JEADV
LETTER TO THE EDITOR
Fixed sunlight eruption: a case report Editor Fixed drug eruption (FDE) is usually due to drug intake; however, some patients cannot recall an offending drug as their cause of FDE. A 56-year-old man was seen because of persistent hyperpigmented macules. He reported that, for 5 years, every summer, about 6 h after sun exposure, he developed identical lesions that disappeared after 72 h leaving long-lasting residual hyperpigmentation. The lesions always reappeared in the same location on his buttocks and groins; he did not use a swimsuit for his sun exposures. The lesions consisted of round areas of erythema and oedema, with a burning sensation, and recurred every year at the beach. His medical history was relevant for dyslipidemia on treatment with simvastatin for 4 years. The patients denied having taken any medication associated with any of the reactivation events. On examination, we found 1–3 cm diameter, oval to round, hyperpigmented macules on buttocks and groins (Fig. 1a). Considering a diagnosis of fixed sunlight eruption, we carried out phototesting in a period of inactive lesions. The patient entered the UV cabin (Medisun 2800 innovation) using photoprotective glasses and covering his body except groins and buttocks. Lesions were elicited 5 h after exposure to UVA (1.27 J/cm2, 25% of MED-UVA) in the same sites they had been appearing during the past 5 years (Fig. 1b). A biopsy revealed a spongiosis, apoptotic keratinocytes, a lymphohistiocytic lichenoid dermatitis and extensive deposits of melanin pigment (Fig. 2a,b). When lesions became inactive, the patient was exposed to UVB in identical way as for UVA. A 25% of MED-UVB dose did not induce (a)
any reaction, but significant lesions appeared when the dosage was doubled (0.1 J/cm2). A skin biopsy showed identical features to the former one. The patient was recommended strict photoprotection, and new attacks have not occurred. Our patient presented a skin eruption consistent with FDE, but due to the absence of any drug trigger, the temporal relationship between sun exposure and the onset of symptoms, and positive phototesting to UVA and UVB, a diagnosis of fixed sunlight eruption was reached. We have only been able to find in the literature one similar case, in which ultraviolet radiation and visible light were found responsible for the lesions.1 Furthermore, it was shown that heat accelerated the process. Other forms of fixed ultraviolet eruptions have been reported,2,3 but they lacked the histopathologic features expected in FDE. Another patient with photodistributed FE on the face and neck has been published, but did not show residual hyperpigmentation typical of FDE, and thus may be considered a variant of polymorphous light eruption (PLE).4 The pathomechanism of fixed sunlight eruption, is postulated to be similar to that described in the classic FE,1 namely, it is a Cell-mediated (type IV) reactions. Lesional skin contains increased numbers of helper and cytotoxic T lymphocytes. CD8+ cytotoxic T cells persist within lesional skin and contributing to immunological memory. When they are activated it triggered an immunological reaction that produce the typical lesion. One can speculate that, in the absence of an offending drug, a photoactivated substance, e.g. some food or additive, might have acted as a trigger. Foods are known to cause fixed eruptions.5 However, we could not identify any specific food related to the eruption. Alternatively, fixed sunlight eruption could be considered one
(b)
Figure 1 The physical examination revealed an oval to round, hyperpigmented macules on buttocks (a) and erythematosus plaques 5 h after exposure to UVA (b).
JEADV 2015
© 2015 European Academy of Dermatology and Venereology
Letter to the Editor
2
(a)
(b)
Figure 2 The biopsy specimen demonstrates a lymphohistiocytic lichenoid dermatitis (a), apoptotic keratinocytes and extensive deposits of melanin pigment (b).
of the ‘idiopathic’ photodermatoses, such as PLE. In both our cases and in the case published previously,1 the appearance of the lesions in areas that are usually covered throughout the year and after a sudden and heavy sun exposure, as well as eliciting of lesions under phototest would support this view. N. Valdeolivas-Casillas,* A.B. Piteiro-Bermejo, n, I. Polo-Rodrıguez, L. Trasobares-Maruga ndez, C. Guirado-Koch, A. Garcıa-Duarte A. Cabrera-Herna Department of Dermatology, Hospital Universitario Prıncipe de Asturias, de Henares, Madrid, Spain Alcala *Correspondence:N.ValdeolivasCasillas.E-mail: [email protected]
JEADV 2015
References 1 Valdivieso R, Ca~ narte C. It is not a fixed drug eruption, it is a fixed “sunlight” eruption. Int J Dermatol 2010; 49: 1421–1423. 2 Langeland J. Exanthema fixum due to ultraviolet radiation. Acta Derm Venereol (Stockh) 1982; 62: 169–171. 3 Del Rıo E, Guimaraens D, Aguilar A, Conde-Salazar L, Sanchez- Yus E. Fixed exanthema induced by ultraviolet radiation. Dermatology 1996; 193: 54–55. 4 Emmett EA. Fixed long ultraviolet eruption. Arch Dermatol 1975; 11: 212–214. 5 Tsuruta D, Sowa J, Kobayashi H, Ishii M. Fixed food eruption caused by Japanese sand lance. Clin Exp Dermatol 2009; 34: e309–e310. doi: 10.1111/ j.1365-2230.2009.03263.x. Epub 2009 May 18. DOI: 10.1111/jdv.13058
© 2015 European Academy of Dermatology and Venereology
