1
|
Di Bartolomeo L, Irrera N, Campo GM, Borgia F, Motolese A, Vaccaro F, Squadrito F, Altavilla D, Condorelli AG, Motolese A, Vaccaro M. Drug-Induced Photosensitivity: Clinical Types of Phototoxicity and Photoallergy and Pathogenetic Mechanisms. FRONTIERS IN ALLERGY 2022; 3:876695. [PMID: 36238932 PMCID: PMC9552952 DOI: 10.3389/falgy.2022.876695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Drug-induced photosensitivity (DIP) is a common cutaneous adverse drug reaction, resulting from the interaction of ultraviolet radiations, mostly ultraviolet A, with drugs. DIP includes phototoxicity and photoallergy. A phototoxic reaction is obtained when topical and systemic drugs or their metabolites absorb light inducing a direct cellular damage, while a photoallergic reaction takes place when the interaction between drugs and ultraviolet radiations causes an immune cutaneous response. Clinically, phototoxicity is immediate and appears as an exaggerated sunburn, whereas photoallergy is a delayed eczematous reaction. DIP may show several clinical subtypes. In this mini-review we report the pathogenetic mechanisms and causative drugs of DIP. We offer a detailed description of DIP clinical features in its classical and unusual subtypes, such as hyperpigmentation/dyschromia, pseudoporphyria, photo-onycolysis, eruptive teleangiectasia, pellagra-like reaction, lichenoid reaction, photodistributed erythema multiforme and subacute/chronic cutaneous lupus erythematosus. We described how physicians may early recognize and manage DIP, including diagnostic tests to rule out similar conditions. We made suggestions on how to improve sun exposure behaviors of patients at risk of DIP by means of an aware use of sunscreens, protective clothing and recent technologic tools. We highlighted the lack of sun safety programs addressed to patients at risk of DIP, who need a formal education about their condition.
Collapse
Affiliation(s)
- Luca Di Bartolomeo
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, Pharmacology, University of Messina, Messina, Italy
| | - Giuseppe Maurizio Campo
- Laboratory of Clinical Biochemistry, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Borgia
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| | - Alfonso Motolese
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| | - Federico Vaccaro
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, Pharmacology, University of Messina, Messina, Italy
| | - Domenica Altavilla
- Department of Clinical and Experimental Medicine, Pharmacology, University of Messina, Messina, Italy
| | - Alessandra Grazia Condorelli
- S.C. Dermatologia, Azienda USL di Reggio Emilia-IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
- *Correspondence: Alessandra Grazia Condorelli
| | - Alberico Motolese
- S.C. Dermatologia, Azienda USL di Reggio Emilia-IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| |
Collapse
|
2
|
Manage drug-induced photosensitivity by preventing, discontinuing offending agents and/or treating when necessary. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-020-00712-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
3
|
Blakely KM, Drucker AM, Rosen CF. Drug-Induced Photosensitivity-An Update: Culprit Drugs, Prevention and Management. Drug Saf 2020; 42:827-847. [PMID: 30888626 DOI: 10.1007/s40264-019-00806-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Photosensitive drug eruptions are cutaneous adverse events due to exposure to a medication and either ultraviolet or visible radiation. In this review, the diagnosis, prevention and management of drug-induced photosensitivity is discussed. Diagnosis is based largely on the history of drug intake and the appearance of the eruption primarily affecting sun-exposed areas of the skin. This diagnosis can also be aided by tools such as phototesting, photopatch testing and rechallenge testing. The mainstay of management is prevention, including informing patients of the possibility of increased photosensitivity as well as the use of appropriate sun protective measures. Once a photosensitivity reaction has occurred, it may be necessary to discontinue the culprit medication and treat the reaction with corticosteroids. For certain medications, long-term surveillance may be indicated because of a higher risk of developing melanoma or squamous cell carcinoma at sites of earlier photosensitivity reactions. A large number of medications have been implicated as causes of photosensitivity, many with convincing clinical and scientific supporting evidence. We review the medical literature regarding the evidence for the culpability of each drug, including the results of phototesting, photopatch testing and rechallenge testing. Amiodarone, chlorpromazine, doxycycline, hydrochlorothiazide, nalidixic acid, naproxen, piroxicam, tetracycline, thioridazine, vemurafenib and voriconazole are among the most consistently implicated and warrant the most precaution by both the physician and patient.
