Case and Research Letters
Urticaria-Like Reaction Secondary to Photodynamic Therapy in 2 Pediatric Patients
Reacción urticariforme secundaria a terapia fotodinámica en 2 pacientes pediátricos
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Miguélez, A. Martín-Santiago, A. Bauzá, Y. Gilaberte" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Miguélez" "email" => array:1 [ 0 => "anamig@telefonica.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Martín-Santiago" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Bauzá" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Y." "apellidos" => "Gilaberte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de la Princesa, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Son Espases, Palma de Mallorca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital San Jorge, Huesca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reacción urticariforme secundaria a terapia fotodinámica en 2 pacientes pediátricos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 482 "Ancho" => 1022 "Tamanyo" => 154423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Observe the cornoid lamella—a column of stacked parakeratotic cells extending through the stratum corneum characteristic of porokeratosis. Hematoxylin-eosin, original magnification ×100. B, Large erythematous, edematous lesions on the left leg on the area where PDT treatment was applied.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">To the Editor:</span></p><p id="par0005" class="elsevierStylePara elsevierViewall">Photodynamic therapy (PDT) is a light therapy that involves the production of reactive oxygen species and free radicals to induce oxidation in biological tissues. The effect is achieved through the application of a photosensitizing agent, which is then activated by exposure to wavelength-specific light.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The most commonly used photosensitizer is methyl aminolevulinate (MAL). PDT is primarily used in the treatment of basal cell carcinoma, actinic keratosis, and Bowen disease, although it can also be used to treat certain non-neoplastic diseases. The most common side effects are pain and local inflammation; wheals are very rare.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We present the cases of 2 pediatric patients who developed urticarial reactions to PDT.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first patient was an 11-year-old girl with nevoid basal cell carcinoma syndrome (Gorlin syndrome) who presented with the characteristic clinical manifestations, including frontal bossing, hypertelorism, small ears, syndactyly, palmar pits, and a large number of small, pedunculated, papular lesions on the neck, axillas, groin, and popliteal fossae. Histologic examination of these lesions revealed basal cell carcinoma. The lesions had previously been treated with cryotherapy, electrocoagulation, and imiquimod. PDT treatment was prescribed and administered on several lesions on the upper back and the neck according to the standard protocol: MAL 160<span class="elsevierStyleHsp" style=""></span>mg/g cream (Metvix) applied under occlusion for 3<span class="elsevierStyleHsp" style=""></span>hours followed by illumination using an Aktilite lamp at a dose of 37<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>. Three minutes after starting illumination, semicircular wheals appeared in the area being treated, and light exposure was stopped (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The lesions disappeared after a few hours without treatment and did not recur. Some months later the patient underwent provocation testing with the MAL cream applied under occlusion for 3<span class="elsevierStyleHsp" style=""></span>hours followed by illumination. Wheals appeared in the illuminated area where the cream had been applied, but no lesions were observed in the area exposed to light without prior application of cream (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The wheals disappeared spontaneously and there was no recurrence.