STUDY
The Natural History of Chronic Actinic Dermatitis: An Analysis at a Single Institution in the United States Jay E. Wolverton, MD, Nicholas A. Soter, MD, and David E. Cohen, MD, MPH Background: Chronic actinic dermatitis is a photosensitivity disorder with scant epidemiologic data. Case series in Europe have previously shown that improvement or resolution of chronic actinic dermatitis occurs over time in most patients. However, the natural history of chronic actinic dermatitis in patients in the United States has not been studied. Objective: To study the natural history of chronic actinic dermatitis in patients in the United States. Methods: We performed a retrospective chart review and telephone questionnaire after a 3- to 19-year follow-up period. Results: Of 20 patients with chronic actinic dermatitis, 7 patients (35%) experienced resolution and an additional 11 patients (55%) experienced improvement of their photosensitivity to sunlight during the follow-up period. The proportion of patients experiencing improvement or resolution of their chronic actinic dermatitis increased at 5, 10, and 15 years after diagnosis. Conclusions: Our study demonstrates that abnormal photosensitivity to sunlight in chronic actinic dermatitis improves or resolves over time in most patients in New York. The rates of improvement or resolution in our patients in New York are similar to the rates in case series in Europe despite likely patient demographic differences.
C
hronic actinic dermatitis (CAD) is a photosensitivity disorder that is defined as a persistent eczematous eruption in sunexposed areas of the body of 3 months or greater duration, with abnormally low phototest results and with a dermal infiltrate that is composed of lymphocytes and macrophages sometimes with epidermal spongiosis and atypical mononuclear cells on histopathologic examination.1 Chronic actinic dermatitis is a disabling condition that is generally believed to worsen during the summer months or after prolonged exposure to sunlight. Our past clinical experiences with patients with CAD have suggested that this condition generally improves, if not resolves, over time through avoidance of sunlight, application of sunscreen, wearing sun-protective clothing, avoidance of any allergen(s), and pharmacologic therapy. Importantly, no studies to date have examined the natural history of CAD in patients in the United States. The characteristics of a cohort of 40 patients with CAD in New York at our institution from 1993 to 2009 were recently described.2 We sought to determine the natural history of CAD in these patients in New York From the Photomedicine and the Occupational and Environmental Dermatology Sections, Skin and Cancer Unit, Ronald O. Perelman Department of Dermatology, New York University, New York, NY. Address reprint requests to David E. Cohen, MD, MPH, Ronald O. Perelman Department of Dermatology, New York University, 530 First Ave, 7R, New York, NY 10016. E-mail: [email protected]. The authors have no funding or conflicts of interest to declare. DOI: 10.1097/DER.0000000000000007 * 2014 American Contact Dermatitis Society. All Rights Reserved.
over a 3- to 19-year follow-up period and focused on the prognosis and timeframe of abnormal photosensitivity in this condition.
MATERIALS AND METHODS Patient Selection and Retrospective Chart Review After approval by our Institutional Review Board, we conducted a retrospective chart review of patients who had a diagnosis of CAD at the New York University (NYU) Skin and Cancer Unit from 1993 to 2009. Patient selection was based on criteria used in prior studies at the same center.1Y3 Patients with CAD were identified by searching the medical records of all patients who had undergone phototesting at our institution from 1993 to 2009. Our methods and equipment sources for conducting phototests, photopatch tests, and patch tests have been previously described.1,2,4,5 Data were collected on the patients’age, sex, skin type, date of diagnosis, duration of symptoms, phototest results, patch test results, photopatch test results, past medical and social histories, atopic status, allergies, and medications. Additional data were collected regarding the current clinical status of patients with CAD who continue to follow up at our institution.
Telephone Questionnaire After approval by our institutional review board, our telephone questionnaire (Fig. 1) was administered to all patients with a diagnosis of CAD at the NYU Skin and Cancer Unit from 1993 to 2009.
Wolverton et al ¡ Natural History of Chronic Actinic Dermatitis
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
27
DERMATITIS, Vol 25 ¡ No 1 ¡ January/February, 2014
28
Figure 1. Standardized institutional review boardYapproved telephone questionnaire.
The telephone numbers of the patients were collected from the patients’ medical records and available telephone directories. Oral consent was obtained from the patient before continuing with the telephone questionnaire. The definitions regarding current clinical status that were used in this study are shown in Figure 2. Several patients had available data on the current status of their CAD from both the telephone questionnaire and current clinical records. In these circumstances, data from the objective current clinical records was used rather than the data from the subjective telephone questionnaires to reduce recall bias. Similarly, the diagnosis of CAD beginning at the objective time of phototesting was preferred over the subjective onset of symptoms of photosensitivity that was obtained in the history to reduce recall bias.
