Photodermatology, Photoimmunology & Photomedicine
LETTER TO THE EDITOR
Erythematotelangiectatic rosacea following occupational ultraviolet radiation injury Kara Heelan, Maeve A. McAleer, Michelle Murphy & John F. Bourke
Department of Dermatology, South Infirmary-Victoria University Hospital, Cork, Ireland.
Correspondence: Dr Kara Heelan, Dermatology Department, South Infirmary Victoria University Hospital, Old Infirmary Road, Cork, Ireland. Tel: +00353 21 4926100 Fax: +00353 21 4926405 e-mail: [email protected]
Accepted for publication: 8 March 2015
Conflicts of interest:
solar elastosis on histopathology specimens of affected areas (3). On the contrary, epidemiologic studies demonstrate that only 17–31% of patients with rosacea report worsening of symptoms by UV exposure (2). Several photoprovocation studies have failed to show heightened skin sensitivity to the acute effects of UV radiation (2, 4). Flushing, persistent central facial erythema and telangiectasias characterize ETR. Central facial oedema, stinging, burning sensations, and roughness or scaling may also be reported (2). We report 3 cases of ETR following occupational UV radiation exposure. The individuals were employees in a medical devices factory. None of the patients had a history of rosacea prior to the occupational UV radiation exposure.
None of the authors have any conflicts of interest to disclose.
Funding sources: No funding was received for this work. None of the authors have any financial disclosures to make.
To the Editor, Rosacea is a common chronic inflammatory skin disease predominantly affecting the central facial skin (1). Traditional classification divides rosacea into 4 main subtypes: erythematotelangiectatic rosacea (ETR), papulopustular rosacea (PPR), phymatous rosacea (PHR) and ocular rosacea (1). The definitive pathogenesis of rosacea remains unknown. Several suggested aetiologic mechanisms are based on both basic laboratory research and clinical anecdotal observation (2). The following have been proposed: vasculature, climatic exposures, matrix degeneration, chemicals and ingested agents, pilosebaceous unit abnormalities and microbial organisms (2). While ultraviolet (UV) exposure is an accepted risk factor, its pathogenic relationship to rosacea remains controversial. Evidence includes an increased prevalence of rosacea in fair-skinned individuals, a characteristic distribution on photo-exposed facial convexities and ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd doi:10.1111/phpp.12174
REPORTS Case One A 34-year-old female used a benchtop transilluminator for 7 h. Several hours later she developed a painful, red, swollen face and eyelids. She remained off work for 11 days. On her return after using the transilluminator for 9 h a similar reaction occurred. A dermatologist assessed her 4 weeks later. She complained of sensitivity and dryness of her facial skin and eyes, exacerbated by sunlight. There were facial erythema, dryness and scattered telangiectasias consistent with ETR. Emollients, minocycline 100 mgs daily and topical metronidazole were commenced. On follow-up 2 months later she continued to have dryness and telangiectasias. Topical metronidazole was discontinued, and a 6-month minocycline course was continued.
Case Two A 43-year-old female used the transilluminator for 4 h. Her face became hot and her eyes sore and itchy. The factory occupational health doctor noted erythema of her face and ears on assessment (Fig. 1). Ophthalmolog271
Letter to the Editor
Fig. 1. Acute ultraviolet radiation injury.
ical examination showed corneal tears and dry eyes. She later developed stenosed lacrimal ducts. Five days later she was examined by a dermatologist who noted macular erythema and desquamation in a photodistributed pattern. Further dermatological review occurred 3 months postinjury. She complained of frequent facial flushing and sun sensitivity. Erythema and telangiectasias of the facial convexities and anterior neck, and erythema of the eyelid margins were observed (Fig. 2). Papular areas were noted on the nose and cheeks 7 months postinitial injury (Fig. 3). Lymecycline 300 mg daily and topical metronidazole were commenced. Dermatological review continued over the ensuing years. Recurrent courses of lymecycline and minocycline were completed. Despite treatment she continued to have flushing, photodistributed telangiectasias and intermittent papules.
Case Three A 34-year-old female worked at the transilluminator for 3 h. Nine hours later she expressed facial pain, erythema and swelling. She subsequently developed stenosed lacrimal ducts. A dermatologist assessed her 9 months after the injury. She reported facial flushing 4 times daily and dryness of the facial skin. On examination she had facial erythema, telangiectasias and dryness consistent with ETR. She was treated with a course of intense pulse light (IPL) with good response.
