Faculty Bibliography

BACKGROUND: Chronic actinic dermatitis is a photosensitivity disorder with scant epidemiologic data. Case series in Europe have previously shown that improvement or resolution of chronic actinic dermatitis occurs over time in most patients. However, the natural history of chronic actinic dermatitis in patients in the United States has not been studied. OBJECTIVE: To study the natural history of chronic actinic dermatitis in patients in the United States. METHODS: We performed a retrospective chart review and telephone questionnaire after a 3- to 19-year follow-up period. RESULTS: Of 20 patients with chronic actinic dermatitis, 7 patients (35%) experienced resolution and an additional 11 patients (55%) experienced improvement of their photosensitivity to sunlight during the follow-up period. The proportion of patients experiencing improvement or resolution of their chronic actinic dermatitis increased at 5, 10, and 15 years after diagnosis. CONCLUSIONS: Our study demonstrates that abnormal photosensitivity to sunlight in chronic actinic dermatitis improves or resolves over time in most patients in New York. The rates of improvement or resolution in our patients in New York are similar to the rates in case series in Europe despite likely patient demographic differences.

BACKGROUND: The standard treatment for patients with pemphigus vulgaris has long consisted of high-dose glucocorticoids. Studies regarding the use of methotrexate in pemphigus vulgaris date back to 1968, but few have quantitatively described a steroid-sparing effect conferred by methotrexate. OBJECTIVES: We sought to evaluate the efficacy of methotrexate in 23 patients with pemphigus vulgaris, using the drug's steroid-sparing effect as the primary indicator of clinical improvement. We investigated whether methotrexate could be used as monotherapy in some patients. METHODS: Retrospective chart review was used to analyse the records of patients with pemphigus vulgaris treated with methotrexate at the New York University Langone Medical Center for at least three consecutive months between 2000 and 2012. Diagnosis was made by tissue biopsy and either direct or indirect immunofluorescence tests and enzyme-linked immunosorbent assay. RESULTS: Improvement in clinical symptoms was observed in 91% of patients. Sixteen patients (70%) were eventually weaned completely off prednisone, with a mean time to discontinuation of 18 months. In total 23% of patients enjoyed a partial steroid-sparing effect, requiring a mean maintenance dose of prednisone of 6.75 mg daily. Two patients (9%) developed possible adverse events requiring cessation of the drug, and one patient received no therapeutic benefit from the drug. CONCLUSIONS: Methotrexate is a useful and well-tolerated therapy with considerable steroid-sparing effect in patients with pemphigus vulgaris. It may be considered a first-line adjuvant therapy in the treatment of this difficult disease.

Background Fentichlor elicits high rates of positive photopatch test reactions despite its currently unknown clinical relevance. Objective: To provide a comprehensive review of fentichlor, investigate the characteristics of patients with photosensitivity to fentichlor, and explore the current uses of fentichlor. Methods: A review of photopatch test studies involving fentichlor was performed. A retrospective chart review was conducted in patients with positive photopatch test reactions to fentichlor at our institution. Product inquiries were placed to manufacturers of fentichlor to elicit the current uses of fentichlor. Results: In selected photopatch test studies, positive reactions to fentichlor occurred in 0.0 to 11.8% of subjects. We found that 25 companies distribute or manufacture fentichlor worldwide, which includes two companies that sell 25 kg drums of fentichlor. The most common current uses of fentichlor are in research, in high throughput screening, and in antibacterial and antifungal creams. Conclusions: Our review of selected photopatch test studies demonstrates that fentichlor remains a potent photosensitizing allergen worldwide. The bulk quantities of fentichlor available for sale and the current uses of fentichlor suggest that fentichlor may be currently incorporated into consumer products. We recommend that fentichlor remains in the standard series of photopatch test allergens

Background: Chronic actinic dermatitis is a photosensitivity disorder with scant epidemiologic data. Case series in Europe have previously shown that improvement or resolution of chronic actinic dermatitis occurs over time in the majority of patients. However, the natural history of chronic actinic dermatitis in patients in the United States has not been studied. Objective: To study the natural history of chronic actinic dermatitis in patients in the United States. Methods: We performed a retrospective chart review and telephone questionnaire after a 3 to 19 year follow-up period. Results: Of 20 patients, 7 patients (35%) experienced resolution and an additional 11 patients (55%) experienced improvement of their chronic actinic dermatitis. The proportion of patients experiencing improvement or resolution of their chronic actinic dermatitis increased at 5, 10, and 15 years after diagnosis. Similar proportions of patients with skin types I to II and skin types III to VI experienced improvement or resolution. Conclusions: Our study demonstrates that abnormal photosensitivity to sunlight in chronic actinic dermatitis improves or resolves over time in themajority ofNew York patients. The rates of improvement or resolution in our New York patients are similar to the rates in case series in Europe, despite likely patient demographic differences

