http://informahealthcare.com/jdt ISSN: 0954-6634 (print), 1471-1753 (electronic) J Dermatolog Treat, Early Online: 1–2 ! 2014 Informa UK Ltd. DOI: 10.3109/09546634.2014.991676
CASE REPORT
Symptomatic dermatographism treated with narrowband UVB phototherapy Kara Heelan and Michelle Murphy
J Dermatolog Treat Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
Dermatology Department, South Infirmary Victoria University Hospital, Cork, Ireland
Abstract
Keywords
Dermatographism occurs when there is an exaggerated response to physical stimulus. There are both simple and symptomatic forms. Symptomatic dermatographsim can be exceedingly difficult to treat. Treatment modalities include H1 and H2 antagonists, leukotriene antagonists, cyclosporine and oral steroids. In a few small case series and studies, phototherapy has been used. We report a further two patients who were treated successfully with TL01 UVB narrowband (NB) phototherapy.
Dermatographism, phototherapy, urticarial
Introduction Dermatographism occurs when there is an exaggerated response to physical stimulus. There are both simple and symptomatic forms (1). Symptomatic dermatographsim can be exceedingly difficult to treat. Treatment modalities include H1 and H2 antagonists, leukotriene antagonists, cyclosporine and oral steroids (1). In a few small case series and studies, phototherapy has been used (2–5). We report a further two patients who were treated with TL01 UVB narrowband (NB) phototherapy.
Case reports The first case is that of a 58-year-old male with a diagnosis of longstanding symptomatic dermatographism not responsive to multiple combinations of oral antihistamines. He was commenced on TL01 UVB NB phototherapy. Following 29 exposures, symptoms had completely resolved. He remained symptom-free off all treatment for 48 months at which point he flared and received a further course of phototherapy. On this occasion, 18 exposures were received. He remains symptom-free 12 months later. The second case is of a 79-year-old female diagnosed with symptomatic dermatographism. She proved unresponsive to multiple agents including gabapentin and montelukast. She received 22 exposures of TL01 UVB NB phototherapy. She was symptom-free following 15 exposures. Treatment was then continued once weekly for a month and subsequently alternate weeks for a further month. She remains symptom-free 4 months after initial response and 2 months after completion of treatment.
Correpondence: Dr Kara Heelan, Dermatology of Department, South Infirmary University Hospital, Old Infirmary Road, Cork, Ireland. Tel: +00353 21 4926100. Fax: +00353 21 4926405. E-mail: [email protected]
History Received 23 October 2014 Accepted 19 November 2014 Published online 29 December 2014
Responses in both cases were measured by patient-reported assessment of itching and whealing.
Discussion Ultraviolet radiation was first reported to be used as a treatment for symptomatic dermatographism in the 1940s (6). A small open study reported 5 of 14 symptomatic dermatographic patients unresponsive to conventional antihistamines experienced a clinically useful reduction of itch during and for up to 3 months after oral psoralen plus UVA (PUVA) (2). There was no effect on whealing (2). A nonrandomized trial of 43 patients found 25 patients were symptom-free after a 3-week course of broadband UVB therapy (5). NB UVB has been reported in a retrospective study to be of benefit for chronic idiopathic urticarial (7). A single study, however, examines its effect in symptomatic dermatographism (4). The authors found that NB UVB phototherapy is an effective second-line treatment for patients with severe symptomatic dermatographism responding poorly to fexofenadine. They showed that NB UVB can lead to subjective relief of pruritus and whealing along with objective reduction of whealing and may restore symptom control with antihistamines in some patients. Most patients relapsed within 2–3 months of completing phototherapy. These data are consistent with patients treated with PUVA who relapsed within 3 months after treatment ended (2). In a study of broadband UVB treatment, most patients with moderate to severe symptomatic dermatographism had a relapse of symptoms within 4–5 months after phototherapy (5). A permanent remission was noted in 26 of 43 of these patients (5). The mechanisms mediating the effects of NB UVB phototherapy for symptomatic dermatographic patients remain unknown. Reducing skin mast cell reactivity is one possible explanation of its efficacy. The effects of phototherapy on skin mast cell degranulation have been investigated in several studies of patients with chronic urticaria and symptomatic dermatographism.
