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Photosensitivity: System View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by OAR@UM – photoperiodicity; is used by animals to synchronize their biological clocks. Light is indeed important for the psychological well being of animals. However the effect of light on humans is much more complex than we think. It influences us in ways we many times do not expect or understand. At least one study has suggested a direct correlation between higher rates of breast cancer in women and the night time brightness of their neighbourhoods.1 It is in fact postulated that this is at least partly due to a dramatic alteration in the lighted environment from a sun-based system to an electricity-based Photosensitivity: system. Increasingly, the natural dark period at night is being seriously eroded for the bulk of humanity.2 Based on the fact Light, sun and pharmacy that light during the night can suppress melatonin, and also disrupt the circadian rhythm, it is proposed that increasing use of Mark L. Zammit BPharm(Hons), MSc(Agr Vet Pharm), Pg Dip Med Tox(Cardiff), MSc Med Tox(Cardiff), MEAPCCT electricity to light the night accounts in part for the rising risk of breast cancer globally.3 Principal Pharmacist, Clinical Pharmacy and Medicines & Poisons Information, Light is nowadays being even considered as a Pharmacy Department, Mater Dei Hospital, Malta public health issue.4 Email: [email protected] Photosensitivity and its epidemiology In the context of pharmacy, an Educational aims important effect of light is what is • To provide an overview of different types of drug-induced photosensitivity reactions termed as photosensitivity. Drug- • To provide an overview of treatment options and prevention strategies induced photosensitivity is termed as an • To provide an practical help as regards the use of sunscreens undesirable pharmacological reaction in light irradiation.5,6 Exposure to either the chemical or the light alone is not sufficient Key words to induce the disease; however, when phototoxic reactions, photoallergic reactions, photosensitivity reaction, sunscreen, sun photoactivation of the chemical occurs, one protection factor or more cutaneous manifestations may arise. These include mainly either a phototoxic or a photoallergic reactions, but may also Light has a profound effect on us. We may not be conscious enough as include a planus lichenoides reaction, regards the existences of many phototoxic substances and chemicals. pseudoporphyria, subacute cutaneous lupus A phototoxic substance is a chemical compound which becomes toxic erythematosus as well as hyperpigmentation, when exposed to light. Phototoxicity may be manifested in various pigmentary changes or berloque dermatitis ways. Proper use of sunscreens may play a vital role in the prevention Photosensitivity reactions may result from systemic medications and topically applied of many such reactions. compounds (Table 1). Wavelengths within the UV-A (320-400 Introduction that have evolved in total darkness such nm) range and, for certain compounds, The sun and the light that it emits are as troglobites[cave dwellers] or deep- within the visible range, are more likely many times taken for granted, however sea animals are often colourless, blind to cause drug-induced photosensitivity light more precisely sunlight powers all and cannot survive outside their natural reactions, although occasionally UV-B (290- life on earth, either directly or indirectly. environment. 320 nm) can also be responsible for such Plants must have sunlight [or full-spectrum For all diurnal species (species that are effects. UV-B wavelengths are most efficient artificial light] to manufacture their food active during the day), including humans, at causing sunburn and nonmelanoma skin by photosynthesis. Plants, in turn, pass on light is important for many reasons. cancer.9 their energy to the animals that consume Obviously, it is required for vision. For many Photosensitivity eruptions typically occur them. Light is also essential for the survival species of animals, full-spectrum light is in locations with prominent sun exposure of most animal species; even nocturnal required for the conversion of cholesterol such as in the face, extensor extremities, animals require low-level light. Animals to vitamin D. Light and its changing cycles upper chest and back of neck. Characteristic 12 Journal of the Malta College of Pharmacy Practice Issue 16 Summer 2010 Table 1. Some medications and other substances associated with photosensitivity7,8,6 solar energy by acting as a chromophore, causing absorption of ultraviolet light and Antibiotics Ciprofloxacin and other quinolones, sulfonamides, dapsone, causing damage to the skin tissue.5 griseofulvin. Tetracyclines [especially demeclocycline; less