Drug-Induced Photosensitivity Follow-up

Author: Alexandra Y Zhang, MD; Chief Editor: Dirk M Elston, MD more...

Updated: Apr 4, 2012

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Deterrence/Prevention
Complications
Prognosis
Patient Education
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Deterrence/Prevention

Patients who experience drug-induced photosensitivity should identify and avoid the causative agent. Patients should use a sunscreen if it is not the offending agent. Sun protection often prevents photosensitivity reactions.

Complications

Chronic cutaneous effects of repeated phototoxic injury have been evaluated only with psoralen-containing compounds. Premature aging of the skin, lentigines, and skin cancer are common. With respect to skin cancer, increases in the incidence of squamous cell carcinoma are greater than those of basal cell carcinoma. The incidence of melanoma may also increase over time. The effects of chronic exposure to virtually all other photosensitizing compounds are unknown.

Persistent light reactivity is a form of chronic actinic dermatitis that occurs in patients with photoallergic contact dermatitis. Note the following:

In patients with persistent light reactivity, photosensitivity persists for months or years after the offending agent is eliminated.
The disease may involve all sun-exposed areas and spread to covered areas of skin.
Initially, persistent light reactivity is misdiagnosed as atopic dermatitis or a lichenoid drug reaction. The photosensitivity can be incapacitating because the patients are sensitive to light not only in the UV-A range but also in both the UV-B and visible ranges.
Some patients confine themselves to darkened rooms because of their severe photosensitivity.
Although systemic drugs (eg, thiazides, quinidine) have been implicated as causes of persistent light reactivity, sunscreens, halogenated salicylanilides and musk ambrette are the most frequent causes.
The treatment of persistent light reactivity involves the avoidance of contact with exacerbating agents and photoallergens.
Emollients, topical steroids, systemic steroids, and (at times) hydroxychloroquine.
Paradoxically, psoralen UV-A (PUVA) and narrow band UV-B have been used, although relapse is common.
Patients who show no signs of improvement may require the use of immunosuppressive agents (eg, azathioprine, cyclosporine).

Prognosis

In most patients, the prognosis is excellent once the offending agent is removed. However, complete resolution of the photosensitivity may take several weeks to months with some compounds. Occasionally, patients have persistent light reactivity for which the prospects for resolution are poor.

Patient Education

Patients need to be counseled regarding the possible photosensitizing properties of both prescription and nonprescription medications. Most often, appropriate sun protection measures prevent drug-induced photosensitivity reactions.

For patient education resources, see the Burns Center, as well as Sunburn.

Contributor Information and Disclosures

Author

Alexandra Y Zhang, MD Assistant Professor, Department of Dermatology, University of Pittsburgh

Alexandra Y Zhang, MD is a member of the following medical societies: American Academy of Dermatology, Dermatology Foundation, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Craig A Elmets, MD Professor and Chair, Department of Dermatology, Director, UAB Skin Diseases Research Center, University of Alabama at Birmingham School of Medicine

Craig A Elmets, MD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, American College of Physicians, American Federation for Medical Research, and Society for Investigative Dermatology

Disclosure: Palomar Medical Technologies Stock None; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor; UpToDate Salary Employment; Biogen Grant/research funds Independent contractor; Clinuvel Independent contractor; Covan Basilea Pharmaceutical Grant/research funds Independent contractor; ISDIN None Consulting; TenX BIopharma Grant/research funds Independent contractor

Specialty Editor Board

Abdul-Ghani Kibbi, MD Professor and Chair, Department of Dermatology, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology

Disclosure: Amgen Honoraria Consulting; Celgene Honoraria Safety Monitoring Committee

Catherine M Quirk, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

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Phototoxic reaction.

Photoallergic reaction.

Pseudoporphyria.

Subacute cutaneous lupus erythematosus exacerbated by terbinafine. Courtesy of Jeffrey P. Callen.

