The clinical and photobiological characteristics of solar urticaria in 40 patients

Solar urticaria: clinical characteristics, treatment effectiveness, long-term prognosis, and QOL status in 29 patients

Introduction

Solar urticaria (SU), a relatively rare skin inflammatory and photosensitivity disease, is often resistant to standard urticaria treatment. Quality of life (QOL) among SU patients has not been extensively explored. This study was performed to clarify the clinical features and effectiveness of therapies (e.g., hardening therapy) for SU and to determine QOL among SU patients.

Methods

The authors examined the characteristics, treatments, and QOL statuses of 29 Japanese SU patients using medical records and a questionnaire approach.

Results

Among 29 patients, H1 antihistamine therapy (H1) was effective in 22 (75.8%) patients. H2 antihistamine therapy (H2) was effective in three of seven (42.9%) patients. Ultraviolet radiation A (UVA) hardening therapy was effective in eight of nine (88.9%) patients. Visible light (VL) hardening therapy was ineffective in three of three patients. In one patient who underwent both UVA and VL hardening therapy, only UVA hardening therapy was effective. In the questionnaire, 18 patients (90%) reported some improvement compared with disease onset (four had complete remission, six had completed treatment although mild symptoms persisted, and eight were receiving treatment with moderate symptoms), whereas two patients reported exacerbation. Patients in complete remission had a mean disease duration of 4 years, whereas patients not in remission had a mean disease duration of 8.8 years. The mean Dermatology Life Quality Index (DLQI) score for the current status was 7.4. There was a correlation between DLQI and symptom/treatment status. However, neither DLQI and action spectra nor DLQI and treatments exhibited significant differences.

Discussion

The questionnaire revealed current QOL status and long-term prognosis in SU patients. Compared with disease onset, most patients showed improvement when assessed for this study. Both H1 and H2 should be attempted for all SU patients. UVA hardening therapy may be an option for SU patients with an action spectrum that includes UVA.

Photo urticaria caused by exposure to LED emitting 633-nm wavelength during hot yoga exercise

Photo urticaria (PU) is a rare type of urticaria that develops after exposure to various wavelengths of light. Inducing urticarial wheals using light sources of pertinent wavelengths can help make the definitive diagnosis of PU. The action spectra (AS) in Japanese patients with PU commonly fall within the ultraviolet radiation A and visible light range. Herein, to the best of our knowledge, we present the first case of PU caused by 633-nm wavelength within the visible light spectrum. Our patient worked as a "hot yoga" instructor, where light-emitting diodes (LEDs) on the ceiling were used to irradiate the entire room with 633-nm wavelength of light for "light treatment." She reported itching and wheals on the face and neck during her "hot yoga" sessions. "Hot yoga" has recently gained popularity globally. The "light treatment" is based on the theory that 633-nm wavelength light within the visible light spectrum reportedly prevents the skin from aging. We induced wheals with erythema by irradiating her skin using a 633-nm LED at a dose of 0.008 J/cm² /s for 1 h. Her condition was diagnosed as PU caused by exposure to 633 nm. Light. Her symptoms have not recurred since she has avoided being exposed to the 633-nm wavelength of LED light.

Pathogenesis of solar urticaria: Classic perspectives and emerging concepts

Solar urticaria is a rare, immunologically mediated photodermatosis in which activation of cutaneous mast cells is triggered by specific wavelengths of solar electromagnetic radiation. This manifests clinically as the rapid development of cutaneous itch, erythema and wheal formation after several minutes of sun exposure. Disease mechanisms in solar urticaria remain incompletely elucidated and there have been few recent investigations of its pathobiology. Historic passive transfer experiments performed during the twentieth century provide support for a 'photoallergy' model of disease pathogenesis, wherein molecular alteration of a putative chromophore by solar electromagnetic radiation produces mast cell activation via an IgE-dependent mechanism. However, this model does not account for several observations made during passive transfer experiments nor does it explain a range of subsequent clinical and photobiological observations made in solar urticaria patients. Furthermore, increased understanding of the molecular dynamics underpinning cutaneous mast cell responses highlights the need to reformulate our understanding of solar urticaria pathogenesis in the context of this contemporary scientific landscape. In this review, we discuss the current understanding of solar urticaria pathogenesis and, by incorporating recent scientific and clinical observations, develop new hypotheses to drive future investigation into this intriguing disorder.

