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Sun protection factor (SPF) is assessed with sunscreen applied at 2 mg cmTo determine (i) whether typical sunscreen use resulted in erythema, epidermal DNA damage and photoimmunosuppression during a sunny holiday, (ii) whether optimal sunscreen use inhibited erythema and (iii) whether erythema is a biomarker for photoimmunosuppression in a laboratory study.Holidaymakers (n = 22) spent a week in Tenerife (very high ultraviolet index) using their own sunscreens without instruction (typical sunscreen use). Others (n = 40) were given SPF 15 sunscreens with instructions on how to achieve the labelled SPF (sunscreen intervention). Personal ultraviolet radiation (UVR) exposure was monitored electronically as the standard erythemal dose (SED) and erythema was quantified. Epidermal cyclobutane pyrimidine dimers (CPDs) were determined by immunostaining, and immunosuppression was assessed by contact hypersensitivity (CHS) response.There was no difference between personal UVR exposure in the typical sunscreen use and sunscreen intervention groups (P = 0·08). The former had daily erythema on five UVR-exposed body sites, increased CPDs (P0·001) and complete CHS suppression (20 of 22). In comparison, erythema was virtually absent (P0·001) when sunscreens were used at ≥ 2 mg cmOptimal sunscreen use prevents erythema during a sunny holiday. Erythema predicts suppression of CHS (implying a shared action spectrum). Given that erythema and CPDs share action spectra, the data strongly suggest that optimal sunscreen use will also reduce CPD formation and UVR-induced immunosuppression.

Summary Background Conventional treatment of basal cell carcinoma (BCC) causes morbidity and/or disfigurement in some patients because of the location (e.g. mid-face) and size of the lesion. Objectives Following reports that such difficult-to-treat BCC lesions have been treated successfully with topical methyl aminolaevulinate (MAL) photodynamic therapy (PDT), a multicentre study was performed to determine the response of such BCC to MAL-PDT. Methods An open, uncontrolled, prospective, multicentre study was conducted comprising patients with superficial and/or nodular BCC who were at risk of complications, poor cosmetic outcome, disfigurement and/or recurrence using conventional therapy. Patients were given one or two cycles within 3 months of topical MAL-PDT, each consisting of two treatments 1 week apart. Tumour response was assessed clinically at 3 months after the last PDT, with histological confirmation of all lesions in clinical remission. The cosmetic outcome was rated. Patients with a BCC in remission will be followed up for 5 years for recurrence, of which the 24-month follow-up is reported here. Ninety-four patients with 123 lesions were enrolled and treated with MAL-PDT at nine European primary care and referral university hospitals. An independent blinded study review board (SRB) retrospectively excluded nine patients and a total of 15 lesions from the efficacy analysis, for not having a difficult-to-treat BCC according to the protocol. Results The lesion remission rate at 3 months was 92% (45 of 49) for superficial BCC, 87% (45 of 52) for nodular BCC, and 57% (four of seven) for mixed BCC, as assessed by clinical examination, and 85% (40 of 47), 75% (38 of 51), and 43% (three of seven), respectively, as assessed by histological examination and verified by the SRB. At 24 months after treatment, the overall lesion recurrence rate was 18% (12 of 66). The cosmetic outcome was graded as excellent or good by the investigators in 76% of the cases after 3 months follow-up, rising to 85% at 12 months follow-up, and 94% at 24 months follow-up. Conclusions Topical MAL-PDT is effective in treating BCC at risk of complications and poor cosmetic outcome using conventional therapy. MAL-PDT preserves the skin and shows favourable cosmetic results.

Objectives: In prospective trials, episodic valaciclovir significantly increased the chance of preventing or aborting the development of painful vesicular genital herpes simplex virus (HSV) lesions compared with placebo. We explored the clinical outcome of aborted lesions and its association with early treatment in a study designed to compare 3 and 5 days’ treatment with valaciclovir. Methods: In a randomised controlled trial, valaciclovir 500 mg twice daily for 3 or 5 days was initiated at the first symptoms of a genital herpes outbreak. The primary end point was length of episode with pain, HSV shedding, and aborted lesions secondary end points. The effect of time from symptom recognition to treatment initiation on aborted lesions was assessed in a post hoc analysis. Results: In 531 patients, no differences were observed between 3 and 5 days’ treatment in episode duration (median 4.7 v 4.6 days), loss of pain/discomfort (2.8 v 3.0 days), or lesion healing (4.9 v 4.5 days). Vesicular lesions were aborted in 27% of patients treated for 3 days v 21% of patients receiving valaciclovir for 5 days. The odds of achieving an aborted episode were 1.93 (95% CI: 1.28 to 2.90) times higher for those initiating treatment with valaciclovir within 6 hours of first sign or symptom. Conclusions: There was no difference between 3 and 5 days’ treatment in reducing episode duration or lesion abortion. Prompt treatment with valaciclovir can abort genital HSV reactivation episodes, preventing a vesicular outbreak. Maximum treatment benefit depends on prompt therapy after recognition of symptoms.

