Photoprotective effects of a broad-spectrum sunscreen in ultraviolet-induced cutaneous lupus erythematosus: A randomized, vehicle-controlled, double-blind study  Annegret Kuhn, MD, Kristina Gensch, MD, Merle Haust, MD, Anna-Maria Meuth, MA, France Boyer, MD, Patrick Dupuy, MD, Percy Lehmann, MD, Dieter Metze, MD, Thomas Ruzicka, MD  Journal of the American Academy of Dermatology  Volume 64, Issue 1, Pages 37-48 (January 2011) DOI: 10.1016/j.jaad.2009.12.053 Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 1 Photoprotective effects of broad-spectrum sunscreen in patients with cutaneous lupus erythematosus (CLE) after ultraviolet (UV) irradiation. For photoprovocation testing, 3 areas of uninvolved skin on the upper aspect of the back were irradiated with single doses of UVA (left side) and UVB (right side), respectively, daily for 3 consecutive days. Sunscreen and its vehicle were applied to uninvolved skin areas 15 minutes before UV irradiation on each side of the upper aspect of the back in random order (vehicle-treated area, sunscreen-treated area, untreated area). A, In patient 1, skin lesions characteristic of lupus erythematosus tumidus were induced by UVA irradiation in vehicle-treated and untreated areas. Slight hyperpigmentation seen between UVA and UVB test sites is result of previous phototesting. B, In patient 9, skin lesions characteristic of subacute CLE were induced by UVB irradiation in vehicle-treated and untreated areas. However, no skin lesions were induced by UV irradiation in sunscreen-treated areas. Journal of the American Academy of Dermatology 2011 64, 37-48DOI: (10.1016/j.jaad.2009.12.053) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 2 Phototesting results of different cutaneous lupus erythematosus (CLE) subtypes in vehicle-treated, untreated, and sunscreen-treated areas. A, Positive test reactions were induced by ultraviolet (UV) irradiation in vehicle-treated and untreated areas of lupus erythematosus (LE) tumidus (LET), discoid LE (DLE), and subacute CLE (SCLE). There were no significant differences between subtypes of CLE and phototesting results (P = .20), and skin lesions were not significantly more often induced in vehicle-treated areas than in untreated areas (P = 1.00). However, statistical analysis revealed significant differences between sunscreen-treated areas of each CLE subtype and vehicle-treated and untreated areas (P < .001). B, Positive test reactions were induced by UVA and UVB irradiation in vehicle-treated and untreated test areas, respectively. Skin lesions were not significantly more often induced by either wavelength in untreated (P = .69) or vehicle-treated (P = .34) areas. However, statistical analysis revealed significant differences in UVA- and UVB-irradiated sunscreen-treated areas compared with UVA- and UVB-irradiated vehicle-treated and untreated areas (P < .001). ∗P < .001. Journal of the American Academy of Dermatology 2011 64, 37-48DOI: (10.1016/j.jaad.2009.12.053) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 3 Correlations of phototesting results with patient history of photosensitivity and age of disease onset in patients with cutaneous lupus erythematosus (CLE). A, History of photosensitivity was positive in 18 (72%) patients with CLE whereas 7 (28%) patients denied any effect of sun exposure associated with their disease. There were no significant differences between subtypes of CLE and history of photosensitivity (P = 1.00); however, significant differences were found between positive and negative history of photosensitivity in each subtype. In addition, there were no significant differences between history of photosensitivity and phototesting results (P = 1.00); however, positive test reactions were induced by ultraviolet irradiation in 5 (71%) of 7 patients who denied any effect of sun exposure on their disease. B, In 14 patients (56%) with CLE, age at disease onset was less than 40 years; 11 (44%) patients were more than 40 years old at disease onset. Statistical analysis revealed a significant difference (P < .05) between age at disease onset in patients with CLE who were younger than 40 years and older than 40 years with regard to patient history of photosensitivity. DLE, Discoid lupus erythematosus; LET, lupus erythematosus tumidus; SCLE, subacute CLE. ∗P < .05. Journal of the American Academy of Dermatology 2011 64, 37-48DOI: (10.1016/j.jaad.2009.12.053) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 4 Histologic analysis of representative skin biopsy specimens from untreated and sunscreen-treated areas after ultraviolet (UV) irradiation in a patient with cutaneous lupus erythematosus (CLE). In patient 13, skin biopsy specimens were taken 11 days after UVB irradiation from untreated area and sunscreen-treated area of the upper aspect of the back. A, In untreated area, hematoxylin-eosin staining demonstrated characteristic early-stage histologic features of subacute CLE (SCLE) with superficial perivascular infiltrate composed of lymphocytes and neutrophils. B, Vacuolar degeneration of dermoepidermal junction and a few lymphocytes and isolated necrotic keratinocytes were seen at higher magnification. C, In sunscreen-treated area, hematoxylin-eosin staining showed normal-appearing skin apart from discrete perivascular edema and some dilated lymph vessels as a result of UV exposure. D, Higher magnification also demonstrated a normal epidermis and dermoepidermal junction without any characteristic histologic features of SCLE. Journal of the American Academy of Dermatology 2011 64, 37-48DOI: (10.1016/j.jaad.2009.12.053) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions