ashley feneran, do jenifer lloyd, do€¦ · actinic prurigo updates study describes successful use...
TRANSCRIPT
![Page 1: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/1.jpg)
Ashley Feneran, DO
Jenifer Lloyd, DO
University Hospitals Regional Hospitals
AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY
![Page 2: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/2.jpg)
Review key points of several photodermatoses
Update knowledge and treatment of photodermatoses
Discuss vitamin D levels in photodermatoses
Objectives
![Page 3: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/3.jpg)
![Page 4: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/4.jpg)
![Page 5: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/5.jpg)
Types of photodermatoses
Immunologically mediated disorders
Defective DNA repair disorders
Photoaggravated dermatoses
Chemical- and drug-induced photosensitivity
![Page 6: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/6.jpg)
Types of photodermatoses
Immunologically mediated disorders
Polymorphous light eruption
Actinic prurigo
Hydroa vacciniforme
Chronic actinic dermatitis
Solar urticaria
![Page 7: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/7.jpg)
Polymorphous light eruption (PMLE)
Most common form of idiopathic
photodermatitis
Possibly due to delayed-type
hypersensitivity reaction to an
endogenous cutaneous photo-
induced antigen
Presents within minutes to
hours of UV exposure and lasts
several days
![Page 8: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/8.jpg)
Superficial and deep lymphocytic infiltrate
Marked papillary dermal edema
Pathology
![Page 9: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/9.jpg)
PMLE Treatment
Topical or oral corticosteroids
High SPF
Restriction of UV exposure
Hardening – natural, NBUVB,
PUVA
Antimalarial
![Page 10: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/10.jpg)
PMLE updates
Study suggests topical vitamin D analogue
used prophylactically may provide
therapeutic benefit in PMLE
Gruber-Wackernagel A, Bambach FJ, Legat A, et al. Br J Dermatol, 2011.
![Page 11: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/11.jpg)
PMLE updates
Study seeks to further elucidate the
pathogenesis of PMLE
Found a decrease in Langerhans cells and an
increase in mast cell density in lesional skin
Wolf P, Gruber-Wackernagel A, Bambach I, et al. Exp Dermatol, 2014.
![Page 12: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/12.jpg)
Actinic prurigo
Similar to PMLE
Common in native American
children
Strong association with HLA
DR4 subtype DRB1*0407
Heals with scarring
![Page 13: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/13.jpg)
Shallow ulcer, neutrophils, & fibrin deposits
Acanthosis, spongiosis, & superficial vessel
telangiectasias
Follicular chelitis
Pathology
![Page 14: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/14.jpg)
Actinic prurigo treatment
Photoprotection
UV protective film on windows
Topical and oral steroids
NBUVB
Thalidomide
Pentoxifylline
Cyclosporine
Azathioprine
TNF-a inhibitors
![Page 15: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/15.jpg)
Actinic prurigo updates
Study describes successful use of thalidomide
in 6 total adult and pediatric patients with
actinic prurigo
Regular nerve conduction studies performed
Crouch R, Foley P, Ng J, et al. Australas J Dermatol, 2002.
![Page 16: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/16.jpg)
Hydroa vacciniforme (HV)
Rare, scarring photodermatosis
seen in early childhood
Some cases are associated
with latent EBV infection
Hemorrhagic bullae heal with
varioliform scars
![Page 17: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/17.jpg)
Spongiosis & epidermal vesicles
Epidermal and upper dermis necrosis
Lymphocytic infiltrate of dermis
Pathology
![Page 18: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/18.jpg)
Hydroa vacciniforme treatment
Refractory to treatment
Close monitoring for atypical
features
Photoprotection
NBUVB
Oral antimalarials
Azathioprine
Thalidomide
Cyclosporine
Beta carotene
Fish oil supplements
![Page 19: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/19.jpg)
Hydroa vacciniforme updates
Recent case report illustrates adult-
onset HV with T-cell monoclonality with
a favorable course
Nomura H, Suzuki H, Egami S, et al. Br J Dermatol, 2015.