LETTER TO THE EDITOR
Fixed sunlight eruption: a case report Editor Fixed drug eruption (FDE) is usually due to drug intake; however, some patients cannot recall an offending drug as their cause of FDE. A 56-year-old man was seen because of persistent hyperpigmented macules. He reported that, for 5 years, every summer, about 6 h after sun exposure, he developed identical lesions that disappeared after 72 h leaving long-lasting residual hyperpigmentation. The lesions always reappeared in the same location on his buttocks and groins; he did not use a swimsuit for his sun exposures. The lesions consisted of round areas of erythema and oedema, with a burning sensation, and recurred every year at the beach. His medical history was relevant for dyslipidemia on treatment with simvastatin for 4 years. The patients denied having taken any medication associated with any of the reactivation events. On examination, we found 1–3 cm diameter, oval to round, hyperpigmented macules on buttocks and groins (Fig. 1a). Considering a diagnosis of fixed sunlight eruption, we carried out phototesting in a period of inactive lesions. The patient entered the UV cabin (Medisun 2800 innovation) using photoprotective glasses and covering his body except groins and buttocks. Lesions were elicited 5 h after exposure to UVA (1.27 J/cm2, 25% of MED-UVA) in the same sites they had been appearing during the past 5 years (Fig. 1b). A biopsy revealed a spongiosis, apoptotic keratinocytes, a lymphohistiocytic lichenoid dermatitis and extensive deposits of melanin pigment (Fig. 2a,b). When lesions became inactive, the patient was exposed to UVB in identical way as for UVA. A 25% of MED-UVB dose did not induce (a)
any reaction, but significant lesions appeared when the dosage was doubled (0.1 J/cm2). A skin biopsy showed identical features to the former one. The patient was recommended strict photoprotection, and new attacks have not occurred. Our patient presented a skin eruption consistent with FDE, but due to the absence of any drug trigger, the temporal relationship between sun exposure and the onset of symptoms, and positive phototesting to UVA and UVB, a diagnosis of fixed sunlight eruption was reached. We have only been able to find in the literature one similar case, in which ultraviolet radiation and visible light were found responsible for the lesions.1 Furthermore, it was shown that heat accelerated the process. Other forms of fixed ultraviolet eruptions have been reported,2,3 but they lacked the histopathologic features expected in FDE. Another patient with photodistributed FE on the face and neck has been published, but did not show residual hyperpigmentation typical of FDE, and thus may be considered a variant of polymorphous light eruption (PLE).4 The pathomechanism of fixed sunlight eruption, is postulated to be similar to that described in the classic FE,1 namely, it is a Cell-mediated (type IV) reactions. Lesional skin contains increased numbers of helper and cytotoxic T lymphocytes. CD8+ cytotoxic T cells persist within lesional skin and contributing to immunological memory. When they are activated it triggered an immunological reaction that produce the typical lesion. One can speculate that, in the absence of an offending drug, a photoactivated substance, e.g. some food or additive, might have acted as a trigger. Foods are known to cause fixed eruptions.5 However, we could not identify any specific food related to the eruption. Alternatively, fixed sunlight eruption could be considered one
(b)
Figure 1 The physical examination revealed an oval to round, hyperpigmented macules on buttocks (a) and erythematosus plaques 5 h after exposure to UVA (b).
JEADV 2015
© 2015 European Academy of Dermatology and Venereology
Letter to the Editor
2
(a)
(b)
Figure 2 The biopsy specimen demonstrates a lymphohistiocytic lichenoid dermatitis (a), apoptotic keratinocytes and extensive deposits of melanin pigment (b).
of the ‘idiopathic’ photodermatoses, such as PLE. In both our cases and in the case published previously,1 the appearance of the lesions in areas that are usually covered throughout the year and after a sudden and heavy sun exposure, as well as eliciting of lesions under phototest would support this view. N. Valdeolivas-Casillas,* A.B. Piteiro-Bermejo, n, I. Polo-Rodrıguez, L. Trasobares-Maruga ndez, C. Guirado-Koch, A. Garcıa-Duarte A. Cabrera-Herna Department of Dermatology, Hospital Universitario Prıncipe de Asturias, de Henares, Madrid, Spain Alcala *Correspondence:N.ValdeolivasCasillas.E-mail: [email protected]
JEADV 2015
References 1 Valdivieso R, Ca~ narte C. It is not a fixed drug eruption, it is a fixed “sunlight” eruption. Int J Dermatol 2010; 49: 1421–1423. 2 Langeland J. Exanthema fixum due to ultraviolet radiation. Acta Derm Venereol (Stockh) 1982; 62: 169–171. 3 Del Rıo E, Guimaraens D, Aguilar A, Conde-Salazar L, Sanchez- Yus E. Fixed exanthema induced by ultraviolet radiation. Dermatology 1996; 193: 54–55. 4 Emmett EA. Fixed long ultraviolet eruption. Arch Dermatol 1975; 11: 212–214. 5 Tsuruta D, Sowa J, Kobayashi H, Ishii M. Fixed food eruption caused by Japanese sand lance. Clin Exp Dermatol 2009; 34: e309–e310. doi: 10.1111/ j.1365-2230.2009.03263.x. Epub 2009 May 18. DOI: 10.1111/jdv.13058
© 2015 European Academy of Dermatology and Venereology
