Solar urticaria--effective treatment by plasmapheresis

Successful serial plasmapheresis for solar urticaria, a case report and literature review

BACKGROUND/PURPOSE

Amidst the emergence of new therapeutic options, traditional therapeutic plasmapheresis (TPE) used in diseases involving a toxic substance in the plasma, remains a viable alternative for cases of recalcitrant solar urticaria (SU). We emphasize the importance of documenting successful experience with repeated plasmapheresis to increase awareness amongst physicians and dermatologists regarding this effective treatment option.

MATERIAL AND METHOD

We reported a case of recalcitrant SU that had not responded to a combination of H1-antihistamines, immunosuppressants, omalizumab and intravenous immunoglobulin. We introduced serial TPE, which involved two consecutive days of procedures for each course was introduced. We detailed the regimen and highlighted the clinical and objective benefits observed with multiple treatments. Additionally, we compared this to other plasmapheresis regimens and their treatment responses previously reported for solar urticaria.

RESULTS

Our patient underwent serial TPE, totaling 42 procedures over five years. Following the last TPE session, phototesting showed a sustained prolongation of minimal urticating doses (MUDS), which exceeded the maximum tested doses across nearly all ultraviolet (UV) and visible light ranges, with the exception of the two short ultraviolet B (UVB) wavelengths. MUDs increased to 25 from 6 mj/cm2 at 307.5± 5nm, and to 500 from 15 mj/cm2 at 320 ± 10nm, before the initial TPE. In our review, we included five articles covering eight SU patients who received TPE. Of these, the five patients with positive intradermal tests responded particularly well immediately after treatment. However, the condition relapsed within two weeks in one patient and within two months in another. In contrast, the other three patients with negative intradermal tests, showed no significant benefits from the treatment. No serious side effects from TPE were reported amongst the patients.

CONCLUSIONS

This review underscores the efficacy of serial plasmapheresis procedures in treating refractory cases of SU, high3lighting the robust results observed.

Potential Therapeutic Approaches for Chronic Urticaria: Beyond H1-Antihistamines and Biologics

Chronic urticaria is a disease that can significantly impact a patient's quality of life and ability to function. There are effective treatment options, such as nonsedating antihistamines or biologics, but some patients do not respond to these therapies, or the therapies are not available or affordable to all patients. This review aims to summarize potential treatment strategies for patients (1) who do not respond to antihistamines and (2) cannot readily access or do not respond to biologics. The review emphasizes the importance of sound clinical practice, including correct diagnosis of chronic urticaria phenotypes, treatment of associated comorbidities, and consideration of add-on pharmacological and nonpharmacological approaches. Although some treatments may lack high-quality evidence, they may still be justifiable in certain cases, provided that there is shared decision-making, regular reassessment, and early recognition of adverse events.

Recent Developments in the Diagnosis and Management of Photosensitive Disorders

Photodermatoses occur in males and females of all races and ages. Onset can be variable in timing and influenced by genetic and environmental factors. Photodermatoses are broadly classified as immunologically mediated, chemical- and drug-induced, photoaggravated, and genetic (defective DNA repair or chromosomal instability) diseases. Advances in the field have led to improved recognition and treatment of many photodermatoses. The purpose of this focused review is to provide an update on the diagnosis and management of a variety of photodermatoses, both common and less common, with review of recent updates in the literature pertaining to their diagnosis and management.

Immunologically mediated photodermatoses: diagnosis and treatment

Electromagnetic radiation may cause distinct skin conditions. The immunologically mediated photodermatoses (IMP, previous term: idiopathic photodermatoses) represent a heterogenous group of disorders presenting with pathologic skin reactions caused by optical radiation, particularly in the UVA wavelength region. The exact pathomechanism in IMP remains to be elucidated; however, it is very likely (auto)-immunologic in nature. Polymorphic light eruption, actinic prurigo, hydroa vacciniforme, chronic actinic dermatitis, and solar urticaria are the most important conditions that may be summarized under the term IMP. IMP frequently result in a significant reduction in quality of life in affected individuals, mainly because of troublesome symptoms such as intractable itch and pain. Photodiagnostic procedures are mandatory for the exact determination of action spectra and the degree of photosensitivity. Broad-spectrum photoprotection is essential in the prevention of IMP. Photo(chemo)therapeutic regimens are predominantly used to increase the cutaneous immunologic tolerance against ambient UV radiation. In severe forms of IMP, immunomodulatory and immunosuppressive therapies may need to be considered. Overall, IMP form a significant group of skin conditions that can be extremely disabling to the patient and are difficult to diagnose and treat.

Solar urticaria successfully treated with intravenous immunoglobulin

Idiopathic solar urticaria (SU) is a rare, debilitating photodermatosis, which may be difficult to treat. First-line treatment with antihistamines is effective in mild cases, but remission after phototherapeutic induction of tolerance is often short-lived. Other treatment options include plasma exchange, photopheresis and cyclosporin. We present two cases of severe, idiopathic SU, which were resistant to conventional treatment. Both patients achieved remission after administration of intravenous immunoglobulin (IVIg) and have remained in remission at 13 months and 4 years, respectively. There are only two case reports of successful treatment of solar urticaria with IVIg. In our experience IVIg given at a total dose of 2 g/kg over several 5-day courses about a month apart is an effective treatment option for severe idiopathic SU. It is also generally safe, even if certainly subject to significant theoretical risks, such as induction of viral infection or anaphylaxis.

