By Gary M. White, MD
Eczematous, inflamed plaques on the neck and ears in a middle-aged postal worker on no medications.
Chronic actinic dermatitis (CAD) (AKA actinic reticuloid) is a photosensitivity dermatitis that gives rise to erythematous and eczematous lesions.
Persistent erythema of the face in a middle-aged to elderly person is characteristic. In one study, the mean age was 62.7 years and males were more commonly affected. Patients with skin types V and VI are preferentially affected. Itching and burning may be present. The rim of the ears, bald scalp, and V of the neck may also be involved. The patient is very sun-sensitive. Even white fluorescent lights may exacerbate the condition. With time, the skin may become eczematous and lichenified, and a leonine facies may result. The term actinic reticuloid has been used for this change. Although histologic features may suggest a lymphoma, CAD is not a premalignant condition.
The diagnostic criteria include:
Patch testing may be positive as these patients have a high incidence of contact allergy sensitivity to plant oleoresin extracts, fragrances, and lichens. This varies by geographic location. For example, allergy to Compositae plants is very common in Scotland, but uncommon in the US. Parthenium dermatitis, a common cause of plant dermatitis in India, is classically an airborne contact dermatitis but may resemble CAD.
The action spectrum usually involves UVB, UVA, and visible light beyond 400 nm. A combination UVA/UVB sunscreen should be used daily. The metal-containing sunscreens (e.g., titanium, zinc, iron) are most effective, blocking more of the UVA spectrum. Narrow-weave, thick clothing (e.g., blue denim) is the best protector. Mylar products can be used for windows which will block the UVA part of the spectrum of the car, home, or office. Topical steroids for mild disease and oral corticosteroids for flares are the initial therapy. Pimecrolimus and tacrolimus have also been used. For more severe cases, azathioprine (e.g., 100-150 mg/day) or UVB (started initially with prednisone 60-100 mg/day to prevent photoexacerbation) may be used to decrease sun sensitivity and control the disease.
Mycophenolate mofetil has also been combined with prednisone as pre-treatment prior to light therapy. Hydroxychloroquine sulfate, 200 mg QD or BID, may be added to the above. Cyclosporin 4-5 mg/kg/day was extremely effective in several patients. Methotrexate and thalidomide have also been used.
An analysis of the natural history suggests that the condition generally improves or resolves completely over time. In a retrospective study of 20 patients in New York [Dermatitis 2014;25:27], 90% experienced resolution (35%) or improvement (55%) of their CAD during a 3-19 year followup.
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