RESULTS Included Patients and Their Demographic Data From 1993 to 2009, 40 patients were diagnosed with CAD at the NYU Skin and Cancer Unit (Table 1).2 Of these, 36 patients remained as potential subjects after the exclusion of 4 patients who had died during the follow-up period. Of the 36 remaining potential subjects, 20 subjects were included in this study: 10 subjects through participation in the telephone questionnaire, 4 subjects through the availability of follow-up clinical records, and 6 subjects through both. Three patients declined participation in
the telephone questionnaire. Thirteen patients either did not respond to repeated telephone calls or did not have their current contact information available. The demographic data of the 20 subjects included in this study is shown in Table 1. The characteristics of the 20 subjects included in this study are adequately representative of the 40 potential patients with a condition diagnosed as CAD at the NYU Skin and Cancer Unit between 1993 and 2009.
Current Status of CAD During the follow-up period, 7 patients (35%) experienced resolution of their CAD and 11 patients (55%) experienced improvement of their CAD (Table 2). Eighteen patients (90%) experienced either resolution or improvement of their CAD during the follow-up period. The status of CAD did not change in one patient (5%) and worsened in one patient (5%). One patient with skin type 1 had a second phototesting performed during the follow-up period which demonstrated normal responses to ultraviolet A (UVA) light, ultraviolet B (UVB) light, and visible light 14 years after the diagnosis of CAD. The patient’s original phototest results showed a minimal erythema dose to UVA of 3 J/cm2, a minimal erythema dose to UVB of 36 mJ/cm2, and a normal response to visible light. Of the 9 patients with skin types 1 to 2, 4 patients experienced resolution and 5 patients experienced improvement of the status of their CAD during the follow-up period. Of the
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Wolverton et al ¡ Natural History of Chronic Actinic Dermatitis
29
Figure 2. Definitions of the current clinical status of CAD used in the study. MED-A, minimal erythema dose to UVA; MED-B, minimal erythema dose to ultraviolet light B.
11 patients with skin types 3 to 6, 3 patients experienced resolution, 6 patients experienced improvement, 1 patient experienced no change, and 1 patient experienced worsening of the status of their CAD during the follow-up period. The 2 patients that experienced either no change or worsening of their CAD during the follow-up period both had skin type 4. The proportion of patients with either improvement or resolution of their CAD increases with time (Table 2). The mean time from phototest diagnosis of CAD until improvement is 1.8 years (range, 0Y6 years). The mean time from phototest diagnosis of CAD until resolution is 5.6 years (range, 1Y14 years). Additionally, if the subjective onset of photosensitivity obtained in the history is considered, the mean time until improvement is 9.0 years (range, 0Y26 years) and the mean time until resolution is 13.6 years (range, 2Y39 years). On average, 7.0 years (range, 0Y30 years) elapsed between the onset of symptoms of CAD and phototest diagnosis. The results of the telephone questionnaire are shown in Table 3. The small number of patients who participated in the telephone questionnaire (n=16) hindered the ability to generate statistically significant prognostic factors from the categories of the telephone questionnaire. Interestingly, one patient was hospitalized owing to
a severe photosensitivity reaction to sunlight, whereupon subsequent phototesting yielded a diagnosis of CAD. Of the 8 patients participating in the telephone questionnaire with allergen(s) previously discovered by patch testing or photopatch testing, 7 patients
TABLE 1. Comparison of Demographic Data and Patch and Photopatch Testing in Patients From 1993 to 2009 and Follow-up in 2012 Category Number of patients Mean age, yrs Male-to-female ratio Patients with skin types 1Y2, n (%) Patients with skin types 3Y4, n (%) Patients with skin types 5Y6, n (%) Patients patch tested, n (%) Patients with positive patch test responses, n (%) Patients photopatch tested, n (%) Patients with positive photopatch test responses, n (%)
1993Y2009
Follow-up
40 57.8 2.1:1 12 (30.0) 11 (27.5) 17 (42.5) 18 (45.0) 12 (66.7)
20 57.2 2.3:1 9 (45.0) 7 (35.0) 4 (20.0) 15 (75.0) 8 (53.3)
30 (75.0) 17 (56.7)
15 (75.0) 6 (40.0)
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
DERMATITIS, Vol 25 ¡ No 1 ¡ January/February, 2014
30
TABLE 2. Current Status of Chronic Actinic Dermatitis After a 3- to 19-Year Follow-up Category
Number of Patients (n=20)
Percent of Patients
7 4 5 7 5.6 11 10 11 11 1.8 18
35.0 20.0 25.0 35.0
Resolved At 5 yrs At 10 yrs At 15 yrs Mean, yrs Improved At 5 yrs At 10 yrs At 15 yrs Mean, yrs Improved or resolved at 5 yrs at 10 yrs at 15 yrs Mean, yrs No change Worsened
14 16 18 3.8 1 1
Range
1Y14 55.0 50.0 55.0 55.0 0Y6 90.0 70.0 80.0 90.0 0Y14 5.0 5.0
(87.5%) reported subjective improvement through avoidance of their allergen(s) and 1 patient (12.5%) reported no change during the follow-up period. None of these patients reported subjective resolution of abnormal sensitivity to their allergen(s).