![Page 20: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/20.jpg)
Chronic actinic dermatitis
Chronic eczema caused by UV
radiation and visible light
Tends to affect older men
Likely a delayed-type
hypersensitivity reaction
Often a pre-existing allergic or
photoallergic contact dermatitis
![Page 21: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/21.jpg)
Spongiosis, acanthosis, superficial perivascular
infiltrate
Occasional apoptotic keratinocytes
Exocytosis of inflammatory cells
Pathology
![Page 22: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/22.jpg)
Chronic actinic dermatitis treatment
Photoprotection
Topical steroids
Topical calcineurin inhibitors
NBUVB
PUVA
Azathioprine
Cyclosporine
Mycophenolate mofetil
![Page 23: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/23.jpg)
Chronic actinic dermatitis updates
This study disproved the hypothesis that
the filaggrin gene plays a strong role in
the pathogenesis of chronic actinic
dermatitis
Harkins C, Waters A, Kerr A, et al. J Invest Dermatol, 2015.
![Page 24: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/24.jpg)
Solar urticaria
Urticaria induced by sun
exposure
Appears within 5-10 minutes of
sun exposure & resolve over
1-2 hours
Most cases do not resolve
Risk of anaphylactic-type
response
![Page 25: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/25.jpg)
Mild perivascular lymphocytic, mast cell, &
eosinophilic infiltrate
Mild dermal edema
Can see intraluminal neutrophils and
eosinophils
Pathology
![Page 26: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/26.jpg)
Solar urticaria treatment
Photoprotection
Sunscreen is not particularly helpful
for those sensitive to visible light
Anti-histamines
Topical steroids
Graduated UV exposure
IVIG
Omalizumab
Plasmapheresis
![Page 27: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/27.jpg)
Solar urticaria updates
This study showed promising results
with IVIG to treat solar urticaria,
however the duration of response was
not prolonged and adverse effects were
frequent
Aubin F, Porcher R, Jeanmougin M. J Am Acad Dermatol, 2014.
![Page 28: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/28.jpg)
Solar urticaria updates
Case studies are conflicting on efficacy of
omalizumab in solar urticariaBaliu-Piqué C, Aquilera Peiró P. J Eur Acad Dermatol Venereol, 2015.
Müller S, Schempp C, Jakob T. J Eur Acad Dermatol Venereol, 2014.
![Page 29: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/29.jpg)
![Page 30: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/30.jpg)
Vitamin D levels
All of the discussed photodermatoses have the
recommendation for photoprotection, but what effect, if
any, does this have on vitamin D levels?
![Page 31: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/31.jpg)
This prospective, longitudinal study
compared sunlight exposure,
photoprotective behavior, and vitamin D
levels in patients with photosensitivity
vs. healthy adults
Rhodes L, Webb A, Berry J, et al. Br J Dermatol, 2014.
![Page 32: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/32.jpg)
Compared to healthy adults,
photosensitive patients had:
Lower weekend UVB doses
Smaller skin area exposure
Greater sunscreen use
Rhodes L, Webb A, Berry J, et al. Br J Dermatol, 2014.
![Page 33: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/33.jpg)
Compared to healthy adults,
photosensitive patients had:
Lower vitamin D levels year-round
Year-round lows
Rhodes L, Webb A, Berry J, et al. Br J Dermatol, 2014.
![Page 34: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/34.jpg)
Recommendation is to educate patients
on potential for year-round decreased
vitamin D levels and supplementation of
400IU daily
![Page 35: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/35.jpg)
Program Director: Jenifer Lloyd, DO
PGY-3
Rosanne Paul, DO
Madeline Tarrillion, DO
PGY-2
Mathew Loesch, DO, PhD
Miesha Merati, DO
PGY-4
Aziza Wahby, DO
AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY
![Page 36: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/36.jpg)
AMERICAN OSTEOPATHIC COLLEGE OF DERMATOLOGY
![Page 37: Ashley Feneran, DO Jenifer Lloyd, DO€¦ · Actinic prurigo updates Study describes successful use of thalidomide in 6 total adult and pediatric patients with actinic prurigo Regular](https://reader034.vdocument.in/reader034/viewer/2022042412/5f2bad05d44d0d2e0b4fd407/html5/thumbnails/37.jpg)
References1. Aubin F, Porcher R, Jeanmougin M. Severe and refractory solar urticarial treated with intravenous immunoglobulins: A phase II multicenter study. J Am Acad Dermatol.
