No abstract

Chronic actinic dermatitis (CAD) is characterized by a photoexposed site dermatitis in association with objective evidence of photosensitivity, often arising on a background of atopic dermatitis (AD). Dupilumab is a monoclonal antibody that inhibits signalling of interleukin (IL)-4 and IL-13 and is licensed for the management of moderate-to-severe AD. To date, nine case reports have suggested that dupilumab can be clinically effective for CAD, yet only five cases had diagnostic baseline phototesting and only two cases could demonstrate objective improvement in photosensitivity on repeat testing. We report a retrospective case series from two UK photobiology units of 11 patients with concomitant AD and CAD treated with dupilumab. Inclusion criteria included baseline phototesting with an irradiation monochromator device confirming a diagnosis of CAD < 3 years prior to starting dupilumab, phototesting repeated after at least 16 weeks on dupilumab and all patients included were refractory or intolerant to at least one other systemic therapy prior to dupilumab. Eleven patients [82% male, median age 40 years (range 21–59) at diagnosis] of skin phototypes I–V were included. All patients had a pre-existing diagnosis of AD before the onset of CAD, and two patients also had a pre-existing diagnosis of allergic contact dermatitis. The average duration of dupilumab therapy prior to repeat phototesting was 15 months (range 4–44). Ten of 11 (91%) patients reported improvement in their AD in terms of both rash and pruritus. Five of 11 patients (45%) reported partial improvement in their subjective photosensitivity of whom two showed ultraviolet B monochromator improvement (3- to 6-fold). Six of 11 (55%) patients reported no clinical change in photosensitivity of whom two showed no improvement or worsening on phototesting; while four showed improvements, they remained in the severely photosensitive range on phototesting. While dupilumab is an effective therapy for moderate-to-severe AD, its potential benefit in managing CAD is more difficult to measure. In 91% of patients with CAD, dupilumab was associated with improvement in AD, while clinical or objective improvement in photosensitivity occurred in 82%, albeit sometimes only to a slight degree. However, these data suggest that, for patients with CAD and concomitant AD, reducing the eczematous response is beneficial and that dupilumab is a treatment worth exploring for this patient cohort for whom other treatment options are limited. Prospective studies of dupilumab in CAD are required to further evaluate its utility in this therapeutically challenging condition.

Actinic keratoses (AK) on the face and scalp are often extensive and are a major cause of morbidity and associated with increased risk of skin cancer. Field-directed treatment approaches, such as daylight photodynamic therapy (DPDT) are required, and this has been shown to be effective, well-tolerated and feasible in the UK between April and September. We have used DPDT since 2013, with good outcomes. Patient engagement indicated that convenience and tolerability were rated as highly as efficacy, and we therefore developed an entirely home-based approach ‘home DPDT (H-DPDT)’ in 2021. Working with an art-and-design student, we developed a fully recyclable home kit to enable patients to self-treat with H-DPDT entirely in their home environment. Patients were selected by a dermatologist and then received nurse-led training prior to treatment. In-person review after the second treatment was undertaken to assess response and decide if further treatment was needed, and telephone follow-up was undertaken after the first and third treatments. Final clinician review was undertaken 3–6 months after the last treatment. We reported on implementation in 2021 and introduced this into our routine PDT service options, and we now wish to report our findings from 2021–22. Seventeen patients (82% male) were treated in 2021–2022 for AK on the head and neck. Each patient completed an average of four (range 2–5) treatments. Clinical response was good (≥ 75% response) in nine of 15 (60%) patients assessed. Response was moderate in one (7%) patient (50–75% response) and the remaining five (33%) had a poor response (< 50% response). Treatment success correlated with grade of disease. Patients with more hyperkeratotic disease had poorer outcomes. In 2022, five patients responded to the routine daylight PDT questionnaire. Of these, two rated the H-DPDT as Excellent and the other three rated it as Good. Four patients stated that they had tried other AK treatments, two of which thought that H-PDT was better. One patient felt alternative treatments were more effective but they tolerated H-PDT better. Three of the five patients expressed a preference for H-DPDT for repeat treatment and would recommend it. This innovative H-DPDT service enables patients to self-treat in their home environment, and the initial results showed high rates of patient satisfaction. Treatment outcomes were better for those with milder disease, highlighting the need for careful patient selection and good surface preparation. As a proof of concept, H-DPDT is a feasible therapeutic option and empowers patients, but it may have more of a place in the treatment of milder AK disease, and further work to optimize this approach is indicated.