Keywords

1 Introduction

Mild sunburn is quite frequent in Sri Lanka, commonly among school children and young mothers. Schooling hours in Sri Lanka are 7.30 am to 1.30 pm. Young mothers who come to pick-up pre-school children do not use any method of sun protection. Therefore school children, young mothers, and manual laborers are the most vulnerable.

Broad classification of photodermatoses is shown below. Out of all more than 90% we see are polymorphic light eruptions (PLE). Mostly PLE is mild or moderate being asymptomatic to mild itching. Commonest clinical presentation is hypopigmented patches on the face and the forearms.

figure a

(photographed by Dr. Ranthilaka R. Ranawaka)

  1. 1.

    Mother of this 8 year-old boy is worried about this asymptomatic hypopigmented patches on the face for 3 months which were worsening.

    1. (a)

      What is your diagnosis?

    2. (b)

      How do you manage this condition?

figure b

(photographed by Dr. Ranthilaka R. Ranawaka).

  1. 2.

    A 32-year-old woman came with itchy hypopigmented patches on her both forearms which were worsening over 6 months. On direct inquiry, we found that she is a mother of two primary school children, and she rides a scooter for transportation.

    1. (a)

      What is your diagnosis?

    2. (b)

      Why information on direct inquiry is important in management?

    3. (c)

      In addition to treatments what advice would you give her?

figure c

(photographed by Dr. Ranthilaka R. Ranawaka).

  1. 3.

    An 11-year-old boy came with this mildly itchy hypopigmented patches on the face. He is a member of school swimming team.

    1. (a)

      What is your diagnosis?

    2. (b)

      What advice would you give him?

figure d

(photographed by Dr. Ranthilaka R. Ranawaka).

  1. 4.

    A 48-year-old man’s these skin patches become itchy and erythematous on sunlight exposure.

    1. (a)

      What is your clinical diagnosis?

    2. (b)

      How do you confirm the diagnosis?

    3. (c)

      What advice would you give regarding sunlight exposure?

Answers

  1. 1.

    Polymorphic light eruption

    Reassurance, mild topical steroid twice daily and sunscreen cream on day time

  2. 2.

    Polymorphic light eruption

    Pre-school children are picked-up at 12 noon (highest sunlight exposure), and mostly mothers ride scooters without over-coats/jerkins. We have to find the possible predisposing factors.

    Educate the woman on predisposing factors, proper sun protection using sunscreen and clothing.

  3. 3.

    Polymorphic light eruption

    He has to use water proof SPF >50 sunscreen during swimming

  4. 4.

    Discoid lupus erythematosus (DLE)

    Skin biopsy for histopathology

    DLE exacerbate on sunlight exposure. Therefore he has to use sunscreens SPF >50 during the day time.

2 Idiopathic Photodermatosis

2.1 Polymorphic Light Eruption (PLE)

PLE is a recurrent, delayed-onset, abnormal reaction to sunlight (or artificial UVR source) that resolves without scarring. It is common and has a wide range of severity but can markedly affect quality of life. PLE is much commoner in women (Roelandts 2000).

Clinical Features

PLE presents as pruritic erythematous or hypopigmented papular rash on exposed sites, mainly neck forearms and legs. Several morphological types including papules, plaques, papulovesicular, vesicularbullous, haemorragic, and erythema mutiforme like lesions described (Ibbotson and Dawe 2016; Lehman et al. 2011; Srinivas et al. 2012).

Diagnosis

Mostly clinical

Management

Sun avoidance and protective measures, broad-spectrum high SPF sunscreens, and topical or systemic corticosteroid therapy are sufficient in mild to moderate PLE.

Prophylactic phototherapy/photochemotherapy is the main second-line therapy used.

Long-term immunosuppressive drugs, such as azathioprine and ciclosporin for refractory cases (Figs. 10.1–10.12).