CONCLUSIONS Resolution or improvement of abnormal photosensitivity was observed in most of the patients with CAD in New York at our institution studied during the 3- to 19-year follow-up period. This spontaneous clinical resolution or improvement regarding the abnormal photosensitivity in CAD is consistent with follow-up studies and case reports in Scotland, Ireland, and England.6Y9 Of the patients with CAD at our institution, 90% experienced resolution or improvement of abnormal photosensitivity by 15 years after phototest diagnosis (Table 2). Similarly, 79% of 178 patients at a tertiary referral center for photodermatoses in Scotland experienced clinical improvement, clinical resolution, or objective resolution of CAD by 15 years after phototest diagnosis.6 In Ireland, 7 (77.8%) of 9 patients with CAD experienced clinical improvement or clinical resolution during a follow-up period of unknown duration.7 These studies demonstrate that the prognosis for clinical resolution or improvement of CAD by 15 years after phototest diagnosis is good. When comparing the time-course of improvement or resolution of CAD in our patients in New York to the patients with CAD in Scotland, it is vital to compare the definitions between the 2 studies. Our definition of resolved is similar to their definition of much improved, and our definition of improved is similar to their definition of clinically improved. We do not have a definition
that is similar to their definition of resolved, as we did not routinely perform repeated phototesting to assess for objective resolution of CAD. The proportion of the patients with CAD in New York at our institution that experience resolution of abnormal photosensitivity increases over time. At 5 years after phototest diagnosis of CAD, 20% of our patients experienced clinical resolution compared with 13% of the patients in Scotland (Table 2).6 At 10 years, 25% of our patients experienced clinical resolution compared with 24% of the patients in Scotland. At 15 years, 35% of our patients experienced clinical resolution compared with 30% of the patients in Scotland. The telephone questionnaire administered to 16 patients in New York provided useful information regarding the persistence of sensitivity to allergen(s). Eight of the 16 patients who participated in the telephone questionnaire had known allergen(s) discovered during prior patch tests and photopatch tests. Seven (87.5%) of these patients reported improvement in the sensitivity to their allergen(s) largely through avoidance of their allergen(s), 1 patient (12.5%) reported no change in the sensitivity to his allergens, and no patients reported subjective resolution of their allergens. None of the 8 patients underwent a second patch testing or photopatch testing at our institution to establish objective resolution to their allergenic sensitivity. These findings are consistent with studies in the literature that have shown that the resolution of the allergenic sensitivity component in some patients with CAD is rare.6,10 Despite the exceptional nature of the resolution of allergenic sensitivity in CAD, the subjective improvement reported by 7 of the 8 patients responding to the telephone questionnaire by avoidance of their allergen(s) shows the importance of patch testing and photopatch testing in patients with CAD. The telephone questionnaire also yielded important information regarding the characteristics of flares in CAD and the adherence to recommended medical therapy by our patients. Eight (50%) of the 16 patients participating in the telephone questionnaire reported experiencing recurrent flares (Table 3). Six (75%) of the 8 patients reported experiencing flares every summer, and 5 patients reported experiencing flares during other seasons (62.5%). The characteristics of these flares support the general
TABLE 3. Telephone Questionnaire Results Category Experience flares Every summer During other seasons Actively wear sunscreen Actively avoid sunlight Actively wear sun-protective clothing Actively avoid topical medications or skin care products Hospitalizations
Number of Patients (n=16)
Percent of Patients
8 6 5 11 12 11
50.00 37.50 31.25 68.75 75.00 68.75
11
68.75
1
6.25
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Wolverton et al ¡ Natural History of Chronic Actinic Dermatitis
