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was referred to our dermatology department due to the appearance of delayed outbreaks of itchy wheals in photoexposed areas throughout the previous 8 years&#46; The lesions appeared within 2&#8211;3<span class="elsevierStyleHsp" style=""></span>h after sun exposure and faded after 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#46; In addition&#44; by the same time&#44; she also had spontaneous outbreaks of wheals in any location unrelated to any activity or triggering physical factors&#46; As previous treatments&#44; she had undergone UVB narrowband phototherapy &#40;34 sessions with a total dose of 17&#46;15<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#41; in other hospital&#44; with frequent outbreaks of lesions that appeared 5<span class="elsevierStyleHsp" style=""></span>h after treatment without achieving skin <span class="elsevierStyleItalic">hardening&#46;</span></p><p id="par0015" class="elsevierStylePara elsevierViewall">Complementary tests included a general blood test with tryptase and autoimmunity that showed no alterations&#46; Total IgE was 210<span class="elsevierStyleHsp" style=""></span>UI&#47;ml&#46; Skin prick test was positive for 4 lines&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient had no relevant dermatological history&#44; and denied consuming or using any medicines prior to the episodes&#46; Her Fitzpatrick phototype was II and no lesions were present at the time of the consultation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Exposure to solar light &#40;face&#44; neck&#44; cleavage area and back of forearms&#41; at 12&#46;00 a&#46;m&#46; induced no lesions after 20<span class="elsevierStyleHsp" style=""></span>min&#46; Two hours after photo-exposure&#44; asymptomatic erythematous lesions appeared in the cleavage area and disappeared in 3&#8211;4<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Phototest&#47;photoprovocation using a UVB&#43;UVA solar simulator &#40;SS&#41; &#40;6 spot doses of 45&#46;01&#44; 33&#46;31&#44; 24&#46;66&#44; 18&#46;25&#44; 13&#44; 51 and 10<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#59; Multiport 601&#44; Solar Light Co&#174;&#44; USA&#41; broad-band UVA &#40;5 spot series up to 8&#46;9<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#59; Gigatest&#44; Medisun&#174; 2008&#44; Germany&#41;&#44; broad-band UVB &#40;5 spot series of 67&#44; 56&#44; 40&#44; 22 and 5<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#59; Gigatest&#44; Medisun&#174; 2008&#44; Germany&#41;&#59; and visible light &#40;VL&#41; &#40;slide projector located 10<span class="elsevierStyleHsp" style=""></span>cm away&#44; with 8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>cm spot area&#44; on the left dorsal area&#44; for 30<span class="elsevierStyleHsp" style=""></span>min&#41; were all negative at immediate reading&#46; However&#44; 12<span class="elsevierStyleHsp" style=""></span>h after the phototest was performed&#44; the patient reported and self-photographed the appearance of wheals in the 6 spots exposed to the SS &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In the 24-h reading&#44; all wheals had disappeared and the minimal erythema dose &#40;MED&#41; was considered to be normal for her phototype &#40;MED&#58; 22<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Several months later&#44; the patient complained of an intense outbreak of itchy erythematous papules on the cleavage&#44; arms and legs&#44; which persisted for several days&#46; The patient reported that she had similar lesions in previous summers&#46; The lesions were considered to be clinically consistent with polymorphic light eruption &#40;PLE&#41;&#46; Further photoprovocation of PLE was not performed&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was treated with seven doses of omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg s&#46;c&#46; every 4 weeks together with bilastine 20<span class="elsevierStyleHsp" style=""></span>mg daily and progressive heliotherapy reaching total control of chronic spontaneous urticaria &#40;CSU&#41; and the pruritus within two weeks as well as improvement of sun tolerance&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Delayed-onset SU is very rarely described in the medical literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#8211;7</span></a> Wheals are elicited by high dose of UVA&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;5</span></a> low doses of UVA or UVB<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;6</span></a> or only by UVB&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> as is the case in our patient&#46; This fact suggests that delayed-onset SU is very rare and it is due in all cases to a spectrum of UV effects rather than to VL&#44; unlike the non-delayed SU series reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2&#44;7&#8211;9</span></a> Co-occurrence