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Drug-Induced Photosensitivity

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Drug-Induced Photosensitivity Acta Dermatovenerol Croat 2016;24(1):55-64 REVIEW Drug-induced Photosensitivity Ewelina Bogumiła Zuba1, Sandra Koronowska1, Agnieszka Osmola- Mańkowska2, Dorota Jenerowicz2 1Student Scientific Group at the Department of Dermatology, Medical University of Poznan, Poznan, Poland; 2Department of Dermatology, Medical University of Poznan, Poznan, Poland Corresponding author: ABSTRACT Ultraviolet radiation is considered the main environmental Ewelina Bogumiła Zuba MD physical hazard to the skin. It is responsible for photoaging, sunburns, carcinogenesis, and photodermatoses, including drug-induced photo- Medical University of Poznan sensitivity. Drug-induced photosensitivity is an abnormal skin reaction 49 Przybyszewskiego St either to sunlight or to artificial light. Drugs may be a cause of photoal- 60-355 Poznan lergic, phototoxic, and photoaggravated dermatitis. There are numerous medications that can be implicated in these types of reactions. Recently, Poland non-steroidal anti-inflammatory drugs have been shown to be a com- [email protected] mon cause of photosensitivity. As both systemic and topical medica- tions may promote photosensitive reactions, it is important to take into Received: November 17, 2014 consideration the potential risk of occurrence such reactions, especially Accepted: January 10, 2016 in people chronically exposed to ultraviolet radiation. KEY WORDS: photoallergic contact dermatitis, photosensitizing agents, phototoxic dermatitis INTRODUCTION Drug-induced photosensitivity is an undesirable Photosensitivity might be associated with differ- effect of topically applied or systemically adminis- ent mechanisms such as phototoxicity, photoallergy, trated pharmaceuticals, followed by exposition to pellagra, pseudoporphyria, lichenoid, and lupus ery- sunlight, mainly ultraviolet A (UVA) or/and ultraviolet thematosus reactions. The most common are pho- B (UVB) radiation as well as visible light. Such reac- totoxicity and photoallergy. The difference between tions usually affect the skin but the eye involvement them is shown in Table 1 (4-5). There are numerous is also possible. There has recently been a substantial drugs which can trigger sun-related skin reactions. increase of drug-induced photoreactions as a conse- Table 2 illustrates which drugs may induce photoal- quence of the ozone-layer depletion that allows in- lergic or phototoxic reactions (6). tense sunlight to reach the surface of Earth. Photosensitivity may be triggered by UVA and PHototoXicity UVB radiation in individuals who take certain medica- Phototoxicity is an abnormal chemical reaction tions or who suffer from particular disorders. Photo- induced by light. Phototoxic drugs are those which sensitivity skin lesions represent 8% of all cutaneous are able to absorb radiation. They must have a single adverse drug reactions (1-3). or double bond or halogenated aromatic rings in the ACTA DERMATOVENEROLOGICA CROATICA 55 Zuba et al. Acta Dermatovenerol Croat Drug-induced photosensitivity 2016;24(1):55-64 Table 1. Phototoxic versus photoallergic reaction (4) Phototoxicity Photoallergy Onset of reaction minutes to hours 1-3 days Incidence more common less common Required exposure to agent single more than one Mechanism reactive oxygen radicals cause UV rays activate immune system promoting activation change in skin molecules leading to of macrophages which leads to the formation of long-term damage or cell death typical for contact dermatitis skin lesions Immunologically mediated no yes, type IV and its subtypes (5) Localization of lesions confined to the sun-exposed skin outbreak is not limited to the sun-exposed skin, it can area spread to the whole body area (less inclined to affect submental, retroauricular areas and upper eyelids) Duration of the reaction active process (sometimes for years) until the trigger is removed, it can persist very even after the triggering factor was rarely for years without further exposure to the removed photosensitizing agent Clinical manifestation exaggerated sunburn with dermatitis blistering, desquamation and hyperpigmentation Concentration relation concentration related concentration not related *UV: ultraviolet molecule that determine the absorption spectrum. toallergen is required. Two mechanisms of photoaller- Typically wavelength causing photosensitive reac- gic reactions have been proposed. In the first case, a tions is above 310 nm. stable photoproduct formed from the reaction of the A molecule that absorbs photons is called a chro- drug with UV radiation serves as a hapten. A complete mophore. The energy of the photon causes promo- antigen is created by a combination of a hapten and tion of the electrons from a ground state to an ex- a carrier molecule. Alternatively, a drug able to absorb cited state. The so-called singlet or triplet state of the light might be shifted to an excited, unstable state. A photosensitizer is an unstable state and exists only molecule reverting to its ground state results in ener- for a short time, typically up to 10-10 s for singlet and gy release that may lead to conjugation with a carrier. 