Acute phototoxicity often begins as an frequently doxycycline, oxytetracycline and tetracycline; exaggerated sunburn reaction with erythema minocycline rarely] and oedema that occurs within minutes to hours of light exposure; vesicles and bullae Antihistamines Dimenhydrinate, cetirizine, loratidine may develop with severe reactions.9 The lesions often heal with hyperpigmentation, Anti-inflammatories Ibuprofen, naproxen, piroxicam which resolves in a matter of weeks to [NSAIDS] months. Chronic phototoxicity may also appear as an exaggerated sunburn reaction. Lichenification often develops because of Anti-malarials Chloroquine and related compounds (such as repeated rubbing and scratching of the hydroxychloroquine), Sulfadoxine with photosensitive area. pyrimethamine [Fansidar®] Distinguishing phototoxic reactions from photoallergic reactions strictly based Cardiovascular drugs ACE inhibitors, amiodarone, amlodipine, clopidogrel, on physical appearance of the lesions may diltiazem, furosemide, losartan, nifedipine, statins, be difficult.9 In contrast to photoallergic thiazide diuretics, sotalol reactions drug-induced phototoxic reactions typically occur on first exposure to the CNS agents Carbamazepine, clomipramine, chlorpromazine, drug, and they are often dose-related. phenotiazines, tricyclic antidepressants, 5,9,10 Cases of drug-induced phototoxic selegiline, zolpidem. reactions are associated with a much quicker onset relative to cases of drug-induced Miscellaneous Acetazolamide, oral contraceptives and oestrogen, photoallergy.12 This could typically be chemotherapy agents, ranitidine, sulfonylureas, tacrolimus within 30 minutes to several hours after exposure to UV light. In general phototoxic Topical agents Deodorants in soaps; perfumes; coal tar products reactions are less severe than photoallergic reactions and resemble a severe sunburn.12 The skin damage that occurs in phototoxic Plants and herbs Celery, giant hogweed, angelica, parsnip, fennel, reactions is typically confined to areas of dill, anise, parsley, lime, lemon, rue, fig, mustard, exposed skin only. Occasionally the nails scurf pea, and chrysanthemums may also be affected. The phototoxic effect is a well-known phenomenon referred to as Essential Oils Fig leaf absolute oil; taget oil; vergena oil and verbena photooncholysis.7,12 absolute oil; bergamot oil; cumin oil; lime (expressed) oil; A classic example of a medicine angelica root oil; rue oil; opopanax oil; orange (bitter associated with phototoxicity [sometimes expressed) oil; lemon (expressed) oil; grapefruit also with photoallergy] is amiodarone, which (expressed) oil induces photosensitivity in 10-50% of the patients treated with this drug.6 Note: This list is NOT comprehensive. Manufacturers’ package inserts should be consulted However some reports even mention regarding potential photosensitivity of medications. rates as high as 75%.13 As mentioned beforehand the development of phototoxicity is dose-dependent. It is reported that an sites of sparing include the upper eyelids, Phototoxic reactions may occur in almost amiodarone-induced phototoxic reaction below the nose and chin, behind the any individual who received a high enough depends on a total dose of amiodarone of earlobes and the finger-webs. dose of the offending agent coupled with 40g which is the minimal cumulative dose Photosensitivity reactions can be sufficient exposure to light irradiation.11 The requirement. Under the regimens commonly classified according to the underlying occurrence of drug-induced phototoxicity used, photosensitivity can be expected mechanism. They are the result of either reactions can thus be dependent on the after 4 months of continuous amiodarone phototoxicity or photoallergy. In patients concentration or amount of the sensitising treatment and appears to be unrelated to the who present with photosensitivity, it is often agent and the amount of light exposure.11 skin type. Phototoxicity gradually decreases difficult to differentiate phototoxic from and returns to normal between 4 and 12 photoallergic reactions. However, they have Phototoxic reactions months after the withdrawal of amiodarone.6 a number of distinguishing characteristics Phototoxic reactions are non- Photo-onycholysis, or separation of (Table 2). Phototoxic reactions represent the immunologic in nature. In these reactions the distal nail plate from the nail bed, is most common form, whereas photoallergic the drug, after ingestion or topical another manifestation of phototoxicity. reactions are generally uncommon.6,10 application is believed to potentiate the Photo-onycholysis has been reported with Issue 16 Summer 2010 Journal of the Malta College of Pharmacy Practice 13 Table 2. Differentiating characteristics of phototoxicity
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