ORIGINAL ARTICLE

Pinpoint papular polymorphous light eruption in Asian skin: a variant in

darker-skinned individuals
Lynn Y. T. Chiam & Wei-Sheng Chong
National Skin Centre, Singapore

Summary

Key words: Background: Polymorphous light eruption (PMLE) is the most common idiopathic but
papular; pinpoint; polymorphous light probably immunologic photodermatosis and has wide morphological variants.
eruption; Singapore Methods: The photobiological features of all patients diagnosed with the pinpoint papular
variant of PMLE at a tertiary dermatology centre in Singapore over a five-year period were
Correspondence: retrospectively examined.
Lynn Y. T. Chiam, National Skin Centre, 1 Mandalay Results: Twenty-one patients were reviewed from 2003 to 2007. There were 11 (52.4%)
Road, Singapore 308205.
Chinese, four (19%) Malays, five (23.8%) Indians and one (4%) Cambodian. 14 (66.7%)
e-mail: lynnchiam@nsc.gov.sg
were males and seven (33.3%) were females. The face/neck (48%) and arms/forearms
(95%) were most often affected. Nineteen (90.5%) had Fitzpatrick skin phototype IV and
Accepted for publication:
24 September 2008.
two (9.5%) had skin phototype V. Six (28.6%) had decreased minimal erythema dose (MED)
to ultraviolet B (UVB) light only, one (4.8%) had decreased MED to ultraviolet A (UVA) light
Conflicts of interest: only and one had decreased MED to both UVA and UVB. Four patients had photoprovocation
None declared. test done, of which three had positive testing to UVA and one had negative testing to both
UVA and UVB. Two histological subtypes were found in our patients, one showing
perivascular dermatitis and the other consistent with lichen nitidus.
Conclusion: Our data suggest that pinpoint papular PMLE is not uncommon in darker-skinned
individuals in our cohort.

P olymorphic light eruption (PMLE), was first coined by

Haxthausen (1) in 1919 and is the most common of
the idiopathic but probably immunologic photodermatosis. It
erupts hours to days after ultraviolet light (UVL) exposure and
characteristically resolves in seven to ten days. PMLE is more
common in females and has a predilection for the arms,
hands, head and neck regions. It has wide morphological
variants including non-scarring erythematous, pruritic papules,
vesicles, papulovesicles, plaques and nodules. However, a variant
commonly coined by most authors as the ‘pinpoint papular’
variant of PMLE, has been increasingly described in the literature,
manifesting as very tiny pin-head sized, whitish, skin-colored or
slightly erythematous papules, very often mimicking lichen
nitidus. In this study, we examine the photobiological
characteristics of this pinpoint papular variant in Asian patients
seen at the National Skin Centre, Singapore.
Materials and methods
Of the 113 patients with a suspected diagnosis of PMLE seen at
the National Skin Centre, Singapore between January 1, 2003
and December 31, 2007, 71 (62.8%) were agreeable for
phototesting. This is a retrospective analysis conducted of the
records of all 21 patients who were phototested and diagnosed
with pinpoint papular PMLE during the above-mentioned
period. The biodata, duration between onset of symptoms
and diagnosis, duration between sun exposure and onset of
pinpoint papular PMLE, results of phototesting, treatment and
response of each case were recorded for further analysis.
Phototesting was conducted using the following light sources:
a Kindermann slide projector equipped with a 150 W light bulb
(Ochsenfurt, Germany) for visible light, a Supuvasun Mutzhas
3000 high-pressure metal-halide source (spectral output
350–450 nm, peak 370–385 nm) (Munich, Germany) for UVA,
and a Dermaray M-DMR-100 bank of seven fluorescent bulbs
(FL20S E-30/DMR 305 nm, emission spectrum 290–390 nm,
peak 305 nm) (Eisai, Tokyo, Japan) for UVB. The patients’
buttocks were exposed to increasing doses of UV radiation. For
UVA, radiation doses ranged in geometric progression from 25
to 100 J/cm2 (irradiance 24 mW/cm2 at 21 cm distance) and for
UVB, 30–200 mJ/cm2 (irradiance 1 mW/cm2 at 30 cm
distance). The patients’ inner forearms were exposed to visible
light emitted from the slide projector placed at a distance of
10 cm. The minimal erythema dose (MED) responses for UVA
and UVB were documented 24 h after phototesting.
Monochromatic phototesting was not available at our centre.