Fig. 2. Erythema and telangiectasias of the facial convexities and eyelid margins.
Fig. 3. Papular areas on the facial convexities and eyelid margins at 7 months.
investigated. The blocking cover had been inadvertently removed and not replaced. All 3 cases occurred within several days of each other. Case two specifically occurred while Case 1 was on sick leave secondary to the injury caused by the transilluminator. None of the reported patients either had a previous history of rosacea or were taking photosensitizing drugs. During exposures none of the patients wore protective eyewear. A health service executive review of all risk assessments associated with the transilluminator was undertaken after the incident. Recommendations to purchase a new transilluminator with protective front guard and adjustable protective screen were made. Other recommendations included the use of UV protective glasses while using the machine, training, hazards identification, preventative guarding and installation of a UV monitor to confirm low exposure levels. A review of these recommendations at 3 months was satisfactory.
DISCUSSION Occupational ultraviolet radiation exposure The UV radiation exposure occurred when the individuals were working at a benchtop transilluminator that provides UV back illumination of transparent fluorescent materials. The transilluminator switches between 302 nm and 365 nm UV wavelengths and has a blocking cover to shield the user from UVR. When the individual’s sustained UVR injury the transilluminator was 272
We report 3 cases of ETR, which we believe support the UVR theory of rosacea pathogenesis. Abram et al. (5) analysed potential risk factors for rosacea. In multivariate analysis a significantly greater risk of rosacea was observed in people with outdoor occupations (OR 3.40; 95% CI 1.21–9.54). Unfortunately, subtype-specific analysis of this association was not performed, but these results may be considered representative of greater UV Photodermatol Photoimmunol Photomed 2015; 31: 271–273 ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Letter to the Editor
exposure being a risk factor for rosacea (5). This observation was substantiated in a cohort of 168 Korean patients with rosacea and suggests that the aetiology is specific to radiation and independent of race. The authors found that the degree of sun exposure was correlated with severity of ETR but not PPR (6). The latter is also supported by an Irish study of 1000 individuals showing lack of correlation of UV exposure or photodamage with PPR but association of photodamage and ETR (3). Despite the fact that excessive UV-induced skin damage can mimic and confound the diagnosis of rosacea, UV may also induce rosacea by triggering innate immune responses (7, 8). Additionally, significantly
elevated levels of reactive oxygen species, which are mainly produced in skin after UV radiation, have been observed in the skin samples of patients with rosacea (9). Several authors have observed that rosacea is often found in persons occupationally exposed to heat (4, 10). Rebora (10) suggested in his experience that ETR is reasonably common in people occupationally exposed to heat with the worst rosacea’s observed in steel-workers. In conclusion we report 3 cases of occupationally UV-induced ETR, which we believe strengthen the theory of UV radiation as a significant factor in the pathogenesis of this subtype of rosacea.
REFERENCES 1. Wilkin J, Dahl M, Detmar M et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol 2002; 46: 584–587. 2. Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol 2004; 51: 327–341; quiz 42-4. 3. McAleer MA, Fitzpatrick P, Powell FC. Papulopustular rosacea: prevalence and relationship to photodamage. J Am Acad Dermatol 2010; 63: 33–39.
4. Brodthagen H. Mepacrine and chloroquine in the treatment of rosacea. Br J Dermatol 1955; 67: 421–425. 5. Abram K, Silm H, Maaroos HI, Oona M. Risk factors associated with rosacea. J Eur Acad Dermatol Venereol 2010; 24: 565–571. 6. Bae YI, Yun SJ, Lee JB, Kim SJ, Won YH, Lee SC. Clinical evaluation of 168 korean patients with rosacea: the sun exposure correlates with the erythematotelangiectatic subtype. Ann Dermatol 2009; 21: 243–249. 7. Steinhoff M, Buddenkotte J, Aubert J et al. Clinical, cellular, and molecular aspects in the pathophysiology of
Photodermatol Photoimmunol Photomed 2015; 31: 271–273 ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
rosacea. J Investig Dermatol Symp Proc 2011; 15: 2–11. 8. Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermatol 2012; 5: 16–25. 9. Bakar O, Demircay Z, Yuksel M, Haklar G, Sanisoglu Y. The effect of azithromycin on reactive oxygen species in rosacea. Clin Exp Dermatol 2007; 32: 197–200. 10. Rebora A. Rosacea. J Invest Dermatol 1987; 88: 56s–60s.