of PLE and SU was reported to be as high as 23&#37; in one case series of 87 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> whereas PLE has only been reported in coexistence with delayed-onset SU in one case&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> as in our case&#46; Lastly&#44; only Ghigliotti et al&#46; reported coexistence of CSU with delayed-onset SU in one patient&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">To conclude&#44; we would like to point out that&#44; in addition to CSU&#44; SU can be also associated with other inducible chronic urticaria&#44; making its diagnosis difficult&#46; Although the association with other photodermatoses has been described&#44; photobiological studies should be carried out in the cases in which a delayed form of SU overlaps with PLE&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Although delayed SU is very rare&#44; it must be clinically considered in order to correctly perform and interpret photoprovocation tests&#46; In our case&#44; the patient collaboration was essential to assess the skin responses several hours later&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">We present the first case of delayed-onset SU induced by UVB radiation&#44; associated with PLE and CSU&#46; The potential relationship between delayed-onset SU&#44; PLE and CSU is unclear and should be investigated in the future&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare not to have any conflict of interest&#46;</p></span></span>"
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Case and Research Letter
Delayed-onset Solar Urticaria Coexisting With Spontaneous Chronic Urticaria and Polymorphic Light Eruption
Inicio demorado de urticaria solar coexistente con urticaria crónica espontánea y erupción polimorfa lumínica
A. Reolid
Corresponding author
alereolid@gmail.com

Corresponding author.
, E. Muñoz-Aceituno, P. Rodríguez-Jiménez, D. de Argila
Department of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Delayed response to broad-band UVB light&#58; &#40;a&#41; Erythema 8<span class="elsevierStyleHsp" style=""></span>h later and &#40;b&#41; wheals 10<span class="elsevierStyleHsp" style=""></span>h after stimulation&#44; which disappeared 24<span class="elsevierStyleHsp" style=""></span>h later&#46; &#40;c&#41; MED determination&#46; MED was 22<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#44; considered to be normal for the patient phototype&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Solar urticaria &#40;SU&#41; is characterized by an immediate onset of erythema and itchy wheals within 5&#8211;10<span class="elsevierStyleHsp" style=""></span>min of exposure to solar radiation&#44; which disappear in a few hours&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> Very uncommon isolated cases of delayed-onset SU have been described&#44; in which the lesions appear several hours after sun exposure and may last up to 24<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#8211;7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 58-year-old woman&#44; with a personal history of asthma and allergic rhinitis&#44; was referred to our dermatology department due to the appearance of delayed outbreaks of itchy wheals in photoexposed areas throughout the previous 8 years&#46; The lesions appeared within 2&#8211;3<span class="elsevierStyleHsp" style=""></span>h after sun exposure and faded after 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#46; In addition&#44; by the same time&#44; she also had spontaneous outbreaks of wheals in any location unrelated to any activity or triggering physical factors&#46; As previous treatments&#44; she had undergone UVB narrowband phototherapy &#40;34 sessions with a total dose of 17&#46;15<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#41; in other hospital&#44; with frequent outbreaks of lesions that appeared 5<span class="elsevierStyleHsp" style=""></span>h after treatment without achieving skin <span class="elsevierStyleItalic">hardening&#46;</span></p><p id="par0015" class="elsevierStylePara elsevierViewall">Complementary tests included a general blood test with tryptase and autoimmunity that showed no alterations&#46; Total IgE was 210<span class="elsevierStyleHsp" style=""></span>UI&#47;ml&#46; Skin prick test was positive for 4 lines&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient had no relevant dermatological history&#44; and denied consuming or using any medicines prior to the episodes&#46; Her Fitzpatrick phototype was II and no lesions were present at the time of the consultation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Exposure to solar light &#40;face&#44; neck&#44; cleavage area and back of forearms&#41; at 12&#46;00 a&#46;m&#46; induced no lesions after 20<span class="elsevierStyleHsp" style=""></span>min&#46; Two hours after photo-exposure&#44; asymptomatic