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Chiam & Chong
For the photoprovocation test, the dorsal surfaces of the
forearms or hands were irradiated. The size of the test field
measured 5  8 cm2. The dose of UVA irradiated daily was 1.5
times the MED over 3–4 consecutive days and UVB dose
irradiated daily was 1.5 times the MED over 3–4 consecutive
days. Reading was done 24–72 h after irradiation.
Results
The diagnosis of PMLE was made based on the history,
morphology of the lesions, results of phototesting and skin
biopsy if available. Of a total of 71 patients who were diagnosed
with PMLE and had phototesting between January 1, 2003 and
December 31, 2007, 21 had pinpoint papular PMLE, constituting
29.6%. Fourteen (66.7%) were males and seven (33.3%) were
females. The mean age of presentation at our centre was 28 years
(ages ranged from 13 to 53 years). Eleven (52.4%) were Chinese,
four (19%) were Malays, five (23.8%) were Indians and one
(4.8%) was Cambodian.
The location of pinpoint papular PMLE varied. In our series,
10 (48%) had lesions on the face/neck (Fig. 1), 20 (95%) had
lesions on their arms/forearms, two (9.5%) had lesions on their
lower limbs and one (4.8%) had lesions on the trunk. Thus the
most common sites of involvement were the arms/forearms and
the face/neck.
The duration of disease at presentation ranged from 0.5 months
to 120 months. The length of sun exposure required for the
appearance of pinpoint papular PMLE ranged from 30 min to 8 h.
Fig. 1. Pinpoint papular Polymorphous light eruption (PMLE) on the
forearm.
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An analysis of the Fitzpatrick’s skin phototype revealed the
following: 19 (90.5%) were of skin phototype IV and two
(9.5%) were of skin phototype V.
Laboratory tests were carried out in all patients diagnosed to
have pinpoint papular PMLE to exclude underlying or associated
photosensitive disorders. In all 21 patients, antinuclear antibodies
were negative. Extractable nuclear antibody testing was not
performed for our patients. Of the 13 patients tested for serum/
urine porphyrins, all had negative results. For normal subjects with
skin type IV and V in our local Asian population, the MED to UVA
and UVB is 100 J/cm2 and 100 mJ/cm2, respectively. Eight
patients had decreased MED to UVA and/or UVB. Of these, six
(28.6%) had decreased MED to UVB only while one (4.8%) had
decreased MED to UVA only and one (4.8%) had decreased MED
to both UVA and UVB. The MED to UVA ranged from 30 to
75 J/cm2 and the MED to UVB ranged from 30 to 95 mJ/cm2 for
our patients. Four patients had photoprovocation test done, of
which three had positive testing to UVA (Fig. 2) and one had
negative testing to both UVA and UVB.
Six patients had biopsy of their lesions performed, of which
five showed superficial perivascular dermatitis (Fig. 3) while one
showed histology consistent with lichen nitidus (Fig. 4).
All patients with pinpoint papular PMLE were treated with
advice on sun avoidance and sun protection, broad-spectrum
sunscreens and topical corticosteroids. None of the patients
required phototherapy or systemic therapy. The majority
(61.9%) reported significant improvement in their symptoms.
Fig. 2. Positive photoprovocation test to ultraviolet A (UVA).
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Fig. 3. Hematoxylin–eosin stain; 40x magnification showing
perivascular lymphocytic infiltrate.
Fig. 4. Hematoxylin–eosin stain; 60x magnification showing a focal
infiltrate of lymphocytes and histiocytes with claw-like extension of the
epidermal rete ridges at the lateral boundaries.
Discussion
PMLE is the most common chronic idiopathic but probably
immunologic photosensitivity disorder. Prevalence is estimated
anywhere from 10% to 20% depending on geographical
location, with a genetic predisposition from 5% to 45% (2).
The majority of cases arise within the first three decades and
there is a slight female preponderance. The lesions develop within
hours to days following sun exposure and are more common on
the sun-exposed areas of the neck and arms. They typically resolve
within a week. Pruritus is a common symptom in PMLE.
The classical prototype of PMLE presenting with erythematous
papules and plaques has been found to be common in fairer-
skinned individuals with skin phototype I–III (3) although Kerr
and Lim had reported that PMLE may be common in darker-
skinned individuals as well (4). However, the pinpoint papular