273
LETTER TO THE EDITOR
Erythematotelangiectatic rosacea following occupational ultraviolet radiation injury Kara Heelan, Maeve A. McAleer, Michelle Murphy & John F. Bourke
Department of Dermatology, South Infirmary-Victoria University Hospital, Cork, Ireland.
Correspondence: Dr Kara Heelan, Dermatology Department, South Infirmary Victoria University Hospital, Old Infirmary Road, Cork, Ireland. Tel: +00353 21 4926100 Fax: +00353 21 4926405 e-mail: [email protected]
Accepted for publication: 8 March 2015
Conflicts of interest:
solar elastosis on histopathology specimens of affected areas (3). On the contrary, epidemiologic studies demonstrate that only 17–31% of patients with rosacea report worsening of symptoms by UV exposure (2). Several photoprovocation studies have failed to show heightened skin sensitivity to the acute effects of UV radiation (2, 4). Flushing, persistent central facial erythema and telangiectasias characterize ETR. Central facial oedema, stinging, burning sensations, and roughness or scaling may also be reported (2). We report 3 cases of ETR following occupational UV radiation exposure. The individuals were employees in a medical devices factory. None of the patients had a history of rosacea prior to the occupational UV radiation exposure.
None of the authors have any conflicts of interest to disclose.
Funding sources: No funding was received for this work. None of the authors have any financial disclosures to make.
To the Editor, Rosacea is a common chronic inflammatory skin disease predominantly affecting the central facial skin (1). Traditional classification divides rosacea into 4 main subtypes: erythematotelangiectatic rosacea (ETR), papulopustular rosacea (PPR), phymatous rosacea (PHR) and ocular rosacea (1). The definitive pathogenesis of rosacea remains unknown. Several suggested aetiologic mechanisms are based on both basic laboratory research and clinical anecdotal observation (2). The following have been proposed: vasculature, climatic exposures, matrix degeneration, chemicals and ingested agents, pilosebaceous unit abnormalities and microbial organisms (2). While ultraviolet (UV) exposure is an accepted risk factor, its pathogenic relationship to rosacea remains controversial. Evidence includes an increased prevalence of rosacea in fair-skinned individuals, a characteristic distribution on photo-exposed facial convexities and ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd doi:10.1111/phpp.12174
REPORTS Case One A 34-year-old female used a benchtop transilluminator for 7 h. Several hours later she developed a painful, red, swollen face and eyelids. She remained off work for 11 days. On her return after using the transilluminator for 9 h a similar reaction occurred. A dermatologist assessed her 4 weeks later. She complained of sensitivity and dryness of her facial skin and eyes, exacerbated by sunlight. There were facial erythema, dryness and scattered telangiectasias consistent with ETR. Emollients, minocycline 100 mgs daily and topical metronidazole were commenced. On follow-up 2 months later she continued to have dryness and telangiectasias. Topical metronidazole was discontinued, and a 6-month minocycline course was continued.
Case Two A 43-year-old female used the transilluminator for 4 h. Her face became hot and her eyes sore and itchy. The factory occupational health doctor noted erythema of her face and ears on assessment (Fig. 1). Ophthalmolog271
Letter to the Editor
Fig. 1. Acute ultraviolet radiation injury.
ical examination showed corneal tears and dry eyes. She later developed stenosed lacrimal ducts. Five days later she was examined by a dermatologist who noted macular erythema and desquamation in a photodistributed pattern. Further dermatological review occurred 3 months postinjury. She complained of frequent facial flushing and sun sensitivity. Erythema and telangiectasias of the facial convexities and anterior neck, and erythema of the eyelid margins were observed (Fig. 2). Papular areas were noted on the nose and cheeks 7 months postinitial injury (Fig. 3). Lymecycline 300 mg daily and topical metronidazole were commenced. Dermatological review continued over the ensuing years. Recurrent courses of lymecycline and minocycline were completed. Despite treatment she continued to have flushing, photodistributed telangiectasias and intermittent papules.
Case Three A 34-year-old female worked at the transilluminator for 3 h. Nine hours later she expressed facial pain, erythema and swelling. She subsequently developed stenosed lacrimal ducts. A dermatologist assessed her 9 months after the injury. She reported facial flushing 4 times daily and dryness of the facial skin. On examination she had facial erythema, telangiectasias and dryness consistent with ETR. She was treated with a course of intense pulse light (IPL) with good response.