Lichturtikaria: Klinik, Diagnostik, Verlauf und Therapiemanagement bei 27 Patienten

BACKGROUND AND OBJECTIVES

Solar urticaria is a rare photodermatosis, yet lacking standardization in diagnosis and therapy. The aim of this research was to use innovative radiation sources for diagnostics with defines and reproducible emission spectrum and doses. A uniform therapy step scheme was to be created.

PATIENTS AND METHODS

In a longitudinal study, 27 patients were examined with solar urticaria over 13 years. With a characteristic anamnesis, the diagnosis was confirmed with phototesting from various radiation sources (UVB, UVB311nm, UVA, UVA1, green light, red light) and a therapy step scheme consisting of light protection, antihistamines, rush hardening with UVA-1 and the treatment with omalizumab.

RESULTS

Action spectrum: UVB 44 %, UVA 70 %, UVA1 89 %, green light 37 % and red light 22 %. Rush hardening was performed on 20 patients, 17 of whom were adequately protected. In three further patients, omalizumab was additionally treated in off-label use.

CONCLUSIONS

Photoprovocation with UVB, UVB311nm, UVA, UVA-1 and visible light with innovative radiation sources is uniformly possible in every major skin clinic. With the help of the therapy step scheme the patients can be adjusted well, a Rush Hardening with UVA-1 is a safe method to help the patients during the sunny season. Omalizumab as the last therapy option is effective, but currently only possible in off-label use.

Solar urticaria: Clinic, diagnostic, course and therapy management in 27 patients

BACKGROUND AND OBJECTIVES

Solar urticaria is a rare photodermatosis, the diagnosis and therapy of which have not yet been standardized. The aim of this research was to use innovative radiation sources for diagnostics with defined and reproducible emission spectra and doses. A uniform therapy step scheme was to be created.

PATIENTS AND METHODS

In a longitudinal study, 27 patients with solar urticaria were examined over 13 years. With a characteristic anamnesis, the diagnosis was confirmed with phototesting (photoprovocation) from various radiation sources (UVB, UVB311nm, UVA, UVA-1, green light, red light) and a therapy step scheme was designed consisting of light protection, antihistamines, rush hardening with UVA-1, and administration of omalizumab.

RESULTS

Action spectrum: UVB 44 %, UVA 70 %, UVA-1 89 %, green light 37 % and red light 22 %. Rush hardening with subsequent maintenance therapy was performed on 20 patients, 17 of whom were hereby adequately protected. In three further patients, omalizumab was additionally administered.

CONCLUSIONS

Phototesting with UVB, UVB311nm, UVA, UVA-1, and visible light with innovative radiation sources is uniformly possible in every major skin clinic. With the help of the therapy step scheme the patients can be adjusted well. Rush hardening with UVA-1 is a safe method to help the patients during the sunny season. Omalizumab as the last therapy option is effective, but currently only possible in off-label use.

Characteristics and clinical significance of augmentation spectra in solar urticaria

Solar urticaria has unique spectra, such as inhibition and augmentation. The clinical significance of these spectra, especially augmentation, is not well understood. Reported cases of solar urticaria with augmentation spectra are extremely rare in the published English-language work. The purposes of this study were to evaluate the clinical features of solar urticaria with augmentation spectra and to elucidate the mechanisms and clinical importance of the spectra. We experienced 11 cases (five females, six males; mean age, 40.1 years; range, 1-74) of solar urticaria with augmentation spectra from April 2007 to July 2019. Augmentation spectra were UV-B in three cases, UV-A in two, visible light in four, UV-A and UV-B in one, and UV-A and visible light in one. Augmentation spectra were observed before action spectra in four cases, after in six, and before and after in one. Injection of sera irradiated with action spectra and augmentation spectra in vitro induced stronger immediate reactions than those of only action spectrum-irradiated sera in four of five cases. The results of injection tests suggested that augmentation spectra enhance the production of urticaria-forming factor. Clinically, we observed severe urticarial reactions in four cases, including anaphylaxis in three and moderate urticarial reactions in three. These results suggest that augmentation spectra are not as rare as previously thought and that they are associated with the severity of solar urticaria. Therefore, phototesting for both augmentation and action spectra should be performed to provide appropriate guidance for patients with solar urticaria.

