Síndrome del bebe bronceado, una complicación impredecible de la fototerapia / Bronze baby syndrome, an unpredictable complication of phototherapy: A case report

Resumen El síndrome del bebe bronceado es una rara discromía que se presenta como una complicación de la fototerapia en recién nacidos con ictericia neonatal. Aunque el fenotipo común se ha descrito en pacientes con hiperbilirrubinemia directa secundaria a colestasis, también se conocen casos con hiperbilirrubinemia indirecta en quienes se invierte el patrón de hiperbilirrubinemia e, incluso, otros con hiperbilirrubinemia indirecta aislada. La fisiopatología de la enfermedad sigue siendo motivo de controversia, por lo que no se ha establecido claramente cuál es la mejor aproximación diagnóstica y terapéutica. En general, el síndrome se considera leve y se resuelve con la suspensión de la fototerapia; no suele prolongarse más allá del periodo neonatal y no tiene secuelas a largo plazo. Sin embargo, su aparición constituye una contraindicación absoluta para continuar la fototerapia. En caso de persistir, se recomienda disminuir los niveles de bilirrubina y recurrir a la exanguinotransfusión, pero dado que esta implica riesgos para el neonato, una conducta adecuada sería suspender la fototerapia y reiniciarla si la bilirrubina directa disminuye y se ha descartado el compromiso colestásico, aunque siempre evaluando en forma seriada posibles manifestaciones de encefalopatía aguda por bilirrubina. El objetivo de este estudio fue presentar el caso de un recién nacido con incompatibilidad de grupo sanguíneo ABO que presentó el síndrome del bebé bronceado. El bebé respondió satisfactoriamente a la suspensión de la fototerapia y a su posterior reanudación, sin necesidad de recurrir a la exanguinotransfusión.

Abstract The bronze baby syndrome is an infrequent dyschromia resulting from phototherapy in newborn babies with neonatal jaundice. Even though the common phenotype has been described in patients with direct neonatal hyperbilirubinemia secondary to cholestasis, several cases of patients with indirect neonatal hyperbilirubinemia who have managed to reverse it have been reported, as well as patients with isolated hyperbilirubinemia. Currently, the physiopathology of this condition is still a subject of controversy and, therefore, there is a lack of clear conducts for its correct diagnosis and treatment. Generally, this syndrome has been considered as a mild condition that is resolved with the suspension of phototherapy. Its duration is usually not greater than the neonatal period, and it has no long-term sequelae. However, its occurrence is considered an absolute contraindication for the continuation of phototherapy. In case of persistence, the recommendation is to decrease bilirrubin levels and proceed with exchange transfusion; this procedure, however, represents risks for the newborn, so our recommendation is to suspend phototherapy and reinitiate it if the direct bilirrubin value decreases, and cholestasis compromise has been discarded. Serial evaluations of acute encephalopathy caused by bilirrubin are absolutely recommended. The objective of this paper was to describe the case of a newborn with ABO incompatibility who developed the bronze baby syndrome. This patient responded satisfactorily to the suspension and resumption of phototherapy without exchange transfusion.

Pigment Deposition of Cosmetic Contact Lenses on the Cornea after Intense Pulsed-Light Treatment

We report a case of corneal deposition of pigments from cosmetic contact lenses after intense pulsed-light (IPL) therapy. A 30-year-old female visited our outpatient clinic with ocular pain and epiphora in both eyes; these symptoms developed soon after she had undergone facial IPL treatment. She was wearing cosmetic contact lenses throughout the IPL procedure. At presentation, her uncorrected visual acuity was 2/20 in both eyes, and the slit-lamp examination revealed deposition of the color pigment of the cosmetic contact lens onto the corneal epithelium. We scraped the corneal epithelium along with the deposited pigments using a no. 15 blade; seven days after the procedure, the corneal epithelium had healed without any complications. This case highlights the importance of considering the possibility of ocular complications during IPL treatment, particularly in individuals using contact lenses. To prevent ocular damage, IPL procedures should be performed only after removing the lenses and applying eyeshields.

