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Ultraviolet radiation and visible light both have biologic effects on the skin. Visible light can induce erythema in light-skinned individuals and pigmentation in dark-skinned individuals. Broad-spectrum sunscreens protect against ultraviolet radiation but do not adequately protect against visible light. For a sunscreen to protect against visible light, it must be visible on the skin. Inorganic filters (also known as mineral filters), namely, zinc oxide and titanium dioxide, are used in the form of nanoparticles in sunscreens to minimize the chalky and white appearance on the skin; as such, they do not protect against visible light. Tinted sunscreens use different formulations and concentrations of iron oxides and pigmentary titanium dioxide to provide protection against visible light. Many shades of tinted sunscreens are available by combining different amounts of iron oxides and pigmentary titanium dioxide to cater to all skin phototypes. Therefore, tinted sunscreens are beneficial for patients with visible light-induced photodermatoses and those with hyperpigmentation disorders such as melasma and postinflammatory hyperpigmentation.

A role for addiction psychiatry in aesthetic treatment-seeking behavior has been evidenced for ultraviolet light tanning.We aim to demonstrate an initial proof of concept for the presence of addictive behaviors in cosmetic procedure use.Adults visiting a cosmetic dermatology practice with history of at least 1 cosmetic procedure and consideration of at least 1 cosmetic procedure in the past 12 months were included. Two previously validated instruments in the detection of alcohol use disorder, the Cut Down, Annoyed, Guilty, Eye-Opener (CAGE) questionnaire, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria were modified to evaluate participants for a substance-related disorder (SRD) in cosmetic procedures.Of 153 adults, 34 (22.2%) met modified CAGE criteria, and 40 (26.1%) met modified DSM-V criteria. Results from both instruments were significantly associated (P .0002). Significant differences in consideration and use of cosmetic treatments were found in SRD positive versus negative groups (P .0001 and P = .009, respectively).Preliminary criteria for SRD in cosmetic procedure use in this study has not yet been validated.A type of SRD involving cosmetic procedures may exist, and qualifying individuals may have increased cosmetic treatment use. Future efforts to rigorously validate an instrument for SRD detection in cosmetic procedures use are warranted for future research and clinical application.

As phototherapy plays an important role in the treatment of early-stage mycosis fungoides (MF), it is possible that environmental ultraviolet (UV) exposure affects the natural history of the disease.To assess the impact of environmental UV exposure on the clinical course of MF.The National Solar Radiation Database was used to identify the top and bottom registries for UV exposure from the Surveillance, Epidemiology, and End Results-18 database. Incidence and survival were determined.The high-UV cohort had a 30% lower risk of developing MF than did the low-UV cohort (hazard ratio, 1.3; 95% confidence interval, 1.20-1.41; P .001). When stratified by stage and race, this difference was appreciable only among those with early-stage disease and white race. There was no difference in survival between the high- and low-UV cohorts (P = .098); however, a small difference was observed among those with early-stage disease and white race, favoring high UV exposure.Retrospective design, use of the National Solar Radiation Database as a surrogate for individual sunlight exposure.It is possible that environmental solar UV exposure may play a role in controlling early-stage MF among patients with photosensitive features.

Cutaneous photobiology studies have focused primarily on the ultraviolet portion of the solar spectrum. Visible light (VL), which comprises 50% of the electromagnetic radiation that reaches the Earth's surface and, as discussed in Part I of this CME, has cutaneous biologic effects, such as pigment darkening and erythema. Photoprotection against VL includes avoiding the sun, seeking shade, and using photoprotective clothing. The organic and inorganic ultraviolet filters used in sunscreens do not protect against VL, only tinted sunscreens do. In the United States, these filters are regulated by the Food and Drug Administration as an over-the-counter drug and are subject to more stringent regulations than in Europe, Asia, and Australia. There are no established guidelines regarding VL photoprotection. Alternative measures to confer VL photoprotection are being explored. These novel methods include topical, oral, and subcutaneous agents. Further development should focus on better protection in the ultraviolet A1 (340-400 nm) and VL ranges while enhancing the cosmesis of the final products.

