eMedicine Specialties > Dermatology > Allergy & Immunology

Drug-Induced Photosensitivity

Author: Alexandra Y Zhang, MD, Assistant Professor, Department of Dermatology, University of Pittsburgh
Coauthor(s): Craig A Elmets, MD, Director of Dermatology, Departments of Dermatology, Pathology, and Environmental Health Sciences; Professor, The Kirklin Clinic, University of Alabama at Birmingham
Contributor Information and Disclosures

Updated: Jan 15, 2010

Introduction

Background

Drug-induced photosensitivity refers to the development of cutaneous disease as a result of the combined effects of a chemical and light. Exposure to either the chemical or the light alone is not sufficient to induce the disease; however, when photoactivation of the chemical occurs, one or more cutaneous manifestations may arise. These include phototoxic and photoallergic reactions, a planus lichenoides reaction, pseudoporphyria, and subacute cutaneous lupus erythematosus. Photosensitivity reactions may result from systemic medications and topically applied compounds (see Table 1 below).

Wavelengths within the UV-A (320-400 nm) range and, for certain compounds, within the visible range, are more likely to cause drug-induced photosensitivity reactions, although occasionally UV-B (290-320 nm) can also be responsible for such effects. UV-B wavelengths are most efficient at causing sunburn and nonmelanoma skin cancer. In patients who present with photosensitivity, it is often difficult to differentiate phototoxic from photoallergic reactions. However, they have a number of distinguishing characteristics (see Table 2 below).

Table 1. Common Photosensitizing Medications

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Table

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 drugs²	Ibuprofen	Yes	No	Yes	No	No
	Ketoprofen	Yes	Yes	No	No	No
	Naproxen³	Yes	No	Yes	Yes	No
	Celecoxib⁴	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, vandetanib⁶	Yes	Yes	Yes	Yes	No
Photodynamic therapy prophotosensitizers	5-Aminolevulinic acid⁷	Yes	No	No	No	No
	Methyl-5-aminolevulinic acid	Yes	No	No	No	No
	Verteporfin⁸	Yes	No	No	No	No
	Photofrin⁹	Yes	No	No	No	No
Neuroleptic drugs¹⁰	Phenothiazines (chlorpromazine, fluphenazine, perazine, perphenazine, thioridazine)¹¹	Yes	Yes	Yes	No	No
Neuroleptic drugs¹⁰	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
Sunscreens¹⁹	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

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 drugs²	Ibuprofen	Yes	No	Yes	No	No
	Ketoprofen	Yes	Yes	No	No	No
	Naproxen³	Yes	No	Yes	Yes	No
	Celecoxib⁴	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, vandetanib⁶	Yes	Yes	Yes	Yes	No
Photodynamic therapy prophotosensitizers	5-Aminolevulinic acid⁷	Yes	No	No	No	No
	Methyl-5-aminolevulinic acid	Yes	No	No	No	No
	Verteporfin⁸	Yes	No	No	No	No
	Photofrin⁹	Yes	No	No	No	No
Neuroleptic drugs¹⁰	Phenothiazines (chlorpromazine, fluphenazine, perazine, perphenazine, thioridazine)¹¹	Yes	Yes	Yes	No	No
Neuroleptic drugs¹⁰	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
Sunscreens¹⁹	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.

Phototoxic reactions occur because of the damaging effects of light-activated compounds on cell membranes and, in some instances, DNA. By contrast, photoallergic reactions are cell-mediated immune responses to a light-activated compound. Phototoxic reactions develop in most individuals if they are exposed to sufficient amounts of light and drug. Typically, they appear as an exaggerated sunburn response, as shown in the image below.

Phototoxic reaction.

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Phototoxic reaction.

Photoallergic reactions resemble allergic contact dermatitis, with a distribution limited to sun-exposed areas of the body. However, when the reactions are severe or prolonged, they may extend into covered areas of skin.