10-6 s for triplet states. Returning to a ground state is After formation of the complete antigen, the mecha- associated with a discharge of energy by radiation, nism of photoallergic dermatitis is identical to the heat emission, or a chemical reaction that results in pathogenesis of allergic contact dermatitis. The anti- the formation of a photoproduct. The energy transfer gen is processed and presented by Langerhans cells, from excited photosensitizer to oxygen leads to the in association with human leukocyte antigen (HLA) II production of excited single oxygen atoms that can antigens. T lymphocytes are activated by Langerhans participate in lipid and/or protein oxidation or deoxy- cells in regional lymph nodes. Skin lesions will occur ribonucleic acid (DNA) damage. That leads to direct when activated T-cells recirculate to the light-exposed cellular damage and may induce an immunological sites and recognize the photoallergen (8). inflammation (7). DNA damage may also lead to pho- togenotoxicity that results in cancerogenesis and de- CLinicaL Features velopment of squamous cell carcinoma. Phototoxic reactions may occur in patients of any age, predominantly in women. Symptoms of photo- PHotoaLLerGY toxic skin reaction resemble an exaggerated sunburn Photoallergy may be elicited by systemic as well as and are limited to the sun-exposed areas. topical drugs. In both cases, photoallergic dermatitis Phototoxicity provokes the occurrence of erythe- is a delayed, T-cell mediated hypersensitivity reaction ma and edema within minutes to hours. Vesiculation (IV type Coombs and Gell classification). Photoaller- and blistering are rare. Persistent hyperpigmentation gic responses produced by systemically administered is also possible. The reaction is an active process of substances are much rarer than those caused by topi- skin cell damage and can persist for years, long after cally applied drugs. Previous sensitization to the pho- the triggering factor has been removed (4). 56 ACTA DERMATOVENEROLOGICA CROATICA Zuba et al. Acta Dermatovenerol Croat Drug-induced photosensitivity 2016;24(1):55-64 Table 2. Common phototoxic and photoallergic drugs (6) Group of drugs Medication Phototoxic reaction Photoallergic Action spectrum reaction Oral treatment Cardiovascular and Furosemide + - Unknown diuretic agents Amiodarone + - UVA Quinidine + + UVA Thiazides + + UVA/UVB Antibiotic Dapsone - + Unknown Sulfonamide + + UVB Tetracycline + - UVA/UVB Ciprofloxacine + - UVA Antifungal Griseofulwin + - UVA Ketoconazole + - Unknown DMARD Hydroxychloroquine - + Unknown NSAID Naproxen + - UVA Piroxicam + UVA Tiaprofen + + UVA Ibuprofen + - UVA Ketoprofen + + UVA Topical treatment Antineoplastics 5-FU + + Unknown Furocoumarins Psoralen + + UVA Keratoplastics Coal tar + - UVA PDT Pro-photosensitizer 5-Aminolevulinic acid + - UVA/visible spectrum NSAID Ketoprofen + + UVA Naproxen + + UVA *UVA: ultraviolet A; UVB: ultraviolet B; DMARD: disease-modifying antirheumatic drugs; NSAID: nonsteroidal anti-inflamma- tory drugs; 5FU: Fluorouracil; PTD: photodynamic therapy Photoallergic dermatitis occurs in patients of any most widely used by elderly patients. Tetracyclines and age. Men are affected more commonly than women. quinolones are often prescribed by dermatologists Onset of these reactions is 24-72 h after exposure. and physicians of other specialties due to their anti- Photoallergic dermatitis generally affects the light- microbial properties. Voriconazole and verumafenib exposed areas: the face, neck, upper chest, and dor- may lead to severe photosensitivity reactions, but sum of hands. Lesions may spread to unexposed ar- their photosensitive potential is not well-known. eas. Symptoms of photoallergic dermatitis are similar Non-steroidal anti-inflammatory drugs to those of contact dermatitis. Consequently, desqua- mation and residual hyperpigmentation occur and Non-steroidal anti-inflammatory drugs are widely can persist for more than a year. The predominant prescribed by physicians of all specialties. They have form of this reaction is eczematous (4). been found to elicit a high level of adverse photo- sensitivity. Some NSAIDs, including ibuprofen and naproxen, are also available over-the-counter (9). DruGS associated witH Both systemic and topical administration of non-ste- PHotosensitiVity roidal anti-inflammatory drugs may promote photo- This paper describes drug-induced photosensitiv- allergic and phototoxic
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