Visible light has been used therapeutically in dermatology for years for a variety of cosmetic and medical indications, including skin rejuvenation and the treatment of inflammatory and neoplastic conditions, among others. Until recently, visible light was thought to be relatively inert compared to its spectral neighbors, ultraviolet and infrared radiation. However, recent literature has described the ability of visible light to cause erythema in light skin and pigmentary changes in individuals with darker skin types. Concern surrounding its potentially damaging cutaneous effects has been raised in both the medical community as well as in social media outlets. In this article, we provide an evidenced-based review describing what is currently known about visible light, focusing on its role in dermatologic diseases including disorders of hyperpigmentation such as melasma and post-inflammatory hyperpigmentation.

Background Ultraviolet light (UVL) is a long established treatment for mycosis fungoides (MF) and Sezary syndrome (SS), subtypes of cutaneous T-cell lymphoma (CTCL). Treatments have traditionally included broadband, narrowband ultraviolet B light (UVB) and psoralen plus ultraviolet A light photochemotherapy (PUVA), but more recently, treatment options have expanded to include UVA1 and excimer laser. UVL is used either as monotherapy or as an adjuvant to systemic therapy, demonstrating efficacy in many cases that equal or surpass systemic medications. Despite its utility and duration of use, the current practice of using UVL guidelines for psoriasis to treat patients with MF/SS is problematic because the goals of prolonging survival and preventing disease progression are unique to CTCL compared to psoriasis. Objectives We sought to develop separate guidelines for phototherapy for MF/SS for both clinical practice and for clinical trials. Methods Literature review and cutaneous lymphoma expert consensus group recommendations. Results This paper reviews the published literature for UVB and UVA/PUVA in MF/SS and suggests practical standardized guidelines for their use. Limitations New standardization of phototherapy. Conclusions These guidelines should allow the comparison of results with phototherapy in MF/SS across different stages of patients, centers, and in combination with other agents in practice and in clinical trials.

Background Brazilian keratin treatment (BKT) and similar straightening products fix and retain a straight shape even when the hair is wet. Unacceptably high concentrations of formaldehyde have been reported in such products. Objective We sought to measure the formaldehyde concentration in all BKT brands marketed in South Africa in 2012. Methods We quantified formaldehyde by high-performance liquid chromatography with ultraviolet light detection after derivatization with dinitrophenylhydrazine. All components of 7 identified commercial brands were each tested 3 times. Results The maximum safe concentration of formaldehyde set by the US Cosmetic Ingredient Review Expert Panel is less than 0.2%. Of the 7 commercial BKT brands, 6 had formaldehyde levels that ranged from 0.96% to 1.4%, ie, 5 times higher than the recommended level; these included 5 brands labeled formaldehyde-free. Limitations The study is limited by not including all internationally available BKT products. Conclusions Formaldehyde concentrations in BKT products may exceed recommended levels and serve as a health hazard. Industry monitoring is needed to improve compliance and protection of hairdressers and consumers.

Background Acute graft-versus-host disease (aGvHD) is a common complication of allogeneic stem cell transplantation. It is usually treated with high doses of corticosteroids and other immunosuppressive agents. When cutaneous features are predominant, narrowband ultraviolet B (NB-UVB) phototherapy may be an attractive option for its steroid-sparing effect. Objective We sought to examine the clinical efficacy of NB-UVB in the treatment of steroid-refractory and steroid-dependent cutaneous aGvHD. Methods We conducted a retrospective chart review of patients with steroid-refractory and steroid-dependent aGvHD, who received NB-UVB between 2005 and 2009 at our institution. Results We identified 14 patients with aGvHD treated with NB-UVB between 2005 and 2009. The median number of treatments was 15, administered over a median of 43 days. Eight of 14 patients (57%) achieved a complete response at the end of treatment; an additional 3 patients (21%) achieved a partial response; and 3 patients (21%) showed no improvement at the time when phototherapy was discontinued (nonresponders). Four patients developed chronic graft-versus-host disease (GvHD). Three of the 8 complete responders remained free of GvHD at 6 months' follow-up. Limitations The rarity of steroid-refractory aGvHD limited the study to a small number of participants. Because GvHD is variable in its presentation and course, and life-threatening in many cases, large controlled prospective trials for potential therapies are difficult. Conclusions NB-UVB is a viable option for the treatment of steroid-refractory and steroid-dependent aGvHD of the skin.