notion that CAD often worsens during the summer or upon exposure to sunlight. The occurrence of flares in both summer and other seasons in 5 patients with CAD at our institution also supports an observation in 9 patients in India with flares of CAD that initially appeared only during the summer but eventually occurred during other seasons.11 We further show that approximately two thirds to three fourths of our patients with CAD adhere to our recommendations of actively avoiding sunlight, applying sunscreen, wearing skin-protective clothing, and avoiding the use of skin care products (Table 3). The limitations of our study included a small number of patients (n=20), particularly in comparison to the 178 patients in Scotland.6 The small number of patients hindered the exploration of statistically significant prognostic factors in CAD, demonstrating the need for further investigation into the prognostic factors of CAD. In addition, we do not routinely perform repeated phototesting on patients with CAD at our institution, in contrast with the patients studied in Scotland.6 As such, we were unable to determine if our patients attained objective resolution of CAD. The use of a telephone questionnaire to obtain follow-up information introduced selection and recall bias to the study. We were able to elicit information on the current status of CAD in 24 patients, which included deceased patients, for a follow-up rate of 60.0%. This follow-up rate is comparable to the 67.7% follow-up rate, including deceased patients, obtained in Scotland.6 The demographic data of the patients with CAD included in this study is adequately representative of the pool of potential patients described at our institution from 1993 to 2009 (Table 1).2 However, a lower percentage of patients (20.0%) with skin types 4 and 6 were included in this follow-up study compared with the percentage of patients with a diagnosis of CAD (42.5%) at our institution from 1993 to 2009 (Table 1).2 In conclusion, our study demonstrated that abnormal photosensitivity to sunlight in patients with CAD resolves or improves over time in an appreciable proportion of patients in New York, with proportions similar to studies in Scotland and Ireland. In
31
addition to instructing patients on regularly avoiding sunlight, applying sunscreen, wearing skin-protective clothing, and avoiding any known allergen(s), our study allows physicians in the United States to inform their patients with CAD that their condition will likely improve, if not resolve, over time.
REFERENCES 1. Lim HW, Morison WL, Kamide R, et al. Chronic actinic dermatitis: an analysis of 51 patients evaluated in the United States and Japan. Arch Dermatol 1994;130:1284Y1289. 2. Que SK, Brauer JA, Soter NA, et al. Chronic actinic dermatitis: an analysis at a single institution over 25 years. Dermatitis 2011;22:147Y154. 3. Lim HW, Buchness MR, Ashinoff R, et al. Chronic actinic dermatitis: study of the spectrum of chronic photosensitivity in 12 patients. Arch Dermatol 1990;126:317Y323. 4. Victor FC, Cohen DE, Soter NA. A 20-year analysis of previous and emerging allergens that elicit photoallergic contact dermatitis. J Am Acad Dermatol 2010;62:605Y610. 5. Zug KA, Warshaw EM, Fowler JF Jr, et al. Patch-test results of the North American Contact Dermatitis Group 2005-2006. Dermatitis 2009; 20:149Y160. 6. Dawe RS, Crombie IK, Ferguson J. The natural history of chronic actinic dermatitis. Arch Dermatol 2000;136:1215Y1220. 7. Healy E, Rogers S. Photosensitivity dermatitis/actinic reticuloid syndrome in an Irish population: a review and some unusual features. Acta Derm Venereol 1995;75:72Y74. 8. Bryden AM, Ibbotson SH, Ferguson J. Spontaneous resolution of chronic actinic dermatitis in a young patient with atopic dermatitis. Clin Exp Dermatol 2002;27:163Y164. 9. Rose RF, Goulden V, Wilkinson SM. The spontaneous resolution of photosensitivity and contact allergy in a patient with chronic actinic dermatitis. Photodermatol Photoimmunol Photomed 2009;25:114Y116. 10. Addo HA, Frain-Bell W. Persistence of allergic contact sensitivity in subjects with photosensitivity dermatitis and actinic reticuloid syndrome. Br J Dermatol 1987;117:555Y559. 11. Somani VK. Chronic actinic dermatitisVa study of clinical features. Indian J Dermatol Venereol Leprol 2005;71:409Y413.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
The Natural History of Chronic Actinic Dermatitis: An Analysis at a Single Institution in the United States Jay E. Wolverton, MD, Nicholas A. Soter, MD, and David E. Cohen, MD, MPH Background: Chronic actinic dermatitis is a photosensitivity disorder with scant epidemiologic data. Case series in Europe have previously shown that improvement or resolution of chronic actinic dermatitis occurs over time in most patients. However, the natural history of chronic actinic dermatitis in patients in the United States has not been studied. Objective: To study the natural history of chronic actinic dermatitis in patients in the United States. Methods: We performed a retrospective chart review and telephone questionnaire after a 3- to 19-year follow-up period. Results: Of 20 patients with chronic actinic dermatitis, 7 patients (35%) experienced resolution and an additional 11 patients (55%) experienced improvement of their photosensitivity to sunlight during the follow-up period. The proportion of patients experiencing improvement or resolution of their chronic actinic dermatitis increased at 5, 10, and 15 years after diagnosis. Conclusions: Our study demonstrates that abnormal photosensitivity to sunlight in chronic actinic dermatitis improves or resolves over time in most patients in New York. The rates of improvement or resolution in our patients in New York are similar to the rates in case series in Europe despite likely patient demographic differences.