A great number of journeys to sunny destinations are sold to the Danish population every year. We suspect that this travel considerably increases personal annual ultraviolet-radiation (UVR) exposure doses. This is important because such exposure is the main cause of skin cancer, and studies have shown a correlation between intermittent solar UVR exposure and malignant melanoma.To prospectively monitor the behaviour of a group of sun seekers during a winter sun holiday and to study the impact of behaviour on personal UVR exposure doses.In this observational study 25 Danish sun seekers were closely monitored by on-site investigators for 6 days during a winter sun holiday in the Canary Islands, thus avoiding the possible recall bias of retrospective studies with questionnaires. The volunteers recorded their location, clothing and sunscreen use in diaries, and their UVR doses were measured by personal UVR dosimeters worn on the wrist. This resulted in 3450 half-hour registrations during 150 participation days.On average, each volunteer received a total UVR dose of 57 standard erythema doses over 6 days, which is 43% of the annual UVR dose of a Danish indoor worker. Their exposed body area, sunscreen use and percentage of body with sunscreen application were positively correlated with their personal UVR doses, and there was also a strong relationship between location and UVR doses received.The behaviour of the volunteers had a major impact on their personal UVR doses. Our results emphasize the importance of changing the behaviour of sun seekers with protanning attitudes to reduce their personal annual UVR exposure doses, and possibly their risk of skin cancer.

Tanning and thickening of the epidermis are cardinal defensive responses of human skin to ultraviolet (UV) radiation that lead to increased photoprotection. Earlier studies have shown that skin pigmentation can be used to predict minimal erythema dose and minimal phototoxic dose. In this study it was calculated how much of the increase in photoprotection after 4 weeks of repeated exposure to suberythemogenic doses of either UVA or UVB radiation sources or psoralen plus UVA (PUVA) therapy that was attributable to melanogenesis. The backs of 12 volunteers were exposed to 6 different UVA and UVB radiation sources 9 times during 4 weeks. Skin pigmentation was assessed by skin reflectance measuring. Photoprotection was determined from the minimal erythema dose. Melanogenesis accounted for 63-95% of the increase in photoprotection after 4 weeks of exposure to UVA radiation. Exposure to two UVB sources induced a significant increase in photoprotection but not in pigmentation. Melanogenesis accounted only for 6-11% of the increase in photoprotection after 4 weeks of UVB exposure. The pigmentary and photoprotective responses to PUVA therapy were followed in 14 patients. After 2 weeks of exposure, the increase in photoprotection was significantly higher than predicted from the increase in skin pigmentation. After 4 weeks, melanogenesis accounted for only 36% of the increase in photoprotection. This study shows that melanogenesis accounts for the increased photoprotection after 2 weeks of exposure to UVA radiation, but after 4 weeks other protective mechanisms occur. During suberythemal UVB exposure and during PUVA therapy the importance of skin pigmentation in the overall photoprotection gradually decreases during a 4-week irradiation period.

It has been reported that patients with cutaneous malignant melanoma (CMM) can lower their risk of a second primary melanoma by limiting recreational sun exposure. Previous studies based on questionnaires and objective surrogate measurements indicate that before their diagnosis, patients with CMM are exposed to higher ultraviolet radiation (UVR) doses than controls, followed by a reduction after diagnosis.In a prospective, observational case-control study, we aimed to assess sun exposure after diagnosis of CMM by objective measurements to substantiate advice about sun behaviour.The study population consisted of 24 patients recently diagnosed with CMM during the 7 months preceding the start of the study; 51 controls who matched these recently diagnosed patients in age, sex, occupation and constitutive skin type; and 29 patients diagnosed with CMM between 12 months and 6 years before the start of the study. During a summer season participants filled in sun exposure diaries daily and wore personal electronic UVR dosimeters in a wristwatch that continuously measured time-stamped UVR doses in standard erythema dose.The UVR dose of recently diagnosed patients on days with body exposure was one-third lower, and the number of days using sunscreen was double that of matched controls. However, in patients diagnosed more than 12 months earlier, the UVR dose on days with body exposure was one-third higher and the number of days using sunscreen was half that of recently diagnosed patients.Patients with CMM limited their UVR dose on days with body exposure, and by using sunscreen further reduced UVR reaching the skin, although only immediately after diagnosis.

