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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Photobiological study of the patient&#46; A&#44; Photopatch reading at 48&#8239;hours&#46; The photopatches on the left were irradiated with UVA for 6&#8239;minutes using a Philips&#174; HB 404 high pressure lamp &#40;13&#46;32&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; The patches on the right were not irradiated&#46; No contact or photo-contact reactions were observed for the standard battery or for the drugs that the patient had been prescribed&#46; Results were also negative after 96&#8239;hours&#46; B&#44; Photoprovocation on day 1 of irradiation &#40;7&#8239;min&#59; 15&#46;54&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; The photoprovoked region consisted of an area directly irradiated with UVA &#40;left&#41; and an area covered with a water-filled Petri dish &#40;right&#41; to eliminate the infrared &#40;IR&#41; component&#46; C&#44; Photoprovocation at 144&#8239;hours&#46; Isolated minute micropapules are evident on the left side of the irradiated area&#46; Some of the lesions near the edge are larger&#46; Milder lesions are also evident in the area protected from IR radiation&#46;</p>"
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isolated&#44; light pink annular lesions &#40;approximately 3&#8211;4&#8239;mm&#41; were present on both arms &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A phototest was performed using different light sources&#46; A reading was taken immediately to determine the minimum urticarial dose and again after 24&#8239;hours to determine the minimum erythematic dose&#46; Photoprovocation and photopatch tests were also performed&#46; The immediate phototest reading revealed a normal response to both ultraviolet &#40;UV&#41; A and UVB light&#46; After 24&#8239;hours the values obtained for the minimum erythematic dose were as expected for the patient&#8217;s phototype &#40;31&#8239;mJ&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#44; and the response to UVA was normal&#46; Double reading of photopatch tests &#40;non-irradiated and UVA-irradiated &#91;13&#46;32&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#93; patches&#41; after exposure to the standard battery&#44; together with the drugs that the patient took habitually&#44; revealed no reaction indicative of exogenous skin photosensitivity at either 24 or 48&#8239;hours after irradiation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In a photoprovocation test&#44; UVB irradiation of the back and shoulder had no effect&#44; while UVA irradiation &#40;24&#46;42&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#59; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41; resulted in the appearance of some micropapules and erythema after 48&#8239;hours&#46; The lesions reappeared on the following days of the photoprovocation test&#44; up until day 6 &#40;cumulative dose&#44; 97&#46;71&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; Based on this finding&#44; a skin biopsy of the newly formed lesions and the pre-existing papules was performed&#46; Histology of the biopsies revealed numerous histiocytes and multinucleated giant cells distributed interstitially in the papillary and reticular dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A and B&#41;&#46; No phagocytosis of elastic fibers was observed in interstitial macrophages &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C&#41;&#46; Based on the clinical and histopathologic findings&#44; the patient was diagnosed with UVA-photoinduced granuloma annulare &#40;GA&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">GA is a benign and self-limiting inflammatory dermatosis of uncertain origin&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> It is characterized by the presence of dermal papules with no appreciable epidermal component and a tendency to coalesce to form mainly asymptomatic arcuate or annular plaques&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> The specific etiology of GA is unknown&#44; although it has been linked to a multitude of comorbidities&#44; including malignant neoplasms&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> viral infections&#44; and drug treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although most resolve spontaneously&#44; even after biopsy&#44; some lesions can leave permanent scars&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Disseminated GA has been more specifically related to systemic conditions such as diabetes mellitus<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> and&#44; in rare cases&#44; sun exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Actinic granuloma&#44; described by O&#8217;Brien&#44; is characterized by the presence in photo-exposed areas of lesions that are suggestive of GA<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> but exhibit degeneration of elastic fibers&#44; which are phagocytosed by histiocytes present in the infiltrate &#40;elastophagocytosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are few published cases of GA induced by light radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9&#44;10</span></a> According to some studies&#44; solar radiation is considered one of the potential causes of GA&#46; Attempts have been made to reproduce GA lesions using ultraviolet light&#44; without success&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We believe that this is the first reported case of photoinduced granuloma annulare in experimental conditions in the context of a photobiological study&#46; There are some published descriptions of photoinduced GA in patients taking medication&#44; such as paroxetine&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; in our patient the results of photopatch tests ruled out a pharmacological etiology&#46; Despite the absence of medication&#44; we believe that in our case a preformed antigen may have undergone a conformational change upon exposure to UVA&#44; triggering GA-like granulomatous dermatitis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment of this entity is often unsatisfactory&#46; Various treatment options have been used&#44; including oral retinoids&#44; antimalarials&#44; and phototherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a> Our patient was recommended exhaustive topical photoprotection with a high sun protection index&#44; including UVA and infrared photoprotection&#44; as well as oral photoprotection&#46; After 9 months of follow-up&#44; the patient has not presented any new lesions and all existing lesions have stabilized&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fonda-Pascual P&#44; de G&#225;lvez MV&#44; Aguilera J&#44; Herrera-Ceballos E&#46; Granuloma anular fotoinducido demostrado experimentalmente mediante fotoprovocaci&#243;n UVA&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;190&#8211;192&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation of the patient&#46; A&#44; Brownish&#44; arciform&#44; erythematous plaques with a tendency to coalesce on the backs of the hands and the dorsal aspect of the forearms&#46; The lesions were mildly infiltrated and lacked an appreciable epidermal component&#46; B&#44; The lesions extended to the volar aspect of the forearms&#44; where they were milder and coalesced less&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Photobiological study of the patient&#46; A&#44; Photopatch reading at 48&#8239;hours&#46; The photopatches on the left were irradiated with UVA for 6&#8239;minutes using a Philips&#174; HB 404 high pressure lamp &#40;13&#46;32&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; The patches on the right were not irradiated&#46; No contact or photo-contact reactions were observed for the standard battery or for the drugs that the patient had been prescribed&#46; Results were also negative after 96&#8239;hours&#46; B&#44; Photoprovocation on day 1 of irradiation &#40;7&#8239;min&#59; 15&#46;54&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; The photoprovoked region consisted of an area directly irradiated with UVA &#40;left&#41; and an area covered with a water-filled Petri dish &#40;right&#41; to eliminate the infrared &#40;IR&#41; component&#46; C&#44; Photoprovocation at 144&#8239;hours&#46; Isolated minute micropapules are evident on the left side of the irradiated area&#46; Some of the lesions near the edge are larger&#46; Milder lesions are also evident in the area protected from IR radiation&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histology of newly formed papules after photoprovocation&#46; A&#44; Well-circumscribed interstitial dermal infiltrate&#46; At low magnification&#44; neither granulomas nor epidermal involvement are observed &#40;hematoxylin-eosin &#91;HE&#93; &#215;2&#44; original magnification &#215;20&#41;&#46; A higher magnification image reveals lymphohistiocytic infiltrate containing an important component of large cytoplasmic cells surrounding collagen bundles to create an interstitial granulomatous dermatitis pattern &#40;HE &#215;10&#44; original magnification &#215;100&#41;&#46; C&#44; High magnification image in which elastophagocytosis is not observed&#44; ruling out a diagnosis of actinic granuloma &#40;HE &#215;20&#44; original magnification &#215;200&#41;&#46;</p>"
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Case and Research Letters
Photoinduced Granuloma Annulare Confirmed by Experimental Exposure to UVA Light
Granuloma anular fotoinducido demostrado experimentalmente mediante fotoprovocación UVA
P. Fonda-Pascuala,b,
Corresponding author
pfonpa1@mde.es

Corresponding author.
, M.V. de Gálvezc, J. Aguilerac, E. Herrera-Ceballosc,d
a Servicio de Dermatología, Hospital Central de la Defensa, Madrid, Spain
b Grupo de Dermatología Experimental y Biología Cutánea, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain
c Unidad de Fotobiología Dermatológica y Oncología Cutánea, Departamento de Dermatología y Medicina, Universidad de Málaga, Málaga, Spain
d Servicio de Dermatología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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isolated&#44; light pink annular lesions &#40;approximately 3&#8211;4&#8239;mm&#41; were present on both arms &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A phototest was performed using different light sources&#46; A reading was taken immediately to determine the minimum urticarial dose and again after 24&#8239;hours to determine the minimum erythematic dose&#46; Photoprovocation and photopatch tests were also performed&#46; The immediate phototest reading revealed a normal response to both ultraviolet &#40;UV&#41; A and UVB light&#46; After 24&#8239;hours the values obtained for the minimum erythematic dose were as expected for the patient&#8217;s phototype &#40;31&#8239;mJ&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#44; and the response to UVA was normal&#46; Double reading of photopatch tests &#40;non-irradiated and UVA-irradiated &#91;13&#46;32&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#93; patches&#41; after exposure to the standard battery&#44; together with the drugs that the patient took habitually&#44; revealed no reaction indicative of exogenous skin photosensitivity at either 24 or 48&#8239;hours after irradiation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In a photoprovocation test&#44; UVB irradiation of the back and shoulder had no effect&#44; while UVA irradiation &#40;24&#46;42&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#59; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41; resulted in the appearance of some micropapules and erythema after 48&#8239;hours&#46; The lesions reappeared on the following days of the photoprovocation test&#44; up until day 6 &#40;cumulative dose&#44; 97&#46;71&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; Based on this finding&#44; a skin biopsy of the newly formed lesions and the pre-existing papules was performed&#46; Histology of the biopsies revealed numerous histiocytes and multinucleated giant cells distributed interstitially in the papillary and reticular dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A and B&#41;&#46; No phagocytosis of elastic fibers was observed in interstitial macrophages &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C&#41;&#46; Based on the clinical and histopathologic findings&#44; the patient was diagnosed with UVA-photoinduced granuloma annulare &#40;GA&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">GA is a benign and self-limiting inflammatory dermatosis of uncertain origin&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> It is characterized by the presence of dermal papules with no appreciable epidermal component and a tendency to coalesce to form mainly asymptomatic arcuate or annular plaques&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> The specific etiology of GA is unknown&#44; although it has been linked to a multitude of comorbidities&#44; including malignant neoplasms&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> viral infections&#44; and drug treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although most resolve spontaneously&#44; even after biopsy&#44; some lesions can leave permanent scars&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Disseminated GA has been more specifically related to systemic conditions such as diabetes mellitus<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> and&#44; in rare cases&#44; sun exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Actinic granuloma&#44; described by O&#8217;Brien&#44; is characterized by the presence in photo-exposed areas of lesions that are suggestive of GA<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> but exhibit degeneration of elastic fibers&#44; which are phagocytosed by histiocytes present in the infiltrate &#40;elastophagocytosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are few published cases of GA induced by light radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9&#44;10</span></a> According to some studies&#44; solar radiation is considered one of the potential causes of GA&#46; Attempts have been made to reproduce GA lesions using ultraviolet light&#44; without success&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We believe that this is the first reported case of photoinduced granuloma annulare in experimental conditions in the context of a photobiological study&#46; There are some published descriptions of photoinduced GA in patients taking medication&#44; such as paroxetine&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; in our patient the results of photopatch tests ruled out a pharmacological etiology&#46; Despite the absence of medication&#44; we believe that in our case a preformed antigen may have undergone a conformational change upon exposure to UVA&#44; triggering GA-like granulomatous dermatitis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment of this entity is often unsatisfactory&#46; Various treatment options have been used&#44; including oral retinoids&#44; antimalarials&#44; and phototherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a> Our patient was recommended exhaustive topical photoprotection with a high sun protection index&#44; including UVA and infrared photoprotection&#44; as well as oral photoprotection&#46; After 9 months of follow-up&#44; the patient has not presented any new lesions and all existing lesions have stabilized&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fonda-Pascual P&#44; de G&#225;lvez MV&#44; Aguilera J&#44; Herrera-Ceballos E&#46; Granuloma anular fotoinducido demostrado experimentalmente mediante fotoprovocaci&#243;n UVA&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;190&#8211;192&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation of the patient&#46; A&#44; Brownish&#44; arciform&#44; erythematous plaques with a tendency to coalesce on the backs of the hands and the dorsal aspect of the forearms&#46; The lesions were mildly infiltrated and lacked an appreciable epidermal component&#46; B&#44; The lesions extended to the volar aspect of the forearms&#44; where they were milder and coalesced less&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Photobiological study of the patient&#46; A&#44; Photopatch reading at 48&#8239;hours&#46; The photopatches on the left were irradiated with UVA for 6&#8239;minutes using a Philips&#174; HB 404 high pressure lamp &#40;13&#46;32&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; The patches on the right were not irradiated&#46; No contact or photo-contact reactions were observed for the standard battery or for the drugs that the patient had been prescribed&#46; Results were also negative after 96&#8239;hours&#46; B&#44; Photoprovocation on day 1 of irradiation &#40;7&#8239;min&#59; 15&#46;54&#8239;J&#47;cm<span class="elsevierStyleSup">2</span>&#41;&#46; The photoprovoked region consisted of an area directly irradiated with UVA &#40;left&#41; and an area covered with a water-filled Petri dish &#40;right&#41; to eliminate the infrared &#40;IR&#41; component&#46; C&#44; Photoprovocation at 144&#8239;hours&#46; Isolated minute micropapules are evident on the left side of the irradiated area&#46; Some of the lesions near the edge are larger&#46; Milder lesions are also evident in the area protected from IR radiation&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histology of newly formed papules after photoprovocation&#46; A&#44; Well-circumscribed interstitial dermal infiltrate&#46; At low magnification&#44; neither granulomas nor epidermal involvement are observed &#40;hematoxylin-eosin &#91;HE&#93; &#215;2&#44; original magnification &#215;20&#41;&#46; A higher magnification image reveals lymphohistiocytic infiltrate containing an important component of large cytoplasmic cells surrounding collagen bundles to create an interstitial granulomatous dermatitis pattern &#40;HE &#215;10&#44; original magnification &#215;100&#41;&#46; C&#44; High magnification image in which elastophagocytosis is not observed&#44; ruling out a diagnosis of actinic granuloma &#40;HE &#215;20&#44; original magnification &#215;200&#41;&#46;</p>"
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Article information
ISSN: 15782190
Original language: English
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Idiomas
Actas Dermo-Sifiliográficas
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