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Indian J Dermatol
Indian J Dermatol
IJD
Indian J Dermatol
Indian Journal of Dermatology
0019-5154
1998-3611
Wolters Kluwer - Medknow India

IJD-69-357
10.4103/ijd.ijd_254_23
Correspondences
The Role of Dermoscopy and Teledermatology in a Case of Erythema Ab Igne Coexisting with Acute Radiation Dermatitis
Lakshmi Basavaraju S.
Ashwini Shankar B.
Ranugha P S S
Kanthraj Garehatty R.
From the Department of Dermatology, Venereology and Leprosy, JSS Medical College and Hospital, JSS Academy of Higher Education and Research (JSSAHER) (Deemed to be University), Mysuru, Karnataka, India E-mail: kanthacad@yahoo.com
Jul-Aug 2024
19 8 2024
69 4 357359
3 2023
4 2024
Copyright: © 2024 Indian Journal of Dermatology
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
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pmcDear Editor,

Radiodermatitis is a cutaneous reaction to ionizing radiation exposure, which varies from mild erythema to severe reactions, such as dry or moist desquamation. This reaction is commonly reported in cancer patients who undergo irradiation of the regions of the head and neck, breast, and pelvis, whose skin is part of the target irradiation area.[1]

Erythema ab igne (EAI) is a persistent, chronic skin condition resulting from prolonged exposure to infrared radiation, experienced as heat. It is characterized by a reticulated pattern of erythema and hyperpigmentation. Once associated with traditional warming sources, such as wood-burning stoves or open fires, modern, infrared exposure originates also from newer devices, such as laptops and heating pads, and may be creating a rebound of EAI.[2]

We report a case of acute radiation dermatitis superimposed on EAI over the lower back in an elderly man with lung carcinoma and bone metastasis in the fifth lumbar vertebra. Dermoscopy aided the diagnosis and he was successfully treated, followed up with patient-assisted teledermatology.

A 67-year-old man, a biopsy-proven case of adenocarcinoma of lungs on Tab. Afatinib since 1 year presented to the Oncology Department with right lower limb pain and backache. As the CT scan and MRI showed a lung lesion with bone metastasis (L5), radiotherapy was administered to L5, sacroiliac joint at a dose of 30 gray in 10 fractions (3DCRT) of energy 6mV, daily for 10 days as a palliative therapy. The patient presented to us 5 days later with asymptomatic lesions over the lower back. On examination, reticulate pigmentation with diffuse erythema was seen over the left and mid-gluteal region while diffuse brown pigmentation was seen over the right gluteal region. A few erosions with scaling and crusting were also present [Figure 1a]. The patient has a history of using hot water bags on the lower back to relieve pain.

Figure 1 (a) Erythematous to hyperpigmented patches over the lower back with erosions and crusting. (b) Resolved erythema ab igne. Image sent by the patient’s attender using the mobile messenger app Whatsapp

Dermoscopy from the lesion over the left gluteal region revealed diffuse erythema, white scaling, and reticulate brown pigmentation [Figure 2a], and from the hyper-pigmented patch over the right side, multiple white dots (eccrine openings), perifollicular hyperpigmentation and scaling were noted [Figure 2b].

Figure 2 Dermoscopic findings. (a) Blue arrow: Brownish reticulate erythematous to hyperpigmented patch. Green arrow: white scaling. (b) Blue arrow: White dots (eccrine openings). Green arrow: perifollicular hyperpigmentation

It was diagnosed as acute radiation dermatitis superimposed on EAI given the patient’s history of persistent skin exposure to localized heat with hot water bags and radiotherapy. Clinical examination and dermoscopy confirmed our diagnosis.

The patient was advised to stop the use of hot water bags. A topical antibacterial for erosions and emollient was prescribed. The patient’s attendee was asked to send serial images once a week using the mobile messenger app WhatsApp (WhatsApp Inc, California, USA) as the patient was immobile, and we compared it to the images taken at baseline and assessed for improvement. After 2 weeks, the lesions had healed with hyper- and hypopigmented patches [Figure 1b].

EAI presents initially as transient, blanchable erythema in a reticular pattern followed by progression to reticulate hyperpigmentation. Epidermal atrophy and telangiectasias may be seen in chronic cases. Frequency, exposure time, and heat source temperature influence the development of EAI, which may develop from 2 weeks to a few months.[2] In our case, the patient developed EAI after a month of continual use of hot water bags. The absence of telangiectasias and atrophy could be because of a short duration of heat exposure.

In acute radiation dermatitis, erythema develops as a response to skin basal layer damage and as a consequence of an inflammatory process that initiates histamine release and hypervascularity.[1] The presentation of acute radiation dermatitis varies from faint or dull erythema (grade 1) to ulceration and necrosis (grade 4) according to RTOG (Radio Therapy Oncology Group). Grade 1 radiation dermatitis presents with follicular, faint or dull erythema/epilation/dry desquamation/decreased sweating.[3] Our patient had faint erythema with dry desquamation in the form of scaling and perifollicular hyperpigmentation corresponding to grade 1 acute radiation dermatitis 5 days after completion of radiotherapy.

There is a paucity of literature on dermoscopy of both EAI and acute radiation dermatitis. Dermoscopic features of EAI include diffuse brownish pigmentation, telangiectatic vessels and whitish scaling.[4] However, in our patient, brownish reticulate pigmentation and white scaling were seen as suggestive of EAI. In acute radiation dermatitis perifollicular hyperpigmentation, scaling, and honeycomb pigment patterns are seen on dermoscopy.[1] In our case, diffuse erythema, perifollicular hyperpigmentation and scaling were present. Dermoscopy confirmed the co-localization of both EAI[5] and acute radiation dermatitis[6] in our case.

Furthermore, teledermatology practice is an effective, safe, and fast medium to reach one who is difficult to reach.[7] We provided tele-follow up care and counselling to avoid in-person visits as the patient was immobile.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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