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Background
This is a term that has been categorized under the general heading of chronic actinic dermatitis. This latter term includes entities suchas persistent light reactivity, photosensitive eczema, and photosensitivity dermatitis. There is a clinical resemblance to polymorphous light eruption but the lesions are usually more eczematous. For the pathologist, the differential diagnosis is with a cutaneous lymphoma since there is often a dense lymphoid infiltrate. Currently, many of these cases are also considered within the specturm of cutaneous lymphoid hyperplasia or pseudolymphoma.
OUTLINE
EPIDEMIOLOGY CHARACTERIZATION SYNONYMS Chronic actinic dermatitis
Persistent light reactionINCIDENCE/
PREVALENCEAGE SEX GEOGRAPHY IRELAND
Acta Derm Venereol. 1995 Jan;75(1):72-4. Abstract quote
Nine patients with photosensitivity dermatitis and actinic reticuloid syndrome are reported. The rash affected light-exposed skin only in 7 patients and extended to covered sites in 2. Seven were sensitive to UVB, UVA and visible light, one to UVA and one to visible light only.
Two patients had significant clinical improvement in spite of both having suffered severe disease previously.
Another patient remains exquisitely light-sensitive after 20 years and has developed two squamous cell carcinomas, one of which metastasized to local lymph nodes, and two keratoacanthomas on light-exposed skin.JAPAN
- Chronic actinic dermatitis. An analysis of 51 patients evaluated in the United States and Japan.
Lim HW, Morison WL, Kamide R, Buchness MR, Harris R, Soter NA.
Dermatology Service, New York (NY) Veterans Affairs Medical Center.
Arch Dermatol. 1994 Oct;130(10):1284-9. Abstract quote
BACKGROUND AND DESIGN: We studied the clinical and photobiologic features of 51 patients with chronic actinic dermatitis who were evaluated at three institutions. The following criteria for patient selection were used: (1) a persistent eczematous eruption in the sun-exposed areas of greater than 3 months' duration; (2) decreased phototest results; and (3) when available, histologic changes of a dermal infiltrate of lymphocytes and macrophages, with or without epidermal spongiosis and atypical mononuclear cells in the dermis and epidermis.
RESULTS: The 51 patients had a mean age of 62.7 years, a male-to-female ratio of 2.6:1, and a mean duration of eruption of 5.8 years. The most common abnormal results of the phototests were decreased minimal erythema doses to both UV-A and UV-B, followed by decreased minimal erythema doses to UV-A alone. Patients with abnormally low responses to UV-A or visible light and normal minimal erythema doses to UV-B had the same clinical profile as the overall patient population. Aside from protection from sunlight, treatment modalities that have been used include PUVA (8-methoxypsoralen and UV-A) photochemotherapy, azathioprine, hydroxychloroquine sulfate, and, for recalcitrant cases, cyclosporine.
CONCLUSIONS: Chronic actinic dermatitis is a persistent photodermatosis associated with abnormal phototest responses to UV-A, and/or UV-B, and/or increased sensitivity to visible light; histopathologic changes are consistent with photodermatitis. Treatment consists of combinations of topical and oral medications.KOREA
Yonsei Med J. 2000 Apr;41(2):190-4. Abstract quote
Chronic actinic dermatitis is a rare disease worldwide and also in Korea. However there has been no clinicohistologic and photobiological analysis of chronic actinic dermatitis in Korea.
We examined 11 patients who were diagnosed as chronic actinic dermatitis and the results of this study were compared with previous reports. Most patients were elderly men who had erythematous papules or lichenified plaques on sun-exposed areas such as the face, neck, and dorsum of the hands with severe itching sensation.
All patients had severe sensitivity to UVB and biopsied specimens showed findings of chronic eczema. Five patients had positive photopatch test materials. The patients were treated with systemic and topical steroid, cyclosporine and antihistamine.
DISEASE ASSOCIATIONS CHARACTERIZATION HIV-AIDS
- Chronic actinic dermatitis associated with human immunodeficiency virus infection.
Meola T, Sanchez M, Lim HW, Buchness MR, Soter NA.
Photomedicine Section, Ronald O.Perelman Department of Dermatology, New York University School of Medicine, NY, USA.
Br J Dermatol. 1997 Sep;137(3):431-6. Abstract quote
Chronic actinic dermatitis is a photodistributed, eczematous dermatitis that preferentially affects elderly men and persists for months to years. Its occurrence in individuals infected with human immunodeficiency virus (HIV) has been described in five patients.
We report four additional cases of this uncommon, chronic photodermatosis associated with HIV infection. In two of the patients, photosensitivity was a presenting disorder leading to the diagnosis of HIV infection.