Physical urticaria

Physical urticarias are a unique subgroup of chronic urticaria in which patients develop urticaria secondary to environmental stimuli. Common triggers include exercise, temperature changes, cold, heat, pressure, sunlight, vibration, and water. Systemic symptoms have occurred during severe episodes. Physical urticarias are responsible for approximately 20% to 30% of all cases of chronic urticaria. A basic knowledge of these unusual disorders is important for all healthcare providers. This article covers the following types of physical urticarias: dermatographism, cholinergic urticaria, local heat urticaria, exercise-induced anaphylaxis, vibratory angioedema, solar urticaria, and aquagenic urticaria.

Urticaire solaire traitée par l’association immunoglobulines polyvalentes et PUVAthérapie

BACKGROUND

Solar urticaria is a rare form of urticaria occurring a few minutes after solar exposure. It is particularly incapaciting because it limits outdoor activities. Antihistamine and phototherapy are sometimes disappointing.

CASE REPORT

A 32 Year-old woman had been suffering from severe solar urticaria since November 2000, which was confirmed by photobiological data. High-dose antihistamine treatment (fexofenadine 180 mg twice a day) was inefficient. Despite a first UVA desensitization, PUVAtherapy produced only a partial improvement and short lasting for protection, with an important handicap in daily life. In March 2002, among the others treatments, we chose intravenous immunoglobulins: 0.5 g/kg the first day then 1 g/kg the second and the third days. The minimal urticaria dose was raised from 1 J/cm2 in UVA before perfusion up to 15.6 J/cm2 48 hours later and in UVB from 100 mJ/cm2 up to 2,200 mJ/cm2. Clinically the improvement was significant but partial in daily activities. It was possible to reintroduce PUVAtherapy without UVA-desensitization and, for the first time, to obtain complete remission for more than 2 Months with an association of intravenous immunoglobulins, PUVAtherapy and antihistamine treatment. In July 2002, treatment was successfully repeated.

DISCUSSION

First intention treatments (antihistamine and PUVAtherapy) are sometimes inefficient. Others treatments (plasmapheresis, ciclosporin, doxepin, cimetidine) are restrictive, not always efficient and can induce severe side-effects. We report the second case of solar urticaria improved by intravenous immunoglobulins. In spite of the cost, intravenous immunoglobulins seem to be an interesting treatment, at least by avoiding UVA-desensitization in severe cases of solar urticaria.

Diagnosis and treatment of solar urticaria

Solar urticaria is one of the most annoying of the photodermatoses. It can be difficult to diagnosis because of phototesting problems, and it is not easy to treat. The different treatment modalities available all have their practical problems, so it is difficult to provide the patient with adequate protection. In many patients, however, treatment can reduce the symptoms and allow regular exposure of the skin to natural sunlight as the skin becomes more tolerant to the provoking wavelengths, the result being more complete protection.

The idiopathic photodermatoses

The idiopathic photodermatoses present a challenge for dermatologists. Although, as in other specialty areas, the classical clinical presentation produces few problems, it is the severe forms and overlap cases that cause the most difficulty. It is fortunate that the semi-objective investigation of phototesting is available, which, when conducted carefully, reveals so much about the nature of this group of conditions. This essential investigation not only helps achieve a diagnosis, but also affords material for study and a means of monitoring therapy response or progress towards spontaneous resolution. Although these conditions are grouped together, throughout this century we have seen a continuing process of distinct diseases emerging as a consequence of careful clinical observation and investigation.

Treatment of refractory solar urticaria with plasma exchange

BACKGROUND

Solar urticaria is a photodermatosis that can be very disabling for patients who are highly sensitive to light and can also be very resistant to therapy.

OBJECTIVE

To correlate the results of serial phototesting in a patient with severe and refractory solar urticaria before and after treatment with plasma exchange.

METHODS

Plasma exchange was performed five times over a period of 10 days. Phototesting to ultraviolet A (UVA) irradiation and visible light was performed with fluorescent ultraviolet tubes and an incandescent lamp.

RESULTS

The urticaria that developed after very low light doses during baseline phototesting could not be provoked following plasma exchange. The patient is now almost symptom-free, with only occasional and transient hives more than 21 months after her last plasma exchange.

CONCLUSIONS

Plasma exchange is a therapeutic modality to consider in highly light-sensitive patients when other treatments have failed.

Cyclosporin A therapy for severe solar urticaria

Solar urticaria is characterized by itching weals that occur a few minutes after exposure to visible or ultraviolet light. The symptoms may sometimes restrict normal daily life. Treatment is difficult in more severe cases. We describe one patient with solar urticaria who was successfully treated with cyclosporin A. The patient had first been treated with antihistamine, PUVA and chloroquine phosphate without effect. Cyclosporin was given in a dose of 4.5 mg/kg body weight/day. Phototesting before, during and after treatment showed a decreased light sensitivity to UVA, UVB and visible light during cyclosporin treatment compared with phototesting before therapy. The patient could be out in the sun for at least 1 h with minimal urticaria during cyclosporin therapy compared with only a few minutes previously. However, 1-2 weeks after cyclosporin therapy was discontinued, skin symptoms returned. Cyclosporin therapy is a possible treatment in severe cases of solar urticaria where other treatments have failed, especially in countries where treatment is necessary only for a few months during summer.