The Photodermatology Society
promotes a greater understanding
of light in health and disease.

Archive of the 23^rd Meeting of the Photomedicine Society

Thursday, March 20, 2014, 8:00 a.m. - 5:00 p.m.
Capital 4, Hyatt Regency Denver
650 15th Street
Denver, Colorado, 80202, USA

The presentations were the following, in order of presentation
(Click on each title to see the abstract and its authors.)

1. ULTRAVIOLET A1 PHOTOTHERAPY IN 163 PATIENTS WITH VARIOUS DERMATOSES: A MULTICENTER STUDY

   Karen L. Connolly¹, Marian McEvoy², Daniel Grabell³, Heidi Jacobe³, Henry W. Lim¹.
   ¹ Department of Dermatology, Henry Ford Hospital, Detroit, MI
   ² Department of Dermatology, Mayo Clinic, Rochester, MN
   ³ Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX

   Purpose Ultraviolet A1 (UVA1) phototherapy utilizes UV radiation in the spectrum of 340 to 400 nm for therapy of a variety of skin conditions. However, UVA1 treatment dose and frequency protocols vary between institutions and disease states. The primary objective was to describe treatment protocols and efficacy for patients with various skin diseases treated at three academic medical centers. The secondary objective was to describe the most effective treatment regimens for the most commonly treated diseases.

   Methods Data from 163 patients treated with low-(20 J/cm2), medium-(50 J/cm2), and high-(70-110 J/cm2) dose UVA1 phototherapy during a 6 year period was retrospectively analyzed. The mean single dose (J/cm2), number of irradiations, and total dose (J/cm2) was evaluated. Effectiveness was assessed by reviewing clinical examination notes from office visits. Statistical analysis was performed for patients with morphea (n=80), scleroderma (n=17), graft-versus-host-disease (n=25), and nephrogenic systemic fibrosis (n=15).

   Results A statistically significant improvement with high dose regimen of UVA1, compared to medium- or low-dose, was seen in patients with scleroderma, graft-versus-host-disease, and nephrogenic systemic fibrosis. In morphea, both medium-dose and high-dose UVA1 treatment showed excellent efficacy. Treatment frequency was typically two to three times weekly, for a series of 30 treatments. Side effects included tanning. One patient developed erosions in the area of treatment, resulting in discontinuation of UVA1. For some of the diseases, our results are limited by a small sample size due to the rarity of the conditions. This is a retrospective study, and a subjective grading system was used to measure disease improvement.

   Conclusions This study confirmed that UVA1 phototherapy is effective and safe in the treatment of morphea, graft-versus-host-disease, nephrogenic systemic fibrosis, and scleroderma. Medium-dose and high-dose regimens are more effective than a low-dose regimen for each of these conditions.

2. AFAMELANOTIDE AND NARROWBAND UVB FOR THE TREATMENT OF VITILIGO: A RANDOMIZED, MULTICENTER TRIAL

   Marsha D. Henderson¹, Henry W. Lim¹, Pearl E. Grimes², Oma Agbai^1,3, Iltefat Hamzavi¹, Madelaine Haddican⁴, Rita Linkner⁴, Mark Lebwohl⁴

   
   ¹ Multicultural Dermatology Center, Department of Dermatology, Henry Ford Hospital, Detroit, MI
   ² Vitiligo and Pigmentation Institute of Southern California, Los Angeles, CA
   ³ University of California Davis, Department of Dermatology, Sacramento, CA
   ⁴ Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY

   Purpose Narrowband ultraviolet B (NB-UVB) therapy is widely used for treatment of vitiligo. Afamelanotide, an analogue of α-melanocyte stimulating hormone, is known to induce tanning of the skin. This study was designed to evaluate the efficacy and safety of afamelanotide and NB-UVB combination in generalized vitiligo.

   Methods Patients who had vitiligo for less than 5 years, with 15-50% body surface involvement, were randomized at three centers. After one month of NB-UVB, afamelanotide 16mg was administered subcutaneously to the combination group monthly for 4 months while continuing NB-UVB; the other group continued with NB-UVB only. Response was evaluated by Vitiligo Area Scoring Index (VASI) and Vitiligo European Task Force (VETF) scoring system.

   Results Twenty-eight patients were enrolled in the combination group, and 27 in the NB-UVB group. Response in the combination group was superior to NB-UVB group (P<0.05), at day 56. For face and upper extremities, significantly higher percentage of patients in the combination group achieved repigmentation, and at earlier time points (face: 41.0 days, vs. 61.0 days, P = 0.001; upper extremities: 46.0 days, vs. 69.0 days, P=0.003). Notable adverse events were erythema in both groups, and minor infections and nausea in the combination group.

