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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HE ×<span class="elsevierStyleHsp" style=""></span>100. Se observa la presencia de células paraqueratósicas agrupadas en una columna en el estrato córneo correspondiendo a la lamela cornoide característica de la poroqueratosis. B. Lesiones eritemato-edematosas de gran tamaño en el área del miembro inferior izquierdo que estaba siendo tratado con TFD.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Miguélez, A. Martín-Santiago, A. Bauzá, Y. Gilaberte" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Miguélez" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Martín-Santiago" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Bauzá" ] 3 => array:2 [ "nombre" => "Y." 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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 11 | 22 |
| 2024 Octubre | 70 | 52 | 122 |
| 2024 Septiembre | 73 | 35 | 108 |
| 2024 Agosto | 102 | 72 | 174 |
| 2024 Julio | 79 | 39 | 118 |
| 2024 Junio | 77 | 30 | 107 |
| 2024 Mayo | 75 | 34 | 109 |
| 2024 Abril | 85 | 31 | 116 |
| 2024 Marzo | 97 | 44 | 141 |
| 2024 Febrero | 75 | 35 | 110 |
| 2024 Enero | 59 | 35 | 94 |
| 2023 Diciembre | 68 | 38 | 106 |
| 2023 Noviembre | 58 | 56 | 114 |
| 2023 Octubre | 80 | 44 | 124 |
| 2023 Septiembre | 77 | 46 | 123 |
| 2023 Agosto | 55 | 29 | 84 |
| 2023 Julio | 76 | 50 | 126 |
| 2023 Junio | 62 | 34 | 96 |
| 2023 Mayo | 63 | 23 | 86 |
| 2023 Abril | 52 | 19 | 71 |
| 2023 Marzo | 43 | 28 | 71 |
| 2023 Febrero | 74 | 20 | 94 |
| 2023 Enero | 49 | 20 | 69 |
| 2022 Diciembre | 46 | 42 | 88 |
| 2022 Noviembre | 20 | 42 | 62 |
| 2022 Octubre | 28 | 23 | 51 |
| 2022 Septiembre | 33 | 55 | 88 |
| 2022 Agosto | 20 | 37 | 57 |
| 2022 Julio | 22 | 43 | 65 |
| 2022 Junio | 21 | 24 | 45 |
| 2022 Mayo | 45 | 44 | 89 |
| 2022 Abril | 57 | 36 | 93 |
| 2022 Marzo | 76 | 73 | 149 |
| 2022 Febrero | 41 | 30 | 71 |
| 2022 Enero | 54 | 38 | 92 |
| 2021 Diciembre | 42 | 53 | 95 |
| 2021 Noviembre | 46 | 41 | 87 |
| 2021 Octubre | 49 | 60 | 109 |
| 2021 Septiembre | 33 | 59 | 92 |
| 2021 Agosto | 26 | 34 | 60 |
| 2021 Julio | 26 | 37 | 63 |
| 2021 Junio | 38 | 31 | 69 |
| 2021 Mayo | 42 | 34 | 76 |
| 2021 Abril | 106 | 52 | 158 |
| 2021 Marzo | 62 | 27 | 89 |
| 2021 Febrero | 46 | 35 | 81 |
| 2021 Enero | 37 | 32 | 69 |
| 2020 Diciembre | 38 | 22 | 60 |
| 2020 Noviembre | 19 | 18 | 37 |
| 2020 Octubre | 28 | 15 | 43 |
| 2020 Septiembre | 39 | 21 | 60 |
| 2020 Agosto | 29 | 24 | 53 |
| 2020 Julio | 29 | 19 | 48 |
| 2020 Junio | 31 | 35 | 66 |
| 2020 Mayo | 32 | 27 | 59 |
| 2020 Abril | 42 | 34 | 76 |
| 2020 Marzo | 31 | 20 | 51 |
| 2020 Febrero | 2 | 9 | 11 |
| 2020 Enero | 4 | 7 | 11 |
| 2019 Diciembre | 8 | 8 | 16 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 0 | 3 | 3 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 4 | 3 | 7 |
| 2019 Julio | 4 | 10 | 14 |
| 2019 Junio | 6 | 5 | 11 |
| 2019 Mayo | 2 | 40 | 42 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Marzo | 2 | 5 | 7 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Noviembre | 6 | 0 | 6 |
| 2018 Octubre | 6 | 0 | 6 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 35 | 5 | 40 |
| 2018 Enero | 35 | 6 | 41 |
| 2017 Diciembre | 35 | 7 | 42 |
| 2017 Noviembre | 20 | 0 | 20 |
| 2017 Octubre | 28 | 5 | 33 |
| 2017 Septiembre | 26 | 6 | 32 |
| 2017 Agosto | 29 | 9 | 38 |
| 2017 Julio | 43 | 8 | 51 |
| 2017 Junio | 40 | 20 | 60 |
| 2017 Mayo | 33 | 6 | 39 |
| 2017 Abril | 24 | 14 | 38 |
| 2017 Marzo | 21 | 86 | 107 |
| 2017 Febrero | 68 | 10 | 78 |
| 2017 Enero | 24 | 5 | 29 |
| 2016 Diciembre | 44 | 5 | 49 |
| 2016 Noviembre | 57 | 22 | 79 |
| 2016 Octubre | 58 | 18 | 76 |
| 2016 Septiembre | 89 | 13 | 102 |
| 2016 Agosto | 42 | 7 | 49 |
| 2016 Julio | 28 | 6 | 34 |
| 2016 Junio | 10 | 8 | 18 |
| 2016 Mayo | 8 | 8 | 16 |
| 2016 Abril | 8 | 10 | 18 |
| 2016 Marzo | 8 | 2 | 10 |
| 2016 Febrero | 11 | 11 | 22 |
| 2016 Enero | 8 | 1 | 9 |
| 2015 Diciembre | 17 | 1 | 18 |
| 2015 Noviembre | 14 | 1 | 15 |
| 2015 Octubre | 17 | 3 | 20 |
| 2015 Septiembre | 1 | 1 | 2 |
| 2015 Agosto | 8 | 4 | 12 |
| 2015 Julio | 39 | 7 | 46 |
| 2015 Junio | 24 | 3 | 27 |
| 2015 Mayo | 37 | 7 | 44 |
| 2015 Abril | 28 | 5 | 33 |
| 2015 Marzo | 25 | 2 | 27 |
| 2015 Febrero | 25 | 4 | 29 |
| 2015 Enero | 28 | 3 | 31 |
| 2014 Diciembre | 31 | 6 | 37 |
| 2014 Noviembre | 26 | 5 | 31 |
| 2014 Octubre | 38 | 3 | 41 |
| 2014 Septiembre | 28 | 2 | 30 |
| 2014 Agosto | 26 | 6 | 32 |
| 2014 Julio | 22 | 6 | 28 |
| 2014 Junio | 28 | 2 | 30 |
| 2014 Mayo | 38 | 7 | 45 |
| 2014 Abril | 27 | 5 | 32 |
| 2014 Marzo | 23 | 4 | 27 |
| 2014 Febrero | 21 | 5 | 26 |
| 2014 Enero | 19 | 3 | 22 |
| 2013 Diciembre | 11 | 3 | 14 |
| 2013 Noviembre | 4 | 3 | 7 |
| 2013 Octubre | 3 | 3 | 6 |
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