Table 2. Distinguishing Characteristics of Phototoxic and Photoallergic Reactions

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Table

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

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

Photoallergic reactions develop in only a minority of individuals exposed to the compound and light; they are less prevalent than phototoxic skin reactions. The amount of drug required to elicit photoallergic reactions is considerably smaller than that required for phototoxic reactions. Moreover, photoallergic reactions, as shown in the image below, are a form of cell-mediated immunity; their onset often is delayed by as long as 24-72 hours after exposure to the drug and light. By contrast, phototoxic responses often occur within minutes or hours of light exposure.

Photoallergic reaction.

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Photoallergic reaction.

Pathophysiology

Phototoxicity

Phototoxic reactions result from direct damage to tissue caused by a photoactivated compound. Many compounds have the potential to cause phototoxicity. Most have at least one resonating double bond or an aromatic ring that can absorb radiant energy. Most compounds are activated by wavelengths within the UV-A (320-400 nm) range, although some compounds have a peak absorption within the UV-B or visible range.

In most instances, photoactivation of a compound results in the excitation of electrons from the stable singlet state to an excited triplet state. As excited-state electrons return to a more stable configuration, they transfer their energy to oxygen, leading to the formation of reactive oxygen intermediates. Reactive oxygen intermediates such as an oxygen singlet, superoxide anion, and hydrogen peroxide damage cell membranes and DNA. Signal transduction pathways that lead to the production of proinflammatory cytokines and arachidonic acid metabolites are also activated. The result is an inflammatory response that has the clinical appearance of an exaggerated sunburn reaction.

The exception to this mechanism of drug-induced phototoxicity is psoralen-induced phototoxicity. Psoralens intercalate within DNA, forming monofunctional adducts. Exposure to UV-A radiation produces bifunctional adducts within DNA. Exactly how bifunctional adducts cause photosensitivity is unknown.

Photoallergic reactions

Photoallergic reactions are cell-mediated immune responses in which the antigen is a light-activated drug. Photoactivation results in the development of a metabolite that can bind to protein carriers in the skin to form a complete antigen. The reaction then proceeds exactly as other cell-mediated immune responses do. Specifically, Langerhans cells and other antigen-presenting cells take up the antigen and then migrate to regional lymph nodes. In those locations, the Langerhans cells present the photoallergen to T lymphocytes that express antigen-specific receptors. The T cells become activated and proliferate, and they return to the site of photoallergen deposition. In the skin, the T cells orchestrate an inflammatory response that usually has an eczematous morphology if the photoallergen is applied topically or the characteristics of a drug eruption if the photoallergen is administered systemically.

Frequency

United States

Although the incidence of drug-induced photosensitivity in the United States is uncertain. Phototoxic reactions are considerably more common than photoallergic reactions.

International

The incidence of drug-induced photosensitivity is unknown.

Mortality/Morbidity

Drug-induced photosensitivity is associated with death only in rare individuals who are exposed to large amounts of sunlight after taking large doses of psoralens. Although mortality is rare, drug-induced photosensitivity can cause significant morbidity in some individuals, who must severely limit their exposure to natural or artificial light. The carcinogenic potential due to prolonged exposure to these photosensitizing drugs has been suggested; its clinical relevance remains to be determined.

Race

The racial incidence of drug-induced photosensitivity reactions is unknown. Photosensitivity reactions can occur in races with heavily pigmented skin.

Sex

Men are more likely to have photoallergic reactions than women.

Age

Drug-induced photosensitivity reactions can occur in persons of any age.