Fototerapia simples versus dupla no tratamento de recém-nascidos a termo com hiperbilirrubinemia não-hemolítica / Single vs. double phototherapy in the treatment of full-term newborns with nonhemolytic hyperbilirubinemia

OBJETIVO: Comparar a eficácia da fototerapia simples (1 painel) versus dupla (2 painéis) na redução da hiperbilirrubinemia não-hemolítica em recém-nascidos a termo. MÉTODOS: Os recém-nascidos a termo foram randomizados prospectivamente para receber fototerapia simples ou dupla. Os níveis de bilirrubina foram medidos no momento da internação e em intervalos de 12 horas, assim como em seguimento 48 horas após a alta. RESULTADOS: Trinta e sete pacientes receberam fototerapia simples, e 40, dupla. A redução média dos níveis de bilirrubina nas primeiras 24 horas de tratamento foi maior no grupo que recebeu fototerapia dupla (5,1±2,2 mg/dL versus 4,3±2,1 mg/dL), porém sem significância estatística (p = 0,18). As taxas de readmissão foram similares e nenhum dos grupos apresentou efeitos adversos. CONCLUSÃO: A fototerapia dupla não foi mais eficaz do que a fototerapia simples no tratamento da hiperbilirrubinemia não-hemolítica em recém-nascidos a termo. Entretanto, nossos resultados sugerem que a fototerapia dupla possa ser mais eficaz em recém-nascidos a termo com níveis de bilirrubina mais altos no momento da internação.

OBJECTIVES: To compare the effectiveness of single (1 panel) vs. double (2 panels) phototherapy in reducing nonhemolytic hyperbilirubinemia in term newborns. METHODS: Term newborns with hyperbilirubinemia were prospectively randomized to receive double or single phototherapy. Bilirubin levels were measured at admission and at 12-hour intervals, as well as at a follow-up 48 hours after discharge. RESULTS: Thirty-seven patients received single and 40 double phototherapy. The mean decrease in bilirubin level in the first 24 hours of treatment was greater in the double phototherapy group (5.1±2.2 mg/dL vs. 4.3±2.1 mg/dL), but without statistical significance (p = 0.18). Readmission rates were similar and no adverse effects were found in either group. CONCLUSIONS: Double-surface was not more effective than single-surface phototherapy in the treatment of nonhemolytic hyperbilirubinemia in term newborns. However, our results suggest that double phototherapy may be more effective in those term newborns with higher bilirubin levels at admission.

Nuestra experiencia en luz pulsada intensa / Our experience in IPL

Objetivos: Evaluar eficacia y efectos adversos de luz pulsada intensa en fotoenvejecimiento, alteraciones vasculares y depilación. Diseño: Estudio observacional, prospectivo, longitudinal, descriptivo. Métodos: se analizaron 158 pacientes. Se confeccionó una ficha para cada paciente que consignaba datos de : sexo, edad fototipo, etnia, número de sesiones, datos específicos de equipo, efectos adversos y respuesta terapéutica. La respuesta terapéutica estaba subdividida a su vez en mala, buena y muy buena. Se realizaron fotografías digitales pre y postratamiento. Resultados: La respuesta terapéutica a nivel de fotodaño fue catalogada como buena en un 43% y muy buena en el 55%. Las reacciones adversas referidas fundamentalmente fueron dolor y ardor. Respecto a lesiones vasculares, la respuesta fue consignada como buena en un 50% y muy buena en el 42,3%. La principal reacción adversa relatada fue dolor. Se realizaron procedimientos de fotodepilación en 29 pacientes; la principal región anatómica involucrada fue el tercio inferior de rostro. De los pacientes sometidos a este procedimiento, 86% de ellos presentaron resultados muy buenos. La tolerancia al procedimiento fue buena en más de 70%, el número de sesiones variaron en un rango de 1 a 3. Conclusión: La LPI es una modalidad, segura y efectiva para fotoenvejecimiento, lesiones vasculares y tofodepilación, con escasos efectos adversos.