C
hronic actinic dermatitis (CAD) is a photosensitivity disorder that is defined as a persistent eczematous eruption in sunexposed areas of the body of 3 months or greater duration, with abnormally low phototest results and with a dermal infiltrate that is composed of lymphocytes and macrophages sometimes with epidermal spongiosis and atypical mononuclear cells on histopathologic examination.1 Chronic actinic dermatitis is a disabling condition that is generally believed to worsen during the summer months or after prolonged exposure to sunlight. Our past clinical experiences with patients with CAD have suggested that this condition generally improves, if not resolves, over time through avoidance of sunlight, application of sunscreen, wearing sun-protective clothing, avoidance of any allergen(s), and pharmacologic therapy. Importantly, no studies to date have examined the natural history of CAD in patients in the United States. The characteristics of a cohort of 40 patients with CAD in New York at our institution from 1993 to 2009 were recently described.2 We sought to determine the natural history of CAD in these patients in New York From the Photomedicine and the Occupational and Environmental Dermatology Sections, Skin and Cancer Unit, Ronald O. Perelman Department of Dermatology, New York University, New York, NY. Address reprint requests to David E. Cohen, MD, MPH, Ronald O. Perelman Department of Dermatology, New York University, 530 First Ave, 7R, New York, NY 10016. E-mail: [email protected]. The authors have no funding or conflicts of interest to declare. DOI: 10.1097/DER.0000000000000007 * 2014 American Contact Dermatitis Society. All Rights Reserved.
over a 3- to 19-year follow-up period and focused on the prognosis and timeframe of abnormal photosensitivity in this condition.
MATERIALS AND METHODS Patient Selection and Retrospective Chart Review After approval by our Institutional Review Board, we conducted a retrospective chart review of patients who had a diagnosis of CAD at the New York University (NYU) Skin and Cancer Unit from 1993 to 2009. Patient selection was based on criteria used in prior studies at the same center.1Y3 Patients with CAD were identified by searching the medical records of all patients who had undergone phototesting at our institution from 1993 to 2009. Our methods and equipment sources for conducting phototests, photopatch tests, and patch tests have been previously described.1,2,4,5 Data were collected on the patients’age, sex, skin type, date of diagnosis, duration of symptoms, phototest results, patch test results, photopatch test results, past medical and social histories, atopic status, allergies, and medications. Additional data were collected regarding the current clinical status of patients with CAD who continue to follow up at our institution.
Telephone Questionnaire After approval by our institutional review board, our telephone questionnaire (Fig. 1) was administered to all patients with a diagnosis of CAD at the NYU Skin and Cancer Unit from 1993 to 2009.
Wolverton et al ¡ Natural History of Chronic Actinic Dermatitis
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
27
DERMATITIS, Vol 25 ¡ No 1 ¡ January/February, 2014
28
Figure 1. Standardized institutional review boardYapproved telephone questionnaire.
The telephone numbers of the patients were collected from the patients’ medical records and available telephone directories. Oral consent was obtained from the patient before continuing with the telephone questionnaire. The definitions regarding current clinical status that were used in this study are shown in Figure 2. Several patients had available data on the current status of their CAD from both the telephone questionnaire and current clinical records. In these circumstances, data from the objective current clinical records was used rather than the data from the subjective telephone questionnaires to reduce recall bias. Similarly, the diagnosis of CAD beginning at the objective time of phototesting was preferred over the subjective onset of symptoms of photosensitivity that was obtained in the history to reduce recall bias.