Clinical

History

Patients with drug-induced photosensitivity often, but not always, note intolerance to sunlight.
- While most individuals can tolerate minutes or hours of sun exposure, patients with drug-induced photosensitivity exhibit skin lesions of one type or another. In most cases, a sunburn response or dermatitis occurs.
- Drug-induced photosensitivity reactions may result in phototoxicity, photoallergy, lichenoid reactions, subacute cutaneous lupus erythematosus (SCLE), or pseudoporphyria, as shown in the images below, respectively.
- Subacute cutaneous lupus erythematosus exacerbated by terbinafine. Courtesy of Jeffrey P. Callen.
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  Subacute cutaneous lupus erythematosus exacerbated by terbinafine. Courtesy of Jeffrey P. Callen.
- Pseudoporphyria.
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  Pseudoporphyria.
Pseudoporphyria may occur with some medications, the most common of which is naproxen.
- Pseudoporphyria is characterized by a bullous reaction that clinically and histologically resembles porphyria cutanea tarda.
- The hypertrichosis and sclerodermoid changes typically seen in porphyria cutanea tarda are not seen in pseudoporphyria.
- The results of porphyrin studies are normal.
Lichenoid reactions that occur in a photodistribution are often difficult to distinguish from idiopathic lichen planus.²⁰
- These reactions are characterized by violaceous or erythematous papules and plaques that sometimes have Wickham striae.
- Hydrochlorothiazide, hydroxychloroquine, and captopril are known causes of drug-induced lichenoid reactions.
Drug-induced photosensitivity reactions also may include lupuslike reactions.
- Drug-induced reactions usually resemble SCLE because of their scaling, annular, and psoriasiform characteristics.
- Hydrochlorothiazide is the drug most frequently associated with this reaction,²¹but calcium channel blockers, ACE inhibitors, griseofulvin, and terbinafine²²are other agents that have been implicated. The rate of reaction is low for any of these agents. Hydrochlorothiazide is commonly used in many combined antihypertensive agents.
- Patients with drug-induced reactions commonly have anti-Ro (SS-A) antibodies.
As photodynamic therapy (PDT) becomes a more popular treatment modality for actinic keratoses and nonmelanoma skin cancer, recognition of PDT photosensitizer–induced phototoxicity is important.
- 5-Aminolevulinic acid or methyl 5-aminolevulinic acid is applied topically, followed by the use of a blue (410-420 nm) or red light (570-670 nm) PDT illuminator.
- 5-Aminolevulinic acid is a prodrug that enters the heme biosynthetic pathway and is metabolized intracellularly to form the photosensitizing molecule protoporphyrin IX (PpIX).
- Light activates PpIX to generate free radicals and cytotoxic reactive oxygen species that may cause destruction of malignant and nonmalignant hyperproliferative tissue.
- Common adverse effects include mild-to-moderate local phototoxic reactions that usually resolve in several days.
Discriminating between photosensitivity diseases and heat-related exacerbation of skin diseases may be difficult for the patient.
- Clarify this issue in the history.
- Assess symptoms of other diseases that are known to cause photosensitivity and determine if a family history of photosensitivity exists.
Establishing whether the photosensitivity can be elicited with exposure to sunlight through window glass may provide information about the wavelengths of light that cause the response. UV-B light does not penetrate window glass, whereas UV-A light and visible light do.
In most patients, the findings of the physical examination suggest a photosensitivity reaction.
- Specifically, inquire about intolerance to the sun.
- Ask patients who report photosensitivity about the medications they are taking and the products they are applying to the skin (see Table 1 in Background). Sunscreens; fragrances; and, occasionally, antibacterial soaps may cause photoallergic reactions when applied to the skin.

Physical

Both phototoxic and photoallergic reactions occur in sun-exposed areas of skin, including the face, V of the neck, and dorsa of the hands and forearms. The hair-bearing scalp, postauricular and periorbital areas, and submental portion of the chin are usually spared. A widespread eruption suggests exposure to a systemic photosensitizer, whereas a localized eruption indicates a reaction to a locally applied topical photosensitizer.

