Polymorphous Light Eruption Clinical Presentation

  • Author: Noah S Scheinfeld, MD, JD, FAAD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jul 27, 2011
 

History

Polymorphous light eruption (PMLE) tends to manifest in the spring.[17] In addition, PMLE is a recurrent condition and patients state they have had the eruption before and that it went away as time passed.

  • Sunlight is clearly the primary etiologic factor for PMLE.
    • The eruption of PMLE typically occurs in spring or, rarely, in winter following ultraviolet radiation exposure reflected from snow.
    • Typically, the lesions of PMLE first erupt at the onset of a vacation in a sunny place or at a high altitude and disappear by the time the patient returns home.
    • The eruption decreases in severity as the summer progresses.
  • The onset of the disease is sudden. The accompanying rash is pruritic and, in some instances, painful.
    • Thirty minutes to several hours of exposure are required to trigger the eruption.
    • Sun-exposed skin, especially that normally covered in winter (eg, upper chest, arms), is primarily affected, but autosensitization may lead to a generalized involvement.
    • The rash appears within hours to days of exposure, and it subsides over the next 1-7 days without scarring.
    • Most patients have associated pruritus, but some patients describe stinging and pain.
  • Occasionally, patients experience systemic flulike symptoms after sun exposure.
  • Unless severe and particularly bothersome, many patients do not visit a physician for PMLE rash. It is often discovered incidentally.
  • Jansen traced the natural history of chronic PMLE in 138 people, 85 of whom were female.[18] Their mean age was 26.4 years. The length of time in the study was 10.5 years. In 57% of cases, the PMLE happened in a rapid fashion. It started in a small photoexposed area in 88% of cases, and extended to a greater area each year. Light sensitivity tended to increase with each subsequent year. The patients’ threshold tolerance to solar radiation occurred 30 minutes after exposure in ≤ 60% of patients. In 50% of patients, yearly hardening phenomena occurred. Ocular and oral involvement occurred in 46% and 49% of the patients, respectively. About 66% patients experienced some general symptoms after solar radiation exposure.
  • Majoie et al in 2010 noted PMLE-like skin lesions in welders caused by ultraviolet C light.[19]
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Physical

As the name implies, clinical manifestations of polymorphous light eruption (PMLE) vary. Many different morphologies may appear on sun-exposed areas, but, usually only one morphology dominates in a given individual.

  • Papules (greatest incidence), plaques, papulovesicles, and erythema multiforme–like lesions are the most common morphologies. Photosensitive erythema multiforme and erythema multiforme–like PMLE can be difficult to distinguish clinically. Combined morphological types of lesions, while uncommon, do occur. For example, the small papular variety may coalesce to form an eczematous type and large papular lesions may produce plaques or assume an annular configuration. Note the images below. Papular variant of polymorphous light eruption. Papular variant of polymorphous light eruption. Large facial plaques. Large facial plaques.
  • Sun-exposed skin, especially that normally covered in winter (eg, upper chest, arms), is affected primarily, but autosensitization may lead to a generalized involvement.
  • Cheilitis is uncommon in patients in the United States. In such patients, the rare diagnosis of actinic prurigo is a more likely cause of the inflammatory photosensitivity disorder. Cheilitis often occurs in the tropics and, when this is the case, can be the only manifestation of the PMLE. That is, it can manifest without involvement of the extremities, face, or torso. In the case of photosensitive cheilitis, PMLE must be distinguished from chronic actinic cheilitis and the eczematous cheilitis produced by photosensitizing agents.
  • In African Americans, a variant of PMLE with pinpoint papules (1-2 mm) can be observed on sun-exposed areas, sparing the face and flexural surfaces.[20]
  • Pinpoint papular PMLE has been described in a series from Singapore.[21]
  • A 2010 study by Gronhagen et al reported on the importance of differentiating systemic lupus and cutaneous lupus erythematosus from PMLE. In this study, 23% of 260 systemic lupus erythematosus patients had cutaneous lupus erythematosus, and a history of PMLE was found in 42%.[22]
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Causes

Although most authorities now consider UV-A light as the causative factor in polymorphous light eruption (PMLE) eruption, UV-B, or even visible light, may be responsible in some individuals. PMLE-like lesions have been reported in welders, resulting from exposure to UV-C light.[19]

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Contributor Information and Disclosures
Author

Noah S Scheinfeld, MD, JD, FAAD  Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, and New York Eye and Ear Infirmary; Private Practice

Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

Sophie Shirin, MD  Consulting Staff, Global Dermatology

Sophie Shirin, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Raul Del Rosario, MD  Consulting Staff, Dermatopathology, Mission Hospital at Laguna Beach

Raul Del Rosario, MD is a member of the following medical societies: American Society for Clinical Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Craig A Elmets, MD  Professor and Chair, Department of Dermatology, Director, UAB Skin Diseases Research Center, University of Alabama at Birmingham School of Medicine

Craig A Elmets, MD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, American College of Physicians, American Federation for Medical Research, and Society for Investigative Dermatology

Disclosure: Palomar Medical Technologies Stock None; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor; UpToDate Salary Employment; Biogen Grant/research funds Independent contractor; Clinuvel Independent contractor; Covan Basilea Pharmaceutical Grant/research funds Independent contractor; ISDIN None Consulting; TenX BIopharma Grant/research funds Independent contractor

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD  Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Consulting fee Consulting; Celgene Honoraria Safety Monitoring Committee; GSK - Glaxo Smith Kline Consulting fee Consulting; TenXBioPharma Consulting fee Safety Monitoring Committee

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Dr. Ada Winkielman, to the development and writing of this article.

References

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The face of a patient with polymorphous light eruption. Note the erythema and an indurated plaque.
Close-up view of polymorphous light eruption plaque.
Papular variant of polymorphous light eruption.
Large facial plaques.
Histopathologic features of polymorphous light eruption. Note the tight perivascular lymphocytic infiltrate in the upper dermis.
Close-up view of the perivascular infiltrate.
Photograph of a springtime eruption of polymorphous light eruption in a 6-year-old boy. The eruption has occurred in the spring since the patient was aged 5 years, and it resolves completely with no scarring by mid to late summer. High block sunscreens attenuate but do not prevent the eruption. No itching or pain occurs. Courtesy of Jeremy F. Harrison, FRCA, FFAEM.
 
 
 
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