Phototherapy is a mainstay in the treatment of psoriasis and is available as psoralen plus UVA (PUVA), broadband UVB (BB-UVB), and narrowband UVB (NB-UVB). Phototherapy can be administered in the hospital, outpatient clinic, or in the patient's home. The purpose of this review is to provide some practical guidance to general dermatologists and residents on the specifics of using phototherapy, which, despite its decreasing use, remains one of our most safe and effective treatment strategies for psoriasis care. We conducted a literature review of home phototherapy, BB-UVB, NB-UVB, and PUVA phototherapy using PubMed, MD Consult, and reference lists. A variety of protocols for BB-UVB, NB-UVB, and PUVA have been used in clinical trials. NB-UVB is more effective than BB-UVB and safer than PUVA. Typical regimens for NB-UVB involve dosing 3 times per week for at least 3 months. Treatment must be independently developed to suit each participant's needs. Ultraviolet light is an effective, relatively safe modality that is a valuable tool in the treatment of psoriasis. NB-UVB phototherapy is considered the first-line treatment for extensive plaque type psoriasis.

Psoriasis is a common, chronic, inflammatory, multi-system disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this third of 6 sections of the guidelines of care for psoriasis, we discuss the use of topical medications for the treatment of psoriasis. The majority of patients with psoriasis have limited disease (

Background Prior studies suggested that direct immunofluorescence (DIF) slides can be stored at room temperature. Objectives We sought to determine the durability of DIF slides stored at room temperature for 5 years. Methods This was a retrospective study of 83 DIF slides archived at room temperature during 2010. The pattern of immunoreactants was compared with those noted in the original report. Results Loss of reactivity was limited to cases with weak fluorescence at original diagnosis. Loss of IgG was noted in 12.5% of cases, IgA in 12%, C3 in 10%, and IgM in 9.75%. Fibrin showed no loss of reactivity. Preservation of immunofluorescence was not related to site of deposition. Overall, a reliable diagnosis could be made in 75 of 79 archived cases (94.9%). Limitations Cases had been archived for periods varying from 4.5 to 5 years. Variations in processing and fluorochromes could affect durability. We have no way of knowing how long slides had been exposed to ultraviolet light at the time of initial examination. Conclusion DIF showed excellent durability in slides kept at room temperature for 5 years.

Skin cancer is the most common cancer in human beings. The increased incidence of skin cancer has brought much attention to the process by which these tumors develop and how they can be prevented. Efforts have been made to educate the public about the importance of protecting skin from excessive ultraviolet light. Despite this work, the incidence of skin cancer continues to increase. Available compounds may be useful in the chemoprevention of skin cancer. Chemoprevention is defined as oral or topical use of dietary or pharmacologic agents to inhibit or reverse the development of cancer. Potential agents included are the retinoids; difluoromethylornithine; T4 endonuclease V; polyphenolic antioxidants, such as (−)-epigallocatechin gallate, found in green tea and grape seed extract; silymarin; isoflavone genestein; nonsteroidal anti-inflammatory drugs; curcumin; lycopene; vitamin E; beta-carotene; and selenium. Many of these agents are available over the counter as topical or oral preparations. Learning objective At the conclusion of this activity, participants should be familiar with the chemopreventive agents and their efficacy, as well as any significant side effects associated with them.

Visual assessment remains one of the "gold standard" methods of assessing skin color and a number of tools are currently available to reduce the interobserver variability. Ultraviolet light examination remains a mainstay of the assessment of pigmentary disorders, while polarized light photography is useful for the appraisal of dermal changes, in particular those related to vascularity. With the introduction of modern instruments, reflectance spectroscopy using tristimulus colorimeters or narrowband spectrophotometers provides a convenient, objective, and reproducible methodology for the evaluation of pigmentation and skin color. In vivo confocal scanning laser microscopy is a powerful technique for the examination of pigmented lesions, which shows promise in the detection and diagnosis of early melanoma. Dermoscopy is also useful for the differential diagnosis of benign melanocytic lesions and melanoma, and its use has been shown to significantly improve diagnostic accuracy.