Collapse
Affiliation(s)
- Kim M Blakely
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aaron M Drucker
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Cheryl F Rosen
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Division of Dermatology, Toronto Western Hospital, Toronto, ON, Canada.
| |
Collapse
|
4
|
Affiliation(s)
- Yoshiki Tokura
- Department of Dermatology; Hamamatsu University School of Medicine; Hamamatsu Japan
| |
Collapse
|
5
|
Pawar M, Singh M. Sparfloxacin-induced photo-onycholysis and photosensitivity characteristically sparing lepromatous skin lesions: an interesting observation. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2018. [DOI: 10.15570/actaapa.2018.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
6
|
Schümann J, Boudon S, Ulrich P, Loll N, Garcia D, Schaffner R, Streich J, Kittel B, Bauer D. Integrated Preclinical Photosafety Testing Strategy for Systemically Applied Pharmaceuticals. Toxicol Sci 2014; 139:245-56. [DOI: 10.1093/toxsci/kfu026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
7
|
|
8
|
Manage drug-induced photosensitivity through prevention and discontinuation of the causative agent once an event has occurred. DRUGS & THERAPY PERSPECTIVES 2012. [DOI: 10.1007/bf03262130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
9
|
Abstract
Photo-induced drug eruptions are cutaneous adverse events due to exposure to a drug and either ultraviolet or visible radiation. Based on their pathogenesis, they can be classified as phototoxic or photoallergic drug eruptions, although in many cases it is not possible to determine whether a particular eruption is due to a phototoxic or photoallergic mechanism. In this review, the diagnosis, prevention and management of drug-induced photosensitivity are discussed. Diagnosis is based primarily on the history of drug intake and the clinical appearance of the eruption, primarily affecting sun-exposed areas of the skin. Phototesting and photopatch testing can be useful adjuncts in making a diagnosis. The mainstay of management is prevention, including informing patients of the possibility of increased sun sensitivity and the use of sun protective measures. However, once the eruption has occurred, it may be necessary to discontinue the culprit medication and treat the eruption with a potent topical corticosteroid. Drugs that have been implicated in causing photosensitive eruptions are reviewed. Tetracycline, doxycycline, nalidixic acid, voriconazole, amiodarone, hydrochlorothiazide, naproxen, piroxicam, chlorpromazine and thioridazine are among the most commonly implicated medications. We review the medical literature regarding evidence for the culpability of each drug, including the results of phototesting, photopatch testing and rechallenge testing.
Collapse
|
10
|
Nishio D, Nakashima D, Mori T, Kabashima K, Tokura Y. Induction of eosinophil-infiltrating drug photoallergy in mice. J Dermatol Sci 2009; 55:34-9. [PMID: 19329284 DOI: 10.1016/j.jdermsci.2009.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 01/09/2009] [Accepted: 02/20/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Drug photoallergy is one of the highly incident adverse effects. Several different histological patterns have been recognized. OBJECTIVE To establish a murine model of the eosinophil-infiltrating type of drug photoallergy by using afloqualone (AQ), a representative photosensitive drug. METHODS AKR/J mice were sensitized by intraperitoneal injection of afloqualone solution (2mg/kg/mouse) and irradiation of shaved abdomen with ultraviolet A light (UVA) (12J/cm(2)). This sensitization procedure was repeated 2-12 times, and 3 days after the last immunization, mice were challenged by a subcutaneous injection of AQ solution and irradiation of the same site with UVA. The draining lymph node cells (LNCs) were used for transfer and cytokine production studies, and the challenged skin was analyzed for chemokine expression. RESULTS More than 10 times of sensitization induced a massive infiltrate of eosinophils and lymphocytes at the challenged site. AKR/J mice were a high responder strain. The sensitivity was transferred with 5-8 x 10(7) immune lymph node and spleen cells into naïve mice. CD4(+) T cells were mainly responsible for this sensitivity, since 1 x 10(7) CD4(+) cells alone induced a high level of sensitivity, but CD8(+) T cells evoked the sensitivity to a lesser degree. Culture supernatants from AQ-photoimmuned lymph node cells contained a higher level of IL-4 and lower interferon-gamma than those from mice immunized with dinitrofluorobenzene. Finally, the skin of AQ-photochallenged site exhibited high expression of CCL24/eotaxin-2, a chemokine for eosinophils. CONCLUSION It is suggested that eosinophilic drug photoallergy is mediated by sensitized Th2 cells and locally produced eosinophil-attracting chemokines.
Collapse
Affiliation(s)
- Daisuke Nishio
- Department of Dermatology, University of Occupational and Environmental Health, Yahatanishi-ku, Kitakyushu, Japan
| | | | | | | | | |
Collapse
|
11
|
|
12
|
Abstract
This paper describes a case of sparfloxacin-induced photodermatitis associated with photo-onycholysis in a 36-year-old man. He was being treated with sparfloxacin, streptomycin, ethambutol and pyrazinamide for pulmonary tuberculosis. He developed an exaggerated sunburn-like rash over the face and the dorsa of hands and feet, and painful onycholysis of finger- and toe-nails. Withdrawal of sparfloxacin resulted in resolution of the skin rash and nail tenderness.