RESULTS Included Patients and Their Demographic Data From 1993 to 2009, 40 patients were diagnosed with CAD at the NYU Skin and Cancer Unit (Table 1).2 Of these, 36 patients remained as potential subjects after the exclusion of 4 patients who had died during the follow-up period. Of the 36 remaining potential subjects, 20 subjects were included in this study: 10 subjects through participation in the telephone questionnaire, 4 subjects through the availability of follow-up clinical records, and 6 subjects through both. Three patients declined participation in
the telephone questionnaire. Thirteen patients either did not respond to repeated telephone calls or did not have their current contact information available. The demographic data of the 20 subjects included in this study is shown in Table 1. The characteristics of the 20 subjects included in this study are adequately representative of the 40 potential patients with a condition diagnosed as CAD at the NYU Skin and Cancer Unit between 1993 and 2009.
Current Status of CAD During the follow-up period, 7 patients (35%) experienced resolution of their CAD and 11 patients (55%) experienced improvement of their CAD (Table 2). Eighteen patients (90%) experienced either resolution or improvement of their CAD during the follow-up period. The status of CAD did not change in one patient (5%) and worsened in one patient (5%). One patient with skin type 1 had a second phototesting performed during the follow-up period which demonstrated normal responses to ultraviolet A (UVA) light, ultraviolet B (UVB) light, and visible light 14 years after the diagnosis of CAD. The patient’s original phototest results showed a minimal erythema dose to UVA of 3 J/cm2, a minimal erythema dose to UVB of 36 mJ/cm2, and a normal response to visible light. Of the 9 patients with skin types 1 to 2, 4 patients experienced resolution and 5 patients experienced improvement of the status of their CAD during the follow-up period. Of the
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Wolverton et al ¡ Natural History of Chronic Actinic Dermatitis
29
Figure 2. Definitions of the current clinical status of CAD used in the study. MED-A, minimal erythema dose to UVA; MED-B, minimal erythema dose to ultraviolet light B.
11 patients with skin types 3 to 6, 3 patients experienced resolution, 6 patients experienced improvement, 1 patient experienced no change, and 1 patient experienced worsening of the status of their CAD during the follow-up period. The 2 patients that experienced either no change or worsening of their CAD during the follow-up period both had skin type 4. The proportion of patients with either improvement or resolution of their CAD increases with time (Table 2). The mean time from phototest diagnosis of CAD until improvement is 1.8 years (range, 0Y6 years). The mean time from phototest diagnosis of CAD until resolution is 5.6 years (range, 1Y14 years). Additionally, if the subjective onset of photosensitivity obtained in the history is considered, the mean time until improvement is 9.0 years (range, 0Y26 years) and the mean time until resolution is 13.6 years (range, 2Y39 years). On average, 7.0 years (range, 0Y30 years) elapsed between the onset of symptoms of CAD and phototest diagnosis. The results of the telephone questionnaire are shown in Table 3. The small number of patients who participated in the telephone questionnaire (n=16) hindered the ability to generate statistically significant prognostic factors from the categories of the telephone questionnaire. Interestingly, one patient was hospitalized owing to
a severe photosensitivity reaction to sunlight, whereupon subsequent phototesting yielded a diagnosis of CAD. Of the 8 patients participating in the telephone questionnaire with allergen(s) previously discovered by patch testing or photopatch testing, 7 patients
TABLE 1. Comparison of Demographic Data and Patch and Photopatch Testing in Patients From 1993 to 2009 and Follow-up in 2012 Category Number of patients Mean age, yrs Male-to-female ratio Patients with skin types 1Y2, n (%) Patients with skin types 3Y4, n (%) Patients with skin types 5Y6, n (%) Patients patch tested, n (%) Patients with positive patch test responses, n (%) Patients photopatch tested, n (%) Patients with positive photopatch test responses, n (%)
1993Y2009
Follow-up
40 57.8 2.1:1 12 (30.0) 11 (27.5) 17 (42.5) 18 (45.0) 12 (66.7)
20 57.2 2.3:1 9 (45.0) 7 (35.0) 4 (20.0) 15 (75.0) 8 (53.3)
30 (75.0) 17 (56.7)
15 (75.0) 6 (40.0)
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
DERMATITIS, Vol 25 ¡ No 1 ¡ January/February, 2014
30
TABLE 2. Current Status of Chronic Actinic Dermatitis After a 3- to 19-Year Follow-up Category
Number of Patients (n=20)
Percent of Patients
7 4 5 7 5.6 11 10 11 11 1.8 18
35.0 20.0 25.0 35.0
Resolved At 5 yrs At 10 yrs At 15 yrs Mean, yrs Improved At 5 yrs At 10 yrs At 15 yrs Mean, yrs Improved or resolved at 5 yrs at 10 yrs at 15 yrs Mean, yrs No change Worsened
14 16 18 3.8 1 1
Range
1Y14 55.0 50.0 55.0 55.0 0Y6 90.0 70.0 80.0 90.0 0Y14 5.0 5.0
(87.5%) reported subjective improvement through avoidance of their allergen(s) and 1 patient (12.5%) reported no change during the follow-up period. None of these patients reported subjective resolution of abnormal sensitivity to their allergen(s).