All patients were men of skin type VI with a mean age of 50 years, all had decreased minimal erythema doses to ultraviolet B, three of the four patients had decreased minimal erythema doses to ultraviolet A and all had CD4 cell counts of < 200 x 10(6)/L.LYMPHOMA
- The photosensitivity dermatitis and actinic reticuloid syndrome: no association with lymphoreticular malignancy.
Bilsland D, Crombie IK, Ferguson J.
Department of Dermatology, Ninewells Hospital and Medical School, Dundee, U.K.
Br J Dermatol. 1994 Aug;131(2):209-14. Abstract quote
In the management of photosensitivity dermatitis/actinic reticuloid syndrome (PD/AR) (syn. chronic actinic dermatitis), a chronic and often severe photodermatosis, there has been concern that patients may be predisposed to the development of lymphoreticular malignancy.
A follow-up study of 231 patients with PD/AR who had been investigated at the Photobiology Unit, Ninewells Hospital, Dundee, between 1971 and 1991, was undertaken to determine (i) the incidence and type of malignancies (ii) the causes of any deaths. This information was obtained from three sources: (a) National Cancer Registry data, (b) death certificates, (c) when possible or practical, by casenote review. Thirty-eight malignancies had occurred (in 37 of the 231 patients). Although six of the 38 malignancies were lymphoma registrations, it emerged from a review of casenotes, pathology reports and death certificates that five of the six were incorrect: two were labelled 'mycosis fungoides' prior to diagnosis of PD/AR; a case of dermatopathic lymphadenopathy was initially reported as Hodgkin's disease; clerical errors had occurred in two cases. The remaining case was a true B-cell lymphoma.
The occurrence of one lymphoreticular malignancy is not significantly different from the number expected in a normal population (0.96), when applying 5-year age-, sex-, and site-specific incidence rates to the cumulative patient years of risk [standardized incidence ratio 1.04 (95% CI 0.03-5.79)]. There was also no significant increase in the risk of non-lymphoma malignancies in the PD/AR subjects.
Since diagnosis, 83 patients have died, the majority from cardiorespiratory or cerebrovascular diseases, or the reported malignancies, a pattern expected in an elderly population.
PATHOGENESIS CHARACTERIZATION
LABORATORY/
RADIOLOGIC/
OTHER TESTSCHARACTERIZATION RADIOLOGIC LABORATORY MARKERS PHOTOTESTING
- The action spectrum for induction of chronic actinic dermatitis is similar to that for sunburn inflammation.
Menage HD, Harrison GI, Potten CS, Young AR, Hawk JL.
Department of Photobiology, St. John's Institute of Dermatology, United Medical School of Guy's Hospital, London.
Photochem Photobiol. 1995 Dec;62(6):976-9. Abstract quote
The action spectrum for induction of the abnormal cutaneous response at 24 h in the photosensitivity disorder chronic actinic dermatitis (CAD) was determined in 15 patients and found to be the same in shape as that for normal sunburn in fair-skinned individuals at 24 h, as determined for 47 control volunteers, although displaced in magnitude.
This suggests that an endogenous chromophore(s), the same as or similar to that/those responsible for human sunburn, may be responsible for initiation of the abnormal reaction to irradiation in CAD, and that the putative antigen associated with the CAD reaction may be derived from that/those or associated molecules.
GROSS APPEARANCE/
CLINICAL VARIANTSCHARACTERIZATION GENERAL
The photosensitivity dermatitis and actinic reticuloid syndrome (chronic actinic dermatitis) occurring in seven young atopic dermatitis patients.
Russell SC, Dawe RS, Collins P, Man I, Ferguson J.
Department of Dermatology, Ninewells Hospital and Medical School, Dundee, U.K.
Br J Dermatol. 1998 Mar;138(3):496-501. Abstract quote
Seven young patients with atopic dermatitis (AD) who presented with a marked photoexposed site dermatitis have been investigated in detail.
The results of phototesting, patch testing and other investigations were compatible with the diagnosis of photosensitivity dermatitis/actinic reticuloid syndrome (PD/AR) (chronic actinic dermatitis). It is known that AD patients may have photoaggravation of their dermatitis or exacerbation secondary to a photodermatosis, such as polymorphic light eruption, actinic prurigo or drug-induced phototoxicity. The patients we describe, however, appear to be an uncommon AD subgroup affected by PD/AR.
We recommend that all AD patients who have a history of sunlight-induced exacerbation or marked intolerance of PUVA or ultraviolet B phototherapy should have phototesting and patch testing conducted.