Background There has been a controversy regarding the cause of brachioradial pruritus: is it caused by a nerve compression in the cervical spine or is it caused by a prolonged exposure to sunlight? Objective The purpose was to study clinical features of patients with brachioradial pruritus and to compare the cutaneous innervation in punch biopsies from the itchy skin of patients with the age-matched controls. Methods Skin biopsy specimens from itchy skin of 16 patients with brachioradial pruritus were collected during the early autumn and were compared with corresponding skin specimens from 11 age-matched controls in the early spring, four of the patients being their own controls. The cutaneous innervation was visualized by antibodies against protein gene product 9.5 (general neuronal marker), by antibodies against calcitonin gene-related peptide (marker for thin sensory nerve fibers), and by antibodies against VR1-receptor (marker for capsaicin-sensitive nerve fibers). Results In all but two of the patients, itching of the arms or shoulders was seasonal. Some patients reported neck pain. In the skin of the lower arm, the number of protein gene product 9.5 immunoreactive nerve fibers was reduced 23% as compared with controls ( P =.03), the number of intraepithelial nerve fibers being reduced by 27% ( P =.03). The number of calcitonin gene-related peptide immunoreactive nerve fibers in the dermis was reduced by 34% ( P =.02) and the number of capsaicin-sensitive nerve fibers by 43% ( P =.008). The innervation of the four patients who were their own controls became normalized during the symptom-free period. Conclusions The temporal course of the brachioradial pruritus and the histological changes in the skin similar to those caused by ultraviolet light, indicate that sunlight is an eliciting factor and that cervical spine disease can be a predisposing factor.

Pemphigus vulgaris is an autoimmune blistering disorder of the skin and mucous membranes. Numerous medications, ultraviolet light, and radiation have all been implicated in the etiology of the disease. We present a patient with pemphigus vulgaris whose disease developed after administration of anthrax vaccine. The histologic and immunofluorescence findings were characteristic of pemphigus vulgaris. Adverse systemic events associated with the anthrax vaccine consist primarily of flu-like symptoms. Previous cases of pemphigus vulgaris associated with anthrax vaccine administration have not been reported. Considering the recent deliberate outbreaks of anthrax and continued threats of bioterrorism, the potential exists for widespread administration of the anthrax vaccine. Accordingly, continued observation and documentation of true adverse events is needed.

The 1920s and 1930s represented an extraordinary time in the shaping of modern attitudes towards ultraviolet light. Dermatologists and other physicians today are still confronting the effects of changes in social behavior that occurred at this time. The discovery that ultraviolet wavelengths played a role in vitamin D synthesis in the skin ushered in a period of enormous popularity for ultraviolet light exposure. A variety of other medical claims were soon made for ultraviolet radiation, including that it increased resistance to disease. The field of phototherapy rapidly expanded, and its use was employed by proponents for a host of unlikely medical conditions. Exposure to sunlight or ultraviolet lamps was widely promoted as a form of preventive medicine. Home sunlamps gained popularity and were aggressively marketed to the public. A suntan, which had previously achieved limited popularity, now was viewed as de rigueur in the United States and Europe. The role that medical advocacy of ultraviolet light exposure played in initially advancing the practice of sunbathing is not commonly appreciated today. Ironically, public health recommendations of the time were often diametrically opposed to those being made at present, since sunlight exposure is currently recognized as the major preventable cause of cancer of the skin.

Keratoacanthoma is a common benign squamous neoplasm that only rarely progresses to metastatic carcinoma. The cause of keratoacanthoma is unclear; however, suspected causes include ultraviolet light, genetic factors, immunosuppression, chemical carcinogens, viruses, and trauma. Keratoacanthomas have been reported only rarely to arise in sites of previous trauma. We report 2 cases of keratoacanthomas arising shortly after episodes of cutaneous trauma and provide a review of the literature of similar cases previously reported. It is likely that an interaction exists between a variety of factors in the development of keratoacanthomas; however, it appears that a predilection exists for these lesions to arise in trauma sites.

We were intrigued by the study of Butler and Fosko reporting a left-sided predominance of skin cancers, particularly among men.1 However, findings for melanoma were inconclusive due to the limited number of cases available for analysis. Therefore, using the large numbers of cases available in the Surveillance, Epidemiology and End Results (SEER) Program, we assessed the incidence of melanoma diagnosed among White residents of 12 SEER registry areas during 1992–2006.2 Histology and topography information are classified according to the International Classification of Diseases for Oncology, third edition.3 Age-adjusted incidence rates (IRs) and IR ratios (IRRs) were estimated for all cutaneous (C-440-449) melanomas (M-8720-8790) for sites with more than 70% of cases having specified laterality: eyelid (n=777; 99%), ear (n=4,772; 99%), other face (n=19,273; 91%), trunk (n=29,329; 71%), upper extremity (32,237; 99%), and lower extremity (23,679; 99%). Among males, incidence of left-sided melanoma was significantly higher than right-sided melanoma across all skin sites, ranging from 7–26% (Table 1). Among women, significantly higher IRs for left-sided melanoma were limited to the face, and upper and lower extremities, although left-sided lesions predominated at all sites (IRRs 1.03–1.15). A left-sided predominance was observed for in situ and invasive melanoma at all sites among males, in contrast to women who had nearly equal or a slight right-sided predominance for in situ melanoma of the ear and trunk and invasive melanoma of the eyelid. Except for eyelid melanoma among older women, left-sided melanoma predominated at all sites among younger (