CONCLUSIONS Resolution or improvement of abnormal photosensitivity was observed in most of the patients with CAD in New York at our institution studied during the 3- to 19-year follow-up period. This spontaneous clinical resolution or improvement regarding the abnormal photosensitivity in CAD is consistent with follow-up studies and case reports in Scotland, Ireland, and England.6Y9 Of the patients with CAD at our institution, 90% experienced resolution or improvement of abnormal photosensitivity by 15 years after phototest diagnosis (Table 2). Similarly, 79% of 178 patients at a tertiary referral center for photodermatoses in Scotland experienced clinical improvement, clinical resolution, or objective resolution of CAD by 15 years after phototest diagnosis.6 In Ireland, 7 (77.8%) of 9 patients with CAD experienced clinical improvement or clinical resolution during a follow-up period of unknown duration.7 These studies demonstrate that the prognosis for clinical resolution or improvement of CAD by 15 years after phototest diagnosis is good. When comparing the time-course of improvement or resolution of CAD in our patients in New York to the patients with CAD in Scotland, it is vital to compare the definitions between the 2 studies. Our definition of resolved is similar to their definition of much improved, and our definition of improved is similar to their definition of clinically improved. We do not have a definition
that is similar to their definition of resolved, as we did not routinely perform repeated phototesting to assess for objective resolution of CAD. The proportion of the patients with CAD in New York at our institution that experience resolution of abnormal photosensitivity increases over time. At 5 years after phototest diagnosis of CAD, 20% of our patients experienced clinical resolution compared with 13% of the patients in Scotland (Table 2).6 At 10 years, 25% of our patients experienced clinical resolution compared with 24% of the patients in Scotland. At 15 years, 35% of our patients experienced clinical resolution compared with 30% of the patients in Scotland. The telephone questionnaire administered to 16 patients in New York provided useful information regarding the persistence of sensitivity to allergen(s). Eight of the 16 patients who participated in the telephone questionnaire had known allergen(s) discovered during prior patch tests and photopatch tests. Seven (87.5%) of these patients reported improvement in the sensitivity to their allergen(s) largely through avoidance of their allergen(s), 1 patient (12.5%) reported no change in the sensitivity to his allergens, and no patients reported subjective resolution of their allergens. None of the 8 patients underwent a second patch testing or photopatch testing at our institution to establish objective resolution to their allergenic sensitivity. These findings are consistent with studies in the literature that have shown that the resolution of the allergenic sensitivity component in some patients with CAD is rare.6,10 Despite the exceptional nature of the resolution of allergenic sensitivity in CAD, the subjective improvement reported by 7 of the 8 patients responding to the telephone questionnaire by avoidance of their allergen(s) shows the importance of patch testing and photopatch testing in patients with CAD. The telephone questionnaire also yielded important information regarding the characteristics of flares in CAD and the adherence to recommended medical therapy by our patients. Eight (50%) of the 16 patients participating in the telephone questionnaire reported experiencing recurrent flares (Table 3). Six (75%) of the 8 patients reported experiencing flares every summer, and 5 patients reported experiencing flares during other seasons (62.5%). The characteristics of these flares support the general
TABLE 3. Telephone Questionnaire Results Category Experience flares Every summer During other seasons Actively wear sunscreen Actively avoid sunlight Actively wear sun-protective clothing Actively avoid topical medications or skin care products Hospitalizations
Number of Patients (n=16)
Percent of Patients
8 6 5 11 12 11
50.00 37.50 31.25 68.75 75.00 68.75
11
68.75
1
6.25
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
Wolverton et al ¡ Natural History of Chronic Actinic Dermatitis
