Letter to the Editor
Home Sunbed and Psoralen Use: A Burning Issue To the Editor: A 19-year-old female caucasian patient presented to the regional burns centre with 70% superficial partial thickness burns 36 hours, following the use of a topical photosensitising agent (8-methoxypsoralen) and subsequent prolonged sunbed exposure. The patient had soaked herself in a psoralen bath for 15 minutes, followed by 30 minutes under a double-canopied rented home sunbed unit. The patient’s intention was to maximise her tanning time and efficiency and the topical psoralen used had not been prescribed by a medical professional. Presentation to the emergency department was with vomiting, pain, and skin blistering 36 hours postexposure (Figure 1). The extent and severity of the burn developed over the following 48 hours (Figure 2) and significant amounts of fluid resuscitation was required and this was further complicated by the delay in initial presentation resulting in third space losses, fluid shifts, and peripheral oedema. This necessitated a short admission to the intensive care unit for invasive monitoring and fluid management. The burn was managed conservatively with initial dressing changes taking place under general anaesthetic. An inpatient stay of 20 days was required in total. The patient healed well but developed hyper-pigmentation of the healed areas on her lower limbs (Figure 3). Psoralens are naturally occurring compounds that can be found in fig plants, celery, and satinwood. Psoralen molecules have the ability to absorb light within the UVA spectrum (320–400 nm) in the epidermis forming a photoactive complex. This results in phototoxicity and melanogenesis. Psoralen +UVA (PUVA) photochemotherapy is widely used in the treatment of cutaneous conditions such as psoriasis, vitiligo, scleroderma, and eczema.1 Treatment with PUVA is either systemic with oral psoralens or topical with a bath soak. UVA exposure is often of very short duration (5–10 minutes) and targeted at small affected areas and then titrated further to patient
Figure 1. Thirty-six hours after exposure.
response. Peak inflammation occurs at 48–96 hours postexposure and is dose-dependent. Photosensitivity and phototoxicity is a well-known side effect of PUVA therapy. The link between long term PUVA therapy and development of skin malignancy has been clearly demonstrated and prescribed PUVA has been associated with significant burns.2,3 This case describes the nonmedicinal use of psoralens with unregulated home sunbed to accelerate tanning. It highlights the potential for life threatening major burns to be sustained and to slowly develop after exposure causing a delay in presentation. This cautionary tail should serve to alert medical professionals and to strongly advise against any unregulated psoralen and sunbed use.
Address correspondence to Timothy P. Crowley, Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000091
Figure 2. Forty-eight hours after exposure. e105
Journal of Burn Care & Research March/April 2015
e106 Letter to the Editor
References 1. Tilkorn DJ, Schaffran A, Benna SA, Hauser J, Steinau HU, Ring A. Severe burn injuries induced by PUVA chemotherapy. J Burn Care Res 2013;34:e195–200. 2. Archier E, Devaux S, Castela E, et al. Carcinogenic risks of psoralen UV-A therapy and narrowband UV-B therapy in chronic plaque psoriasis: a systematic literature review. J Eur Acad Dermatol Venereol 2012;26:22–31. 3. Hemington-Gorse SJ, Slattery MA, Drew PJ. Burns related to sunbed use. Burns 2010;36:920–3.
Figure 3. Three months postburn.
Lisa Ng, MBBS, MRCS Timothy P. Crowley, MBChB, MRCS Sanjay Varma, FRCS (Plast) Department of Plastic Surgery Royal Victoria Infirmary Newcastle upon Tyne, United Kingdom.
Home Sunbed and Psoralen Use: A Burning Issue To the Editor: A 19-year-old female caucasian patient presented to the regional burns centre with 70% superficial partial thickness burns 36 hours, following the use of a topical photosensitising agent (8-methoxypsoralen) and subsequent prolonged sunbed exposure. The patient had soaked herself in a psoralen bath for 15 minutes, followed by 30 minutes under a double-canopied rented home sunbed unit. The patient’s intention was to maximise her tanning time and efficiency and the topical psoralen used had not been prescribed by a medical professional. Presentation to the emergency department was with vomiting, pain, and skin blistering 36 hours postexposure (Figure 1). The extent and severity of the burn developed over the following 48 hours (Figure 2) and significant amounts of fluid resuscitation was required and this was further complicated by the delay in initial presentation resulting in third space losses, fluid shifts, and peripheral oedema. This necessitated a short admission to the intensive care unit for invasive monitoring and fluid management. The burn was managed conservatively with initial dressing changes taking place under general anaesthetic. An inpatient stay of 20 days was required in total. The patient healed well but developed hyper-pigmentation of the healed areas on her lower limbs (Figure 3). Psoralens are naturally occurring compounds that can be found in fig plants, celery, and satinwood. Psoralen molecules have the ability to absorb light within the UVA spectrum (320–400 nm) in the epidermis forming a photoactive complex. This results in phototoxicity and melanogenesis. Psoralen +UVA (PUVA) photochemotherapy is widely used in the treatment of cutaneous conditions such as psoriasis, vitiligo, scleroderma, and eczema.1 Treatment with PUVA is either systemic with oral psoralens or topical with a bath soak. UVA exposure is often of very short duration (5–10 minutes) and targeted at small affected areas and then titrated further to patient
Figure 1. Thirty-six hours after exposure.
response. Peak inflammation occurs at 48–96 hours postexposure and is dose-dependent. Photosensitivity and phototoxicity is a well-known side effect of PUVA therapy. The link between long term PUVA therapy and development of skin malignancy has been clearly demonstrated and prescribed PUVA has been associated with significant burns.2,3 This case describes the nonmedicinal use of psoralens with unregulated home sunbed to accelerate tanning. It highlights the potential for life threatening major burns to be sustained and to slowly develop after exposure causing a delay in presentation. This cautionary tail should serve to alert medical professionals and to strongly advise against any unregulated psoralen and sunbed use.
Address correspondence to Timothy P. Crowley, Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000091
Figure 2. Forty-eight hours after exposure. e105
Journal of Burn Care & Research March/April 2015
e106 Letter to the Editor
References 1. Tilkorn DJ, Schaffran A, Benna SA, Hauser J, Steinau HU, Ring A. Severe burn injuries induced by PUVA chemotherapy. J Burn Care Res 2013;34:e195–200. 2. Archier E, Devaux S, Castela E, et al. Carcinogenic risks of psoralen UV-A therapy and narrowband UV-B therapy in chronic plaque psoriasis: a systematic literature review. J Eur Acad Dermatol Venereol 2012;26:22–31. 3. Hemington-Gorse SJ, Slattery MA, Drew PJ. Burns related to sunbed use. Burns 2010;36:920–3.
Figure 3. Three months postburn.
Lisa Ng, MBBS, MRCS Timothy P. Crowley, MBChB, MRCS Sanjay Varma, FRCS (Plast) Department of Plastic Surgery Royal Victoria Infirmary Newcastle upon Tyne, United Kingdom.
