Diagnosis and pharmacological treatment of chronic actinic dermatitis in the elderly: an update

The Effectiveness and Safety of Dupilumab for the Treatment of Recalcitrant Chronic Actinic Dermatitis: A Case Series

Background

Although dupilumab is an effective treatment approach for chronic actinic dermatitis (CAD) in some cases, its effectiveness and safety in CAD have not been sufficiently assessed.

Purpose

Evaluation of the effectiveness and safety of dupilumab in patients with recalcitrant CAD was performed.

Methods

We retrospectively reviewed the medical records of CAD patients treated with dupilumab. Data regarding demographics were collected, and disease severity scores were assessed using the following: Clinical Severity Score of CAD (CSS-CAD), Atopic Dermatitis Control Tool (ADCT), Dermatology Life Quality Index (DLQI), and Numeric Rating Scale (NRS)-itch scores.

Results

After 12 weeks of treatment, there was a significant decrease in disease severity scores of 16 CAD patients. Only one patient achieved a good response and most of the patients (62.5%, 10/16) had no significant symptom improvement after 4 weeks of treatment. However, after 12 weeks of treatment, 43.75% (7/16) of the patients reached excellent response (>75% improvement of CSS-CAD), 31.25% (5/16) good response (50%-75% improvement of CSS-CAD), 6.25% (1/16) partial response (25%-50% improvement of CSS-CAD), and only 18.75% (3/16) no response (<25% improvement of CSS-CAD). One patient complained of injection site reaction at the first injection.

Conclusion

This study supports dupilumab as an effective and safe treatment option for patients with recalcitrant CAD. Patients may require at least 4 weeks of treatment before the partial response is noted.

Nomenclature and clinical phenotypes of atopic dermatitis

Atopic dermatitis is a heterogeneous disease and resists classification. In this review, we discuss atopic dermatitis nomenclature and identify morphologic phenotypes, which will facilitate correct diagnoses and development of treatment strategies. We support using the term 'atopic dermatitis' rather than eczema, because it describes the allergic background and inflammation ('itis') as drivers of the disease. Atopic dermatitis has many morphologic manifestations that vary by topographic area affected, age, or race and require consideration in differential diagnosis. Different phenotypes based on morphology and topographic location, ethnicity, and age are discussed. A better-defined phenotype identification for atopic dermatitis will facilitate earlier and correct diagnosis of this complex condition and inform selection of the most appropriate treatment choice in an era in which targeted therapies may generate more individualized patient care.

Up-regulation of hsa-miR-221-3p induced by UVB affects proliferation and apoptosis of keratinocytes via Bcl-xL/Bax pathway

BACKGROUND

Chronic actinic dermatitis (CAD) is a photoallergic skin disease with abnormal hyperplasia. At present, the mechanism of abnormal proliferation is not clear.

OBJECTIVE

To explore possible mechanism of CAD proliferative lesions.

METHODS

Immunohistochemistry (IHC) assay and small RNA sequencing were carried out. Quantitative real-time PCR (qRT-PCR) analysis was performed to evaluate expression levels of hsa-miR-221-3p and FOS. The interaction between hsa-miR-221-3p and FOS was identified by dual-luciferase reporter assay. Expression of hsa-miR-221-3p also was detected by qRT-PCR after UVB irradiation. Influences of hsa-miR-221-3p and FOS on cell viability and apoptosis were assessed through a series of functional experiments and rescue experiments. Western blot analysis was used to detect protein expression of fos, Bax, Bcl-xL, and caspase-3.

RESULTS

Patients with CAD had marked epidermal hyperplasia. The expression of hsa-miR-221-3p was up-regulated in CAD while FOS was significantly down-regulated. Dual-luciferase reporter assay confirmed that hsa-miR-221-3p targeted FOS 3'UTR. Hsa-miR-221-3p induced by UVB ranged from 0 to 30 mJ. Moreover, hsa-miR-221-3p overexpression or FOS knockdown promoted cell proliferation and reduced cell apoptosis. Western blot showed that hsa-miR-221-3p negatively regulated fos, which regulated Bcl-xL/Bax. Cell proliferation caused by hsa-miR-221-3p overexpression or FOS knockdown could be reversed by Bcl-xL inhibitor.

CONCLUSION

Hsa-miR-221-3p induced by UVB targeted FOS 3'UTR, which played an important role in regulating proliferation and apoptosis of keratinocytes via Bcl-xL/Bax pathway; this may provide a new insight for CAD proliferative lesions.

Ultraviolet A rush hardening for chronic actinic dermatitis: Pilot treatment outcomes

Chronic actinic dermatitis (CAD) is a common debilitating photodermatosis. Patients often have to completely avoid outdoor activities, which severely impacts their quality of life. Phototherapy is effective for CAD and seems to increase patients' tolerance towards sunlight and consequently decrease the extent of disease. Unfortunately, the slower onset and time-consuming nature of phototherapy limits the clinical application. Considering the effectiveness and time-saving nature of ultraviolet (UV)-A rush hardening in solar urticaria, we performed a pilot study to determine whether UV-A rush hardening is effective in CAD. Six patients with CAD were exposed to multiple sessions of UV-A for 4-5 days at 1-h intervals/day. Subsequently, maintenance UV-A exposure was performed at 1-2-week intervals. Phototesting at baseline showed that three patients were sensitive to both UV-A and -B, and the other three patients only showed UV-A sensitivity. All of the patients responded well to UV-A rush hardening and four (67%) maintained a good remission status after 1 year. The results of this pilot study suggest that UV-A rush hardening phototherapy is effective and well tolerated in the treatment of CAD, while future larger prospective studies using objective scores of disease activity and quality of life are needed.