Photodynamic therapy (PDT) with methyl aminolaevulinate (MAL) is effective for thin actinic keratoses (AKs) in field-cancerized skin. Ablative fractional laser resurfacing (AFXL) creates vertical channels that facilitate MAL uptake and may improve PDT efficacy.To evaluate efficacy and safety of AFXL-assisted PDT (AFXL-PDT) compared with conventional PDT in field-directed treatment of AK.Fifteen patients with a total of 212 AKs (severity grade I-III) in field-cancerized skin of the face and scalp were randomized to one treatment with PDT and one treatment with AFXL-PDT in two symmetrical areas. Following curettage of both treatment areas, AFXL was applied to one area using 10 mJ per pulse, 0·12 mm spot, 5% density, single pulse (UltraPulse(®), DeepFx handpiece; Lumenis Inc., Santa Clara, CA, U.S.A.). MAL cream was then applied under occlusion for 3 h and illuminated with red light-emitting diode light at 37 J cm(-2). Fluorescence photography quantified protoporphyrin IX (PpIX) before and after illumination.At 3-month follow-up, AFXL-PDT was significantly more effective than PDT for all AK grades. Complete lesion response of grade II-III AK was 88% after AFXL-PDT compared with 59% after PDT (P = 0·02). In grade I AK, 100% of lesions cleared after AFXL-PDT compared with 80% after PDT (P = 0·04). AFXL-PDT-treated skin responded with significantly fewer new AK lesions (AFXL-PDT n = 3, PDT n = 11; P = 0·04) and more improved photoageing (moderate vs. minor improvement, P = 0·007) than PDT-treated skin. Pain scores during illumination (6·5 vs. 5·4; P = 0·02), erythema and crusting were more intense, and long-term pigmentary changes more frequent from AFXL-PDT than PDT (P = not significant). PpIX fluorescence was higher in AFXL-pretreated skin [7528 vs. 12,816 arbitrary units (AU); P = 0·003] and photobleached to equal intensities after illumination (AFXL-PDT 595 AU, PDT 454 AU; P = 0·59).AFXL-PDT is more effective than conventional PDT for treatment of AK in field-cancerized skin.

Photodynamic therapy (PDT) is an attractive therapy for nonmelanoma skin cancers and actinic keratoses (AKs). Daylight-mediated PDT is a simple and tolerable treatment procedure for PDT. Methyl aminolaevulinate (MAL)-PDT is approved for the treatment of thin or nonhyperkeratotic AKs on the face and scalp. However, thick AK lesions are often treated as well when present in the field-cancerized treatment area.In a randomized multicentre study to evaluate efficacy of daylight-mediated PDT for different severity grades of AKs.One hundred and forty-five patients with a total of 2768 AKs (severity grades I-III) of the face and scalp were randomized to either 1½ or 2½ h exposure groups. After application of a sunscreen (sun protection factor 20) and gentle lesion preparation, MAL was applied to the entire treatment area. Patients left the clinic immediately after application and exposed themselves to daylight according to randomization. Daylight exposure was monitored with a wrist-borne dosimeter.No difference in lesion response was found between the 1½ and 2½ h exposure group. The mean lesion response rate was significantly higher in grade I lesions (75·9%) than in grade II (61·2%) and grade III (49·1%) lesions (P0·0001). Most grade II (86%) and III AKs (94%) were in complete response or reduced to a lower lesion grade at follow-up. Large variations in response rate of grade II and III AKs were found between centres. No association was found between response rate and light dose in patients who received an effective light dose of3·5 J cm(-2).Daylight-mediated PDT of moderate to thick AKs was less effective than daylight-mediated PDT of thin AKs especially in some centres. However, nearly all thicker lesions (grades II and III) were reduced to a lower lesion grade at 3 months after a single treatment of daylight-mediated PDT.

Most epidemiological data of sunburn related to skin cancer have come from self-reporting in diaries and questionnaires. We thought it important to validate the reliability of such data.To validate the quality of self-reported erythema by sun worshippers and skiers, and to validate the ability to determine erythema visually compared with objectively measured erythema.The skin in a group of sun worshippers in Tenerife and of skiers in Austria was closely monitored over a week. The participants used a diary to record any erythema assessed on different skin sites and underwent a twice daily skin examination by researchers who assessed erythema on the same sites. Lastly, the erythema assessment was validated by objective measurements.We found that the participants' agreed with researchers' assessment of erythema in only 57-61% of cases, and that the researchers detected up to 28% more of the objectively measured erythema than the participants did. We also found that, even for the trained eye (researchers), it was difficult to detect an increase in erythema as only 71-91% of those cases with an increase15 in measured erythema percentage were detected in the evening. Possibly, detection was impeded by a simultaneous increase in pigmentation.Self-assessment of erythema from diaries is unreliable. Erythema is considerably underestimated and possibly neglected. Even for the trained eye, it can be difficult to detect erythema.

It is known that ultraviolet (UV) B radiation increases serum 25-hydroxyvitamin D(3) [25(OH)D] level. However, there is uncertainty about the relationship between the maintenance of vitamin D status and UVB.To define the frequency of UVB exposure necessary for maintaining summer 25(OH)D levels during the winter.In total, 60 participants were included from October 2008 to February 2009 (16weeks) and randomized for UVB exposure of 1 standard erythema dose (SED) to ∼88% body area once a week (n=15 completed), every second week (n=14 completed) or every fourth week (n=12 completed). The controls (n=14 completed) had no intervention. Vitamin D was measured at baseline, every fourth week before exposure, and 2days after the last UVB exposure.The 25(OH)D levels (mean) after UVB exposure once a week increased significantly (from 71·9 to 84·5nmolL(-1) ) (P0·0001), whereas UVB exposure every second week maintained 25(OH)D levels (P=0·16). A significant decrease in mean 25(OH)D levels (from 56·4 to 47·8nmolL(-1) ) (P0·0001) was found after UVB exposure once every fourth week and for the control group (from 64·8 to 40·1nmolL(-1) ) (P0·0001). The development in 25(OH)D levels during the 16-week study period were negatively correlated with baseline 25(OH)D (P0·0001). Further, the increase in 25(OH)D after the last UVB exposure was negatively correlated with the 25(OH)D level just before the last UVB exposure (P0·0001).Exposure to a UVB dose of 1 SED every second week to ∼88% body area is sufficient for maintaining summer 25(OH)D levels during the winter.