erythematous lesions appeared in the cleavage area and disappeared in 3&#8211;4<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Phototest&#47;photoprovocation using a UVB&#43;UVA solar simulator &#40;SS&#41; &#40;6 spot doses of 45&#46;01&#44; 33&#46;31&#44; 24&#46;66&#44; 18&#46;25&#44; 13&#44; 51 and 10<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#59; Multiport 601&#44; Solar Light Co&#174;&#44; USA&#41; broad-band UVA &#40;5 spot series up to 8&#46;9<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#59; Gigatest&#44; Medisun&#174; 2008&#44; Germany&#41;&#44; broad-band UVB &#40;5 spot series of 67&#44; 56&#44; 40&#44; 22 and 5<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#59; Gigatest&#44; Medisun&#174; 2008&#44; Germany&#41;&#59; and visible light &#40;VL&#41; &#40;slide projector located 10<span class="elsevierStyleHsp" style=""></span>cm away&#44; with 8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>cm spot area&#44; on the left dorsal area&#44; for 30<span class="elsevierStyleHsp" style=""></span>min&#41; were all negative at immediate reading&#46; However&#44; 12<span class="elsevierStyleHsp" style=""></span>h after the phototest was performed&#44; the patient reported and self-photographed the appearance of wheals in the 6 spots exposed to the SS &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In the 24-h reading&#44; all wheals had disappeared and the minimal erythema dose &#40;MED&#41; was considered to be normal for her phototype &#40;MED&#58; 22<span class="elsevierStyleHsp" style=""></span>mJ&#47;cm<span class="elsevierStyleSup">2</span>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Several months later&#44; the patient complained of an intense outbreak of itchy erythematous papules on the cleavage&#44; arms and legs&#44; which persisted for several days&#46; The patient reported that she had similar lesions in previous summers&#46; The lesions were considered to be clinically consistent with polymorphic light eruption &#40;PLE&#41;&#46; Further photoprovocation of PLE was not performed&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was treated with seven doses of omalizumab 300<span class="elsevierStyleHsp" style=""></span>mg s&#46;c&#46; every 4 weeks together with bilastine 20<span class="elsevierStyleHsp" style=""></span>mg daily and progressive heliotherapy reaching total control of chronic spontaneous urticaria &#40;CSU&#41; and the pruritus within two weeks as well as improvement of sun tolerance&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Delayed-onset SU is very rarely described in the medical literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#8211;7</span></a> Wheals are elicited by high dose of UVA&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;5</span></a> low doses of UVA or UVB<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;6</span></a> or only by UVB&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> as is the case in our patient&#46; This fact suggests that delayed-onset SU is very rare and it is due in all cases to a spectrum of UV effects rather than to VL&#44; unlike the non-delayed SU series reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2&#44;7&#8211;9</span></a> Co-occurrence of PLE and SU was reported to be as high as 23&#37; in one case series of 87 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> whereas PLE has only been reported in coexistence with delayed-onset SU in one case&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> as in our case&#46; Lastly&#44; only Ghigliotti et al&#46; reported coexistence of CSU with delayed-onset SU in one patient&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">To conclude&#44; we would like to point out that&#44; in addition to CSU&#44; SU can be also associated with other inducible chronic urticaria&#44; making its diagnosis difficult&#46; Although the association with other photodermatoses has been described&#44; photobiological studies should be carried out in the cases in which a delayed form of SU overlaps with PLE&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Although delayed SU is very rare&#44; it must be clinically considered in order to correctly perform and interpret photoprovocation tests&#46; In our case&#44; the patient collaboration was essential to assess the skin responses several hours later&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">We present the first case of delayed-onset SU induced by UVB radiation&#44; associated with PLE and CSU&#46; The potential relationship between delayed-onset SU&#44; PLE and CSU is unclear and should be investigated in the future&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare not to have any conflict of interest&#46;</p></span></span>"
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ISSN: 00017310
Original language: English
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