Azathioprine: its uses in dermatology

This is a narrative review of azathioprine. This medication is immunomodulatory and immunosuppressive, and it has been used widely through different medical specialties to modify disease. It has been proven useful for several dermatoses and it has encountered success when used as an off-label indication for other dermatologic diseases. Its mechanism of action is described thoroughly, as well as precautions for monitoring adequate levels in patients using it. Dermatologists should also be aware of the possible adverse events it may present. In dermatology it can be used in bullous and autoimmune diseases, and in other conditions, including intractable pruritus, atopic dermatitis, photodermatoses, psoriasis, and others. Azathioprine offers an alternative as a steroid-sparing agent and this review helps dermatologists prescribe it safely to all patients who require it.

Upregulation of hsa-miR-31-3p induced by ultraviolet affects keratinocytes permeability barrier by targeting CLDN1

Chronic actinic dermatitis (CAD) is a photoallergic skin disease with complicated pathogenesis. However, skin barrier dysfunction may be involved according to clinical manifestation. To investigate the mechanism of CAD barrier dysfunction, noninvasive detection of skin barrier and small RNA sequencing were carried out. Quantitative real-time PCR (qRT-PCR) was used to evaluate the expression levels of hsa-miR-31-3p and CLDN1. The correlation between hsa-miR-31-3p and CAD severity was explored. Further, dual-luciferase reporter assay was performed to identify the relationship between hsa-miR-31-3p and CLDN1. In addition, expression of hsa-miR-31-3p was detected after ultraviolet (UV) irradiation. Influences of hsa-miR-31-3p on primary human keratinocytes barrier were assessed by FITC-Dextran permeability assay. Moreover, western blot was used to detect the expression of claudin-1, filaggrin, loricrin and involucrin. Our results showed that transepidermal water loss (TEWL) significantly increased in CAD, while stratum corneum hydration (SCH) significantly decreased. The expression of hsa-miR-31-3p was up-regulated in CAD while CLDN1 was down-regulated. Hsa-miR-31-3p was correlated with TEWL, UV-MED (minimal erythema dose) and clinical severity scores of CAD (CSS-CAD). Dual-luciferase reporter assay confirmed that hsa-miR-31-3p targeted the 3'UTR region of CLDN1. Moreover, hsa-miR-31-3p was induced by UVB (0-30 mJ/cm²) and UVA (0-4 J/cm²). Furthermore, overexpression of hsa-miR-31-3p increased FITC-Dextran flux of primary human keratinocytes and reduced the expression of claudin-1, filaggrin, loricrin and involucrin. In conclusion, we demonstrated that hsa-miR-31-3p induced by UV was correlated with CAD severity, which played an important role in regulating keratinocytes permeability barrier through targeting CLDN1.

The role of antihistamines in chronic actinic dermatitis treatment

Inveterate actinic dermatitis is an immunologically mediated photodermatosis characterized by itchy eczematous dermhelminthiasis exposed to sunlight. The disease proceeds in the same way as the atopic eczema or atopic dermatitis. The treatment of patients with inveterate actinic dermatitis is similar to the treatment of patients with atopic dermatitis and eczema. Administration of the modern antihistaminic preparation desloratadine (Aerius) in the treatment has a positive effect on the skin process relief and on some cellular and humoral immunity factors.

Chronic actinic dermatitis

Chronic actinic dermatitis (CAD) is an immunologically mediated photodermatosis characterized by pruritic eczematous and lichenified plaques located predominantly on sun-exposed areas with notable sparing of eyelids, skin folds, and postauricular skin. CAD is thought to be due to secondary photosensitization of an endogenous antigen in the skin. Management of CAD should include strict photoprotection and topical agents, including corticosteroids and calcineurin inhibitors. Other treatments with noted efficacy include oral prednisone, cyclosporine, azathioprine, and mycophenolate mofetil. Photoprotection and avoidance of allergens, if identified, may lead to spontaneous resolution of CAD in 50% of patients over 15 years.

Geriatric dermatoses: a clinical review of skin diseases in an aging population

Geriatric dermatoses are a challenging job for the physician in terms of diagnosis, management, and followup. Since skin of the elderly population is going through a lot of changes from both an intrinsic and extrinsic point of view, it is imperative for the physician to have a better understanding of the pathophysiology of geriatric skin disorders and their specific management, which differs slightly from an adult population. This review focuses on a brief introduction to the pathophysiological aspects of skin disorders in elderly, the description of some common geriatric skin disorders and their management and the new emerging role of psychodermatological aspects of geriatric dermatoses is also discussed. At the end, ten multiple choice questions are also added to further enhance the knowledge base of the readers.