Phototherapy in the Evaluation and Management of Photodermatoses

Ultraviolet light (UV) and visible light are important components in the diagnosis of photodermatoses, and UV has the unique ability to also be used to manage photodermatoses. Phototesting, provocative light testing, and photopatch testing can provide important information in diagnosing patients with photodermatoses; phototesting can be used to determine the starting dose for phototherapy in these patients. Once photosensitivity is established, narrowband UVB and UVA1 therapy have helped to improve the quality of life of photosensitive patients, such as those with polymorphous light eruption, chronic actinic dermatitis, and solar urticaria.

Real-life experience in the treatment of solar urticaria: retrospective cohort study

BACKGROUND

Solar urticaria (SU) is a rare photodermatosis causing a significant impact on patients' quality of life (QoL), and treatment is often challenging.

AIM

To analyse clinical experience with a tailored stepwise therapeutic approach.

METHODS

A retrospective cohort design was used. Patients with suspected SU underwent laboratory investigations and photoprovocation. Those with a high minimal urticaria dose (MUD) were treated with a single antihistamine (protocol 1), and those with a lower MUD received three types of antihistamines (protocol 2); both protocols included a leucotriene receptor antagonist (LRA). In cases of failure, treatment was switched to omalizumab at doses of < 300 mg/month with incremental dosage increases as necessary (monthly dose range, 150-600 mg/month). Symptom relief and photoprovocation under treatment were evaluated.

RESULTS

In total, 30 patients (10 men, 20 women) were enrolled. Most (87%) were sensitive to visible light (1-70 J/cm² ) with or without extension to ultraviolet A. Of the 30 patients, 23 opted for our stepwise approach: 22 achieved complete remission on protocols 1 or 2 (n = 17) or after switching to omalizumab (n = 5), and another patient achieved partial remission under omalizumab. There were no treatment-related severe adverse effects.

CONCLUSIONS

Symptoms of SU can be well controlled by treatment with antihistamines and an LRA tailored to the degree of photosensitivity, followed by omalizumab in refractory cases. This has important implications for patient QoL.

Ultraviolet radiation and skin mast cells: Effects, mechanisms and relevance for skin diseases

Mast cells (MCs) are well known as versatile effector cells in allergic reactions and several other immune responses. Skin MCs and cutaneous MC responses are subject to the effects of environmental factors including ultraviolet radiation (UVR). Numerous studies have assessed the effects of UVR on MCs, in vitro and in vivo. Interestingly, UVR seems to have variable effects on non-activated and activated mast cells. In general, UV therapy is beneficial in the treatment of urticaria and mastocytosis, but the effects are variable depending on treatment regimen and type of UVR. Here, we review and summarise key reports from the older and current literature on the crosstalk of UVR and skin MCs. Specifically, we present the literature and discuss published reports on the effects of UVR on skin MCs in rodents and humans. In addition, we review the role of MCs in UVR-driven skin diseases and the influence of UV light on MC-mediated skin diseases. This summary of our current understanding of the interplay of skin MCs and UVR may help to improve the management of patients with urticaria and other MC disorders, to identify current gaps of knowledge, and to guide further research.

Solar urticaria: Epidemiology and clinical phenotypes in a Spanish series of 224 patients

BACKGROUND

Solar urticaria is a chronic inducible urticaria also classified as an idiopathic dermatosis. The objective of this paper is to define the phenotypic characteristics of solar urticaria and to evaluate its incidence.

MATERIAL AND METHOD

This was a retrospective multicenter study in which data were gathered on the epidemiology and clinical, photobiologic, laboratory, and therapeutic characteristics of solar urticaria.

RESULTS

A total of 224 patients (141 women and 83 men) were included from 9 photobiology units. The mean age of the patients was 37.9 years (range, 3-73 years). A history of atopy was detected in 26.7%, and the most common presentation was allergic rhinitis (16.5%). Clinical signs were limited to sun-exposed areas in 75.9% of patients. The light spectrum most commonly implicated was visible light only (31.7%), and in 21% of cases it was only possible to trigger solar urticaria with natural light. The treatments most widely used by photobiology experts were oral antihistamines (65.46%), followed by different forms of phototherapy (34%). Complete resolution was observed most often in patients with solar urticaria triggered exclusively by visible or natural light, with statistically significant differences with respect to other wavelengths (P<.05). No increase in the annual incidence of solar urticaria was observed.

CONCLUSIONS

We have presented the largest series of solar urticaria published to date. The epidemiological, clinical, and photobiologic findings confirm previously reported data, although there was a particularly high rate of negative phototests in our series. Reactivity exclusively to visible or natural light was associated with a higher probability of resolution. No increasing trend was observed in the annual incidence.