- Photosensitivity dermatitis and actinic reticuloid syndrome (chronic actinic dermatitis).
Ferguson J.
Department of Dermatology, Ninewells Hospital and Medical School, Dundee, Scotland.
Semin Dermatol. 1990 Mar;9(1):47-54. Abstract quote
The photosensitivity dermatitis and actinic reticuloid syndrome (chronic actinic dermatitis) is a common eczematous photodermatosis of unknown aetiology that in severe form is an extremely disabling condition.
It is unclear why males are particularly affected. Difficulties in diagnosis arise in patients who have perennial problems in whom clinical photosensitivity may not be volunteered. An additional problem for the clinician is the finding of contact allergy that is frequently multiple, which further complicates the clinical picture that may, in severe cases, present as an erythroderma or a pseudolymphomatous state. Patch testing and phototesting are the key investigations, with broad ultraviolet (UV) waveband sensitivity occurring as a dermatitis rather than a sunburn response. Contact allergy recognition and avoidance, along with photoprotective measures, are helpful in most cases.
Photochemotherapy (PUVA) and systemic immunosuppression may be required in those patients who fail to respond. In some cases, spontaneous resolution follows after a number of years.
- Actinic reticuloid via persistent light reaction from photoallergic contact dermatitis.
Horio T.
Arch Dermatol. 1982 May;118(5):339-42. Abstract quote
Photoallergic contact dermatitis developed in a patient who had used deodorant soaps containing tribromsalan. He persistently reacted to light, since the dermatitis persisted long after cessation of contact with the causative chemical. During this period, he experienced generalized, eczematous dermatitis on several occasions.
On testing, the patient showed extremely severe photosensitivity extending through the ultraviolet to the visible spectrum. At that time, a skin biopsy specimen showed the microscopic findings of eczematous dermatitis. A diagnosis of actinic reticuloid was first made histologically nine years after the initial examinations, when the patient was 56 years old.
This long-term follow-up study may support the view that photoallergic contact dermatitis, persistent light reaction, and actinic reticuloid could constitute various phases of a single disease.
HISTOLOGICAL TYPES CHARACTERIZATION GENERAL
- Chronic actinic dermatitis: a time course study of histopathological changes.
Miyauchi H, Horio T, Asada Y, Hayami M.
Department of Dermatology, Kansai Medical University, Moriguchi, Osaka, Japan.
Photodermatol Photoimmunol Photomed. 1991 Apr;8(2):65-8. Abstract quote
We report herein a case of chronic actinic dermatitis in which histopathological changes were observed on several occasions during the course of 2 years.
The findings were quite different among stages of the eruption. At a half year after the appearance of the lesion, histological findings revealed eczematous changes. However, gradually a granulomatous change appeared with histiocytes and giant cells.
Although the mechanism of histogenesis is not clear, the appearance of histiocytic giant cells seems to be unusual in chronic actinic dermatitis.
SPECIAL STAINS/
IMMUNOPEROXIDASE/
OTHERCHARACTERIZATION SPECIAL STAINS IMMUNOPEROXIDASE
J Dermatol Sci. 1990 Jul;1(4):289-96 Abstract quote.
Biopsy specimens of chronic lesions and ultraviolet-induced lesions from actinic reticuloid patients were examined by immunoperoxidase techniques and compared with those of allergic contact dermatitis skin, one of the delayed-type hypersensitivity conditions.
Each lesion of actinic reticuloid showed a clear predominance of suppressor/cytotoxic T cells to helper/inducer T cells and an increase of Langerhans cells in the epidermis and the dermis.
These findings are generally similar to those in the late phase (on day 7 and 11) but not in the early phase (on day 2) of allergic contact dermatitis and suggest that delayed-type hypersensitivity might be involved in some parts of the pathogenesis of actinic reticuloid. CD36+DR+ epidermal cells were also observed in ultraviolet-induced lesions from actinic reticuloid patients, suggesting a possible role in the modulation of the mechanism.
- Actinic reticuloid: immunohistochemical analysis of the cutaneous infiltrate in 13 patients.
Toonstra J, Van der Putte SC, van Wichen DF, van Weelden H, Henquet CJ, van Vloten W.
Department of Dermatology, University Hospital, Utrecht, The Netherlands.
Br J Dermatol. 1989 Jun;120(6):779-86. Abstract quote
An immunohistological study on cryostat sections of skin biopsies in 13 patients with actinic reticuloid has been performed using a panel of 21 monoclonal antibodies against lymphoid and non-lymphoid infiltrate cells.
