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P6019Successful treatment of scleredema diabeticorum by combining localpsoralen plus ultraviolet A light phototherapy and colchicine
Chayada Kokpol, MD, Division of Dermatology, Faculty of Medicine, RamathibodiHospital, Mahidol University, Bangkok, Thailand; Natta Rajatanavin, MD, Divisionof Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University,Bangkok, Thailand; Ploysyne Rattanakemakorn, MD, Division of Dermatology,Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok,Thailand
Background: Scleredema is a rare condition of unknown exactly pathogenesis. It isclassically divided into 3 types based on the association: postinfection (usuallystreptococcal), monoclonal gammopathy, and diabetes mellitus (Scleredema dia-beticorum). Scleredema diabeticorum often has a subtle onset, persistent involve-ment and refractory to therapies. Numerous therapies have been tried with mixedand inconsistent result. We report herein the case of scleredema diabeticorum,which is successfully treated by combining local PUVA with colchicine.
Case report: A 53-year-old Thai woman with a history of long-standing and poorlycontrolled diabetes mellitus presented to our clinic with a history of 2-yearprogressive thickening and wooden induration of her posterior neck and upperback. She could not lie in the supine position because of pain and paresthesia. Hershoulder range of movement was also limited. Incisional biopsy was done and thehistopathologic result was compatible with scleredema. Epidermal thickness at skinlesion using 17-MHz probe ultrasound was 0.7 mm and dermal thickness was 6.3mm. The patient received local PUVA treatment 2 times per week using oral 8-MOPand local UVA (Partial Body UV Therapy System UV 181, Waldmann MedicalTechonology), which irradiated only to her upper back and posterior neck. The totalaccumulative UVA dose was 671 J/cm2. We also add on colchicine 1.8 mg/day to ourtreatment. Her lesion started to improve after the tenth PUVA treatment. Fiftypercent and 80% softening and pain reduction were noticed by visual analogue scaleafter treatments 30 and 50, respectively. At the end of treatment (60th treatment),the 17-MHz probe ultrasound was repeated at the same side. The epidermalthickness was decrease from 0.7 mm to 0.46 mm (34.28% reduction of epidermalthickness) and dermal thickness was decreased from 6.3 mm to 5.9 mm (6.34%reduction of dermal thickness).
Discussion: Treatment for scleredema diabeticorum is quite difficult and offerslimited success. PUVA is now using in sclerotic disorder because of its effect inactivation of collagenase in dermal fibroblast. While colchicine has an inhibitoryeffect to collagen by interfering transport and secretion of collagen. We report thefirst case of successfully combining local PUVA with colchicine for treatment ofscleredema diabeticorum.
APRIL 20
cial support: None identified.
CommerP6197The effectiveness and tolerability of a combination of cosmetic founda-tions for photosensitivity in erythropoietic protoporphyria
Ayaka Hirao, MD, Kinki University Faculty of Medicine, Osaka-Sayama City, Japan;Akira Kawada, MD, PhD, Kinki University Faculty of Medicine, Osaka-SayamaCity, Japan; Hajime Asano, Kose Laboratories, Tokyo, Japan; Kuriko Higuchi, MD,Kinki University Faculty of Medicine, Osaka-Sayama City, Japan; Ryoichi Kamide,MD, PhD, Tokyo Jikei Medical University Third hospital, Komae, Japan; ShigeruKawara, MD, PhD, Kanazawa Red Cross Hospital, Kanazawa, Japan; TakashiTeramura, Kose Laboratories, Tokyo, Japan
Background: Erythropoietic protoporphyria (EPP) is an inherited disorder of hemebiosynthesis that is characterized with photosensitivity to visible light and liverdysfunction. The aim of this study was to investigate the effectiveness andtolerability of a combination of two cosmetic foundations for photosensitivity inEPP. This combination was selected to have most absorption for protoporphyrin IX.
Methods: A combination of liquid and powder foundations was used on the face andhands in 9 cases with EPP for more than 6 months. The effectiveness and tolerabilitywere investigated.
Results: Five cases showed effective and 4 cases did slightly effective. No caseshowed ineffective. No adverse effects were found.
Conclusion: We conclude that this combination of 2 different types of foundationsmay be a new modality for protection against photosensitivity in EPP.
cial support: None identified.
Commer13
P6855Voriconazole-induced photosensitivity concerning for StevenseJohnsonsyndrome
Rebecca Hartman, Perelman School of Medicine at the University ofPennsylvania, Philadelphia, PA, United States; Daniela Kroshinsky, MD, MPH,Department of Dermatology, Massachusetts General Hospital, Boston, MA,United States; William Tsiaras, MD, PhD, Department of Dermatology,Massachusetts General Hospital, Boston, MA, United States
Background: Voriconazole causes adverse cutaneous effects in 10% of patients,typically rashes. More serious acute skin side effects, including StevenseJohnsonsyndrome (SJS), are rare. Photosensitivity, occasionally severe enough to induce skincancer, has also been reported. Here, we report a patient with recent use of multipleantimicrobials who presented with voriconazole photosensitivity with ocularinvolvement concerning for SJS.