   Comparison between Fitzpatrick skin phototypes (SPTs) showed IV-VI patients in combination group had improvement in the VASI at days 56 and 84 (p<0.05); no significant difference noted in SPT III.

   Conclusions Afamelanotide and NB-UVB treatment resulted in clinically apparent, statistically significant superior and more rapid repigmentation, compared to NB-UVB monotherapy. The response was more noticeable in those with SPT IV-VI.

3. COMPARISON OF PHOTODERMATOSES IN AFRICAN AMERICANS AND CAUCASIANS: A FOLLOW-UP STUDY

   Mio Nakamura¹, Marsha Henderson², Gordon Jacobsen³, Henry W. Lim^{2
   1} Wayne State University School of Medicine, Detroit, MI
   ² Department of Dermatology, Henry Ford Hospital, Detroit, MI
   ³ Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI

   Background/Purpose Only a few studies have compared frequencies of photodermatoses between different races and skin types. This is an extension of a study performed by Kerr and Lim (2007) and evaluates the frequency of photodermatoses in African Americans compared to Caucasians in the same institution during an 8-year period.

   Methods Retrospective chart review of dermatology clinic charts from October 2004 to August 2012 was performed. Charts of patients with International Classification of Diseases, Ninth Revision diagnostic codes related to photodermatoses were included.

   Results We identified 229 patients with photodermatoses. Of these patients, 138 (46.6%) were African American and 63 (42.2%) were Caucasian. The distribution of photodermatoses in African Americans and Caucasians, respectively, were as follows: Chronic actinic dermatitis (2.9% and 1.6%), photoallergic dermatitis (0% and 1.6%), photosensitivity not-otherwise specified (9.4% and 11.1%), phototoxic drug eruption (0.7% and 15.9%), phytophotodermatitis (0% and 6.3%), polymorphous light eruption (86.2% and 54%), porphyrias (0% and 7.9%), and solar urticaria (0.7% and 1.6%). The higher proportion of African Americans with polymorphous light eruption compared to Caucasians was statistically significant (p<0.0001). There were higher proportions of Caucasians with porphyrias (p=0.003), phototoxic drug eruption (p<0.0001), and phytophotodermatitis (p=0.009) compared to African Americans.

   Conclusion Combined with data from Kerr and Lim, this is the largest study of photodermatoses in African Americans to date, including a total of 509 patients evaluated over a 15-year period. Congruent to former studies, photodermatoses occur regularly in dark-skinned individuals. Overall, the frequency of photodermatoses in African Americans and Caucasians are similar, with the exception of polymorphous light eruption, which occurs more commonly in African Americans, and porphyias, which are more common in Caucasians.

4. COMMUNICATING SUNSCREEN EFFECTIVENESS AS “PERCENTAGE OF SUNRAYS BLOCKED” LEADS LAYPEOPLE TO UNDERESTIMATE THE INCREASE IN PROTECTION WHEN COMPARING SUNSCREENS

   Stefan Herzog¹, Isadora de Maddalena, Uli Osterwalder^{2
   1} Max Planck Institute for Human Development, Berlin, Germany
   ² BASF PCN GmbH, Monheim, Germany

   Introduction The Sun Protection Factor (SPF) is commonly used to convey a sunscreen’s efficacy in protecting primarily against erytemogenic energy. Some media outlets and health professionals promote the misconception that high SPFs offer only marginal improvements in sun protection, arguing that the percentage of UVB rays blocked (%-blocked) increases much slower than SPF increases. For example, doubling SPF from 30 to 60 increases %-blocked only from 96.7% to 98.3%. In fact, SPF-60 is twice as effective as SPF-30: it allows only half the erythemogenic rays to reach the skin (%-through: 1.7% vs. 3.3%, assuming laboratory conditions). We tested the prediction that the %-blocked format leads laypeople to underestimate increases in sun protection when comparing sunscreens.

   Methods 343 US laypeople completed a randomized web-experiment. Sunscreen effectiveness was communicated as %-blocked, SPF, or %-through. Participants judged the increase in sun protection for 10 pairs of sunscreens (all combinations of SPFs 10, 15, 20, 30, and 50). Main participant outcome measures: (a) mean bias (under-/overestimation of protection increase; i.e., ratio of minimal erythema doses); (b) mean subjective rating (range: 1–7). HDI: 95% Bayesian posterior density interval.