2014; 71(5): 948-953.
2. Baliu-Piqué C, Aquilera Peiró P. Three cases of solar urticaria successfully treated with omalizumab. J Eur Acad Dermatol Venereol. 2015. Epub ahead of print.
3. Bruderer P, Shahabpour M, Christoffersen S, Andre J, Ledoux M. Hydroa vacciniforme treated by a combination of beta-carotene and canthaxanthin. Dermatology.
1995;190:343-345.
4. Collins P, Ferguson J. Narrow-band UVB (TL-01) phototherapy: an effective preventative treatment for the photodermatoses. Br J Dermatol. 1995;132:956-963.
5. Crouch R, Foley P, Ng J, et al. Thalidomide experience of a major Australian teaching hospital. Australas J Dermatol. 2002; 43(4): 278-284.
6. Durbec F, Regulai Z, Leonard F, Pluot M, Bernard P. Efficacy of v-3 polyunsaturated fatty acids for the treatment of refractory hydroa vacciniforme. Pediatr Dermatol.
2012;29: 118-119.
7. Gruber-Wackernagel A, Bambach I, Legat FJ. Randomized double-blinded placebo-controlled intra-individual trial on topical treatment with a 1,25-dihydroxyvitamin D₃analogue in polymorphic light eruption. Br J Dermatol 2011; 165(1): 152-63.
8. Hall L, Eminger L, Hesterman K. Epstein-Barr virus: Dermatologic associations and implications: part I. Mucocutaneous manifestations of Epstein-Barr virus and
nonmalignant disorders. J Am Acad Dermatol. 2015; 72(1): 1-19.
9. Harkins C, Waters A, Kerr A, et al. Loss-of-function mutations in the gene encoding filaggrin are not strongly associated with chronic actinic dermatitis. J Invest Dermatol.
2015; 135(7): 1919-1921.
10. Kutlubay Z, Sevim A, Engin B, et al. Photodermatoses, including phototoxic and photoallergic reactions (internal and external). Clin Dermatol. 2014; 32: 73-79.
11. Lim H, Snauwaert J. Vitamin D and photodermatoses. Br J Dermatol. 2014; 171(6): 1297-1298.
12. Müller S, Schempp C, Jakob T. Failure of omalizumab in the treatment of solar urticarial. J Eur Acad Dermatol Venereol. 2014. Epub ahead of print.
13. Nitiyarom R, Wongpraparut C. Hydroa vacciniforme and solar urticaria. Dermatol Clin. 2014; 32(3): 345-353.
14. Nomura H, Suzuki H, Egami S, et al. A patient with elderly-onset atypical hydroa vacciniforme with an indolent clinical course. Br J Dermatol. 2015. Epub ahead of print.
15. Rhodes L, Durham B, Fraser W, et al. Dietary fish oil reduces basal and ultraviolet B-generated PGE2 levels in skin and increases the threshold to provocation of
polymorphic light eruption. J Invest Dermatol. 1995; 105: 532-535.
16. Rhodes L, Webb A, Berry J, et al. Sunlight exposure behaviour and vitamin D status in photosensitive patients: Longitudinal comparative study with healthy individuals at
U.K. latitude. Br J Dermatol. 2014; 171(6): 1478-1486.
17. Rhodes L, White S. Dietary fish oil as a photoprotective agent in hydroa vacciniforme. Br J Dermatol. 1998; 138: 173-178.
18. Valbuena M, Muvdi S, Lim H. Actinic prurigo. Dermatol Clin. 2014; 32(3): 335-344.
19. Wolf P, Gruber-Wackernagel A, Bambach I, et al. Photohardening of polymorphic light eruption patients decreases baseline epidermal Langerhans cell density while
increasing mast cell numbers in the papillary dermis. Exp Dermatol. 2014; 23: 424-448.