Polymorphous light eruption
- Craig A Elmets, MD
Craig A Elmets, MD
- Section Editor — Photodermatology
- Professor and Chair of Dermatology
- University of Alabama at Birmingham
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — Dermatology
- Professor of Dermatology and Public Health
- University of Colorado School of Medicine
- Colorado School of Public Health
- Chief, Dermatology Service
- US Department of Veterans Affairs
- Eastern Colorado Health Care System
- Jeffrey Callen, MD, FACP, FAAD
Jeffrey Callen, MD, FACP, FAAD
- Editor-in-Chief — Dermatology
- Section Editor — Skin and Systemic Disease
- Professor of Medicine
- University of Louisville School of Medicine
Polymorphous light eruption (PMLE) is the most common idiopathic photodermatosis; it is sometimes called "sun poisoning" or "sun allergy." PMLE usually presents as a pruritic rash in sun-exposed areas hours to days after sun exposure and persists for several days before subsiding. Juvenile spring eruption is a variant of PMLE. (See 'Juvenile spring eruption (PMLE variant)' below.)
An overview of cutaneous photosensitivity and a review of other photodermatoses are presented separately. (See "Overview of cutaneous photosensitivity: Photobiology, patient evaluation, and photoprotection" and "Photosensitivity disorders (photodermatoses): Clinical manifestations, diagnosis, and treatment".)
The onset of polymorphous light eruption (PMLE) typically occurs within the first three decades of life, and a female preponderance is reported [1,2]. Fair-skinned individuals are the most commonly affected, although PMLE can develop in individuals of all ethnicities and skin types . It occurs more frequently in temperate areas. Several studies have indicated that the prevalence of PMLE is directly related to the latitude, ranging from 1 percent in Singapore to 20 percent in Sweden [1,2,4-6].
Both ultraviolet A (UVA) and ultraviolet B (UVB) radiation, and occasionally visible light, have been implicated in the development of polymorphous light eruption (PMLE) . In most studies, a higher proportion of patients develops the disease in response to UVA than UVB . The eruption may be influenced by the dose and frequency of the UV radiation as well as by the extent and site of irradiated skin . PMLE occurring after exposure to UVC radiation generated from welding arcs has been reported . (See "Overview of cutaneous photosensitivity: Photobiology, patient evaluation, and photoprotection", section on 'Phototesting'.)
Patients with PMLE appear to have a genetic susceptibility, as evidenced by increased concordance in monozygotic twins . In addition, a positive family history is present in 15 to 46 percent of cases [4,11]. Genetic modeling of PMLE in families with photosensitivity disorders suggests a dominant mode of inheritance with low penetrance . No gene locus has been associated with PMLE. Candidate gene analysis has been inconclusive despite investigating IL-10, FCGR2A, SELE, ICAM-1, IL1-alpha, IL1-beta, IL1RN, and TNF-alpha .
- Morison WL, Stern RS. Polymorphous light eruption: a common reaction uncommonly recognized. Acta Derm Venereol 1982; 62:237.
- Hönigsmann H. Polymorphous light eruption. Photodermatol Photoimmunol Photomed 2008; 24:155.
- Stratigos AJ, Antoniou C, Katsambas AD. Polymorphous light eruption. J Eur Acad Dermatol Venereol 2002; 16:193.
- Ros AM, Wennersten G. Current aspects of polymorphous light eruptions in Sweden. Photodermatol 1986; 3:298.
- Pao C, Norris PG, Corbett M, Hawk JL. Polymorphic light eruption: prevalence in Australia and England. Br J Dermatol 1994; 130:62.
- Khoo SW, Tay YK, Tham SN. Photodermatoses in a Singapore skin referral centre. Clin Exp Dermatol 1996; 21:263.
- Boonstra HE, van Weelden H, Toonstra J, van Vloten WA. Polymorphous light eruption: A clinical, photobiologic, and follow-up study of 110 patients. J Am Acad Dermatol 2000; 42:199.
- Hölzle E, Plewig G, Hofmann C, Roser-Maass E. Polymorphous light eruption. Experimental reproduction of skin lesions. J Am Acad Dermatol 1982; 7:111.
- Majoie IM, van Weelden H, Sybesma IM, et al. Polymorphous light eruption-like skin lesions in welders caused by ultraviolet C light. J Am Acad Dermatol 2010; 62:150.
- Millard TP, Bataille V, Snieder H, et al. The heritability of polymorphic light eruption. J Invest Dermatol 2000; 115:467.
- Guarrera M, Micalizzi C, Rebora A. Heterogeneity of polymorphous light eruption: a study of 105 patients. Arch Dermatol 1993; 129:1060.
- McGregor JM, Grabczynska S, Vaughan R, et al. Genetic modeling of abnormal photosensitivity in families with polymorphic light eruption and actinic prurigo. J Invest Dermatol 2000; 115:471.
- Millard TP, Kondeatis E, Cox A, et al. A candidate gene analysis of three related photosensitivity disorders: cutaneous lupus erythematosus, polymorphic light eruption and actinic prurigo. Br J Dermatol 2001; 145:229.
