Dermatology Online Journal

Chronic actinic dermatitis
Lesley Clark-Loeser MD
Dermatology Online Journal 9(4): 41

From the Ronald O. Perelman Department of Dermatology, New York University

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Abstract

A 52-year-old man experienced a pruritic and erythematous eruption on his face, neck, upper chest, and arms. On examination his lesions consisted of edematous, erythematous plaques with scale and lichenified plaques. His clinical presentation, a skin biopsy specimen with a spongiotic dermatitis, positive patch and photopatch tests, and low MEDB and MEDA tests provided a diagnosis of chronic actinic dermatitis.

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Clinical summary

History.—A 52-year-old man had a 6-month history of erythema of the face, chest, and upper extremities. The patient was referred to the Charles C. Harris Skin and Cancer Pavilion in October 2002, for evaluation of a history of erythema, pruritus, and scale on the face, arms, and upper chest. At the time of presentation, he was being treated with a 2-week course of prednisone. He had also received a 1-week course of cephalexin with only slight relief of his symptoms. The patient denied any recent illnesses, new and or changed medications, or the use of any new cosmetic or household products.

In 1990, the patient sought dermatologic care for itchy patches on his face and hands, which he treated with a glucocorticoid cream. He denied a history of eczema, seasonal allergies or allergic rhinitis, or asthma. The patient's father and paternal grandmother both had eczema, and his uncle died 5 years earlier from anaphylactic shock.

The patient is an operating room nurse and frequently wears rubber gloves. He reported a needle-stick approximately 1-2 months prior to presentation. He also commented that, when he wears a lead gown in the operating room, his skin that has contacted the gown becomes itchy and red.

The patient lives in a New Jersey suburb with a garden, which contains many trees and flowering plants and is adjacent to a golf course. The possibility exists that this patient has been sensitized to thiuram via his occupational exposure and subsequently developed a thiuram allergy that was elicited by thiuram-containing pesticides used on the golf course near his home.

The patient's past medical history includes hypertension. His medications are amlodipine and quinapril.

Physical examination.—On the face, neck, and upper chest in a V distribution were diffuse erythema, edema, and scale. On the dorsal upper extremities (distal > proximal) were lichenified, erythematous plaques with scale and scattered, crusted, linear erosions.

Figure 1	Figure 2

Laboratory data.—Antinuclear, anti-SSA, and anti-SSB antibodies were absent, and the erythrocyte sedimentation rate was normal. Positive patch-test reactions to thiuram, amidoamine, and propylene glycol and positive photopatch tests to tanacetum vulgare and alantolactone were present. Phototests showed a low minimal erythema dose test (MED) to ultraviolet A (UVA) of 4J/cm2 and a low MED to ultraviolet B (UVB) of 36 mJ/cm².

Histopathology.—There is a superficial and deep perivascular infiltrate of lymphocytes and eosinophils. Some lymphocytes extend to a hyperplastic epidermis where there is spongiosis, a few individual necrotic keratinocytes, and parakeratosis with serum. There is no evidence of lymphocytic atypia.

Diagnosis.—Chronic actinic dermatitis.

Comment

Chronic actinic dermatitis (CAD) comprises a spectrum of photosensitivity disorders, which includes persistent light reactivity, photosensitive eczema, and actinic reticuloid, which were defined 20 or more years ago [1, 2]. These conditions were originally defined on the basis of the following three criteria: (1) a persistent eczematous eruption of infiltrated papules and plaques that predominantly affected exposed skin, although sometimes extended to covered areas; (2) biopsy specimens consistent with chronic eczema with or without lymphoma-like changes; and (3) reduction in the minimal erythema dose test to ultraviolet B (UVB) irradiation and often also longer wavelengths. It has been suggested that occasionally the phototest abnormalities may be confined to ultraviolet A (UVA).

A high incidence of both allergic contact dermatitis and photoallergic contact dermatitis has been noted among those with CAD [3]. Positive patch-test reactions to one or more allergens occurs in 75 percent of patients. Compositae extracts, of the family of plant allergens to which this patient reacted, are commonly identified as allergens. Other allergens may include fragrance, colophony, rubber, and sunscreens. The mechanism by which contact allergy or contact photoallergy leads to state of persistent light reactivity remains unclear [3]. CAD can occur after the administration of medications or de novo in otherwise healthy individuals [2, 4].

The histology of involved skin demonstrates a spectrum of abnormality from changes resembling chronic eczema to those of cutaneous T-cell lymphoma. Dermal infiltrates consist predominantly of T lymphocytes, usually with a lower CD4:CD8 ratio in patients with more atypical histology [2]. CD8 lymphocytes are the predominant cell in the epidermis [5].

The first and foremost recommendation in the treatment of CAD involves avoidance and protection from ultraviolet radiation. A sunscreen with a physical blocker such as titanium dioxide is recommended. Azathioprine, hydroxycholorquine, PUVA photochemotherapy, topical and oral corticosteroids, tacrolimus ointment [6], and cyclosporine have been used [2].

References

1. Hawke JLM, Magnus IA. Chronic actinic dermatitis: An idiopathic photosensitivity syndrome including actinic reticuloid and photosensitive eczema. Br J Dermatol 17:24, 1979.

2. Lim HW, et al. Chronic actinic dermatitis: An analysis of 51 patients evaluated in the United States and Japan. Arch Dermatol 130:1284, 1994.

3. Mark KA, et al. Allergic contact and photoallergic dermatitis to plant and pesticide allergens. Arch Dermatol 135:67, 1999.

4. Dawe RS, et al. The natural history of chronic actinic dermatitis. Arch Dermatol 136:1215, 2000.

5. Heller P, et al. Chronic actinic dermatitis: An immunohistochemical study of its T-cell antigenic profile, with comparison to cutaneous T-cell lymphoma. Am J Dermatopathol 16:510, 1994.

6. Uetsu N, et al. Treatment of chronic actinic dermatitis with tacrolimus ointment. J Am Acad Dermatol 47:881, 2000.

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