variant of PMLE has been notably found exclusively in darker-
skinned individuals with skin phototype IV–VI (5).
At the National Skin Centre, Singapore, over a five-year period
(from 2003 to 2007), pinpoint papular PMLE represented not an
uncommon variant of PMLE, accounting for almost a third
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Journal compilation r 2009 Blackwell Munksgaard  Photodermatology, Photoimmunology & Photomedicine 25, 71–74
Pinpoint papular polymorphous light eruption in Asian skin
(29.6%) of all PMLE patients who had phototesting was
performed. However, as the patients included in this study were
from the pool of patients who had phototesting performed,
this percentage may or may not be representative of all patients
with PMLE. In our series, we had more males as compared with
females with a ratio of 2 : 1. The majority of our patients were
below 30 years of age. The possible explanation for a greater
proportion of males in our study could be due to the following
reasons. Firstly, males in our society participate more in outdoor
activities and thus have greater exposure to sunlight. Secondly,
all Singaporean males have to serve National Service in the
Singapore Armed Forces and thus have greater exposure to sun-
light. And lastly, most men serving National Service are between
18–20 years of age, thus accounting for the relatively young
mean age of our cohort.
More than 50% of our patients had normal phototest results,
which is consistent with other reports where the majority of pati-
ents with PMLE had normal MED to UVA and UVB. Interestingly,
the majority of our patients who had abnormal phototest results
had reduced MED to UVB only. This is in contrast to other reports
on patients with PMLE where among those with abnormal
phototest results, the decreased MED is to UVA mainly (6–8). Our
findings are also consistent with a previous report by Kontos et al.
(5), which indicated that in individuals with highly pigmented
skin (phototype IV–VI); PMLE may manifest as a ‘pinpoint’ variant.
Although, the majority of our patients with abnormal phototest
results had reduced MED to UVB, the results of photo-
provocation test showed positive results to UVA only. This discre-
pancy may be related to the possibilities of a relatively inadequate
exposure time and irradiation dose of UVB. Nevertheless, the
positive testing to UVA in our cohort is consistent with previous
reports of UVA being the main provocating wavelength in PMLE.
Bansal et al. (9) reported two histological subtypes of patients
with this ‘pinpoint’ variant of PMLE. The acute lesions (biopsy
done at 0–3 days) showed focal vesicular formation, spongiosis,
oedema, red blood cell extravasation and a superficial and
deep perivascular and interstitial lymphocytic infiltration with
occasional eosinophils. The subacute lesions (biopsy done at
1–4 weeks) showed parakeratosis, atrophic epidermis overlying a
sharply demarcated lichenoid infiltrate comprising lymphocytes
and histiocytes, a claw-like extension of epidermal rete ridges
forming the lateral boundaries of the lesion and an accompanying
perivascular chronic inflammatory lymphocytic infiltrate.
Six of our patients had biopsy of their lesions performed. Five
showed superficial perivascular dermatitis while one showed
histology consistent with lichen nitidus. Thus the histology of
our patients’ lesions correlated with the previous published
findings. However, as this is a retrospective analysis, we are
unable to comment on the association of the histological subtype
and the time pertaining to the acuteness or subacuteness of the
lesions when the biopsy was taken.
Conclusion
Pinpoint papular PMLE is not an uncommon variant of PMLE in
our cohort, accounting for 29.6% of all cases, which were
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Chiam & Chong
phototested. It is seen mainly in darker-skinned individuals of
skin type IV–V in our cohort with a propensity to affect young
males. Majority of our patients who had abnormal phototest
results had reduced MED to UVB only. However, among those
who had positive photoprovocation test, the results were positive
to UVA only. Two histological subtypes were found in our
patients: superficial perivascular dermatitis and lichen nitidus.
The vast majority of our patients had good clinical response to
sun avoidance and sun protection, broad-spectrum sunscreens
and topical corticosteroids.
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