- Hönigsmann H, Hojyo-Tomoka MT. Polymorphous light eruption, hydroa vacciniforme, and actinic prurigo. In: Photodermatology, Lim HW, Hönigsmann H, Hawk JLM (Eds), CRC Press, 2007.
- Norris PG, Morris J, McGibbon DM, et al. Polymorphic light eruption: an immunopathological study of evolving lesions. Br J Dermatol 1989; 120:173.
- Gruber-Wackernagel A, Byrne SN, Wolf P. Polymorphous light eruption: clinic aspects and pathogenesis. Dermatol Clin 2014; 32:315.
- Kölgen W, van Meurs M, Jongsma M, et al. Differential expression of cytokines in UV-B-exposed skin of patients with polymorphous light eruption: correlation with Langerhans cell migration and immunosuppression. Arch Dermatol 2004; 140:295.
- van de Pas CB, Kelly DA, Seed PT, et al. Ultraviolet-radiation-induced erythema and suppression of contact hypersensitivity responses in patients with polymorphic light eruption. J Invest Dermatol 2004; 122:295.
- Kölgen W, Van Weelden H, Den Hengst S, et al. CD11b+ cells and ultraviolet-B-resistant CD1a+ cells in skin of patients with polymorphous light eruption. J Invest Dermatol 1999; 113:4.
- Palmer RA, Friedmann PS. Ultraviolet radiation causes less immunosuppression in patients with polymorphic light eruption than in controls. J Invest Dermatol 2004; 122:291.
- Schweintzger N, Gruber-Wackernagel A, Reginato E, et al. Levels and function of regulatory T cells in patients with polymorphic light eruption: relation to photohardening. Br J Dermatol 2015; 173:519.
- Reddy H, Carmichael AJ, Wahie S. Severity of polymorphic light eruption in pre- and post-menopausal women: a comparative study. J Eur Acad Dermatol Venereol 2015; 29:97.
- Hiramoto K, Tanaka H, Yanagihara N, et al. Effect of 17beta-estradiol on immunosuppression induced by ultraviolet B irradiation. Arch Dermatol Res 2004; 295:307.
- Rivers JK, Norris PG, Murphy GM, et al. UVA sunbeds: tanning, photoprotection, acute adverse effects and immunological changes. Br J Dermatol 1989; 120:767.
- Kontos AP, Cusack CA, Chaffins M, Lim HW. Polymorphous light eruption in African Americans: pinpoint papular variant. Photodermatol Photoimmunol Photomed 2002; 18:303.
- Chiam LY, Chong WS. Pinpoint papular polymorphous light eruption in Asian skin: a variant in darker-skinned individuals. Photodermatol Photoimmunol Photomed 2009; 25:71.
- Isedeh P, Lim HW. Polymorphous light eruption presenting as pinhead papular eruption on the face. J Drugs Dermatol 2013; 12:1285.
- Dover JS, Hawk JL. Polymorphic light eruption sine eruption. Br J Dermatol 1988; 118:73.
- Molina-Ruiz AM, Sanmartín O, Santonja C, et al. Spring and summer eruption of the elbows: a peculiar localized variant of polymorphous light eruption. J Am Acad Dermatol 2013; 68:306.
- Janssens AS, Pavel S, Out-Luiting JJ, et al. Normalized ultraviolet (UV) induction of Langerhans cell depletion and neutrophil infiltrates after artificial UVB hardening of patients with polymorphic light eruption. Br J Dermatol 2005; 152:1268.
- Wolf P, Gruber-Wackernagel A, Bambach I, et al. Photohardening of polymorphic light eruption patients decreases baseline epidermal Langerhans cell density while increasing mast cell numbers in the papillary dermis. Exp Dermatol 2014; 23:428.
- Hawk JLM, Calonje E. The photosensitivity disorders. In: Lever's Histopathology of the Skin,, 9th ed, Elder DE (Ed), Lippincott Williams and Wilkins, Philadelphia 2005. p.365.
- Proby CM, Baker CS, Morton O, Hawk JL. New broad-spectrum sunscreen for polymorphic light eruption. Lancet 1993; 341:1347.
- Allas S, Lui H, Moyal D, Bissonnette R. Comparison of the ability of 2 sunscreens to protect against polymorphous light eruption induced by a UV-A/UV-B metal halide lamp. Arch Dermatol 1999; 135:1421.
- Fourtanier A, Moyal D, Seité S. Sunscreens containing the broad-spectrum UVA absorber, Mexoryl SX, prevent the cutaneous detrimental effects of UV exposure: a review of clinical study results. Photodermatol Photoimmunol Photomed 2008; 24:164.
- DeLeo VA, Clark S, Fowler J, et al. A new ecamsule-containing SPF 40 sunscreen cream for the prevention of polymorphous light eruption: a double-blind, randomized, controlled study in maximized outdoor conditions. Cutis 2009; 83:95.