BACKGROUND: Fentichlor elicits high rates of positive photopatch test reactions despite its currently unknown clinical relevance. OBJECTIVES: The aims of this study were to provide a comprehensive review of fentichlor, to investigate the characteristics of patients with photosensitivity to fentichlor, and to explore the current uses of fentichlor. METHODS: A review of photopatch test studies involving fentichlor was performed. A retrospective chart review was conducted in patients with positive photopatch test reactions to fentichlor at our institution. Product inquiries were placed to manufacturers of fentichlor to elicit the current uses of fentichlor. RESULTS: In selected photopatch test studies, positive reactions to fentichlor occurred in 0.0% to 11.8% of subjects. We found that 25 companies distribute or manufacture fentichlor worldwide, which includes 2 companies that sell 25-kg drums of fentichlor. The most common current uses of fentichlor are in research, in high throughput screening, and in antibacterial and antifungal creams. CONCLUSIONS: Our review of selected photopatch test studies demonstrates that fentichlor remains a potent photosensitizing allergen worldwide. The bulk quantities of fentichlor available for sale and the current uses of fentichlor suggest that fentichlor may be currently incorporated into consumer products. We recommend that fentichlor remain in the standard series of photopatch test allergens.

A 25-year-old man presented with a 13-year history of an erythematous, papular eruption of his face and trunk, which was treated in the past as acne and psoriasis with isotretinoin and methotrexate, respectively. Histopathologic examination demonstrated an infiltrate of Langerhans cells, which was consistent with Langerhans cell histiocytosis. The epidemiology, clinical presentation, and treatment options of this disease are reviewed.

PURPOSE: Our study identified the most common diagnoses in patients with a history of photosensitivity or with a photodistributed eruption and normal minimal erythema dose (MED) responses. METHODS: We retrospectively reviewed the diagnoses and phototest results of 319 patients who were phototested at the New York University Photomedicine Section of the Charles C. Harris Skin and Cancer Pavilion from 1993 to 2009. Patients were phototested if they had a history of photosensitivity or had an eruption with a distribution that suggested photosensitivity. RESULTS: The majority of patients with normal MEDs were diagnosed with polymorphous light eruption, followed by contact or photocontact dermatitis, photodistributed dermatitis not otherwise specified (idiopathic), solar urticaria and photoexacerbated atopic dermatitis. DISCUSSION: The clinical history of photosensitivity and physical findings remain as important metrics in the diagnosis of patients with photodistributed dermatoses and normal MEDs.

BACKGROUND: There is a paucity of investigation on which to base the treatment of chronic urticaria after a patient fails maximum therapy with antihistamines. One prospective, open-label, uncontrolled study suggested that mycophenolate mofetil may be a successful second-line therapy. OBJECTIVE: We sought to evaluate the efficacy and safety of mycophenolate mofetil in 19 patients with autoimmune and chronic idiopathic urticaria. METHODS: In a retrospective chart review, records of patients with autoimmune and chronic idiopathic urticaria who were evaluated between 2001 and 2009 were analyzed. RESULTS: Improvement in urticaria was observed in 89% of patients, specifically 91% of patients with autoimmune urticaria and 88% with chronic idiopathic urticaria. Time to initial improvement ranged from 1 to 9 weeks. In 59% of these patients, complete control of urticaria was achieved, which included 70% of patients with autoimmune urticaria and 43% with chronic idiopathic urticaria. Mean time to complete control was 14 weeks, with a range of less than 1 to 31 weeks. The dose of mycophenolate mofetil at complete control ranged from 1000 to 6000 mg divided twice daily. Mycophenolate mofetil was tapered in 7 of these 10 patients after an average of 7 weeks. Six of the 7 patients tapered then discontinued mycophenolate mofetil with remissions lasting between 2 and 16 weeks up to when the chart review ended. Mycophenolate mofetil was well tolerated with no serious infections or laboratory abnormalities. Gastrointestinal symptoms were most common. LIMITATIONS: This was a retrospective chart analysis. The number of patients was relatively small. CONCLUSIONS: Mycophenolate mofetil is a useful and well-tolerated second-line therapy for patients with autoimmune and chronic idiopathic urticaria in whom antihistamines and other therapeutic agents have failed.

BACKGROUND: Chronic actinic dermatitis (CAD) is a rare photosensitivity disorder with scant epidemiologic data. OBJECTIVE: To evaluate demographic data and results of photopatch and patch tests over a 25-year period. METHODS: Retrospective chart review of patients with CAD from 1993 to 2009. RESULTS: Forty patients had a mean age of 57.8 years, and 27 (67.5%) were men. Twelve patients (30%) were skin types I and II, and 17 (42.5%) were skin types V and VI. Nine patients (22.5%) were younger than 50 years, and 4 of these (44.4%) were men. One of the nine patients (11.1%) was skin type I, and 4 (44.4%) were skin types V and VI. Carba mix and para-phenylenediamine were the two most commonly positive agents in patch tests. Sunscreens and plants and plant derivatives were the most commonly positive agents in photopatch tests. CONCLUSIONS: Our findings suggest a trend of two new classes of North American patients at our institution being diagnosed with CAD-younger women with skin types IV to VI and older men with skin types I to III. We observed a greater-than-expected number of positive patch-test reactions to para-phenylenediamine. We suggest that patch testing and photopatch testing of individuals may be useful adjuncts in the assessment of CAD