Previous studies on ultraviolet radiation (UVR) exposure before and after a diagnosis of cutaneous malignant melanoma (CMM) have been based primarily on questionnaires. Objective measures are needed.To assess changes in UVR exposure in patients with CMM using objective surrogate parameters in a descriptive study.Ten patients recently diagnosed with CMM during the 5 months (autumn and winter) preceding study start in February 2009; 21 patients diagnosed from 12 months to 6 years before study start; and 15 controls, who matched the recently diagnosed patients on age, sex, residential area, constitutive skin type and occupation completed the investigations. UVR exposure before and after diagnosis of CMM was assessed using measures of serum 25-hydro vitamin D [25(OH)D], skin pigmentation and by interviews. Winter 25(OH)D was used as a surrogate parameter of UVR exposure the previous summer - the summer before CMM diagnosis in recently diagnosed patients.Winter 25(OH)D was significantly higher among recently diagnosed patients compared with controls (P = 0·02, R² = 0·60) and patients diagnosed up to 6 years earlier (P = 0·01). The increase in 25(OH)D during the summer after diagnosis was significantly lower for recently diagnosed patients than for controls (P = 0·005, R² = 0·51) and patients diagnosed up to 6 years earlier (P = 0·008). No difference was found in summer 25(OH)D between the groups.Our findings suggest that patients with CMM had a higher UVR exposure the summer before diagnosis than did controls and patients diagnosed up to 6 years earlier, and that after diagnosis UVR exposure fell to the level of controls in patients with CMM.

Actinic keratoses (AKs) are common dysplastic skin lesions that may differentiate into invasive squamous cell carcinomas. Although a superior cosmetic outcome of photodynamic therapy (PDT) is advantageous compared with equally effective treatments such as cryotherapy and curettage, the inconvenience of clinic attendance and discomfort during therapy are significant drawbacks. Daylight-mediated PDT could potentially reduce these and may serve as an alternative to conventional PDT.To compare the efficacy of methyl aminolaevulinate (MAL)-PDT with 1½ vs. 2½ h of daylight exposure in a randomized multicentre study.One hundred and twenty patients with a total of 1572 thin AKs of the face and scalp were randomized to either 1½- or 2½-h exposure groups. After gentle lesion preparation and application of a sunscreen of sun protection factor 20, MAL was applied to the entire treatment area. Immediately after, patients left the clinic and exposed themselves to daylight according to the randomization. Daylight exposure was monitored with a wristwatch dosimeter and patients scored their pain sensation during treatment.The mean lesion response rate at 3 months was 77% in the 1½-h group and 75% in the 2½-h group (P = 0·57). The mean duration of daylight exposure was 131 and 187 min in the two groups. The mean overall effective light dose was 9·4 J cm(-2) (range 0·2-28·3). Response rate was not associated with effective daylight dose, exposure duration, treatment centre, time of day or time of year during which the treatment was performed. Treatment was well tolerated, with a mean ± SD maximal pain score of 1·3 ± 1·5.Daylight-mediated MAL-PDT is an effective, convenient and nearly pain-free treatment for patients with multiple thin AKs. Daylight-mediated PDT procedures were easily performed and 2 h of daylight exposure resulted in uniformly high response rates when conducted in the period from June to October in Nordic countries.

Ultraviolet (UV) B radiation increases serum vitamin D level expressed as 25-hydroxyvitamin-D(3) [25(OH)D], but the relationship to body surface area and UVB dose needs investigation.To investigate the importance of body surface area and UVB dose on vitamin D production after UVB exposure.We randomized 92 participants to have 6%, 12% or 24% of their skin exposed to 0·75 (7·5 mJ cm(-2) at 298 nm using the CIE erythema action spectrum), 1·5 (15 mJ cm(-2) ) or 3·0 (30 mJ cm(-2) ) standard erythema doses (SED) of UVB. Each participant underwent four UVB exposures at intervals of 2-3 days. Skin pigmentation and 25(OH)D levels were measured before and 48 h after the final exposure.The increase in 25(OH)D after irradiation [Δ25(OH)D] was positively correlated with body surface area (P = 0·006; R(2) = 0·08) and UVB dose (P0·0001; R(2) = 0·28), and negatively correlated with baseline 25(OH)D (P0·0001; R(2) = 0·18), for the entire data sample. However, when analysing each body surface area separately, we found a significant UVB response correlation for 6% (P0·0001; R(2) = 0·48) and 12% (P = 0·0004; R(2) = 0·35), but not for 24%. We also found a significant skin area response correlation for 0·75 SED (P0·0001; R(2) = 0·56), but not for 1·5 and 3·0 SED when analysing each UVB dose separately. The relationships did not change significantly after adjustment of Δ25(OH)D for baseline 25(OH)D.The increase in 25(OH)D depends mainly on the UVB dose; however, for small UVB doses the area of irradiated body surface is important.

