontact allergic test reactions, and that a reduction of either the UVA dose level or the standard allergen concentrations of the Scandinavian photopatch test guidelines may cause loss of significant photocontact test reactions in a proportion of the cases.

A three-year photopatch study in Thailand

Photopatch testing was performed on 274 patients who had history of photosensitivity at the Institute of Dermatology Thailand from 1987 through 1989. A total of 92 positive photocontact reactions and 71 positive contact reactions were seen. The most frequent positive photopatch test reactions were to sulfanilamide (18.2%) followed by Jadit (4.4%) chlorpromazine (3.6%) promethazine (3.6%) and fenticlor (3.2%). The most common photodermatoses was polymorphous light eruption (60.9%). Photocontact dermatitis was established in 28 patients (10.2%) while other skin diseases aggravated by sunlight were seen in 47 patients (17.2%).

Photopatch testing: A six-year experience

The results of photopatch testing performed at the Mayo Clinic from 1980 through 1985 were analyzed. During the 6 years, 70 patients underwent photopatch testing. Of the 70 patients, 27 (38.5%) had positive photopatch test reactions and 22 (31%) had ordinary contact reactions. Of the 27 patients with photocontact reactions, 14 had relevant reactions. The most frequent positive reactions were to chlorpromazine (13 patients), musk ambrette (nine patients), and promethazine (eight patients). Photopatch testing is an essential part of the evaluation of patients who are suspected of having photosensitive dermatitis. In some patients with recalcitrant eruptions, testing may help in excluding photosensitivity as a possible contributing factor.

Measurement of urinary constituents and output using diposable napkins

The results of photopatch testing performed at the Mayo Clinic from 1980 through 1985 were analyzed. During the 6 years, 70 patients underwent photopatch testing. Of the 70 patients, 27 (38.5%) had positive photopatch test reactions and 22 (31%) had ordinary contact reactions. Of the 27 patients with photocontact reactions, 14 had relevant reactions. The most frequent positive reactions were to chlorpromazine (13 patients), musk ambrette (nine patients), and promethazine (eight patients). Photopatch testing is an essential part of the evaluation of patients who are suspected of having photosensitive dermatitis. In some patients with recalcitrant eruptions, testing may help in excluding photosensitivity as a possible contributing factor.

Contact and photocontact allergy in persistent light reactivity.

The patient group consisted of 18 elderly male patients with persistent light reactivity who were subjected to extensive phototesting with different wavelengths, including patch and photopatch testing. All reacted adversely to ultraviolet light and some also to longer wavelengths when tested on normal appearing skin. 17 patients showed contact or photocontact reactions, of which 12 were positive photopatch test reactions and 11 were plain contact reactions. Contact allergy to constituents of oak moss and different lichen compounds was twice as common as allergy to Compositae oleoresins. 72 patients with chronic polymorphic light eruption were used as a control group. 10 of these patients had either a positive photopatch test reaction or a plain contact allergy. Patients with persistent light reactivity are characterized by a particular susceptibility to develop a delayed-type hypersensitivity. They frequently have both photo and plain contact allergy, often to substances used in cosmetics. In 13 of 16 patients in whom a biopsy was carried out, the histology supported the clinical diagnosis. In none of the biopsies was the picture diagnostic in itself. This underlines the inadequacy of light microscopy as the only diagnostic procedure.

The Scandinavian multicenter photopatch study. Preliminary results.

The Scandinavian photopatch test procedure has been applied to 745 patients with suspected photodermatoses during the years 1980-1981. Our experience has been encouraging with the recording of several relevant reactions. A total of 132 positive photocontact reactions and 120 ordinary contact reactions were seen. Photocontact reactions to musk ambrette (19 cases) and PABA (19 cases) were surprisingly frequent. The next most common photocontact reactions were to promethazine (24), chlorpromazine (22 cases) and fentichlor (12). Ordinary contact reactions were observed to balsam of Peru (30), PABA (23), lichen mix (21), wood mix (14) and to perfume mix (10).

The investigation of photocontact dermatitis in a dye manufacturing process.

Summary.— An investigation of photocontact dermatitis occurring in a dye manufacturing process is described. Sixteen employees were studied by photopatch testing to the complete anthraquinone‐based dye: Disperse Blue 35 and to chromatographically separated bands. By irradiation of the skin with visible light between 400 and 700 nm evidence was obtained to show that the complete dye produced photo‐contact dermatitis in individuals, whether they had previously been exposed to it or not. Using the same technique, only 4 of the 10 constituent hands produced a similar photocontact reaction.