Fototerapia causa danos ao DNA de leucócitos mononucleares periféricos em recém-nascidos a termo / Phototherapy causes DNA damage in peripheral mononuclear leukocytes in term infants

OBJETIVO: Determinar se a fita de DNA de leucócitos mononucleares endógenos é alvo de fototerapia. MÉTODOS: O estudo incluiu 65 recém-nascidos a termo com idades entre 3 e 10 dias que haviam sido expostos a fototerapia intensiva (n = 23) ou convencional (n = 23) por pelo menos 48 horas devido à icterícia neonatal, além de um grupo controle (n = 19). Dano ao DNA foi avaliado por eletroforese alcalina em gel de célula única (ensaio cometa). A capacidade antioxidante total plasmática e os níveis de estado oxidativo total também foram medidos, e a correlação entre danos ao DNA e estresse oxidativo foi investigada. RESULTADOS: Os valores médios de escores de danos ao DNA nos grupos de fototerapia intensiva e convencional foram significativamente maiores do que os do grupo controle (p < 0,001). Os valores médios e desvio padrão foram 32 (9), 28 (9), 21 (7) unidades arbitrárias, respectivamente. Os níveis de estado oxidativo nos grupos de fototerapia intensiva e convencional foram significativamente maiores do que os do grupo controle (p < 0,005). Os valores médios (desvio padrão) foram 18, 1 (4,2), 16.9 (4,4), 13,5 (4,2) µmol H2O2 equivalente/L, respectivamente. De maneira semelhante, os níveis de estresse oxidativo nos grupos de fototerapia intensiva e convencional foram significativamente maiores do que os do grupo controle (p = 0,041). A capacidade antioxidante total plasmática e os níveis de bilirrubina total não diferiram entre os grupos (p > 0,05). Não houve correlações significativas entre escores de danos ao DNA e bilirrubina, estado oxidante total e níveis de estresse oxidativo entre os grupos de fototerapia (p > 0,05). CONCLUSÕES: Tanto a fototerapia intensiva quanto a convencional causam danos ao DNA dos leucócitos mononucleares endógenos em recém-nascidos a termo com icterícia.

OBJECTIVE: Our aim was to determine whether endogenous mononuclear leukocyte DNA strand is a target of phototherapy. METHODS: The study included 65 term infants aged between 3-10 days that had been exposed to intensive (n = 23) or conventional (n = 23) phototherapy for at least 48 hours due to neonatal jaundice, and a control group (n = 19). DNA damage was assayed by single-cell alkaline gel electrophoresis (comet assay). Plasma total antioxidant capacity and total oxidant status levels were also measured, and correlation between DNA damage and oxidative stress was investigated. RESULTS: Mean values of DNA damage scores in both the intensive and conventional phototherapy groups were significantly higher than those in the control group (p < 0.001). Mean values and standard deviation were 32 (9), 28 (9), 21 (7) arbitrary unit, respectively. Total oxidant status levels in both the intensive and conventional phototherapy groups were significantly higher than those in the control group (p = 0.005). Mean (standard deviation) values were 18.1 (4.2), 16.9 (4.4), 13.5 (4.2) µmol H2O2 equivalent/L, respectively. Similarly, oxidative stress index levels in both the intensive and conventional phototherapy groups were significantly higher than those in the control group (p = 0.041). Plasma total antioxidant capacity and total bilirubin levels did not differ between the groups (p > 0.05). There were no significant correlations between DNA damage scores and bilirubin, total oxidant status and oxidative stress levels in either phototherapy group (p > 0.05). CONCLUSIONS: Both conventional phototherapy and intensive phototherapy cause endogenous mononuclear leukocyte DNA damage in jaundiced term infants.

Aplicações da fototerapia na dermatologia / Applications of the phototherapy in the dermatology

A fototerapia é uma importante modalidade terapêutica utilizada na dermatologia, que se baseia no controle ou regressão de diversas dermatoses através da interação entre a radiação ultravioleta e a pele. Este artigo versará sobre o conceito de fototerapia, as fontes de radiação ultravioleta, a fotobiologia, os tipos, as indicações, os efeitos adversos e as contra-indicações desse tratamento.

Estado oxidante/antioxidante total em recém-nascidos ictéricos antes e depois da fototerapia / Total oxidant/antioxidant status in jaundiced newborns before and after phototherapy