notion that CAD often worsens during the summer or upon exposure to sunlight. The occurrence of flares in both summer and other seasons in 5 patients with CAD at our institution also supports an observation in 9 patients in India with flares of CAD that initially appeared only during the summer but eventually occurred during other seasons.11 We further show that approximately two thirds to three fourths of our patients with CAD adhere to our recommendations of actively avoiding sunlight, applying sunscreen, wearing skin-protective clothing, and avoiding the use of skin care products (Table 3). The limitations of our study included a small number of patients (n=20), particularly in comparison to the 178 patients in Scotland.6 The small number of patients hindered the exploration of statistically significant prognostic factors in CAD, demonstrating the need for further investigation into the prognostic factors of CAD. In addition, we do not routinely perform repeated phototesting on patients with CAD at our institution, in contrast with the patients studied in Scotland.6 As such, we were unable to determine if our patients attained objective resolution of CAD. The use of a telephone questionnaire to obtain follow-up information introduced selection and recall bias to the study. We were able to elicit information on the current status of CAD in 24 patients, which included deceased patients, for a follow-up rate of 60.0%. This follow-up rate is comparable to the 67.7% follow-up rate, including deceased patients, obtained in Scotland.6 The demographic data of the patients with CAD included in this study is adequately representative of the pool of potential patients described at our institution from 1993 to 2009 (Table 1).2 However, a lower percentage of patients (20.0%) with skin types 4 and 6 were included in this follow-up study compared with the percentage of patients with a diagnosis of CAD (42.5%) at our institution from 1993 to 2009 (Table 1).2 In conclusion, our study demonstrated that abnormal photosensitivity to sunlight in patients with CAD resolves or improves over time in an appreciable proportion of patients in New York, with proportions similar to studies in Scotland and Ireland. In
31
addition to instructing patients on regularly avoiding sunlight, applying sunscreen, wearing skin-protective clothing, and avoiding any known allergen(s), our study allows physicians in the United States to inform their patients with CAD that their condition will likely improve, if not resolve, over time.
REFERENCES 1. Lim HW, Morison WL, Kamide R, et al. Chronic actinic dermatitis: an analysis of 51 patients evaluated in the United States and Japan. Arch Dermatol 1994;130:1284Y1289. 2. Que SK, Brauer JA, Soter NA, et al. Chronic actinic dermatitis: an analysis at a single institution over 25 years. Dermatitis 2011;22:147Y154. 3. Lim HW, Buchness MR, Ashinoff R, et al. Chronic actinic dermatitis: study of the spectrum of chronic photosensitivity in 12 patients. Arch Dermatol 1990;126:317Y323. 4. Victor FC, Cohen DE, Soter NA. A 20-year analysis of previous and emerging allergens that elicit photoallergic contact dermatitis. J Am Acad Dermatol 2010;62:605Y610. 5. Zug KA, Warshaw EM, Fowler JF Jr, et al. Patch-test results of the North American Contact Dermatitis Group 2005-2006. Dermatitis 2009; 20:149Y160. 6. Dawe RS, Crombie IK, Ferguson J. The natural history of chronic actinic dermatitis. Arch Dermatol 2000;136:1215Y1220. 7. Healy E, Rogers S. Photosensitivity dermatitis/actinic reticuloid syndrome in an Irish population: a review and some unusual features. Acta Derm Venereol 1995;75:72Y74. 8. Bryden AM, Ibbotson SH, Ferguson J. Spontaneous resolution of chronic actinic dermatitis in a young patient with atopic dermatitis. Clin Exp Dermatol 2002;27:163Y164. 9. Rose RF, Goulden V, Wilkinson SM. The spontaneous resolution of photosensitivity and contact allergy in a patient with chronic actinic dermatitis. Photodermatol Photoimmunol Photomed 2009;25:114Y116. 10. Addo HA, Frain-Bell W. Persistence of allergic contact sensitivity in subjects with photosensitivity dermatitis and actinic reticuloid syndrome. Br J Dermatol 1987;117:555Y559. 11. Somani VK. Chronic actinic dermatitisVa study of clinical features. Indian J Dermatol Venereol Leprol 2005;71:409Y413.
Copyright © 2014 American Contact Dermatitis Society. Unauthorized reproduction of this article is prohibited.