2
K. Heelan & M. Murphy
Fjellner et al. (8) showed a reduced flare response to intradermal injection of the histamine liberator, compound 48/80 after treatment with UVB, UVA, or PUVA. In a different study a reduced wheal response was noted after intradermal injection of codeine phosphate following UV treatment, inparticular UVB (9).
Conclusion In conclusion, the authors feel that TLO1 UVB phototherapy is a very valuable, safe and underused treatment modality in symptomatic dermatographic patients. We encourage its usage in routine practice for these often very difficult to treat patients.
Declaration of interest No funding was received for this work. None of the authors have any conflicts of interest to disclose
J Dermatolog Treat Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
References 1. Mecoli CA, Morgan AJ, Schwartz RA. Symptomatic dermatographism: current concepts in clinical practice with an emphasis on the pediatric population. Cutis. 2011;87:221–5.
J Dermatolog Treat, Early Online: 1–2
2. Logan RA, O’Brien TJ, Greaves MW. The effect of psoralen photochemotherapy (PUVA) on symptomatic dermographism. Clin Exp Dermatol. 1989;14:25–8. 3. Gambichler T, Breuckmann F, Boms S, et al. Narrowband UVB phototherapy in skin conditions beyond psoriasis. J Am Acad Dermatol. 2005;52:660–70. 4. Borzova E, Rutherford A, Konstantinou GN, et al. Narrowband ultraviolet B phototherapy is beneficial in antihistamine-resistant symptomatic dermographism: a pilot study. J Am Acad Dermatol. 2008;59:752–7. 5. Johnsson M, Falk ES, Volden G. UVB treatment of factitious urticaria. Photo-dermatology. 1987;4:302–4. 6. Rich WG. Dermographia. Br Med J. 1949;2:6005. 7. Berroeta L, Clark C, Ibbotson SH, et al. Narrow-band (TL-01) ultraviolet B phototherapy for chronic urticaria. Clin Exp Dermatol. 2004;29:97–8. 8. Fjellner B, Hagermark O. Influence of ultraviolet light on itch and flare reactions in human skin induced by histamine and the histamine liberator compound 48/80. Acta Derm Venereol. 1982; 62:137–40. 9. Gollhausen R, Kaidbey K, Schechter N. UV suppression of mast cell-mediated wealing in human skin. Photodermatology. 1985;2: 58–67.
CASE REPORT
Symptomatic dermatographism treated with narrowband UVB phototherapy Kara Heelan and Michelle Murphy
J Dermatolog Treat Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
Dermatology Department, South Infirmary Victoria University Hospital, Cork, Ireland
Abstract
Keywords
Dermatographism occurs when there is an exaggerated response to physical stimulus. There are both simple and symptomatic forms. Symptomatic dermatographsim can be exceedingly difficult to treat. Treatment modalities include H1 and H2 antagonists, leukotriene antagonists, cyclosporine and oral steroids. In a few small case series and studies, phototherapy has been used. We report a further two patients who were treated successfully with TL01 UVB narrowband (NB) phototherapy.
Dermatographism, phototherapy, urticarial
Introduction Dermatographism occurs when there is an exaggerated response to physical stimulus. There are both simple and symptomatic forms (1). Symptomatic dermatographsim can be exceedingly difficult to treat. Treatment modalities include H1 and H2 antagonists, leukotriene antagonists, cyclosporine and oral steroids (1). In a few small case series and studies, phototherapy has been used (2–5). We report a further two patients who were treated with TL01 UVB narrowband (NB) phototherapy.
Case reports The first case is that of a 58-year-old male with a diagnosis of longstanding symptomatic dermatographism not responsive to multiple combinations of oral antihistamines. He was commenced on TL01 UVB NB phototherapy. Following 29 exposures, symptoms had completely resolved. He remained symptom-free off all treatment for 48 months at which point he flared and received a further course of phototherapy. On this occasion, 18 exposures were received. He remains symptom-free 12 months later. The second case is of a 79-year-old female diagnosed with symptomatic dermatographism. She proved unresponsive to multiple agents including gabapentin and montelukast. She received 22 exposures of TL01 UVB NB phototherapy. She was symptom-free following 15 exposures. Treatment was then continued once weekly for a month and subsequently alternate weeks for a further month. She remains symptom-free 4 months after initial response and 2 months after completion of treatment.