   Results On average, the %-blocked format led participants to underestimate the increase in sun protection by a factor of 2.04 (HDI [2.00–2.09]), whereas the SPF format led to only slight (1.20, HDI [1.12–1.26]), and the %-through format to moderate underestimation (1.45, HDI [1.35–1.55]). Furthermore, %-blocked led to lower subjective impressions of increases (4.0, HDI [3.8–4.2]) than did SPF (4.9, HDI [4.7–5.1]) or %-through (4.5, HDI [4.3–4.7]).

   Conclusion Communicating sunscreen effectiveness as %-blocked leads laypeople to underestimate the increase in sun protection when comparing sunscreens, whereas using SPF leads to appropriate perceptions. The media and health professionals should thus use SPFs rather than %-blocked to communicate sunscreen effectiveness to laypeople.

5. ANTI-INFLAMMATORY EFFECT OF SPF 100+ SUNSCREEN NOT CONFIRMED IN SPF TESTING

   Uli Osterwalder¹, John Staton², Steven Wang³, Joe Stanfield⁴, Christian Surber^{5
   1} BASF PCN, Monheim, Germany
   ² Dermatest Pty Ltd, Sydney, Australia
   ³ Sloan Kettering Memorial, New York, NY, USA
   ⁴ Suncare Research Laboratories, LLC, Winston Salem, NC, USA
   ⁵ University of Basel, Basel, Switzerland

   Introduction The SPF may range from as low as 2 to up to 100 and more. Recently the suspicion has been voiced that UV filters as well as other ingredients may induce anti-inflammatory properties attenuating ultraviolet-induced erythema or delay the erythema response on the skin. As a consequence this may lead to higher SPFs and hence will give a false sense of security. For this above reason, we decided to determine the potential impact of a post-irradiation application of a SPF 100+ sunscreen containing UV filters that may have an anti-inflammatory effect.

   Methods A commercial sunscreen, labeled SPF 100+ was utilized. 10 volunteers were enrolled after standard enrollment procedures. A solar simulator (Model 16S Solar Light Co USA) was used to induce mild erythema on designated areas of the back of the volunteers. The experimental principles were compliant with those applied for the measurement of sun protection factor (SPF) as detailed in ISO 24444. Immediately after irradiation the SPF 100+ test product was applied to the previously exposed skin at a rate of 2mg/cm2. The product was left in place up to the 4 hour time point. The induced erythema was assessed visually and instrumentally after 4h, 24h, 5d and 18d.

   Results The effect of post-treatment with the SPF 100+ product is not significant compared to the control sites that were not post-treated. Sayre et al recently reported to have found an effect when applying a post treatment by an SPF 100+ sunscreen with anti-inflammatory ingredients, however with a number of subjects of n=1.

   Conclusion An anti-inflammatory effect of SPF 100+ sunscreen could not be confirmed in a standard SPF testing set-up. Furthermore, the effect of post treatment can go either way; hence no conclusion can be drawn with a study on a single subject.

6. SUNSCREEN USE IN CUTANEOUS LUPUS ERYTHEMATOSUS PATIENTS

   Elizabeth N. Le, Danielle Lin, Ira Bernstein, and Benjamin F. Chong
   University of Texas Southwestern Medical Center, Dallas, TX

   Purpose To determine the frequency of sunscreen use and identify barriers to sunscreen use in patients with cutaneous lupus erythematosus (CLE).

   Methods A cross-sectional survey on sunscreen use was administered on-line, by telephone, by mail, or in person to patients enrolled in the University of Texas Southwestern CLE Registry. Demographics and patient history were obtained from the registry database and medical charts. Additional information including disease severity and quality of life scores were collected from patients seen in person.

   Results A total of 100 CLE patients completed the survey. The minority of CLE patients (42%) reported using sunscreen at least five days per week (i.e. regular users), whereas 58% of CLE patients used sunscreen four or fewer days a week (i.e. irregular users). Significant barriers reported by patients include forgetfulness (p=0.005), inconvenience (p=0.004) and lack of efficacy in preventing lupus flares (p=0.05) with sunscreen use. When comparing characteristics of regular and irregular sunscreen users, significant differences were seen in marital status (i.e. irregular users were more likely to be single or separated (p=0.003)), education (i.e. irregular users were more likely to have a high school degree or lower (p=0.04)) and SKINDEX emotion scores (i.e. irregular users reported worse quality of life in the emotion domain (p=0.047)).