Fig. 10.1
figure 1

Polymorphic light eruption (PLE); hypopigmented macules. Mostly asymptomatic, sometimes itchy when expose to sunlight. This is the commonest PLE type seen in children and as total clinical manifestations in Sri Lanka. Usually the skin patches are bilateral as seen in this child (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.2
figure 2

Polymorphic light eruption (PLE) in an 8-year-old boy (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.3
figure 3

PLE in a 6-year-old girl. Generalized non-itchy hypopigmented rash on the face and the trunk on sun-exposed areas in school children are common in Sri Lanka. Play outdoor on bare trunk is common in hot sunny days (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.4
figure 4

PLE in a 13-year-old girl. These lesions were itchy and eczematous (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.5
figure 5

PLE is sometimes erythematous on sun exposure (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.6
figure 6

Polymorphic light eruption. Note hypopigmented macules are confined to extensor aspect of upper limbs. Flexure aspect is spared (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.7
figure 7

Polymorphic light eruption. Itchy hypopigmented rash on the face in a 15-year-old girl. Secondary “eczematization” develops particularly in atopic persons if itching persists (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.8
figure 8

Polymorphic light eruption. Chronic eczematous type (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.9
figure 9

Polymorphic light eruption. Erythematous maculo-papular type in a 44-year-old woman following acute sunburn (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.10
figure 10

Polymorphic light eruption. Acute vesicular type, following acute severe sunburn (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.11
figure 11

Polymorphic light eruption. Showing skin eruption clearly demarcated to sun exposed areas (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.12
figure 12

Polymorphic light eruption. Hypopigmented papules and plaques. These lesions are permanent and accumulative over the time unless strict sun avoidance is practiced which is not practical in a tropical country. Fortunately this PLE type is not common in Sri Lanka (photographed by Dr. Ranthilaka R. Ranawaka).

Full size image

2.2 Hydroa Vacciniformae

Characterized by vesicles and crust formation after sun exposure. Lesions typically occur on photoexposed sites and may persist several weeks and heal with varioliform scarring. Usually presents in childhood with spontaneous improvement during adolescence. This type is not seen in Sri Lanka.

2.3 Chronic Actinic Dermatitis (CAD)

CAD is a persistent or recurring dermatitis predominantly affecting photo-exposed sites. There is evidence of photosensitivity. Typically occurs in elderly men who worked in outdoor exposed to hot sunlight, e.g., farmers, manual laborers. All patients have abnormal photosensitivity, and most of them have multiple contact allergies.

Clinical presentation ranges from dermatitis, depigmentation, and erythroderma (Wolverton et al. 2014; Henry et al. 1994).

Differential Diagnosis

Airborne contact dermatitis, photoaggravated atopic or seborrhoeic eczema, drug-induced photosensitivity, cutaneous T-cell lymphoma.

Management

Very potent/potent topical corticosteroids, topical tacrolimus or pimecrolimus, PUVA, UVB phototherapy can be effective.

In-patient nursing behind visible- and UV-absorbing window film may be required in extensive cases.

Hydroxychloroquine, ciclosporin, mycophenolate mofetil, hydroxycarbamide, etretinate, danazol, thioguanine, topical nitrogen mustard, thalidomide, infliximab, and INF-α have been reported to be effective but only in small case series and case reports (Paek and Lim 2014; Ibbotson and Dawe 2016).

The avoidance of combined photo (chemo) therapy and systemic immunosuppressant, particularly ciclosporin, is advised due to photo-carcinogenic risk (Figs. 10.13–10.18) (Lenane & Murphy 2001).

Fig. 10.13
figure 13

Chronic actinic dermatitis in a 56-year-old mason who worked in outdoor without sun protection (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.14
figure 14

Chronic actinic dermatitis in a 76-year-old farmer who worked in out-door without sun protection (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.15
figure 15

Chronic actinic dermatitis in a 76 year-old man. Note lesions are clearly demarcated to sun exposed areas of the body (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.16
figure 16

Chronic actinic dermatitis in a 45 year-old manual laborer. A nodular prurigo-like morphology. Note the skin lesions are strictly limited to sunlight exposed areas (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.17
figure 17

Chronic sun damage in a 78 year-old woman (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.18
figure 18

Chronic sun damage in a 31-year-old Sri Lankan woman with Albinism. Note sparing of flexural aspect of the forearm (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image

2.4 Solar Urticaria

Immediate type of hypersensitivity reaction usually to UVA and visible light, less often to UVB. Characterized by itching, erythema, and whealing over exposed sites. Usually idiopathic but can be seen association with medication (Fig. 10.19) (Botto & Warshaw 2008; Perez-Ferriols et al. 2017).

2.5 Actinic Prurigo

Uncommon acquired idiopathic photodermatosis. Usually manifest in childhood. Pruritis is a common feature. They develop patchy edematous erythema with papules, occasionally vesicles. Later transform into chronic excoriated prurigo lesions often with nodules and plaques. Maximum on exposed sites, heals leaving scarring (Fig. 10.20).