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The second patient was a 4-year-old girl with no relevant past history or family history who presented with brownish, erythematous, maculopapular lesions in a blaschkoid distribution affecting the dorsum and anterior aspect of the left forearm, thigh, and left leg. Porokeratosis was revealed on histology (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The lesions had not responded to treatment with topical corticosteroids or retinoids. Treatment with PDT was administered using the standard protocol without pretreatment curettage. After 2<span class="elsevierStyleHsp" style=""></span>minutes of light exposure, large erythematous, edematous lesions appeared in the area being treated and the procedure was stopped (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The lesions disappeared after a few hours without treatment and did not recur. Provocation testing was not carried out due to the young age of the patient.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In both patients, Giemsa staining of skin biopsies taken prior to PDT showed no significant increase in the number of mast cells.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Urticarial reactions to PDT using 5-aminolevulinic acid and MAL have been described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> A 2008 study reported a 0.9% prevalence (12/1353 patients) for severe itching and wheals within the first minute of illumination.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The patients most predisposed to reaction were those who had received more than 7 courses of treatment (3.8% prevalence).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Those authors postulated that this type of urticaria may be mediated by immunoglobulin E with histamine release from mast cells in the dermis. This pathogenesis is consistent with the recurrent nature of the reactions in subsequent treatments, the satisfactory control of these reactions through the administration before treatment of an antihistamine such as cetirizine, and the immediate appearance of urticaria in areas not previously treated with PDT.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our patients, urticaria appeared during the first course of treatment. In the first patient, a subsequent provocation skin test confirmed that the reaction was produced by the combination of MAL and illumination, and not by either one separately.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of particular note was the especially extensive reaction in our patients. We found no reports in the literature of nevoid basal cell carcinoma syndrome involving a similar reaction to PDT, despite the increasing use of PDT in these patients.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> Similarly, we found no reports of urticarial reactions in patients with porokeratosis treated with PDT.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> An additional associated factor could be the young age of these patients. We found no cases in the literature of reaction to PDT in children, but this treatment is rarely used in this age group. It has been suggested that mast cells may play a role in this type of reaction and at the same time participate in the nonspecific immune response that results in the tissue damage caused indirectly by PDT. We therefore postulated the possibility of high mast cell counts in the affected areas, but this hypothesis was ruled out by the results of Giemsa staining.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary, these 2 rare cases of urticaria during PDT in children, a previously unreported reaction in this age group, demonstrate the need for dermatologists to be aware of this reaction so that they will stop illumination promptly and treat the resulting lesions appropriately.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Miguélez A, et al. Reacción urticariforme secundaria a terapia fotodinámica en 2 pacientes pediátricos. Actas Dermosifiliogr. 2013;104:727–9.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 625 "Ancho" => 1699 "Tamanyo" => 124584 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Large semicircular wheals on the upper back where PDT was administered. B, Wheals on the skin illuminated following the application of methyl aminolevulinate cream (Metvix) and no visible lesion on the illuminated area where no cream was applied (positive provocation test result).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 482 "Ancho" => 1022 "Tamanyo" => 154423 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Observe the cornoid lamella—a column of stacked parakeratotic cells extending through the stratum corneum characteristic of porokeratosis. Hematoxylin-eosin, original magnification ×100. B, Large erythematous, edematous lesions on the left leg on the area where PDT treatment was applied.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Terapia fotodinámica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Y. Gilaberte" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2008" "editorial" => "Aula Médica" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complicaciones en la terapia fotodinámica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 11 | 22 |