Tazarotene in combination with phototherapy is being used clinically for the treatment of plaque psoriasis. This study investigates the dose of UVB light required to induce minimal erythema and the dose of UVA light required to induce immediate pigment darkening, with and without pretreatment with tazarotene 0.1% gel. The photostability of tazarotene is also assessed. Pretreatment with tazarotene 0.1% gel 3 times per week for 2 weeks before phototherapy significantly reduced the mean minimal erythema dose (MED) for UVB from 56.25 to 42.50 mJ/cm(2) (P

Background: Ultraviolet light (UVL) upregulates HIV transcription in vitro and in transgenic mice. AIDS-associated psoriasis and pruritus respond to phototherapy. Objective: Our goal was to determine the effect of phototherapy on viral load and immunologic parameters in HIV-positive patients. Methods: T cell subsets, p24, plasma cytokines, serum or plasma HIV-RNA, dosage, and antivirals were assessed in HIV-positive patients and negative controls receiving 6 weeks of phototherapy with UVB and in untreated controls. Results: Phototherapy improved skin conditions without significantly affecting T cell numbers. Plasma p24 increased 2-fold ( P = .055) and HIV-RNA levels 4-fold ( P = .022) 6 weeks from baseline in patients who entered the trial before March 1995. Later patients who were mostly receiving combination antiviral therapy showed a 4-fold reduction in serum HIV-RNA ( P = .012) at 2 weeks. The effect of UVB on viral load at 6 weeks was dependent on the baseline level ( P = .006). IL-10 increased and was inversely related to HIV-RNA levels ( P = .0267). Conclusion: Phototherapy is associated with HIV load alterations, depending on patients' initial HIV-RNA, antiviral therapy, skin type, and UVL dosage. (J Am Acad Dermatol 1999;40:48-60.)

We reviewed all studies since 1940 on the prognosis of squamous cell carcinoma (SCC) of the skin and lip. The following variables are correlated with local recurrence and metastatic rates: (1) treatment modality, (2) prior treatment, (3) location, (4) size, (5) depth, (6) histologic differentiation, (7) histologic evidence of perineural involvement, (8) precipitating factors other than ultraviolet light, and (9) host immunosuppression. Local recurrences occur less frequently when SCC is treated by Mohs micrographic surgery. This local recurrence rate differential in favor of Mohs micrographic surgery holds true for primary SCC of the skin and lip (3.1% vs 10.9%), for ear SCC (5.3% vs 18.7%), for locally recurrent (previously treated) SCC (10% vs 23.3%), for SCC with perineural involvement (0% Ys 47%), for SCC of size greater than 2 cm (25.2% vs 41.7%), and for SCC that is poorly differentiated (32.6% vs 53.6%).

To get further insight into the pathogenesis of polymorphous light eruption, we studied nine patients with polymorphous light eruption and six healthy persons. Two skin biopsy specimens were obtained from each person, one from previously ultraviolet light-irradiated skin and another one from unirradiated skin. An epidermal cell suspension, skin homogenate, or both were prepared from each specimen. Autologous cultures were made with peripheral blood mononuclear cells combined with irradiated or unirradiated skin homogenate and peripheral blood mononuclear cells combined with irradiated or unirradiated epidermal cell suspension. Cell proliferation was assessed by 3H-thymidine incorporation assay. The response of peripheral blood mononuclear cells to unirradiated epidermal cells or unirradiated skin homogenate was similar in both patients and controls. However, peripheral blood mononuclear cells from patients with polymorphous light eruption showed a significantly increased proliferative response to both irradiated epidermal cells and irradiated skin homogenate. Our results indicate that ultraviolet light increases the stimulatory capability of polymorphous light eruption epidermal cells in a unidirectional mixed culture with autologous peripheral blood mononuclear cells. This suggests that an immune sensitization against autologous ultraviolet light-modified skin antigens occurs in polymorphous light eruption.