Observation: A 61-year-old woman with a history of allergic fungal sinusitis onvoriconazole for 2 months presented with 3 weeks of photodistributed hyperpig-mentation and facial erythema despite limited sun exposure. She completed coursesof oral vancomycin and nitrofurantoin 1 and 2 weeks before presentation, respec-tively. She also reported 3 days of eye pain, lip erosions, and toe blisters.Ophthalmology noted ocular chemosis and injection. She was diagnosed withvoriconazole photosensitivity, but her concurrent blistering, ocular, and mucosalfindings raised concern for superimposed SJS. She showed improvement after 1 dayof hospitalization, consistent with photosensitivity rather than SJS.
Discussion: Our patient had obvious chronic photosensitivity, but her acutesymptoms were concerning. Lip erosions, cheilitis, and pseudoporphyria havebeen reported frequently, but ocular involvement is less common. Althoughvoriconazole rarely causes SJS, our patient had recent exposures to multipleantimicrobials, characteristic of the voriconazole patient population. The mecha-nism of photosensitivity is unknown; it may be related to a retinoid-like effect frominhibition of vitamin A breakdown, suggested by high-normal plasma levels of all-trans retinal, but not all-trans retinoic acid, in affected patients. Another proposedmechanism is that the medication or a metabolite is phototoxic. Photosensitivitymost likely occurs after at least 3 months of treatment. The drug is primarilymetabolized by the CYP2C19 isoenzyme, but neither serum drug concentrationsnor CYP2C19 genotypes have been linked to photosensitivity. The reaction istypically reversible with discontinuation of the drug. However, lasting sequelae,including photoaging and skin cancer, can occur. Because this patient population isoften exposed to multiple medications, it is important to differentiate photosensi-tivity induced blistering with mucosal involvement from life-threatening diseaseslike SJS.
cial support: None identified.
CommerPIGMENTARY DISORDERS AND VITILIGO
P6231A comparative study of safety and efficacy between 4% hydroquinone and30% salicylic acid peel in treatment of periorbital hyperpigmentation indark-skinned patients
Rashmi Sarkar, MD, Maulana Azad Medical College, New Delhi, India; RashmiRanjan, MBBS, Maulana Azad Medical College, New Delhi, India; Vijay Garg, MD,Maulana Azad Medical College, New Delhi, India
Background: Periorbital hyperpigmentation is a common pigmentary condition inAsians but there is hardly any literature on its etiology or treatment. It is consideredto have a multifactorial origin, with hyperpigmentation and vascular factors playinga significant role. As it is a facial pigmentation, it is emotionally stressful for the dark-skinned patient, and hence there is a need of studies on the safety and efficacybetween different modalities of treatment for periorbital hyperpigmentation.
Objectives: To compare the efficacy and safety of 4% hydroquinone and 30% salicylicacid peels in periorbital hyperpigmentation.
Method: Fifty patients of both the sexes attending the dermatology outpatient clinic,with clinically evident bilateral distinctly visible periorbital hyperpigmentation(POH) were included in the study. Patients were divided into 2 groups of 25 each byrandomization. One group of patients received 4% hydroquinone and the otherreceived 30% salicylic acid peel. The peel was applied serially at 2weekly intervals at0, 2, 4, 6, 8, and 10 weeks. Patients were asked to apply 4% hydroquinone creamduring night in the periorbital area for 12 weeks. A broad-spectrum sunscreen wasadvised daily for both the groups. Clinical photographs using standardized posi-tioning were taken at baseline, 6, and 12 weeks. Subjective assessment of theresponse was made by the patient and the treating physician at 4, 8, and 12 weeksand was evaluated on a visual analogue scale.
Results: At the end of 12weeks of treatment, 47 % patients on salicylic acid peels and72% patients of hydroquinone group showed 30% (mild) improvement in theirhyperpigmentation, whereas 36% pts of salicylic acid peel group and 18% patients ofhydroquinone group showed 30% to 60% (moderate) improvement. The change inthe VAS at 4, 8, and 12 weeks (both doctor’s and patient’s VAS) was found highlysignificant (P \ .001) in both groups. Within the groups, there was a significantchange in the VAS from baseline to the end of treatment (P\.05). No significant sideeffects were noted in the 2 groups.
Conclusion: From the results, it can be concluded that both agents have comparableefficacy and safety in the treatment of periorbital hyperpigmentation, although theyonly show mild to moderate improvement. This could be related to the fact thatperiorbital hyperpigmentation has a multifactorial etiology, including pigmentaryand vascular factors, heredity as well as laxity of eyelid skin.
cial support: None identified.
CommerJ AM ACAD DERMATOL AB187
