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Chronic actinic dermatitis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Chronic actinic dermatitis (CAD) is a chronic dermatitis mainly involving photoexposed sites, which is associated with objective evidence of abnormal photosensitivity. The photosensitivity is usually broadband although predominantly involving the ultraviolet B (UVB) waveband and often extending into the ultraviolet A (UVA) and even visible wavebands. The condition is considered to have an immunological basis, and no specific genetic susceptibility has been identified. Typically, CAD affects elderly males, although in younger patients it is reported particularly in association with atopic dermatitis. It is increasingly recognized in females and in patients of higher skin phototypes. Most cases arise on the background of a dermatitis, such as atopic, seborrheic, or contact allergic dermatitis. In more than 75% of cases of CAD, patch testing is positive, confirming the association with contact allergic dermatitis. Patient and clinician may not be aware of the link with sunlight because of perennial symptoms and covered site involvement, leading to delays in diagnosis.
Management Strategy
Thus the essential first step of management is accurate diagnosis and exclusion of other conditions, such as photoaggravated eczema or reversible causes, particularly drug-induced photosensitivity. Phototesting is essential and the gold standard investigation is monochromator phototesting, allowing accurate definition of wavelengths involved (action spectrum) and the degree of photosensitivity.
Photoprotection is essential, with emphasis on environmental and behavioral measures (including use of window film to prevent all ultraviolet (UV) transmission and double-envelope compact fluorescent lamps or light-emitting diodes (LEDs) for those with severe photosensitivity; seeking out the shade and avoiding sunlight in the middle of the day), clothing choices (tightly woven and dark colors if visible wavelengths are involved), and high SPF fragrance-free sunscreens. Patient education to reduce exposure to contact allergens is also essential, as contact allergy tends to persist indefinitely, whereas photosensitivity can resolve over time.
Active disease should be treated with emollients and topical corticosteroids. With severe flares or erythroderma, admission to hospital may be required to allow the patient to be nursed behind photoprotective screens. Systemic corticosteroids may be required for acute flares and then tapered over weeks. Treatment with photo(chemo)therapy may be possible, although patients are usually too UVB sensitive to be able to tolerate UVB phototherapy, and, thus, psoralen-UVA (PUVA) may be more effective and better tolerated. If these measures are inadequate for disease control, systemic immunosuppression may be needed.
Specific Investigations
Comparison of demographic and photobiological features of chronic actinic dermatitis in patients with lighter v darker skin types
Tan KW, Haylett AK, Ling TC, et al. JAMA Dermatol 2017; 153: 427–35.
Chronic actinic dermatitis: changing trends
Fityan A, Cho S-Y, Plant A, et al. Br J Dermatol 2019; 181(S1): 99.
These reports from UK centers indicate that CAD is now less frequently seen as a disease of elderly males, with Tan et al., reporting on 70 patients, with mean age of onset of 42.6 years and 41% (much higher than in their catchment area population) being of skin phototype V or VI. There was younger onset in the higher skin phototype patients and also a 2:1 male to female ratio in the lower skin phototypes and 1:2 in those of higher skin phototype. The authors also found that 23% had positive photopatch tests to sunscreens and/or non-steroidal antiinflammatories. Fityan et al. reported on 110 cases of CAD, with a mean age of onset of 42.3 years and males and females equally represented. Again, there was overrepresentation of skin phototypes V and VI and most were atopic, particularly in younger patients.
A preliminary investigation into the effect of exposure of photosensitive individuals to light from compact fluorescent lamps
Eadie E, Ferguson J, Moseley H. Br J Dermatol 2009; 160: 659–64.
Energy-saving lamps and their impact on photosensitive and normal individuals
Fenton L, Ferguson J, Ibbotson S, et al. Br J Dermatol 2013; 169: 910–5.
Tungsten lamp and chronic actinic dermatitis
Hu SC, Lan CE. Australas J Dermatol 2017; 58: e14–6.
Is photodynamic diagnostic flexible ureterorenoscopy suitable for a patient presenting with chronic actinic dermatitis?
Valentine R, Kata S, Ibbotson S, et al. Photodermatol Photoimmunol Photomed 2015; 31: 279–81.
Patients with CAD may be at risk from exposure to UV radiation from compact fluorescent (‘energy-saving’) lamps. They also can have severe visible light sensitivity (such as through window glass and exposure to a bright ‘ordinary’ tungsten source used for ear cleaning), may be at risk from exposure to a wide range of artificial light sources, and this should be investigated and considered in management approaches.
Contact allergic sensitivity to plants and the photosensitivity dermatitis and actinic reticuloid syndrome
Frain-Bell W, Johnson BE. Br J Dermatol 1979; 101: 503–12.
Contact and photocontact sensitization in chronic actinic dermatitis: sesquiterpene lactone mix is an important allergen
Menagé H, Ross JS, Norris PG, et al. Br J Dermatol 1995; 132: 543–7.
Case report of chronic actinic dermatitis accompanied by UVA sensitivity in a chrysanthemum farmer
Fujii S, Washio K, Masaki T. J Dermatol 2019; 46: e229–30.
This case highlights the importance of considering CAD in any patient with Asteraceae (Compositae) contact allergy.
A European multicenter photopatch test study
European Multicenter Photopatch Test Study (EMCPPTS) Taskforce. Br J Dermatol 2012; 166: 1002–9.
Photopatch testing: recommendations for a European photopatch test baseline series
Goncalo M, Ferguson J, Bonevalle A, et al. Contact Dermatitis 2013; 68: 239–43.
Contact and/or photocontact allergy is common in CAD. Standard allergens, including fragrances, plants, and sunscreens, must be considered. Patch and photopatch testing, repeated at intervals as indicated by history, are essential investigations in order not to ‘miss’ new allergens or photoallergens. Because many CAD patients are abnormally sensitive to the UVA sources used for photopatch testing, this technique may be difficult to undertake and interpret. However, photopatch testing with suberythemal UVA doses should be undertaken where possible.
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