Epidermoid inclusion cysts are common lesions with unclear etiology. We sought to examine evidence for human papillomavirus (HPV) infection and ultraviolet light (UV) exposure as risk factors in the formation of epidermoid inclusion cysts. We performed HPV typing of biopsied cysts with polymerase chain reaction for a patient with darkly-pigmented skin, epidermodysplasia verruciformis (EV) and more than 250 photodistributed cysts. HPV types 8 and 6 DNA was demonstrated within biopsy specimens of 3 cysts. In one biopsy specimen, abnormal keratinocytes bridging the follicular infundibulum were seen. We concluded that UV exposure and HPV viral infection may be risk factors for the formation of epidermoid inclusion cysts.

Background: Calcipotriene is often used with UVB or PUVA, but interactions between UV radiation and calcipotriene have not been examined extensively. Objective: Our purpose was to examine interactions between calcipotriene and UV light. Methods: Minimal erythema doses (MEDs) were determined with UVB and immediate pigment darkening was measured for UVA. The effect of calcipotriene ointment applied before phototesting was examined. Thick and thin applications of calcipotriene were compared. Calcipotriene ointment was applied to a small area on the skin before phototherapy. Patients received either UVB, PUVA, UVA, or no phototherapy. After phototherapy, the ointment was collected and assayed by reverse-phase, high-performance liquid chromatography. Results: MEDs for UVB and immediate pigment darkening for UVA were unaffected by calcipotriene. Thick application of calcipotriene, however, increased the MED. UVA caused substantial reductions in the concentration of detectable calcipotriene. Conclusion: When used in conjunction with PUVA, calcipotriene should be applied after exposure to UVA. (J Am Acad Dermatol 1997; 37:93–5.)

Background Indoor tanning is a common adolescent risk behavior that has been hypothesized to be motivated and maintained by the mood-altering effects of ultraviolet light. Objective Our purpose was to explore heretofore anecdotal reports that indoor tanning leads to dependency. Methods A telephone interview was conducted among 1275 adolescents, ages 14 to 17 years. Self-reported difficulty in quitting indoor tanning was assessed among 267 adolescents (20.9% of total) who tanned indoors more than once in the previous year in relation to age of initiation, frequency of use, and positive or negative consequences of the practice. Results Difficulty in quitting was more likely with younger age at initiation (age 13 years or younger vs ages 16 to 17; odds ratio=4.3, 95% confidence interval 1.3-14.7) and higher frequency of use ( P = .009), even after accounting for positive or negative consequences of indoor tanning and other demographic characteristics. Limitations This was a cross-sectional study design with a limited outcome measure. Conclusion Although preliminary, our findings for age at initiation and frequency of use in relation to difficulty in quitting indoor tanning are consistent with other potentially addictive behaviors taken up during adolescence.

Background Physical and emotional stressors have been found to mediate a wide variety of biological changes including the facilitation of tumor progression; however most of these paradigms utilized artificial sources of neoplasms and stress. Methods Skh mice were exposed to carcinogenic doses of ultraviolet light (UV). The stressed group was subjected to the close proximity of fox urine as a source of stress from the presence of the odor of their natural predator, while the control group remained stress free. Results A significant acceleration in the development of cutaneous neoplasms was observed in mice that had been exposed to the stressor. The first tumor appeared in the group after 8 weeks, whereas nonstressed mice began to develop these by week 21. Conclusion These results suggest that stress plays a role in potentiating cutaneous carcinogenesis.

From Ta Fund Conf Repr W A 42-year-old woman presented with a 9-month history of increasing hyperpigmentation and recurrent vesicles. The physical examination revealed erosions, healing crusts, scarring, milia, mottled hyperpigmentation, and remnants of vesicles and blisters on the dorsal surfaces of her hands, nose, V-neck area, and face (Fig 1). She also developed facial hypertrichosis that was most pronounced on the zygomatic skin (Fig 2). A direct immunofluorescence study of the skin was performed (Fig 3, A; immunoglobulin G), and her urine was examined with ultraviolet light (Fig 3, B). Her serum iron and ferritin levels were elevated. Lamotrigine had been added for her epilepsy 10 months earlier.