Correpondence: Dr Kara Heelan, Dermatology of Department, South Infirmary University Hospital, Old Infirmary Road, Cork, Ireland. Tel: +00353 21 4926100. Fax: +00353 21 4926405. E-mail: [email protected]
History Received 23 October 2014 Accepted 19 November 2014 Published online 29 December 2014
Responses in both cases were measured by patient-reported assessment of itching and whealing.
Discussion Ultraviolet radiation was first reported to be used as a treatment for symptomatic dermatographism in the 1940s (6). A small open study reported 5 of 14 symptomatic dermatographic patients unresponsive to conventional antihistamines experienced a clinically useful reduction of itch during and for up to 3 months after oral psoralen plus UVA (PUVA) (2). There was no effect on whealing (2). A nonrandomized trial of 43 patients found 25 patients were symptom-free after a 3-week course of broadband UVB therapy (5). NB UVB has been reported in a retrospective study to be of benefit for chronic idiopathic urticarial (7). A single study, however, examines its effect in symptomatic dermatographism (4). The authors found that NB UVB phototherapy is an effective second-line treatment for patients with severe symptomatic dermatographism responding poorly to fexofenadine. They showed that NB UVB can lead to subjective relief of pruritus and whealing along with objective reduction of whealing and may restore symptom control with antihistamines in some patients. Most patients relapsed within 2–3 months of completing phototherapy. These data are consistent with patients treated with PUVA who relapsed within 3 months after treatment ended (2). In a study of broadband UVB treatment, most patients with moderate to severe symptomatic dermatographism had a relapse of symptoms within 4–5 months after phototherapy (5). A permanent remission was noted in 26 of 43 of these patients (5). The mechanisms mediating the effects of NB UVB phototherapy for symptomatic dermatographic patients remain unknown. Reducing skin mast cell reactivity is one possible explanation of its efficacy. The effects of phototherapy on skin mast cell degranulation have been investigated in several studies of patients with chronic urticaria and symptomatic dermatographism.
2
K. Heelan & M. Murphy
Fjellner et al. (8) showed a reduced flare response to intradermal injection of the histamine liberator, compound 48/80 after treatment with UVB, UVA, or PUVA. In a different study a reduced wheal response was noted after intradermal injection of codeine phosphate following UV treatment, inparticular UVB (9).
Conclusion In conclusion, the authors feel that TLO1 UVB phototherapy is a very valuable, safe and underused treatment modality in symptomatic dermatographic patients. We encourage its usage in routine practice for these often very difficult to treat patients.
Declaration of interest No funding was received for this work. None of the authors have any conflicts of interest to disclose
J Dermatolog Treat Downloaded from informahealthcare.com by Nyu Medical Center on 06/17/15 For personal use only.
References 1. Mecoli CA, Morgan AJ, Schwartz RA. Symptomatic dermatographism: current concepts in clinical practice with an emphasis on the pediatric population. Cutis. 2011;87:221–5.
J Dermatolog Treat, Early Online: 1–2
2. Logan RA, O’Brien TJ, Greaves MW. The effect of psoralen photochemotherapy (PUVA) on symptomatic dermographism. Clin Exp Dermatol. 1989;14:25–8. 3. Gambichler T, Breuckmann F, Boms S, et al. Narrowband UVB phototherapy in skin conditions beyond psoriasis. J Am Acad Dermatol. 2005;52:660–70. 4. Borzova E, Rutherford A, Konstantinou GN, et al. Narrowband ultraviolet B phototherapy is beneficial in antihistamine-resistant symptomatic dermographism: a pilot study. J Am Acad Dermatol. 2008;59:752–7. 5. Johnsson M, Falk ES, Volden G. UVB treatment of factitious urticaria. Photo-dermatology. 1987;4:302–4. 6. Rich WG. Dermographia. Br Med J. 1949;2:6005. 7. Berroeta L, Clark C, Ibbotson SH, et al. Narrow-band (TL-01) ultraviolet B phototherapy for chronic urticaria. Clin Exp Dermatol. 2004;29:97–8. 8. Fjellner B, Hagermark O. Influence of ultraviolet light on itch and flare reactions in human skin induced by histamine and the histamine liberator compound 48/80. Acta Derm Venereol. 1982; 62:137–40. 9. Gollhausen R, Kaidbey K, Schechter N. UV suppression of mast cell-mediated wealing in human skin. Photodermatology. 1985;2: 58–67.