| 2024 October | 70 | 52 | 122 |
| 2024 September | 73 | 35 | 108 |
| 2024 August | 102 | 72 | 174 |
| 2024 July | 79 | 39 | 118 |
| 2024 June | 77 | 30 | 107 |
| 2024 May | 75 | 34 | 109 |
| 2024 April | 85 | 31 | 116 |
| 2024 March | 97 | 44 | 141 |
| 2024 February | 75 | 35 | 110 |
| 2024 January | 59 | 35 | 94 |
| 2023 December | 68 | 38 | 106 |
| 2023 November | 58 | 56 | 114 |
| 2023 October | 80 | 44 | 124 |
| 2023 September | 77 | 46 | 123 |
| 2023 August | 55 | 29 | 84 |
| 2023 July | 76 | 50 | 126 |
| 2023 June | 62 | 34 | 96 |
| 2023 May | 63 | 23 | 86 |
| 2023 April | 52 | 19 | 71 |
| 2023 March | 43 | 28 | 71 |
| 2023 February | 74 | 20 | 94 |
| 2023 January | 49 | 20 | 69 |
| 2022 December | 46 | 42 | 88 |
| 2022 November | 20 | 42 | 62 |
| 2022 October | 28 | 23 | 51 |
| 2022 September | 33 | 55 | 88 |
| 2022 August | 20 | 37 | 57 |
| 2022 July | 22 | 43 | 65 |
| 2022 June | 21 | 24 | 45 |
| 2022 May | 45 | 44 | 89 |
| 2022 April | 57 | 36 | 93 |
| 2022 March | 76 | 73 | 149 |
| 2022 February | 41 | 30 | 71 |
| 2022 January | 54 | 38 | 92 |
| 2021 December | 42 | 53 | 95 |
| 2021 November | 46 | 41 | 87 |
| 2021 October | 49 | 60 | 109 |
| 2021 September | 33 | 59 | 92 |
| 2021 August | 26 | 34 | 60 |
| 2021 July | 26 | 37 | 63 |
| 2021 June | 38 | 31 | 69 |
| 2021 May | 42 | 34 | 76 |
| 2021 April | 106 | 52 | 158 |
| 2021 March | 62 | 27 | 89 |
| 2021 February | 46 | 35 | 81 |
| 2021 January | 37 | 32 | 69 |
| 2020 December | 38 | 22 | 60 |
| 2020 November | 19 | 18 | 37 |
| 2020 October | 28 | 15 | 43 |
| 2020 September | 39 | 21 | 60 |
| 2020 August | 29 | 24 | 53 |
| 2020 July | 29 | 19 | 48 |
| 2020 June | 31 | 35 | 66 |
| 2020 May | 32 | 27 | 59 |
| 2020 April | 42 | 34 | 76 |
| 2020 March | 31 | 20 | 51 |
| 2020 February | 2 | 9 | 11 |
| 2020 January | 4 | 7 | 11 |
| 2019 December | 8 | 8 | 16 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 0 | 3 | 3 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 3 | 7 |
| 2019 July | 4 | 10 | 14 |
| 2019 June | 6 | 5 | 11 |
| 2019 May | 2 | 40 | 42 |
| 2019 April | 0 | 1 | 1 |
| 2019 March | 2 | 5 | 7 |
| 2019 January | 2 | 0 | 2 |
| 2018 November | 6 | 0 | 6 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 3 | 0 | 3 |
| 2018 March | 1 | 0 | 1 |
| 2018 February | 35 | 5 | 40 |
| 2018 January | 35 | 6 | 41 |
| 2017 December | 35 | 7 | 42 |
| 2017 November | 20 | 0 | 20 |
| 2017 October | 28 | 5 | 33 |
| 2017 September | 26 | 6 | 32 |
| 2017 August | 29 | 9 | 38 |
| 2017 July | 43 | 8 | 51 |
| 2017 June | 40 | 20 | 60 |
| 2017 May | 33 | 6 | 39 |
| 2017 April | 24 | 14 | 38 |
| 2017 March | 21 | 86 | 107 |
| 2017 February | 68 | 10 | 78 |
| 2017 January | 24 | 5 | 29 |
| 2016 December | 44 | 5 | 49 |
| 2016 November | 57 | 22 | 79 |
| 2016 October | 58 | 18 | 76 |
| 2016 September | 89 | 13 | 102 |
| 2016 August | 42 | 7 | 49 |
| 2016 July | 28 | 6 | 34 |
| 2016 June | 10 | 8 | 18 |
| 2016 May | 8 | 8 | 16 |
| 2016 April | 8 | 10 | 18 |
| 2016 March | 8 | 2 | 10 |
| 2016 February | 11 | 11 | 22 |
| 2016 January | 8 | 1 | 9 |
| 2015 December | 17 | 1 | 18 |
| 2015 November | 14 | 1 | 15 |
| 2015 October | 17 | 3 | 20 |
| 2015 September | 1 | 1 | 2 |
| 2015 August | 8 | 4 | 12 |
| 2015 July | 39 | 7 | 46 |
| 2015 June | 24 | 3 | 27 |
| 2015 May | 37 | 7 | 44 |
| 2015 April | 28 | 5 | 33 |
| 2015 March | 25 | 2 | 27 |
| 2015 February | 25 | 4 | 29 |
| 2015 January | 28 | 3 | 31 |
| 2014 December | 31 | 6 | 37 |
| 2014 November | 26 | 5 | 31 |
| 2014 October | 38 | 3 | 41 |
| 2014 September | 28 | 2 | 30 |
| 2014 August | 26 | 6 | 32 |
| 2014 July | 22 | 6 | 28 |
| 2014 June | 28 | 2 | 30 |
| 2014 May | 38 | 7 | 45 |
| 2014 April | 27 | 5 | 32 |
| 2014 March | 23 | 4 | 27 |
| 2014 February | 21 | 5 | 26 |
| 2014 January | 19 | 3 | 22 |
| 2013 December | 11 | 3 | 14 |
| 2013 November | 4 | 3 | 7 |
| 2013 October | 3 | 3 | 6 |
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