Background Caucasian renal transplant recipients living in Queensland, Australia, have the highest risk of nonmelanoma skin cancer in the world. Objective To determine clinical and environmental factors associated with posttransplantation nonmelanoma skin cancer in Queensland. Methods 361 Caucasian adult recipients completed a structured interview and full skin examination. Skin cancer details were obtained from hospital records. Results Squamous cell carcinoma was strongly associated with blue or hazel eyes, time resident in a hot climate, and pretransplantation squamous cell carcinoma; tumor numbers were associated with birth in a hot climate, childhood sunburn, pretransplantation actinic keratoses, and smoking. The risk of basal cell carcinoma was strongly associated with acute or intermittent sun exposure during childhood and pretransplantation basal cell carcinoma; numbers were associated with blue or hazel eyes, time spent living in a hot climate, and male gender. Conclusion Clinical and environmental factors can be used to identify recipients at risk of nonmelanoma skin cancer in Queensland.

The use of the various forms of phototherapy remains an essential treatment option for psoriasis vulgaris. Expertise concerning the mechanisms involved with the actions of therapeutic ultraviolet light and the proper delivery of office-based treatments resides within the specialty of dermatology. New therapies for the treatment of moderate to severe psoriasis will soon become available which have specific actions on the cutaneous immune system. A better understanding of the known mechanisms of action for ultraviolet light therapy makes it appropriate to include this area of treatment with new biologic agents. Photochemotherapy and various forms for delivery of narrow band ultraviolet B can be used as treatments, either as monotherapy or in combination with other agents, to effectively treat moderate and severe psoriasis.

New developments in the topical therapy and phototherapy of psoriasis have greatly improved our ability to safely and effectively treat this debilitating disease. Topical corticosteroids remain the most commonly prescribed agents for psoriasis, but they are frequently prescribed with other agents. Investigations of corticosteroids claiming an improved benefit/risk ratio have yielded promising results, but more work is needed. Use of anthralin and tar has declined with the availability of the noncorticosteroids calcipotriene and tazarotene. Other experimental topical therapies are in various stages of development. Broadband ultraviolet B (UVB) remains the most commonly used phototherapy light source, but many patients are being treated with a new form of ultraviolet light, narrowband UVB. Although PUVA remains one of the most effective psoriasis treatments, its use is declining because of its association with cutaneous malignancies. New radiation sources such as lasers have been added to our armamentarium of available therapies and even newer light source-based treatments are being examined. (J Am Acad Dermatol 2001;45:487-98.) Learning objective: At the conclusion of this learning activity, participants should be familiar with the varying topical treatments for psoriasis as well as the different modalities of phototherapy. Participants should also have a better understanding of side effects associated with each treatment, which should help in determining options for therapy.

Background: Actinic prurigo is a specific familial photodermatosis of uncertain pathogenesis. Objective: Our purpose was to investigate the immunohistologic presentation of actinic prurigo to explore the involved pathomechanisms. Methods: The present immunohistochemical study was performed on biopsy specimens from 20 Mexican patients presenting with a severe and perennial form of the disease. Results: The dense inflammatory infiltrate was composed predominantly of helper T type 1 lymphocytes admixed with scattered B-cell lymphoid follicles and numerous dermal dendrocytes. Keratinocytes contained abundant tumor necrosis factor-α and calprotectin. Conclusion: In subjects genetically predisposed to actinic prurigo, ultraviolet light may trigger excessive tumor necrosis factor-α production by keratinocytes whose sustained release in turn exerts its proinflammatory activity and deleterious epidermal effects. Such a cascade of events is in line with the therapeutic benefit already reported when thalidomide is used to treat actinic prurigo. (J Am Acad Dermatol 2001;44:957-61.)

In addition to the naturally occurring, physical, and systemic photoprotective agents reviewed in part I, topical ultraviolet radiation filters are an important cornerstone of photoprotection. Sunscreen development, efficacy, testing, and controversies are reviewed in part II of this continuing medical education article.