Quantification of quality of life (QoL) related to disease severity is important in patients with atopic eczema (AE), because the assessment provides additional information to the traditional objective clinical scoring systems.To measure health-related QoL (HRQoL) in patients with AE; to analyse discriminant, divergent and convergent validity by examining the association between various QoL methods; and to examine the association between disease severity assessed by an objective Severity Scoring of Atopic Dermatitis (SCORAD) and QoL.HRQoL was assessed at two visits at a 6-monthly interval in 101 patients with AE and 30 controls with one dermatology-specific questionnaire [Dermatology Life Quality Index (DLQI) or Children's DLQI (CDLQI)], one generic instrument (SF-36) and three visual analogue scales (VASs) of severity and pruritus. Objective SCORAD was used to measure disease severity.Patients with AE had significantly lower QoL than healthy controls and the general population. DLQI /CDLQI, pruritus, and patient and investigator overall assessment of eczema severity were significantly (P0.0001) and positively correlated with SCORAD, while the generic questionnaire showed only poor correlation. A gender difference was found for the mental component score of SF-36 (P = 0.019).AE has an impact on HRQoL. Patients' mental health, social functioning and role emotional functioning seem to be more affected than physical functioning. A simple VAS score of patients' assessment of disease severity showed the highest and most significant correlations with most of the HRQoL methods used. There is evidence to support the ability of patients with AE to make an accurate determination of their disease severity and QoL.

Personal annual ultraviolet (UV) radiation data based on daily records are needed to develop protective strategies.To compare UV radiation exposure patterns in the winter half-year (October-March) and the summer half-year (April-September) for Danish indoor workers.Nineteen indoor workers (age range 17-56 years) wore personal UV dosimeters, measuring time-stamped UV doses continuously during a year. The corresponding sun exposure behaviour was recorded in diaries. Similar data were collected for 28 volunteers during sun holidays in the winter half-year. The relationship between UV dose and sun exposure behaviour was analysed.The ambient UV dose during the winter in Denmark (at 56 degrees N) was 394 standard erythema doses (SED) or 10.5% of the annual ambient UV dose. In winter compared with summer the subjects had: (i) a lower percentage of ambient UV radiation, 0.82% vs. 3.4%; (ii) a lower solar UV dose in Denmark, 3.1 SED (range 0.2-52) vs. 133 SED (range 69-363); (iii) less time outdoors per day with positive dosimeter measurements, 10 min vs. 2 h; and (iv) no exposure (0 SED) per day on 77% vs. 19% of the days. Sun holidays outside Denmark in winter gave a median 4.3 SED per day (range 0.6-7.6) and 26 SED (range 3-71) per trip.In the winter half-year indoor workers received a negligible UV dose from solar exposure in Denmark and needed no UV precautions. No UV precautions are needed from November to February during holidays to latitudes above 45 degrees N, while precautions are needed the whole year around at lower latitudes.

The purpose of this study was to quantify the impact of recurrent genital herpes (RGH) on health-related quality of life, healthcare resource and workplace productivity. This was a cross-sectional survey conducted in 5 countries (Australia, Denmark, Italy, The Netherlands and UK). Patients with a confirmed history of RGH completed the MOS 36-Item Short Form Health Survey (SF-36) and the Recurrent Genital Herpes Quality of Life questionnaire (RGHQoL). Questionnaires addressing frequency of access to healthcare services and workplace productivity were also completed and patients' medical history was obtained. Scores for 6 of the 8 domains of the SF-36 were significantly lower ( P

The purpose of this study was to investigate the reliability of measuring solar ultraviolet radiation (UVR) doses with personal UV dosimeters worn on the wrist. Individual solar UVR exposure was measured over one day under standardised conditions (One-day Beach Study), and over an extended period of time with varying UV exposure and activities (Holiday Study). Dosimeters of a UV-sensitive spore-film filter type (VioSpor) were placed on the right wrist and on the top of head of the test subjects. The wrist was chosen as being a practical position for personal dosimetry and the head position as an internal control for maximal personal UV doses. The One-day Beach Study took place in the vicinity of Copenhagen in June 1998 over 5 h and included 11 subjects. The Holiday Study included 9 subjects during a period with a mean of 14 days in Scandinavia and Europe from June to September 1998. The head position received the highest UV dose in all subjects in both studies. In both studies, despite considerable individual variation, the mean wrist dose was the same (50%) of that received on the head, although the wrist dose correlated significantly with head dose (P0.01) only in the Holiday Study. We conclude that the wrist position is a practical and convenient body site for personal dosimetry, yielding reliable results in group exposure studies.