OBJETIVO: Avaliar o efeito da fototerapia no estado oxidante e antioxidante no soro de recém-nascidos a termo com hiperbilirrubinemia. MÉTODO: Trinta e quatro recém-nascidos a termo com idades entre 3 e 10 dias submetidos a fototerapia foram avaliados. O estado antioxidante do soro foi determinado pela capacidade antioxidante total e por componentes antioxidantes individuais: vitamina C, ácido úrico, albumina, concentração de tiol e bilirrubina total. O estado oxidante foi avaliado através do estado oxidante total, índice de estresse oxidativo e componentes oxidantes individuais: malondialdeído e níveis de hidroperóxido lipídico. RESULTADOS: As concentrações de vitamina C, ácido úrico, bilirrubina total e malondialdeído foram significativamente mais baixas, enquanto que o estado oxidante total, níveis de hidroperóxido lipídico e o índice de estresse oxidativo foram significativamente maiores após a fototerapia (p < 0,05). Houve correlações positivas significativas entre a bilirrubina sérica total e a concentração de malondialdeído (r = 0,434, p = 0,001). CONCLUSÕES: Embora a concentração de malondialdeído tenha diminuído após a fototerapia, esta exerce um efeito negativo sobre as diversas partes do sistema de defesa oxidante/antioxidante em recém-nascidos a termo ictéricos, expondo-os a um possível estresse oxidativo.

OBJECTIVE: To assess the effect of phototherapy on serum oxidant and antioxidant status in hyperbilirubinemic full-term newborns. METHOD: Thirty-four full-term infants from 3 to 10 days of age exposed to phototherapy were studied. The serum antioxidant status was assessed by measuring the total antioxidant capacity (TAC) and individual antioxidant components: vitamin C, uric acid, albumin, thiol contents and total bilirubin. The oxidant status was assessed by determining the total oxidant status (TOS), oxidative stress index (OSI) and individual oxidant components: malondialdehyde (MDA), and lipid hydroperoxide levels. RESULTS: Vitamin C, uric acid, total bilirubin and MDA concentration were significantly lower, whereas serum TOS, lipid hydroperoxide and OSI levels were significantly higher after phototherapy (p < 0.05). There were significant positive correlations between serum total bilirubin and MDA (r = 0.434, p = 0.001). CONCLUSIONS: Although the MDA level was reduced after phototherapy, phototherapy has a negative impact on numerous parts of the oxidant/antioxidant defense system in jaundiced full-term newborns, exposing them to potential oxidative stress.

Determining the efficacy of erythromycin ointment 0.5% in protection of conjunctivitis in neonates under phototherapy with eye patches

Ophthalmia neonatorum is a form of conjunctivitis that occurs in infants younger than 4 weeks of age. It is the most common eye disease in newborns. It presents as the inflammation of mucous membrane lining posterior layer of eyelids and bulbar part of eyeball except cornea. It's complications are corneal ulcer, corneal perforation and blindness. The aim of this randomised clinical trial was to investigate the effect of erythromycin ointment 0.5% to prevent the incidence of conjunctivitis in icteric neonates who were under phototherapy with eye patches. A total of 200 cases of icteric newborns in Javaheri hospital who admitted for phototherapy were considered. Neonatal conjunctivitis was not correlated with gestational age, duration of admission, type of delivery, and weight. It was not associated with erythromycin use, however, there was a significant association between conjunctivitis and age of newborn. Results showed that erythromycin ointment is not useful for protecting conjunctivitis in neonates under phototherapy with eye patches

Evaluation of efficacy and complication between three mode of phototherapy

Even though phototherapy has been used for more than 30 years, reports of significant toxicity are rare. Phototherapy is highly effective method for preventing and treating hyperbilirubinemia. A prospective study was performed in 200 neonates with hyperbilirubinemia in Children's Medical Center, Tehran. Complications of phototherapy [weight loss, fever, loose stool, Hypocalcaemia, thrombocytopenia] were evaluated. There was a positive relation between efficacy and irradiance but complications were not different. Hypocalcaemia, thrombocytopenia and loose stool [P<0/05] were found. Intensive phototherapy and double phototherapy were more effective than single phototherapy. There was no relation between mode of phototherapy and complications

Lâmpadas azuis especiais (monocromáticas) causam efeitos colaterais em circunstantes de recém-nascidos em fototerapia? / Do special blue lamps cause collateral effects on newborn's attendants in phototherapy?