- Bissonnette R, Nigen S, Bolduc C. Influence of the quantity of sunscreen applied on the ability to protect against ultraviolet-induced polymorphous light eruption. Photodermatol Photoimmunol Photomed 2012; 28:240.
- Marini A, Jaenicke T, Grether-Beck S, et al. Prevention of polymorphic light eruption by oral administration of a nutritional supplement containing lycopene, β-carotene, and Lactobacillus johnsonii: results from a randomized, placebo-controlled, double-blinded study. Photodermatol Photoimmunol Photomed 2014; 30:189.
- Tanew A, Radakovic S, Gonzalez S, et al. Oral administration of a hydrophilic extract of Polypodium leucotomos for the prevention of polymorphic light eruption. J Am Acad Dermatol 2012; 66:58.
- Fabrikant J, Touloei K, Brown SM. A review and update on melanocyte stimulating hormone therapy: afamelanotide. J Drugs Dermatol 2013; 12:775.
- Biolcati G, Marchesini E, Sorge F, et al. Long-term observational study of afamelanotide in 115 patients with erythropoietic protoporphyria. Br J Dermatol 2015; 172:1601.
- Ling TC, Gibbs NK, Rhodes LE. Treatment of polymorphic light eruption. Photodermatol Photoimmunol Photomed 2003; 19:217.
- Addo HA, Sharma SC. UVB phototherapy and photochemotherapy (PUVA) in the treatment of polymorphic light eruption and solar urticaria. Br J Dermatol 1987; 116:539.
- Bilsland D, George SA, Gibbs NK, et al. A comparison of narrow band phototherapy (TL-01) and photochemotherapy (PUVA) in the management of polymorphic light eruption. Br J Dermatol 1993; 129:708.
- Murphy GM, Logan RA, Lovell CR, et al. Prophylactic PUVA and UVB therapy in polymorphic light eruption--a controlled trial. Br J Dermatol 1987; 116:531.
- Berg M, Ros AM, Berne B. Ultraviolet A phototherapy and trimethylpsoralen UVA photochemotherapy in polymorphous light eruption--a controlled study. Photodermatol Photoimmunol Photomed 1994; 10:139.
- Man I, Dawe RS, Ibbotson SH, et al. Is topical steroid effective in polymorphic light eruption. Br J Dermatol 2000; 143 (Suppl 57):113.
- Gruber-Wackernagel A, Bambach I, Legat FJ, et al. Randomized double-blinded placebo-controlled intra-individual trial on topical treatment with a 1,25-dihydroxyvitamin D₃ analogue in polymorphic light eruption. Br J Dermatol 2011; 165:152.
- Patel DC, Bellaney GJ, Seed PT, et al. Efficacy of short-course oral prednisolone in polymorphic light eruption: a randomized controlled trial. Br J Dermatol 2000; 143:828.
- Murphy GM, Hawk JL, Magnus IA. Hydroxychloroquine in polymorphic light eruption: a controlled trial with drug and visual sensitivity monitoring. Br J Dermatol 1987; 116:379.
- Pareek A, Khopkar U, Sacchidanand S, et al. Comparative study of efficacy and safety of hydroxychloroquine and chloroquine in polymorphic light eruption: a randomized, double-blind, multicentric study. Indian J Dermatol Venereol Leprol 2008; 74:18.
- Shipley DR, Hewitt JB. Polymorphic light eruption treated with cyclosporin. Br J Dermatol 2001; 144:446.
- Norris PG, Hawk JL. Successful treatment of severe polymorphous light eruption with azathioprine. Arch Dermatol 1989; 125:1377.
- Jansén CT, Karvonen J. Polymorphous light eruption. A seven-year follow-up evaluation of 114 patients. Arch Dermatol 1984; 120:862.
- ANDERSON D, WALLACE HJ, HOWES EI. Juvenile spring eruption. Lancet 1954; 266:755.
- Tan E, Eberhart-Phillips J, Sharples K. Juvenile spring eruption: a prevalence study. N Z Med J 1996; 109:293.
- Berth-Jones J, Norris PG, Graham-Brown RA, et al. Juvenile spring eruption of the ears: a probable variant of polymorphic light eruption. Br J Dermatol 1991; 124:375.
- Stratigos AJ, Antoniou C, Papadakis P, et al. Juvenile spring eruption: clinicopathologic features and phototesting results in 4 cases. J Am Acad Dermatol 2004; 50:S57.
- Lava SA, Simonetti GD, Ragazzi M, et al. Juvenile spring eruption: an outbreak report and systematic review of the literature. Br J Dermatol 2013; 168:1066.
- CLINICAL MANIFESTATIONS
- Skin hardening effect
- Differential diagnosis
- Preventive measures
- - Sun protection
- - Systemic photoprotection
- - Photohardening
- - Other
- - Patients with mild to moderate eruption
- - Patients with severe eruption
- JUVENILE SPRING ERUPTION (PMLE VARIANT)
- SUMMARY AND RECOMMENDATIONS