Phototoxic reactions in skin
- Acute phototoxicity often begins as an exaggerated sunburn reaction with erythema and edema that occurs within minutes to hours of light exposure. Vesicles and bullae may develop with severe reactions. The lesions often heal with hyperpigmentation, which resolves in a matter of weeks to months. Chronic phototoxicity may also appear as an exaggerated sunburn reaction. However, lichenification often develops because of repeated rubbing and scratching of the photosensitive area. Thus, distinguishing phototoxic reactions from photoallergic reactions strictly based on physical appearance of the lesions may be difficult.
- Other less common skin manifestations of phototoxicity include pigmentary changes. A blue-gray pigmentation is associated with several agents, including amiodarone, chlorpromazine, and some tricyclic antidepressants. Reactions to psoralen-containing botanicals (phytophotodermatitis) and drugs may resolve, with a brownish discoloration. Frequently, the pigmentary change is preceded by a typical sunburn reaction. If the reaction is not severe, some patients may not notice the erythema.
- Photosensitizing drugs may also cause a lichen planus–like eruption in sun-exposed areas. Drugs likely to cause this type of reaction include demeclocycline, hydrochlorothiazide, enalapril, quinine, quinidine, chloroquine, and hydroxychloroquine.
- Pseudoporphyria, which involves porphyria cutanea tarda–like changes of skin fragility and subepidermal blisters on the dorsa of hands, may occur after exposure to naproxen, nalidixic acid, tetracycline, sulfonylureas, furosemide, dapsone, amiodarone, bumetanide, and pyridoxine. Frequent use of sun-tanning beds and chronic renal failure are other predisposing factors.
Phototoxic reactions in nails
- Photo-onycholysis, or separation of the distal nail plate from the nail bed, is another manifestation of phototoxicity. Photo-onycholysis has been reported with the use of many systemic medications, including tetracycline, psoralen, chloramphenicol, fluoroquinolones, oral contraceptives, quinine, and mercaptopurine.
- Photo-onycholysis may be the only manifestation of phototoxicity in individuals with heavily pigmented skin.
Photoallergic reactions in skin
- Photoallergic reactions typically develop in sensitized individuals 24-48 hours after exposure. The reaction usually manifests as a pruritic eczematous eruption. Erythema and vesiculation are present in the acute phase.
- More chronic exposure results in erythema, lichenification, and scaling.
- Hyperpigmentation does not occur in photoallergic reactions.

Causes

Most phototoxic reactions result from the systemic administration of drugs.
Photoallergic reactions can be caused by either topical or systemic administration of the chemical.
Compounds that commonly cause phototoxic and/or photoallergic reactions are listed in Table 1 in Background.

More on Drug-Induced Photosensitivity

Overview: Drug-Induced Photosensitivity

Differential Diagnoses & Workup: Drug-Induced Photosensitivity

Treatment & Medication: Drug-Induced Photosensitivity

Follow-up: Drug-Induced Photosensitivity

Multimedia: Drug-Induced Photosensitivity

References

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References

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Keywords

drug-induced photosensitivity, phototoxicity, phototoxic reactions, photoallergic reactions, photosensitivity reaction, sun exposure, sunburn, UV-A, UVA, UV-B, UVB

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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, Director of Dermatology, Departments of Dermatology, Pathology, and Environmental Health Sciences; Professor, The Kirklin Clinic, University of Alabama at Birmingham
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; Amgen Consulting fee Review panel membership; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor

Medical Editor

Abdul-Ghani Kibbi, MD, Chairman and Professor, Department of Dermatology, American University of Beirut Medical Center, Lebanon
Disclosure: none None None

Pharmacy Editor

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.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, 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; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Medicis Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

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, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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eMedicine Specialties > Dermatology > Allergy & Immunology

Drug-Induced Photosensitivity

Introduction

Background

Table

Phototoxic reaction.

Phototoxic reaction.

Table

Photoallergic reaction.

Photoallergic reaction.

Pathophysiology

Frequency

United States

International

Mortality/Morbidity

Race

Sex

Age

Clinical

History

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

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

Pseudoporphyria.

Pseudoporphyria.

Physical

Causes

More on Drug-Induced Photosensitivity

References

Further Reading

Keywords

Contributor Information and Disclosures

Author

Coauthor(s)

Medical Editor

Pharmacy Editor

Managing Editor

CME Editor

Chief Editor