Objetivo: comparar os sintomas referidos nos acompanhantes/mães de recém-nascidos submetidos à fototerapia com lâmpadas fluorescentes azuis especiais e com lâmpadas tipo "luz do dia". Métodos: mães e/ou acompanhantes de neonatos submetidos à fototerapia foram submetidos a estudo-piloto a fim de se apurar reações adversas a duas diferentes fontes de radiação usadas. Foram elaborados questionários não direcionados diretamente ao objetivo do estudo, ou seja, osn questionários não sugeriam de forma direta problemas relacionados ao tipo de terapia. As entrevistas foram realizadas com seis, 24 e 48 h de fototerapia. Um dos grupos estudados teve contacto com lâmpadas monocromáticas e outro, o grupo controle, com lâmpadas "luz do dia". A análise dos dados foi realizada de forma comparativa entre as variáveis dependentes e os dois grupos de fonte radiante (variável independente), em cada um dos três momentos, pelos testes qui-quadrado de Pearson, de Yates ou o teste exato de Fisher. Em seguida, comparou-se os dados obtidos às 6 horas com aqueles obtidos às 24 e 48 horas por meio do teste quiquadrado de McNemar para amostras emparelhadas. Resultados: o grupo I (azuis especiais) era constituído de pessoas com maior idade (p=0,01) e com maior proporção de auto-avaliação apenas regular da saúde (p=0,001). Não houve diferença estatisticamente significativa em termos de desconforto relacionado à fototerapia nos dois grupos, Conclusões: beste estudo, o uso exclusivo de lâmpadas azuis especiais não foi responsável pelos efeitos habitualmente descritos durante fototerapia com uso das mesmas.

Clear topical ointment decreases transepidermal water loss in jaundiced preterm infants receiving phototherapy.

The evaporation rate (ER) from the skin was measured in 40 jaundiced preterm infants born at less than or equal to 34 weeks of gestation. The baseline measurements were executed in both the right and left side in 3 positions: upper arm, back and lower leg. The patients were randomly recruited to a treatment or a control group. The treatment group received 3.0 ml of clear topical ointment just before phototherapy. Conventional phototherapy was placed above the incubators in both groups. ER and ambient skin temperature were measured at the same point at 30 minutes and 5 hours during phototherapy. In the control group, ER was increased by 8.0 per cent (P value = 0.01) and 14.5 per cent (P value < 0.001) at 30 minutes and 5 hours during phototherapy, respectively. In the treatment group, clear topical ointment decreased ER by 19.2 per cent (P value < 0.001) and 13.2 per cent (P value = 0.003) at 30 minutes and 5 hours during phototherapy, respectively. Ambient skin temperature during phototherapy was increased significantly (P < 0.01) in both groups. Serum microbilirubin difference of pre and post phototherapy at 24 hours of phototherapy between the 2 groups was not significantly different (P = 0.38). The authors concluded that conventional phototherapy, in premature infants nursed in an incubator, increased transepidermal water loss (TEWL) significantly and the application of clear topical ointment on the skin of jaundiced preterm infants receiving conventional phototherapy in incubators reduce TEWL significantly, without effect on serum microbilirubin.

Transepidermal water loss during conventional phototherapy in nonhemolytic hyperbilirubinemia term infants.

The evaporation rate from the skin was measured in 40 healthy term infants and 40 non-hemolytic jaundice term infants who required phototherapy. All infants were born at the gestational age of 38-41 weeks. The method for measurement of evaporation rate was based on determination of the water pressure gradient close to the skin surface. Conventional phototherapy was given in open cribs. In the phototherapy group, non of the infants had received phototherapy before the start of measurement. Evaporation rate was measured at the chest, interscapular and buttock. The measurement was made before phototherapy, 30 minutes, and 6 hours after starting phototherapy. The mean evaporation rate increased from 7.2 to 7.8 and 8.4 g/m2 h, respectively (p<0.001). In the control group, the measurement was made at the consecutive time as in the phototherapy group. The mean of the evaporate rate was 7.3, 7.6 and 7.5 g/m2 h (p=0.30). We conclude that conventional phototherapy in full term infants in open cribs increases transepidermal water loss.

Oxidative stress, phototherapy and the neonate.

Phototherapy is the most widely used form of therapy for unconjugated hyperbilirubinaemia. Its non-invasive nature and few side effects reported earlier have led to the assumption that it is innocuous. Recent research has revealed that phototherapy is a photodynamic stress and can induce lipid peroxidation. There is increasing evidence that many severe diseases of the neonate are caused by oxidative injury and lipid peroxidation. In the present communique, we review the oxidative susceptibility of the neonate and the evidence now available that phototherapy induces oxidative stress. Although intensive phototherapy (up to 40 mwatt/cm2/nm) has been reported to be increasingly effective, a little caution, we believe is warranted, till more definite data in the human neonate, help resolve the issue.