Table 1. Common Photosensitizing Medications

Class	Medication	Phototoxic Reaction	Photoallergic Reaction	Lichenoid Reaction	Pseudoporphyria	Subacute Cutaneous Lupus Erythematosus
Antibiotics	Tetracyclines (doxycycline, tetracycline)	Yes	No	Yes	Yes	No
	Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin)^[1]	Yes	No	No	No	No
	Sulfonamides	Yes	No	No	No	No
Nonsteroidal anti-inflammatory drugs^[2]	Ibuprofen	Yes	No	Yes	No	No
	Ketoprofen	Yes	Yes	No	No	No
	Naproxen^[3]	Yes	No	Yes	Yes	No
	Celecoxib^[4]	No	Yes	No	Yes	No
Diuretics	Furosemide	Yes	No	No	Yes	No
	Bumetanide	No	No	No	Yes	No
	Hydrochlorothiazide	Yes	No	No	No	Yes
Retinoid	Isotretinoin	Yes	No	No	No	No
Retinoid	Acitretin	Yes	No	No	No	No
Hypoglycemics	Sulfonylureas (glipizide, glyburide)^[1]	No	Yes	Yes	Yes	No
HMG-CoA* reductase inhibitors	Statins (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin)^[5]	Yes	Yes	Yes	Yes	No
Epidermal growth factor receptor inhibitors	Cetuximab, panitumumab, erlotinib, gefitinib, lapatinib, vandetanib^[6]	Yes	Yes	Yes	Yes	No
Photodynamic therapy prophotosensitizers	5-Aminolevulinic acid^[7]	Yes	No	No	No	No
	Methyl-5-aminolevulinic acid	Yes	No	No	No	No
	Verteporfin^[8]	Yes	No	No	No	No
	Photofrin^[9]	Yes	No	No	No	No
Neuroleptic drugs^[10]	Phenothiazines (chlorpromazine, fluphenazine, perazine, perphenazine, thioridazine)^[11]	Yes	Yes	Yes	No	No
Neuroleptic drugs^[10]	Thioxanthenes (chlorprothixene, thiothixene)	Yes	No	No	No	No
Antifungals	Terbinafine	No	No	No	No	Yes
	Itraconazole	Yes	Yes	No	No	No
	Voriconazole^{[12, 13, 14, 15]}	Yes	No	No	Yes	No
	Griseofulvin	Yes	Yes	No	No	Yes
Other drugs	Para-aminobenzoic acid	Yes	Yes	No	No	No
	5-Fluorouracil	Yes	Yes	Yes	Yes	No
	Paclitaxel^{[2, 16]}	Yes	No	No	No	Yes
	Amiodarone	Yes	No	No	Yes	No
	Diltiazem	Yes	No	No	No	Yes
	Quinidine	Yes	Yes	Yes	No	No
	Hydroxychloroquine	No	No	Yes	No	No
	Coal tar	Yes	No	No	No	No
	Enalapril	No	No	No	No	Yes
	Dapsone	No	Yes	Yes	Yes	No
	Oral contraceptives^{[17, 18]}	No	Yes	No	Yes	No
Sunscreens^[19]	Para-aminobenzoic acid	No	Yes	No	No	No
	Cinnamates	No	Yes	No	No	No
	Benzophenones	No	Yes	No	No	No
	Salicylates	No	Yes	No	No	No
Fragrances	Musk ambrette	No	Yes	No	No	No
Fragrances	6-Methylcoumarin	No	Yes	No	No	No
*3-Hydroxy-3-methylglutaryl coenzyme A.

Table 2. Distinguishing Characteristics of Phototoxic and Photoallergic Reactions

Feature	Phototoxic Reaction	Photoallergic Reaction
Incidence	High	Low
Amount of agent required for photosensitivity	Large	Small
Onset of reaction after exposure to agent and light	Minutes to hours	24-72 hours
More than one exposure to agent required	No	Yes
Distribution	Sun-exposed skin only	Sun-exposed skin, may spread to unexposed areas
Clinical characteristics	Exaggerated sunburn	Dermatitis
Immunologically mediated	No	Yes; Type IV

View Table List

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