The infiltrate consisted of activated T cells, numerous histiocytes and macrophages, and small numbers of B cells. In 10 out of 13 patients the majority of the lymphocytes expressed the phenotype of suppressor cells. The number of Leu 8+ cells was inversely proportional to HLA-DR expression by the dermal infiltrate, which suggested a negative correlation between a state of activation and the concentration of Leu 8+ cells.
There was a striking number of IgE bearing dendritic cells in the dermis associated with elevated serum IgE levels.ELECTRON MICROSCOPY
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES POLYMORPHOUS LIGHT ERUPTION PSEUDOLYMPHOMA
PROGNOSIS CHARACTERIZATION
- The natural history of chronic actinic dermatitis.
Dawe RS, Crombie IK, Ferguson J.
Photobiology Unit, Department of Dermatology, Ninewells Hospital and Medical School, Dundee, DD1 9SY, Scotland.
Arch Dermatol. 2000 Oct;136(10):1215-20. Abstract quote
OBJECTIVE: To determine the prognosis for resolution of abnormal cutaneous photosensitivity in patients with chronic actinic dermatitis (also known as the photosensitivity dermatitis and actinic reticuloid syndrome).
DESIGN: Historical cohort study involving follow-up of patients for up to 24 years from diagnosis.
SETTING: A Scottish tertiary referral center for investigation of photodermatosis.
PATIENTS: One hundred seventy-eight patients with chronic actinic dermatitis, 62% of a cohort of 285 living patients identified in the Photobiology Unit database.
INTERVENTIONS: Recall for repeated clinical assessment and monochromator phototesting. All patients underwent patch testing when initially assessed; this was repeated at follow-up in a subgroup of patients.
MAIN OUTCOME MEASURES: Resolution of abnormal photosensitivity, defined as clinical resolution and return of phototest responses to within normal population limits. In addition, possible prognostic factors for resolution of photosensitivity were examined.
RESULTS: The probability of abnormal photosensitivity resolving by 10 years from diagnosis is 1 in 5. Particularly severe abnormal UV-B photosensitivity (minimal erythema dose at 305+/-5 nm half-maximum bandwidth, < or =5.6 mJ x cm(-2)) and the identification of separate contact allergens in 2 or more patch test batteries are predictors of a poorer prognosis for resolution. Loss of contact allergies was not associated with a different prognosis for photosensitivity resolution. Our findings probably underestimate the probability of resolution, as those referred to a tertiary referral center and willing to attend for follow-up may include a disproportionate number of severely affected patients.
CONCLUSIONS: Newly diagnosed patients can be told that most of them will improve with appropriate UV/visible light and allergen avoidance and that there is hope that their photosensitivity will completely resolve.
TREATMENT CHARACTERIZATION GENERAL
- Diagnosis and treatment of chronic actinic dermatitis.
Dawe RS, Ferguson J.
Photobiology Unit, Department of Dermatology, Ninewells Hospital and Medical School, Dundee, Scotland.
Dermatol Ther. 2003;16(1):45-51 Abstract quote.
Chronic actinic dermatitis, synonymous with the photosensitivity dermatitis and actinic reticuloid syndrome, presents as a dermatitis and/or a pseudolymphomatous eruption. Abnormal photosensitivity to ultraviolet (UV) and often visible radiation is a feature. Many patients also have multiple contact allergens.
Histopathologic features vary, with a spectrum from mild dermatitis to pseudolymphomatous (reticuloid) features. The essential tests to make the diagnosis and to guide advice on avoidance of the responsible wavelengths and any contact allergens are phototesting and patch testing. Chronic actinic dermatitis can be regarded as a disorder of increased susceptibility, for reasons that remain uncertain, to develop delayed-type allergic responses to both endogenous photoallergens and exogenous allergens.
Treatment consists of detailed advice on sunlight and allergen avoidance (guided by the results of investigations), topical corticosteroids, and emollients. When these measures are insufficient alone, systemic immunosuppressives may be considered: systemic prednisolone for acute exacerbations or azathioprine if systemic treatment is required for more than a few weeks.TACROLIMUS
- Successful treatment of recalcitrant chronic actinic dermatitis with tacrolimus.
Schuster C, Zepter K, Kempf W, Dummer R.
Department of Dermatology, University Hospital Zurich, Switzerland.
Dermatology. 2004;209(4):325-8 Abstract quote.
Therapeutically, chronic actinic dermatitis is a problematic condition. Frequently applied sunscreen usually fails to mitigate the clinical symptoms, and steroids--while efficient--exert many undesired side-effects with prolonged usage.
We present a case of chronic actinic dermatitis responding well to topically applied tacrolimus (Protopic) in combination with chemical and physical UV protection.Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.
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