The definition, diagnostic testing, and management of chronic inducible urticarias - The EAACI/GA(2) LEN/EDF/UNEV consensus recommendations 2016 update and revision

These recommendations for the definition, diagnosis and management of chronic inducible urticaria (CIndU) extend, revise and update our previous consensus report on physical urticarias and cholinergic urticaria (Allergy, 2009). The aim of these recommendations is to improve the diagnosis and management of patients with CIndU. Our recommendations acknowledge the latest changes in our understanding of CIndU, and the available therapeutic options, as well as the development of novel diagnostic tools.

Solar urticaria in a 1-year-old infant: diagnosis and management

Solar urticaria is a type of inducible urticaria triggered by sun exposure resulting in hives on exposed skin as well as risk of developing systemic symptoms. Most cases are reported in the adult population. However, cases do occur in children. We present a case of visible light induced urticaria in a 12-month-old girl that demonstrates the need for accurate diagnosis and appropriate management.

Photodermatoses: environmentally induced conditions with high psychological impact

Photodermatoses are a group of skin disorders caused or exacerbated by ultraviolet and/or visible radiation, which collectively affect a high proportion of the population and substantially affect quality of life (QoL). Our objective was to assess the psychological impact of these conditions. Patients with a range of photodermatoses diagnosed at a specialist investigation centre in the UK completed questionnaires evaluating (i) anxiety and (ii) depression, using the Hospital Anxiety and Depression Scale (HADS), (iii) social anxiety, using the Fear of Negative Evaluation measure (FNE), (iv) coping strategies (brief COPE) and (v) QoL, using the Dermatology Life Quality Index (DLQI). Questionnaires were returned by 185 of 260 patients (71.1% response rate). Mean age was 50.2 years (SD 14.5, range 20-85), 80.3% female. Polymorphic light eruption was the most common diagnosis, followed by photoaggravated eczema, other photoaggravated dermatological conditions and solar urticaria. Across the sample, high percentages, i.e. 23% and 7.9% of individuals, showed scores indicating clinical levels of anxiety and depression, respectively. Facial involvement was a strong indicator for depression (t = 2.7, p < 0.01). In regression analyses psychological factors (particularly depression and adaptive coping) were the principle predictors of QoL, accounting for 17.7% of the variance (F = 7.61, p < 0.01), while clinical variables accounted for an additional 10.1% (F = 8.96, p < 0.01), with number of months/year affected exerting a significant effect (p < 0.01). This study demonstrates the high psychological comorbidity of these conditions; more awareness of this is required, with adoption of a biopsychosocial approach to their management.

Urticaria and angioedema

Urticaria and angioedema are common disorders that can severely impair the quality of a patient's life and can be extremely difficult to treat. Symptoms can persist for years to decades. The causes of urticaria and angioedema are varied and may be immunologic, nonimmunologic, or idiopathic. This article reviews the literature and provides primary care physicians with up-to-date information of the epidemiology, basic pathophysiology, diagnosis, and management of this common and often debilitating condition. Additionally, clinical manifestations of acute and chronic urticaria, hereditary and acquired angioedema, as well as the physical urticarias will be discussed.

Photodermatoses: classification, evaluation and management

Photodermatoses are skin disorders induced or exacerbated by light. They can be broadly classified into four groups: (i) immunologically mediated photodermatoses (idioapathic); (ii) drug- and chemical-induced photosensitivity; (iii) defective DNA repair disorders; and (iv) photoaggravated dermatoses. The exact pathomechanism of those diverse skin reactions to light radiation remains unclear. Immunologically mediated photodermatoses are the most common dermatoses among all photosesnsitive disorders. The management of photodermatoses starts with clinical recognition of characteristic lesions localized predominantly in light exposed skin. Detailed history-taking, phototesting and photopatch testing are required to establish a correct diagnosis, especially if patients present in disease-free intervals. Classification and short description of distinctive clinical features of most common photodermatoses, several practical aspects of evaluation and management of the patient with photosensitivity will be outlined.

The inhibition spectrum of solar urticaria suppresses the wheal-flare response following intradermal injection with photo-activated autologous serum but not with compound 48/80

BACKGROUND

The inhibition spectrum (IS) in solar urticaria was identified mainly in Japanese patients with solar urticaria, although the mechanism of action of the IS has not been elucidated.