Fig. 2. Erythema and telangiectasias of the facial convexities and eyelid margins.
Fig. 3. Papular areas on the facial convexities and eyelid margins at 7 months.
investigated. The blocking cover had been inadvertently removed and not replaced. All 3 cases occurred within several days of each other. Case two specifically occurred while Case 1 was on sick leave secondary to the injury caused by the transilluminator. None of the reported patients either had a previous history of rosacea or were taking photosensitizing drugs. During exposures none of the patients wore protective eyewear. A health service executive review of all risk assessments associated with the transilluminator was undertaken after the incident. Recommendations to purchase a new transilluminator with protective front guard and adjustable protective screen were made. Other recommendations included the use of UV protective glasses while using the machine, training, hazards identification, preventative guarding and installation of a UV monitor to confirm low exposure levels. A review of these recommendations at 3 months was satisfactory.
DISCUSSION Occupational ultraviolet radiation exposure The UV radiation exposure occurred when the individuals were working at a benchtop transilluminator that provides UV back illumination of transparent fluorescent materials. The transilluminator switches between 302 nm and 365 nm UV wavelengths and has a blocking cover to shield the user from UVR. When the individual’s sustained UVR injury the transilluminator was 272
We report 3 cases of ETR, which we believe support the UVR theory of rosacea pathogenesis. Abram et al. (5) analysed potential risk factors for rosacea. In multivariate analysis a significantly greater risk of rosacea was observed in people with outdoor occupations (OR 3.40; 95% CI 1.21–9.54). Unfortunately, subtype-specific analysis of this association was not performed, but these results may be considered representative of greater UV Photodermatol Photoimmunol Photomed 2015; 31: 271–273 ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Letter to the Editor
exposure being a risk factor for rosacea (5). This observation was substantiated in a cohort of 168 Korean patients with rosacea and suggests that the aetiology is specific to radiation and independent of race. The authors found that the degree of sun exposure was correlated with severity of ETR but not PPR (6). The latter is also supported by an Irish study of 1000 individuals showing lack of correlation of UV exposure or photodamage with PPR but association of photodamage and ETR (3). Despite the fact that excessive UV-induced skin damage can mimic and confound the diagnosis of rosacea, UV may also induce rosacea by triggering innate immune responses (7, 8). Additionally, significantly
elevated levels of reactive oxygen species, which are mainly produced in skin after UV radiation, have been observed in the skin samples of patients with rosacea (9). Several authors have observed that rosacea is often found in persons occupationally exposed to heat (4, 10). Rebora (10) suggested in his experience that ETR is reasonably common in people occupationally exposed to heat with the worst rosacea’s observed in steel-workers. In conclusion we report 3 cases of occupationally UV-induced ETR, which we believe strengthen the theory of UV radiation as a significant factor in the pathogenesis of this subtype of rosacea.
REFERENCES 1. Wilkin J, Dahl M, Detmar M et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol 2002; 46: 584–587. 2. Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol 2004; 51: 327–341; quiz 42-4. 3. McAleer MA, Fitzpatrick P, Powell FC. Papulopustular rosacea: prevalence and relationship to photodamage. J Am Acad Dermatol 2010; 63: 33–39.
4. Brodthagen H. Mepacrine and chloroquine in the treatment of rosacea. Br J Dermatol 1955; 67: 421–425. 5. Abram K, Silm H, Maaroos HI, Oona M. Risk factors associated with rosacea. J Eur Acad Dermatol Venereol 2010; 24: 565–571. 6. Bae YI, Yun SJ, Lee JB, Kim SJ, Won YH, Lee SC. Clinical evaluation of 168 korean patients with rosacea: the sun exposure correlates with the erythematotelangiectatic subtype. Ann Dermatol 2009; 21: 243–249. 7. Steinhoff M, Buddenkotte J, Aubert J et al. Clinical, cellular, and molecular aspects in the pathophysiology of
Photodermatol Photoimmunol Photomed 2015; 31: 271–273 ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
rosacea. J Investig Dermatol Symp Proc 2011; 15: 2–11. 8. Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermatol 2012; 5: 16–25. 9. Bakar O, Demircay Z, Yuksel M, Haklar G, Sanisoglu Y. The effect of azithromycin on reactive oxygen species in rosacea. Clin Exp Dermatol 2007; 32: 197–200. 10. Rebora A. Rosacea. J Invest Dermatol 1987; 88: 56s–60s.
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