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Clinical and Experimental Dermatology 1998; 23: 7778.

A complex photodermatosis: solar urticaria progressing to polymorphic light eruption


GIRISH K.PATEL, D.J.GOULD, J.L.M.HAWK AND JANE M.MCGREGOR Photobiology Department, St Johns Institute of Dermatology, St Thomas Hospital, London SE1 7EH, UK Accepted for publication 15 January 1998 Summary We report an unusual case of localized solar urticaria which progressed on each occasion to polymorphic light eruption (PLE); this was initially noted following provocation by narrow band ulraviolet B (311313 nm) phototherapy. anterior chest and upper arms but not other sites, including those where previous monochromatic irradiation tests had been performed, nor at other wavelengths. Solar simulated irradiation (1 kW Oriel Solar Simulator) also provoked an immediate urticarial response of the anterior chest and shoulders, but not any other sites (Fig. 1). The urticaria resolved within hours but 1224 h later, at previously irradiated urticated but not unaffected sites, a papular eruption consistent with PLE appeared (Fig. 2). Skin biopsy then conrmed this diagnosis, showing parakeratosis, spongiosis and a perivascular lymphocytic inltrate. A nal diagnosis of localized solar urticaria evolving rapidly into PLE was thus established. The patient was treated with a twice weekly desensitization psoralen photochemotherapy (PUVA) regimen covered with the antihistamine Coratidine 10 mg and prednisolone 25 mg given 1 h before the UVA (315400 nm) exposure. Following 16 treatments, she was then untroubled by either the PLE or solar urticaria during the subsequent summer. Discussion Idiopathic solar urticaria is a rare disorder rst described by Merklen in 1904.1 It is an urticarial reaction following exposure of the skin to either natural sunlight or articial radiation. Although there are no good epidemiological data on its prevalence in the general population, in one series of 203 photosensitive patients referred to a specialist clinic in the USA,2 the condition comprised only 4% of the diagnoses, compared with PLE and chronic actinic dermatitis (CAD), which comprised 26 and 17%, respectively. In another series by Khoo et al.3 in a Singapore skin referral centre, 5.3% of all such conditions were solar urticaria again compared with PLE and CAD which comprised 13 and 5.3%, respectively. Solar urticaria usually presents between the ages of 10 and 50 years, with a greater incidence in women, typically with a sensation of burning or itching of the exposed skin followed usually within minutes by erythema and wealing. Occasionally, in severe cases, additional symptoms may be headache, nausea, bronchospasm and 77

Case report A 38-year-old woman presented with an 8-year history of a seasonal, itchy, urticated, followed by a rmer, more papular eruption across the chest, neck, shoulders and occasionally the face; it did not affect the hands and typically began in February or March and settled by the autumn months. It would occur within several minutes of exposure to natural sunlight and resolve by 23 days. Monochromatic irradiation tests (300600 nm) were initially normal on the standard sites, namely on either side of the midline of the upper back. An initial diagnosis of polymorphic light eruption (PLE) was made and treatment with a narrow band ultraviolet (UV)B (311313 nm) desensitization regimen initiated. However, several minutes after an initial whole body dose of 30 mJ/cm2, she developed a widespread urticarial eruption of the upper chest, arms, and two areas of the back different from those initially tested with the monochromator, along with sparing of all other sites. Investigations revealed a normal full blood count, normal serum urea and electrolyte concentrations and normal liver function tests. Antinuclear antibody and extractable nuclear antigen titres were also negative, as was quantitative porphyrin analysis of the blood, urine and faeces. Following the immediate reaction to narrow-band UVB phototherapy, further monochromatic irradiation tests were performed at the affected sites. These now revealed immediate urticarial reactions at 300 nm on the
Correspondence: Dr G.K.Patel, 102 St. Kingsmark Avenue, Chepstow, Monmouthshire, NP6 55N, UK.
1998 Blackwell Science Ltd

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G.K.PATEL et al. another at 380 nm.5 In both cases, later re-testing revealed a broadening of the action spectrum, markedly in one in whom re-testing after 17 years revealed the wavelengths from 300600 nm induced the condition. It is also apparently unusual for solar urticaria to localize to specic sites, although this has been described once before in a series of three patients, where the eruption was referred to as xed solar urticaria;10 all these had involvement of the chest, as in our case. Our patient in summary appears to have the complex photodermatosis of solar urticaria rapidly progressing to PLE. Such a clinical picture is highly unusual in our experience, although a delayed papular response following solar urticaria was thought by Magnus et al. to be quite common.11 It is not entirely clear whether this latter phenomenon is PLE as we now describe since the previous reports were not supported by histopathology. Nonetheless, the localization of PLE to sites of solar urticaria in rare patients suggests there may very possibly be a common inducing photoallergen involved in such cases. Acknowledgement The authors would like to thank Jacqui Nagel, photobiology technician in the Department of Photobiology, for her assistance. References
1. Merklen P. Urticaire. La Pratique Dermatologique 1904; 72871. 2. Fotiades J, Soter N, Lim H. Results of evaluation of 203 patients for photosensitivity in a 7.3-year period. J Am Acad Dermatol 1995; 33: 597602. 3. Khoo SW, Tay YK, Tham SN. Photodermatoses in a Singapore skin referral centre. Clin Exp Dermatol 1996; 21: 2638. 4. Armstrong R, Horan D, Silvers D. Leucocytoclastic vasculitis in urticaria induced by ultraviolet irradiation. Arch Dermatol 1985; 121: 11458. 5. Murphy GM, Hawk JLM. Broadening of action spectrum in a patient with solar urticaria. Clin Exp Dermatol 1987; 12: 4556. 6. Horio T, Fujigaki K. Augmentation spectrum in solar urticaria. J Am Acad Dermatol 1988; 18: 118993. 7. Hasei K, Ichihashi M. Solar urticaria: Determination of action and inhibition spectra. Arch Dermatol 1982; 188: 34650. 8. Harber LC, Holloway R, Wheatley V et al. Immunologic and biophysical studies in solar urticaria. J Invest Dermatol 1963; 41: 43943. 9. Ravits M, Armstrong R, Harber LC. Solar urticaria: clinical features and wavelength dependance. Arch Dermatol 1982; 118: 22831. 10. Reinauer S, Leenutaphong V, Ho lzle E. Fixed solar urticaria. J Am Acad Dermatol 1993; 29: 1615. 11. Ive H, Lloyd J, Magnus IA. Action spectra in idiopathic solar urticaria. Br J Dermatol 1965; 77: 22943.

Figure 1. Photograph 10 min after solar simulated irradiation (face, neck and upper arms shielded) showing erythema and wealing of solar urticaria. Note sparing of skin protected by high factor sunscreen previously applied.

even syncope. Characteristically lesions resolve over 1 2 h, persistence for greater than 24 h suggesting the much rarer solar urticarial vasculitis.4 Solar urticaria is most often induced by a spectrum of UV and visible wavelengths, although this spectrum for a given patient may vary with time5 and be enhanced6 or diminished7 by preceding longer wavelength irradiation.8 Relatively monochromatic solar urticaria, as apparently present in our patient, is very rare, having been described only twice before, in one patient at 4909 and

Figure 2. Photograph 24 h after irradiation showing polymorphic light eruption. Note sparing of skin at protected sites.

1998 Blackwell Science Ltd, Clinical and Experimental Dermatology, 23, 7778

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