METHODS

Because an intradermal injection of action spectrum (AS)-irradiated serum in a case of solar urticaria induced a wheal response, we studied the responsiveness of the intradermal injection after an IS irradiation.

RESULTS

An AS in this patient was composed of visible light shorter than 500 nm, while an IS was composed of visible light longer than 530 nm. When the IS was exposed immediately after the AS irradiation, the wheal response was inhibited. However, when the IS was exposed before the AS irradiation, the wheal response was not inhibited. An intradermal injection of her serum produced no reaction, whereas an intradermal injection of her serum pre-irradiated with visible light induced a wheal flare response. Further examination revealed that the in vivo wheal-inducing activity of her serum irradiated with visible light could be attenuated by post-IS irradiation at the injection site, while the wheal-inducing activity of her visible light-irradiated serum was not inhibited by irradiation of the activated serum with the IS. The wheal-flare response induced by compound 48/80 and histamine was not altered by IS irradiation at the site of skin tests.

CONCLUSION

These findings indicate that photoallergens in the patient's serum that are activated by visible light irradiation are responsible for the development of her symptoms and that the IS may suppress the wheal response by inhibiting the binding of the photoallergens to mast cells, not by inactivating the photoallergens and stabilizing mast cells.

Analysis of photodermatoses seen in a predominantly Asian population at a photodermatology clinic in Singapore

BACKGROUND

The idiopathic photodermatoses have been reported to be rarer in tropical Singapore than in countries of higher latitude, with photoaggravated dermatoses and systemic phototoxicity making up most of the photodermatoses seen here. This study aims to reassess the spectrum of photodermatoses seen at the National Skin Centre, Singapore, compared with almost a decade ago, and analyse the clinical and photobiological characteristics, as compared with other countries.

MATERIALS AND METHODS

We reviewed the clinical data of 141 patients phototested from January 2000 to December 2001, and analysed the epidemiological, clinical and photobiological features.

RESULTS

Photosensitive dermatoses were diagnosed in 88% (124/141) of patients phototested. In those diagnosed with photodermatoses, polymorphic light eruption (PMLE) (28%) was the most common diagnosis, followed by photoaggravated dermatoses (26%), chronic actinic dermatitis (CAD) (15%), systemic phototoxicity (15%), solar urticaria (SU) (7%), actinic prurigo (AP) (5%) and photoallergic contact dermatitis (4%). Ethnic Indians appeared to be more predisposed to PMLE; AP was diagnosed only in ethnic Chinese. The other photodermatoses occurred proportionally in all racial groups. AP differed from that found in Caucasians, being of adult onset and persistent. Abnormal phototest results were obtained in all patients with CAD, SU and AP, but only in 56% and 49% of systemic phototoxicity and PMLE, respectively.

CONCLUSION

Idiopathic photodermatoses are more commonly diagnosed in Singapore than a decade ago, while the incidence of systemic phototoxicity has remained stable. The spectrum of photodermatoses in our Asian population now approximates that seen in Caucasian cohorts.

Urticaria solar. Estudio de 20 casos

INTRODUCTION

Solar urticaria is an infrequent disorder, but is probably underdiagnosed. It is characterized by the sudden appearance of weals in areas that are not usually photoexposed after exposure to the sun or to artificial sources of visible or ultraviolet light. Few cases have been published in literature, so the information available about this disorder and its natural evolution is limited.

MATERIAL AND METHODS

We have compiled data from 20 patients diagnosed with solar urticaria in our department in the last 12 years (1990-2002) in order to try to obtain information about the characteristics of this condition.

RESULTS

As the most relevant characteristics of our series, we can mention the fact that 60 % of the patients were women, and the average duration of the condition before consulting a dermatologist was 3 years. In 55 % of the patients, areas that are usually photoexposed, such as the face and hands, were less severely affected (due to acclimatization or hardening). The spectra responsible for the SU were visible light, UVA and UVB, in that order. With regard to treatment, we obtained a partial response with antihistamines and photoprotectors, and good results using progressive desensitization with UVA/sunlight.

CONCLUSION

Solar urticaria is probably an underdiagnosed condition in our milieu. There are few series in literature that provide any information about the most significant characteristics of this disorder. We have compiled the most relevant data from our patients and we have compared it with the other published series in an attempt to learn more about this photodermatosis.