   Conclusions The majority of CLE patients use sunscreen less than five days per week. Irregular users were more likely to be single and cited forgetfulness as a significant barrier to sunscreen use. Advising patients to bring family members or friends to their clinic visits may aid in greater adherence to a sunscreen regimen as they may provide accountability to the patients. Irregular users also tended to be less educated, and practitioners are encouraged to take time to educate them about the importance and efficacy of regular sunscreen use. Furthermore, educational programs geared towards improving sunscreen use in these populations will be developed and implemented in future pilot studies.

7. ULTRAVIOLET-INDUCED CELLULAR DAMAGE AND SKIN AGING

   Raaj Khusial, Siming Chen, Michelle Slade, Teena Jacob, Jolanta Idkowiak-Baldys and Uma Santhanam
   Global R & D, Avon Products Inc. Suffern, NY

   The skin serves as a protective shield for our bodies, acting as the first line of defense from various environmental insults including ultraviolet radiation (UVR). Exposure of the skin to UVR leads to a series of damaging molecular and structural changes that have profound detrimental effects on the skin over time. The damage, if not prevented or corrected, will accumulate, resulting in premature skin aging and increasing the risk for developing skin cancer. UVR penetrates through the epidermal and dermal layers of the skin, thereby inflicting damage to the different skin cells including keratinocytes, fibroblasts and melanocytes. At the molecular level, UVR causes broad damage to critical cellular components such as DNA, proteins and lipids thereby affecting essential cellular functions such as replication, transcription, translation, protein functionality, and loss of membrane integrity. Therefore, understanding the molecular changes underlying UVR-induced skin aging is of crucial importance. Here we have employed 3D reconstructed human skin models to study UVR-induced cellular damage. These 3D systems closely mimic human skin and therefore serve as improved in vitro models to understand skin’s physiology compared to in vitro 2D monolayer systems. The types of damage reported from UVR in human skin, such as lipid peroxidation, pyrimidine dimer formation and protein modifications can also be observed in the 3D models. They can also be used to understand the contribution of melanin to the protection of skin against UVR. Furthermore, these models also serve as useful tools to screen for topical agents that can repair or prevent such damage, and thereby provide benefits against skin aging.

8. LUNG CANCER FREQUENCY IN SYSTEMIC SCLEROSIS PATIENTS TREATED WITH EXTRACORPOREAL PHOTOPHERESIS: A LONG TERM RETROSPECTIVE ANALYSIS

   S. Topuzoglu, R. Knobler, U. Just, D. Födinger, C. Jantschitsch
   Division of General Dermatology, Department of Dermatology, Medical University of Vienna, Austria

   Introduction Systemic sclerosis (SSc) is a chronic connective tissue disease associated with fibrosis and thickening of the skin and multiple internal organs. Available evidence shows that SSc is associated with a higher frequency of lung cancer. Present therapy of systemic sclerosis is unsatisfactory and is often associated with the severity of the disease and affected organ systems. Photopheresis or extracorporeal photochemotherapy (ECP), is a treatment with a very low side effect profile and can, when initiated early enough, often contribute to improvement of skin sclerosis. In the present study the goal was to determine the risk of lung carcinoma in ECP-treated SSc-patients.

   Methods A cohort study with an anonymous retrospective analysis of 71 patients with SSc who were treated with ECP between 1991 and 2013 at the Photopheresis Center of the Department of Dermatology at the Medical University of Vienna, Austria.

   Results Lung cancer was detected in 7 (= 10%) of 71 patients with SSc. In the Austrian general population the cumulative risk to develop lung cancer before the age of 75 is 2.1% for women and 4.5% for men. SSc patients of our cohort had a risk of 10% and thus an increased risk for developing lung cancer. A total of 54 % of our collective had developed a non-specific interstitial pneumonia (NSIP). Of interest was the observation that all of the lung carcinoma patients had been diagnosed with a NSIP prior to the development of lung carcinomas. In this study, patients with systemic sclerosis have a standardized incidence rate (SIR) of 2.34 (95% CI 0.84 to 4.58) for developing this malignancy.

   Conclusion As reported in previous studies patients with systemic sclerosis have an increased risk of developing a lung cancer. Since lung cancer appeared only in SSc patients previously diagnosed with an NSIP we also conclude that NSIP in systemic sclerosis could be a contributing factor for the development of lung cancer. Photopheresis treated patients did not present with a higher than reported incidence.