Background Granulomatous mycosis fungoides (GMF) is an uncommon variant of mycosis fungoides (MF). Objective We sought to analyze the relative frequency, clinicopathologic characteristics, prognosis, and therapeutic responses of GMF. Methods We conducted a retrospective case-control study of patients with GMF and age- and stage-matched patients with classic MF between 1981 and 2012. Results A total of 27 patients with GMF were identified, representing 6.3% of all patients with MF at our center. Skin manifestations were similar to classic MF having an atypical lichenoid CD4 + CD8 − lymphocytic infiltrate with interstitial histiocytes and/or perivascular granulomas with giant cells. Fewer patients with GMF achieved a partial response or complete response with topical (57% vs 83%; P = .002) or ultraviolet light (62% vs 90%; P = .006) therapy. The 5- and 10-year progression-free survival rates were significantly lower in patients with GMF (59% and 33%) compared with patients with classic MF (84% and 56%; P = .02), but overall survival was similar between groups (86% and 72% vs 85% and 85%; P = .54). Limitations The retrospective methodology may underestimate the frequency of GMF. The median follow-up time may be too short to detect possible differences in overall survival. Conclusion More frequent disease progression and poorer response to skin-directed therapies were observed in patients with GMF. Our findings may be helpful in selecting the most appropriate treatment for these patients.

Squamous cell carcinoma (SCC) is a rare complication of cutaneous lupus erythematosus (LE). Aside from the documented role of ultraviolet light, SCC may arise in areas of chronic scarring, such as in lesions of discoid LE. Iatrogenic immunosuppression associated with organ transplantation also results in a predisposition to SCC, often with multiple tumors. A role for certain human papillomaviruses (HPV) in the development of squamous cell carcinoma has been documented; specifically, HPV types 5 and 8 are detected in SCCs in patients with epidermodysplasia verruciformis and in recipients of organ transplants. HPV-11 is generally found in benign genital condylomata or laryngeal papillomas, but has not yet been associated with malignancy. We describe a patient with nonscarring cutaneous LE who was treated with azathioprine and prednisone and developed multiple SCCs. HPV-11 DNA and the target oncogenes neu and Ki- ras were detected in tumor tissue with the polymerase chain reaction. The HPV may have been involved in tumor induction and the azathioprine may have been involved in tumor promotion.

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The effect of psoralens and long-wave ultraviolet light (PUVA) therapy on human melanocytes was studied at the ultrastructural level. The results demonstrate an increase in the number of melanocytes, a change in their location, and an increase in the size of the melanosomes. Significantly, some of the melanocytes extend in narrow columns deep into the dermis, limited by the basal lamina, while others are found free within the dermis. Other morphologic alterations in the melanocytes consist of abnormal mitochondria, a swollen and distorted endoplasmic reticulum, and large lysosomes. The aforementioned abnormalities were also present in PUVA-treated skin that was examined 15 months after the treatment had been stopped.

Four hundred eighteen patients were treated with oral photochemotherapy up to 5 years and monitored regularly for the occurrence of precancerous conditions or tumors of the skin. Out of this group, six patients (1.4%) developed actinic keratoses and five (1.2%), epidermal tumors (three squamous cell carcinomas, one basal cell carcinoma, one keratoacanthoma) 12 to 53 months after initiation . of 8-methoxypsoralen-photochemotherapy (PUVA). Ten of these eleven patients belonged to a group of 172 individuals with a history of previous exposure to arsenic, ionizing radiation, and/or methotrexate who were considered a risk group. All of the four carcinoma patients had previously had one or more courses of arsenic therapy. No tumors were observed in the remaining 246 nonrisk patients. The mean age of the keratosis-tumor group (59 ± 9 years) and the total cumulative long-wave ultraviolet light (UVA) dose (1,045 ± 959 J/cm 2 ) were significantly higher (p 2 ) of the 407 patients without such skin changes. The skin type and the time period between initiation of PUVA therapy and the final evaluation of the patients did not exhibit substantial differences in both groups. The observed incidence of epidermal carcinomas in the risk group (2.3%) was considerably higher than the expected age-sex-specific incidence of a randomized population (0.1%), whereas the incidence in the nonrisk group (0%) corresponded to the expected rate. However, data on the tumor incidence in psoriatics not treated with PUVA and matched for previous treatments and risk factors were not available. This study shows that the incidence of nonmelanoma skin tumors in long-term PUVA patients without previous medication of arsenic or treatment with ionizing radiation does not differ from the expected incidence of the general population. However, there is an increased incidence of tumors in PUVA patients if certain risk factors are present. The risk factor in our series is previous medication with arsenic, which is carcinogenic per se.