eMedicine Specialties > Dermatology > Photo-Related Diseases

Polymorphous Light Eruption: Differential Diagnoses & Workup

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Coauthor(s): Sophie Shirin, MD, Consulting Staff, Global Dermatology; Raul Del Rosario, MD, Consulting Staff, Surgical Pathology and Dermatopathology, South Coast Medical
Contributor Information and Disclosures

Updated: Oct 23, 2009

Differential Diagnoses

Contact Dermatitis, Allergic
Lupus Erythematosus, Subacute Cutaneous

Other Problems to Be Considered

Some physicians regard actinic prurigo as a distinct photodermatosis, and other physicians consider it an insidiously developing, markedly excoriated variant of polymorphous light eruption (PMLE). Actinic prurigo is characterized by a high incidence of atopy and family predisposition. It is likely to involve the covered skin.

Chronic actinic dermatitis is a term that encompasses several syndromes previously considered separate entities (ie, actinic reticuloid, persistent light reactivity, photosensitive eczema, photosensitivity dermatitis), but, now, they are considered to be variants of the same condition. Clinically, lesions are usually more eczematous and infiltrated than in PMLE and involve mostly exposed skin, but they may generalize to erythroderma. The actinic reticuloid form of chronic actinic dermatitis has a histologic pattern that resembles cutaneous lymphoma, with CD8+ cells predominating. The minimal erythema dose (MED) to UV-B, and sometimes UV-A, is reduced.
Solar urticaria represents an immediate hypersensitivity response to UV radiation. Characteristic whealing may be accompanied by systemic symptoms of faintness, nausea, and bronchospasm.

Workup

Laboratory Studies

  • In polymorphous light eruption (PMLE), laboratory tests are generally performed to rule out other dermatoses, such as erythropoietic protoporphyria or lupus erythematosus. Antinuclear antibody (ANA), anti-Ro (SS-A), and anti-La (SS-B) tests, as well as urine, stool, and blood porphyrin levels, should be obtained.17
  • The diagnosis of PMLE is usually based on the clinical picture. Normal titers of ANA, as well as normal urine, stool, and blood porphyrin levels, support the diagnosis.

Other Tests

  • Results of phototesting in polymorphous light eruption (PMLE) patients are controversial, ranging from an ability to reproduce the eruption by repeat phototesting in 60-100% of patients to an inability to do so except in patients who are very photosensitive.18 These differences may be explained by a lack of a standardized test procedures, variation in radiation sources used, and imprecision in diagnostic criteria for the disease.
  • Perform phototests with UV-A, UV-B, and visible light sources.
    • Determine the MED from these sources. MEDs are normal in PMLE and lowered or abnormal in chronic actinic dermatitis. In solar urticaria, irradiation results in reproduction of the lesion.
    • Perform repetitive light testing; irradiating 3 times the MED to UV-A on the right forearm and 3 times the MED to UV-B on the left forearm for 3 consecutive days. Results are read immediately, at 24 and 72 hours. A delayed reading at 1 week may also be helpful.
    • The test results are often positive in PMLE. A negative result does not exclude the diagnosis.
    • If a lesion (eg, papule, vesicle) develops, biopsy confirmation is suggested.
    • Histologically, a superficial and deep perivascular lymphocytic infiltrate will be apparent with dermal edema.
  • Photopatch tests to rule out a photoallergic or airborne contact dermatitis should be performed.
    • Two identical strips of standard photoallergens are placed on the back. One of the two strips is exposed to UV-A radiation 24 hours later. Both the irradiated site and the unirradiated site are read at 24, 48, and 96 hours.
    • A positive reaction at the irradiated site but not at the unirradiated patch test site is diagnostic of a photocontact allergy. Positive reactions at both the irradiated site and the unirradiated site are indicative of a contact allergy.
    • According to Leroy et al in 2002, polychromatic phototesting seems to be more sensitive than UV-A phototesting to assess PMLE, and results suggest UV-B is a key trigger of PMLE.19

Histologic Findings

The most striking feature of the biopsy specimen from a patient with polymorphous light eruption (PMLE) is edema in the upper part of the dermis. Tight, perivascular lymphocytic infiltrate is observed in the upper and mid dermis. When eczematous epidermal changes are present clinically, spongiosis, edema, dyskeratosis, and basal cell vacuolization may be observed. Occasionally, neutrophils and eosinophils may be present in the infiltrate. The dominant cell, however, is the lymphocyte.

Histopathologic features of polymorphous light er...

Histopathologic features of polymorphous light eruption. Note the tight perivascular lymphocytic infiltrate in the upper dermis.

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Histopathologic features of polymorphous light er...

Histopathologic features of polymorphous light eruption. Note the tight perivascular lymphocytic infiltrate in the upper dermis.


Close-up view of the perivascular infiltrate.

Close-up view of the perivascular infiltrate.

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Close-up view of the perivascular infiltrate.

Close-up view of the perivascular infiltrate.


More on Polymorphous Light Eruption

Overview: Polymorphous Light Eruption
Differential Diagnoses & Workup: Polymorphous Light Eruption
Treatment & Medication: Polymorphous Light Eruption
Follow-up: Polymorphous Light Eruption
Multimedia: Polymorphous Light Eruption
References
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References

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Further Reading

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Keywords

polymorphous light eruption, polymorphic light eruption, PLE, PMLE rash, idiopathic photodermatosis, reaction to sunlight, ultraviolet radiation exposure, UV-R exposure, erythema multiforme–like lesions

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Contributor Information and Disclosures

Author

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, 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, Surgical Pathology and Dermatopathology, South Coast Medical
Raul Del Rosario, MD is a member of the following medical societies: American Society for Clinical Pathology
Disclosure: Nothing to disclose.

Medical Editor

Craig A Elmets, MD, Director of Dermatology, Departments of Dermatology, Pathology, and Environmental Health Sciences; Professor, The Kirklin Clinic, University of Alabama at Birmingham
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; Amgen Consulting fee Review panel membership; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University 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.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, 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 Honoraria Consulting; Centocor Honoraria Consulting; Medicis Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

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 None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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