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Chapter 93: Chronic Actinic Dermatitis

Robert S. Dawe

CHRONIC ACTINIC DERMATITIS

Therapeutic Approach

Chronic actinic dermatitis (CAD) is an uncommon, but important, form of eczematous dermatitis that involves severe abnormal cutaneous photosensitivity (nearly always to ultraviolet B, usually to ultraviolet A and often also to visible light). It typically arises on top of another preexisting dermatitis (such as atopic eczema, seborrheic dermatitis, or contact allergic dermatitis). Often, even when not arising from it, contact allergy is another contributing component. The mainstay of management is avoidance of the relevant wavelengths of ultraviolet and visible light. While behavioral, environmental, and clothing photoprotection are of high importance, topical sunscreens are also part of photoprotection. Avoidance of identified contact allergens is also important. Below are specific treatments for CAD. Systemic immunosuppressive approaches are appropriate if avoidance measures and topical treatments are insufficient. Always before any phototherapy or PUVA treatments, these patients should be assessed in an expert photodermatology unit. See Table 93-1.

Table 93-1Chronic Actinic Dermatitis Treatment Table
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Table 93-1 Chronic Actinic Dermatitis Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Potent to very potent corticosteroids Localized and generalized disease Anti-inflammatory, local immunosuppression 1× to 2× daily, eg, clobetasol propionate 0.05% ointment If used long term to large area Cushing’s; long term on face can cause periorificial dermatitis and rarely “skin thinning” None IV1-4

Tacrolimus 0.1% and 0.03% ointments

Pimecrolimus 1% cream

 Localized disease. Has been used for more generalized disease and reticuloid changes. Calcineurin inhibitors, anti-inflammatory, local immunosuppression

1× daily 0.1% ointment for 4 wk, then 2× weekly

2× daily (pimecrolimus 1% cream)

 Skin irritation None III5-17
SPF 50+ and UVA sunscreens All disease As part of package of photoprotection measures; guided by phototesting—visible photoprotection also sometimes needed Aim for at least 2 hourly to exposed skin Contact allergy and photoallergy None IV18
Systemic Therapy
Prednisolone For severe flares and sometimes for first few weeks of a phototherapy course Systemic immunosuppressive Generally 40 mg orally daily—gradually reducing dose if long or recurrent course Increased infection risks, Cushing’s, diabetes mellitus, weight gain (due to insulin resistance), arterial hypertension Blood pressure, blood glucose IV1
Azathioprine For disease inadequately responsive to avoidance measures and topical treatment Systemic immunosuppressive Oral 50 mg alternate days to 200 mg daily depending upon baseline TPMT and response Increased infection risks, hepatotoxicity, myelosuppression CBC, LFTs, baseline TPMT to guide dosing IB19
Methotrexate For disease inadequately responsive to avoidance measures and topical treatment Systemic immunosuppressive 7.5-25 mg once a week orally or subcutaneous Increased infection risks, hepatotoxicity, myelosuppression, nausea, homocystinuria (concomitant folic acid reduces latter two). Not suitable in possible, or definite, pregnancy Baseline CBC, LFTs, BUN/Cr, Hep B/C serologies, HIV; CBC, LFTs, BUN/Cr following dose increases and every 3 mo on stable dosing consider P3NP or other tests to monitor for possible liver fibrosis III1-4...

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