The purpose of this pilot study was to determine if photodynamic therapy with topical application of 5-aminolaevulinic acid followed by irradiation with incoherent filtered and unfiltered light (ALA-PDT) is an effective therapy for recalcitrant hand and foot warts. In 30 patients with recalcitrant warts, 49 regions with a total of 250 warts were randomized to one of the following five treatments: (i) ALA-PDT with white light applied three times within 10 days (W3); (ii) ALA-PDT with white light applied once (W1); (iii) ALA-PDT with red light applied three times within 10 days (R3); (iv) ALA-PDT with blue light applied three times within 10 days (B3), and (v) cryotherapy applied up to four times within 2 months (CRYO). The ALA-PDT treatment modality was repeated in case of partially responding warts. Significantly more warts were completely healed after W3 and W1 than after R3, B3 and CRYO (P0.01): 73% of the warts treated with W3 were completely healed, 71% after W1, 42% after R3, 23% after B3 and 20% after CRYO. No scars were observed in the ALA-PDT treated areas and patients treated for foot warts were all able to walk after the treatment. No recurrences in completely responding ALA-PDT treated warts were observed after 12 months of follow-up. In conclusion, photodynamic therapy with topical 5-aminolaevulinic acid followed by irradiation with white light is a promising treatment for recalcitrant hand and foot warts.

In two identical and simultaneously performed case-control studies of basal cell carcinoma (BCC) and cutaneous malignant melanoma (CMM) with age-matched, sex-matched and residence-matched controls, skin pigmentation was measured objectively by skin reflectance spectroscopy in 145 BCC patients and 174 matched controls and in 168 CMM patients and 176 matched controls. Measurements were performed at the forehead, the upper chest, the upper back, the lateral and medial aspects of the upper arm, and the buttocks. Self-estimation of sun exposure in childhood, in youth and in adulthood was performed by all subjects. There were no statistically significant differences in constitutive skin pigmentation at the buttocks between BCC patients and controls (P = 0.96) or between CMM patients and controls (P = 0.13). Facultative skin pigmentation in ultraviolet-exposed sites was not significantly different between BCC patients and controls except that women patients had higher pigmentation at the lateral side of the upper arm. For CMM, men patients had higher pigmentation at the lateral side of the upper arm. Self-estimations of sun exposure did not show differences between patients and controls but indicated high exposure levels in childhood and youth and in adult leisure time. Sun exposure estimated by increase in facultative pigmentation above the constitutive level (the Sun Exposure Index) was not significantly different between BCC patients and controls, whereas CMM men patients had higher estimates for the lateral side of the upper arm, the chest and the back.

Episodes of intense sun exposure, particularly in childhood, seem to carry a risk for the development of malignant melanoma in later life. However, little is known about photosensitivity and natural photoprotection in children. In adult subjects, photoprotection is provided mainly by the epidermal content of melanin and the thickness of the stratum corneum, while the amount of urocanic acid (UCA), a major ultraviolet-absorbing component of the stratum corneum, is not thought to contribute significantly to photoprotection. The minimal erythema dose (MED) was determined in 22 healthy children aged 6-13 years and in 36 healthy adults (mean age 28.1 years). Pigmentation was measured at six body sites by use of reflectance spectroscopy and the concentration of UCA isomers was measured in a sun-exposed area (upper back) and in unexposed buttock skin. No significant differences between children and adults were found, either in pigmentation at exposed and unexposed body sites, or in MED. The concentration of total UCA was significantly higher in the children than in the adults on the buttock (median 22.2 vs. 13.6 nmol/cm2), but not on the back. On exposed back skin, the children had a significantly higher percentage of cis-UCA than the adults (median 60.1 vs. 28.3%), while no difference was found on the buttock. In both groups, a significant correlation was found between pigmentation and MED (children: Spearman correlation coefficient 0. 58, P = 0.006; adults: Spearman correlation coefficient 0.69, P0. 0001), indicating that pigmentation is of major importance in determining photosensitivity in children as well as in adults. The concentration of total UCA did not correlate with the MED in either group.

To determine the evidence base for routine therapeutic decisions in dermatologic out-patients.A retrospective review of a random sample of primary therapy and literature.University hospital, dermatologic out-patient clinic in CopenhagenA random sample of the case notes from 115 out-patients.The evidence base of therapy prescribed when the diagnosis was ascertained was studied in literature searches in MEDLINE and EMBASE. Evidence was structured into primary evidence consisting of randomized controlled trials, and secondary evidence consisting of follow-up studies or the application of trial results between diseases with pathogenic or clinical similarities, e.g. atopic and seborrheic dermatitis.Randomized controlled trials could be found describing 38% (95% confidence interval: 30-47) of all treatments. Secondary evidence was found for 33% (24-41), while no evidence was found for 23% (16-31) of the given treatments.Approximately three-quarters of dermatologic out-patient therapy is based on scientific evidence ranging from randomized controlled trials to logical deduction from analogous clinical situations. The proportion of evidence-based medicine in dermatologic therapy therefore appears to be comparable with that of internal medicine and may thus be above expectations.