Fig. 10.19
figure 19

Solar urticaria (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.20
figure 20

Actinic prurigo (photographed by Dr. Hiromel de Silva)

Full size image

3 Photocontact Dermatitis

3.1 Drug-Induced Photosensitivity

There are number of groups of drugs which can cause photosensitivity. Range of reactions can vary widely and can give rise to various clinical manifestations including urticaria, erythema, blisters, eczematization, and lupus-like and lichenoid reactions.

Some of common drugs responsible for photosensitivity are tetracyclines, griseofulvin, thiazides, isotretinoin/acitretin, phenothiazines, psoralens, and NSAIDS (Fig. 10.21).

Fig. 10.21
figure 21

Griseofulvin-induced photodermatitis (photographed by Dr. Hiromel de Silva)

Full size image

3.2 Photoaggravated Dermatosis

There are some diseases which can be aggregated by exposure to light.

Classical: Atopic dermatitis, psoriasis, lupus erythematosis, Jessner lymphocytic infiltrate, dermatomyositis, lymphocytoma cutis, actinic lichen planus, erythema multiformae, acne vulgaris, pemphigus, Darier disease, transient acantholytic dermatosis, disseminated superficial actinic porokeratosis, pellagra, and viral exanthems including herpes simplex.

Other photoaggravated dermatosis are allergic contact dermatitis, seborrhoeic dermatitis, rosecea, melasma, mycosis fungoides, vitiligo, bullous pemphigoid, linear IGA disease, dermatitis herpitiformis, chronic ordinary urticaria, facial telangiectasia, pityriasis rubra, reticulate erythematosis musinosis, keratosis pillaris, actinic granuloma (Figs. 10.22–10.38) (Kerker & Morison 1990).

Fig. 10.22
figure 22

Photoaggravated dermatitis lichen planus (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.23
figure 23

Photoaggravated dermatitis lichen nitidus (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.24
figure 24

Photoaggravated dermatitis lichen planus pigmentosus (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.25
figure 25

Photoaggravated dermatitis pityriasis rosea (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.26
figure 26

Photoaggravated dermatitis actinic keratosis in an albino man (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.27
figure 27

Photoaggravated dermatitis rosacea (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.28
figure 28

Photoaggravated dermatitis pellagra (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.29
figure 29

Photoaggravated dermatitis porokeratosis (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.30
figure 30

(a and b) Photoaggravated dermatitis atopic eczema (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.31
figure 31

Photoaggravated dermatitis lichen planus actinic (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.32
figure 32

Photoaggravated dermatitis psoriasis (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.33
figure 33

Photoaggravated dermatitis vitiligo (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.34
figure 34

Photoaggravated dermatitis discoid lupus erythematosus (DLE) (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.35
figure 35

(a and b) Photoaggravated dermatitis discoid lupus erythematosus. Note DLE lesions are confined to sun-exposed areas including the scalp (photographed by Dr. Ranthilaka R. Ranawaka)

Full size image
Fig. 10.36
figure 36

Photoaggravated dermatitis granuloma multiforme (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.37
figure 37

Photoaggravated dermatitis Darier’s disease (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.38
figure 38

Photoaggravated dermatitis Jessner lymphocytic infiltration (photographed by Dr. Hiromel de Silva)

Full size image

3.3 Phytophotodermatitis

Naturally occurring chemicals from plants when come in contact with skin and are subsequently irritated by sunlight producing characteristic clinical features. Lesions are mainly distributed on face, V area on the neck, arms, and sometimes trunk and legs depending on the types of clothing they wear. Some plants will produce phototoxic reactions, while some will produce photoallergy.

Citrus family can produce characteristic pigmentation on exposure to sunlight. Sandalwood can be included in beauty regimes and can cause hyperpigmentation and eczematization. As a cure for some skin diseases people use to wash their bodies in herbs boiled water which can cause severe photodermatitis (Figs. 10.39–10.42) (Moreau et al. 2014; Pfurtscheller & Trop 2014).

Fig. 10.39
figure 39

Phytophotodermatitis induced by washing with herbal remedies (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.40
figure 40

Phytophotodermatitis induced by garlic applied on acne (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.41
figure 41

Phytophotodermatitis induced by sandle wood (photographed by Dr. Hiromel de Silva)

Full size image
Fig. 10.42
figure 42

(a and b) Phytophotodermatitis induced by lemon (photographed by Dr. Hiromel de Silva)

Full size image