Diagnosis at first sight
Sunburn despite sunscreen
Quemaduras solares a pesar de protección solar
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Madeleine Di Frisco, José Luis del Pozo" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Miguel" "apellidos" => "Sogbe" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">♢</span>" "identificador" => "fn0005" ] ] ] 1 => array:4 [ "nombre" => "Andrés" "apellidos" => "Blanco-Di Matteo" "email" => array:1 [ 0 => "ablancod@unav.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">♢</span>" "identificador" => "fn0005" ] ] ] 2 => array:3 [ "nombre" => "I. Madeleine" "apellidos" => "Di Frisco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "José Luis" "apellidos" => "del Pozo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas y Microbiología, Clínica Universidad de Navarra, Pamplona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina Interna, Clínica Universidad de Navarra, Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Neumología, Clínica Universidad de Navarra, Pamplona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Quemaduras solares a pesar de protección solar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 542 "Ancho" => 755 "Tamanyo" => 73132 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">First- and second-degree burns on the back of both hands.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 90-year-old man with a medical history of high blood pressure, hypercholesterolaemia and a pacemaker for third-degree atrioventricular block who attended Accident & Emergency with a two-day history of fever of up to 38<span class="elsevierStyleHsp" style=""></span>°C associated with oedema in the lower limbs and dyspnoea on minimal exertion, with orthopnoea and paroxysmal nocturnal dyspnoea. In the initial assessment, he was found to be haemodynamically stable, with fever of 38.1<span class="elsevierStyleHsp" style=""></span>°C and oxygen saturation of 90% on room air. Auscultation of the heart revealed a holosystolic murmur at the left sternal border, while lung auscultation identified crackles up to the middle lung fields, and the patient had pitting oedema in the lower limbs up to his knees. Given the findings of heart failure, he was admitted to hospital. Methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span> was isolated in two out of two blood cultures of samples taken in Accident and Emergency. Tests were completed with a transthoracic echocardiogram, which revealed vegetation on the pacemaker lead. He was treated with oxacillin for six weeks. Due to the high surgical risk and life-threatening situation, a multidisciplinary meeting decided on suppressive therapy with doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h, for which he was advised to wear sun protection with sunscreen and clothing covering his arms and legs. The sun protection used by the patient contained oxybenzone as sunscreen. One week after starting the treatment and using the recommended sun protection, the patient noticed a burning sensation and erythema on his scalp and hands. The erythema became worse and blisters appeared on his hands, with pain ranging from moderate to severe. Physical examination showed first- and second-degree burns on the patient's scalp (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and the back of both hands (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patient was subsequently diagnosed with doxycycline-induced phototoxicity.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Progress</span><p id="par0010" class="elsevierStylePara elsevierViewall">The doxycycline was reduced to 100<span class="elsevierStyleHsp" style=""></span>mg once a day. He was advised to limit sun exposure time, use a sunscreen with zinc oxide and wear a hat. The patient made a full recovery, with no residual pigmentation.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Closing remarks</span><p id="par0015" class="elsevierStylePara elsevierViewall">The main dermatological side effect of doxycycline is photosensitivity. After 24<span class="elsevierStyleHsp" style=""></span>h of intense sun exposure, a burning sensation is felt and erythema appears on the exposed areas<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Slightly palpable erythematous plaques then appear, possibly accompanied by small papules<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. In severe cases, up to 80% of the body may be affected<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. The symptoms resolve within 10–14 days after stopping the treatment and avoiding exposure to the sun<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Layton and Cunliffe<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> treated 106 patients with acne with doxycycline (150 or 200<span class="elsevierStyleHsp" style=""></span>mg/day) for two years; 20% of those treated with 150<span class="elsevierStyleHsp" style=""></span>mg of doxycycline/day and 42% who received 200<span class="elsevierStyleHsp" style=""></span>mg/day developed phototoxicity. The authors concluded that it was a dose-dependent effect. In the case we present here, the patient developed phototoxicity despite following sun protection measures. Oxybenzone absorbs radiation in the 340<span class="elsevierStyleHsp" style=""></span>nm–360<span class="elsevierStyleHsp" style=""></span>nm wavelength region, while the wavelength associated with doxycycline phototoxicity is UVA 1, which fluctuates between 340<span class="elsevierStyleHsp" style=""></span>nm and 400<span class="elsevierStyleHsp" style=""></span>nm, meaning the protection provided to the patient is inadequate, and that may explain the burns despite following the sun protection recommendations. We believe that this case puts the spotlight on an important factor to be taken into account to avoid an adverse effect that is widely known by clinicians. There is some debate about oxybenzone in terms of repercussions on health, because <span class="elsevierStyleItalic">in vitro</span> it has anti-androgenic and pro-oestrogenic effects, and skin absorption has also been demonstrated. As a result, some consider it to be a disruptive chemical for the endocrine system. However, as absorption is limited, it probably does not represent a risk. It has also been demonstrated that oxybenzone dissolved in the sea is toxic to corals.</p><p id="par0020" class="elsevierStylePara elsevierViewall">One strategy for promoting adherence to the recommendation on using sunscreens that may effectively prevent doxycycline photosensitivity is to use sunscreens labelled as “coral-friendly” or “ocean-friendly”. However, in addition to sun protection creams, sun-safe behaviour and wearing clothing that prevents further exposure are useful tools in preventing phototoxicity<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a>.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0025" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">José Luis del Pozo has participated in training or consulting activities funded by Pfizer, MSD, Gilead and Novartis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The other authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Progress" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Closing remarks" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "♢" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">They share the main authorship of this article.</p>" "identificador" => "fn0005" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1302 "Ancho" => 755 "Tamanyo" => 137560 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">First- and second-degree burns on the scalp.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 542 "Ancho" => 755 "Tamanyo" => 73132 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">First- and second-degree burns on the back of both hands.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phototoxicity of doxycycline: a systematic review on clinical manifestations, frequency, cofactors, and prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Goetze" 1 => "C. Hiernickel" 2 => "P. Elsner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000458761" "Revista" => array:6 [ "tituloSerie" => "Skin Pharmacol Physiol." "fecha" => "2017" "volumen" => "30" "paginaInicial" => "76" "paginaFinal" => "80" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28291967" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phototoxic eruptions due to doxycycline—a dose-related phenomenon" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.M. Layton" 1 => "W.J. Cunliffe" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.1993.tb02242.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol." "fecha" => "1993" "volumen" => "18" "paginaInicial" => "425" "paginaFinal" => "427" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8252763" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendation: daily sun protection in the prevention of chronic UV-induced skin damage" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Elsner" 1 => "E. Hölzle" 2 => "T. Diepgen" 3 => "S. Grether-Beck" 4 => "H. Hönigsmann" 5 => "J. Krutmann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1610-0387.2007.06099.x" "Revista" => array:6 [ "tituloSerie" => "J Dtsch Dermatol Ges." "fecha" => "2007" "volumen" => "5" "paginaInicial" => "166" "paginaFinal" => "173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17274786" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/2529993X/0000004100000006/v2_202311091242/S2529993X22003124/v2_202311091242/en/main.assets" "Apartado" => array:4 [ "identificador" => "63560" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Diagnosis at first sight" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/2529993X/0000004100000006/v2_202311091242/S2529993X22003124/v2_202311091242/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X22003124?idApp=UINPBA00004N" ]
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