To investigate the presence of melanin and melanocytes (MC) in stable vitiligo, skin biopsies from five patients with vitiligo lesions of between 1 to 17 years duration were examined under the electron microscope. Areas of the upper dermis and epidermis were explored. There was a significant amount of melanin in a few keratinocytes (KC) grouped in the stratum basale in 1-3 year-old vitiligo lesions. In these KC, the melanosomes were most often aggregated into melanosome complexes (MCo) while the remaining KC were completely devoid of melanin. Solitary MCo were also observed in a few dermal cells in all vitiligo biopsies. All non-keratinocytes were scrutinized in series of 200-300 consecutive sections and were identified according to morphological characteristics. Neither active nor inactive MC, nor MC dendrites were found. These observations show that melanin in non-negligible amounts can be found even in 3 year-old vitiligo epidermis. Since there were no MC detected in the epidermis it implies that the melanosomes can persist in certain KC for some time after the onset of vitiligo.

The lack of standard systems for assessment of disease severity poses a problem for the introduction of rational quality control in dermatology. The scoring systems often involve assessment of the same aspects of disease, and it may therefore be conceivable that one system could potentially be applied to routine clinical work and form the basis of disease quantification in dermatology. This study was undertaken to compare PASI (Psoriasis Area and Severity Index) and SCORAD (SCOring index of Atopic Dermatitis) scoring systems, to assess disease severity in patients with atopic dermatitis and psoriasis. Patients with psoriasis (14) and atopic dermatitis (14) were scored with both systems, and correlation coefficients and multiple regression coefficients were calculated. A significant correlation between SCORAD and PASI was found (rs = 0.66). Correlation coefficients were highest (rs = 0.87) when only atopic patients were studied, and lowest (rs = 0.57) when only psoriatic patients were studied. Assessments of area and erythema are suggested as candidates for a generalised scoring systems for dermatological disease. The results suggest that in spite of the overlap between the two score systems, significant diagnosis-specific differences exist, and neither PASI nor SCORAD is an optimal general dermatological scoring system for disease severity. Additional methodological developments are necessary.

We measured skin pigmentation by skin reflectance monthly from May 1992 to April 1993 in 36 healthy Caucasians. Pigmentation was measured at four UV-exposed sites at the forehead, the upper chest, the inside of the upper arm, and at the upper back. The pigmentation and UV sensitivity were simultaneously measured at UV-protected buttock skin. The results showed a considerable seasonal variation for skin pigmentation at the UV-exposed sites. Buttock skin had a pigmentation and UV sensitivity that varied only marginally. We recommend that measurements of genetically controlled skin pigmentation and constitutive UV sensitivity should be performed at UV-unexposed skin on the buttocks, except in persons that expose this site to artificial or natural sunlight.

Epidermal melanin is a limiting factor for obtaining beneficial results in dermatological treatment of vascular malformations. The aim of our study was to predict the highest laser intensity and energy fluence which can be applied to skin with different degrees of pigmentation before side effects are induced.Thirteen human volunteers with different degrees of skin pigmentation were laser-treated on the inside of the brachium with an argon laser (AL, 488 nm and 514.5 nm) and a copper vapor laser (CVL, 578 nm), both connected to a Hexascan. Three input intensities were used. 0.7, 1.0, and 1.3 W. Pulse duration was kept constant at 200 msec, resulting in hexascan fluences of 14.1, 20.2, and 26.2 J/cm2. At the 6-month assessment it was noted whether pigmentary changes or scarring were clinically absent or present. The results were analysed by logistic regression.We found that pretreatment pigmentation percentage and laser intensity were significant risk factors of inducing side effects (P.001), whereas it was without significant importance whether the AL or the CVL was used (P.05). Contour lines of 1, 2.5, 5, 10, 25, and 50% risk levels of inducing clinically recognizable pigmentary changes and scarring were calculated. Pigmentary changes occurred at a significantly lower intensity level than skin texture changes (P = .006).On basis of our results, we recommend assessment of skin pigmentation prior to laser treatment with the CVL and the AL, and we recommend that the illustrated risk levels are taken into consideration.

Pigmentation, stratum corneum and viable epidermis are considered to be the main factors protecting against ultraviolet radiation. We quantitatively investigated the degree of photoprotection provided by these structures in vitiligo and adjacent normally pigmented skin. In 14 patients 61 MED tests were performed in vitiligo and adjacent normally pigmented skin using a solar simulator. The thickness of stratum corneum and viable epidermis was determined from frozen skin sections, and pigmentation was calculated by measuring skin reflectance at 555 nm and 660 nm. To analyse photoprotection, the UV dose necessary to evoke erythema was regressed against the thickness of stratum corneum and viable epidermis, pigmentation and the erythema grade in the MED test. By analysing regression coefficients we found that stratum corneum was the main photoprotective factor not only in vitiligo but also in normally pigmented skin. The effect of pigmentation in normal skin was slightly less prominent. Stratum corneum was thicker in vitiligo than in normally pigmented skin. However, the photoprotection due to stratum corneum was similar in both groups because significantly less photoprotection was achieved per thickness unit of stratum corneum in vitiligo than in normal skin. Neither in vitiligo nor in normally pigmented skin did the photoprotection depend on viable epidermis. Our data quantitatively document the importance of stratum corneum and pigmentation. Hyperkeratosis in vitiligo offers just as efficient photoprotection as does the normal stratum corneum in pigmented skin.

Three patients with cheilitis were successfully treated by photodynamic therapy using the topical application of 5-aminolevulinic acid (ALA), followed by irradiation with incoherent visible light. The three patients had had, for several years, disabling lesions on the lower lip, and histopathological examination showed dysplastic lesions without signs of carcinoma. Conventional treatments were ineffective. During photodynamic therapy, all patients reported a burning sensation when irradiated at the ALA treated area, diminishing immediately after removal of the light source, and vanishing within 4 days after treatment. Superficial peeling began 4 days after treatment, and lasted some months. Follow-up, after 6 and 12 months, did not reveal any sign of recurrence.

A 48-year-old, uncircumcised man presented with plasma cell balanitis, which is a chronic, erosive dermatitis at the glans penis and the inner surface of the prepuce, which is normally treated by circumcision. He was treated with three sessions of copper vapour laser over a period of three months and apart from a minor relapse after seven months he has to our knowledge been well.

The melanogenic potential of multiple suberythemogenic doses of 6 different ultraviolet (UV) sources was investigated. The UV sources emitted different amounts of UVA and UVB. The backs of 12 volunteers were exposed to the 6 UV sources 10 times during 4 weeks. Every volunteer was exposed to the same suberythemogenic dose (0.75 basic minimal erythema dose) of each of the UV sources. The changes in pigmentation and minimal erythema dose of the UV exposed test sites were registered during the 10 sessions. Three UVA sources with a low emission in the UVB area (0.2-3.1%) had a high melanogenic potential. Two UVB sources (UVB emission 74.3% and 94.5%) were unable to induce a significant increase in skin pigmentation. The 3 UVA sources with a low UVB output increased skin pigmentation significantly better than a UVA source with a UVB output of 6.9%. All 6 lamps were able to increase photoprotection significantly. The increase in photoprotection was not significantly different between any of the 6 UV sources. This study shows that, if humans are exposed to equally suberythemogenic doses of different types of UV radiation, then radiation obtained from UVA sources greatly enhances melanogenesis, whereas UVB radiation sources are unable to induce pigmentation.

Twenty-eight subjects were phototested to determine their erythemal responses to oral methoxsalen with UV-A and UV-B irradiation. Skin pigmentation was measured by skin reflectance at 550 and 660 nm before irradiation. The smallest UV radiation dose to produce erythema (minimal phototoxic dose and minimal erythema dose, respectively) was determined. The serum concentration of methoxsalen was measured at the time of UV-A irradiation.There was a positive correlation between skin pigmentation and both 72-hour minimal phototoxic dose and 24-hour minimal erythema dose. No correlation was demonstrated between methoxsalen serum concentration and minimal phototoxic dose. The combination of skin pigmentation and methoxsalen level did not give a better prediction of minimal phototoxic dose than skin pigmentation alone.Skin pigmentation measurements can be used to predict the minimal phototoxic and erythema doses. Skin pigmentation measurements are easy to perform and should be included in both phototherapy and photochemotherapy to improve the efficiency and reliability of the treatment.

The effect of solar exposure during a one-week sunbathing vacation in May at 29 degrees N latitude was investigated in 22 volunteers. The following end-points were measured before and after the holiday: skin reflectance at 507 nm, transmission of radiation from 289 nm to 448 nm through the epidermis, epidermal thickness, minimal erythema dose (MED), total white cell, neutrophil, lymphocyte, and lymphocyte subpopulation counts in blood, spontaneous DNA synthesis, DNA strand breaks and sister-chromatid exchange in lymphocytes, and the UVC tolerance of lymphocytes. There was a statistically significant decrease in skin reflectance (p0.001) and epidermal transmission (p0.01) after the holiday, reflecting increased pigmentation and epidermal thickening. There was a statistically significant increase in epidermal thickness (p0.001), MED (p0.05), spontaneous DNA synthesis (p0.01) and DNA strand breaks in lymphocytes (p0.02) after the holiday. The other end-points were not significantly changed. We report that changes in skin pigmentation and epidermal thickness occur after one week of UV exposure. It was also observed that a one-week UV exposure increased both spontaneous DNA repair and the amount of DNA strand breaks in the lymphocytes of the volunteers, while no changes in T-cell subsets were detected.

Chromosome analysis of lymphocytes from the peripheral blood of 20 patients with sarcoidosis and 10 healthy controls showed a significantly greater number of hypomodal cells among the patients. Two patients receiving systemic treatment with glucocorticoids had many chromosomal aberrations.

Sister chromatid exchanges (SCE) and sister chromatid exchange points (SCE-points) were counted in lymphocytes in peripheral blood drawn from hospital personnel exposed to anaesthetics as well as from persons not exposed. A total of 38 healthy persons were investigated, representing female nurse anaesthetists, male physicians practising anaesthesia, female nurses from the intensive care unit, and female secretaries. The mean SCE number per cell for each person was used as the variable, and the Mann-Whitney U-test was applied to test for differences between groups. The group of secretaries seemed to differ from the other three groups, which appeared identical (P