Collapse
Affiliation(s)
- Vikram K Mahajan
- Department of Dermatology, Venereology and Leprosy, Indira Gandhi Medical College, Shimla, India
| | | |
Collapse
|
13
|
Dawe RS, Ibbotson SH, Sanderson JB, Thomson EM, Ferguson J. A randomized controlled trial (volunteer study) of sitafloxacin, enoxacin, levofloxacin and sparfloxacin phototoxicity. Br J Dermatol 2004; 149:1232-41. [PMID: 14674902 DOI: 10.1111/j.1365-2133.2003.05582.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluoroquinolone antibiotics (FQs) are associated with phototoxic skin reactions following exposure to sunlight. OBJECTIVES We aimed to compare the phototoxic potential of sitafloxacin, a novel FQ with three others: sparfloxacin, enoxacin, levofloxacin and placebo in Caucasian volunteers. In a second study, two dosage regimens of sitafloxacin were compared with placebo in Oriental subjects. METHODS Randomized, placebo-controlled, assessor-blinded clinical trial. In 40 healthy Caucasians, sitafloxacin 100 mg twice a day (n = 8), sparfloxacin 200 mg day-1 (n = 8), enoxacin 200 mg three times a day (n = 8), levofloxacin 100 mg three times a day (n = 8) and placebo (n = 8) were given in oral doses for 6 days. In the second study, sitafloxacin 50 mg and 100 mg, both twice daily, were compared with placebo in 17 healthy Oriental subjects. Using an established monochromator technique, baseline threshold erythema levels were established pre-drug and on-drug. The phototoxic index (PI) baseline, minimal erythema dose (MED) divided by on-drug MED for each medication at each wavelength was determined and related to sitafloxacin peak plasma levels. The duration of susceptibility to phototoxicity was assessed by repeat phototesting daily after stopping medication. RESULTS In the Caucasian study, sitafloxacin 100 mg twice a day produced mild ultraviolet (UV) A-dependent phototoxicity (median PI = 1.45) at 365 +/- 30 nm (half-maximum bandwidth), maximal at 24 h with normalization by 24 h postdrug cessation. The sparfloxacin group experienced severe phototoxicity maximal at 24 h and, unusually for an FQ, extended in the visible region (430 +/- 30 nm), maximal at 400 +/- 30 nm (median PI = 12.35) with abnormal pigmentation at on-drug phototest sites lasting, although fading, for up to 1 year. Enoxacin showed UVA-dependent phototoxicity (335-365 +/- 30 nm) median PI 3.94 (at 365 +/- 30 nm) returning to normal 48 h after stopping the drug. Fading pigmentation at phototoxic sites also lasted up to 1 year. Phototoxicity was not detected in the levofloxacin or placebo groups. In the Oriental study, no clinically relevant phototoxicity was seen with either sitafloxacin or placebo groups. CONCLUSIONS We conclude that 100 mg twice a day sitafloxacin in Caucasians is associated with a mild degree of cutaneous phototoxicity. Enoxacin 200 mg three times a day and sparfloxacin 200 mg day-1 are much more photoactive. Sparfloxacin phototoxicity is induced by UVA and visible wavelengths. Levofloxacin and placebo failed to show a phototoxic effect. In the Oriental study, sitafloxacin 50 mg twice a day and 100 mg twice a day failed to demonstrate a clinically significant phototoxic effect.
Collapse
Affiliation(s)
- R S Dawe
- Photobiology Unit and DDS Medicines Research Ltd, Ninewells Hospital and Medical School, Dundee DD1 9SY, Scotland, U.K
| | | | | | | | | |
Collapse
|
14
|
|
15
|
Hamanaka H, Mizutani H, Asahig K, Shimizu M. Melanocyte melanin augments sparfloxacin-induced phototoxicity. J Dermatol Sci 1999; 21:27-33. [PMID: 10468189 DOI: 10.1016/s0923-1811(99)00010-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Quinolone has become one of the common causative agents of drug-induced photosensitive dermatitis, and its phototoxicity has now become a clinical issue. The mechanisms of long-lasting phototoxicity induced by sparfloxacin (SPFX) were investigated using melanotic and amelanotic melanoma cell lines. The sensitivities to SPFX and UVA irradiation up to 6 J/cm2 of both cells were not significantly different. However, the melanotic melanoma cell cultured with 1-150 microg/ml of SPFX showed significantly higher sensitivity to UVA irradiation compared with that of the amelanotic melanoma cell. By pulse culture with SPFX, the bound SPFX level of melanotic cell line was 10-20 times higher than that of the amelanotic cell line. These data strongly suggest that the melanin in melanocytes and keratinocytes accumulates the antibacterial quinolone and increases its tissue concentration in the basal epidermis and contributes to the long-lasting photo-injury and liquefaction degeneration of the basal cells in antibiotic quinolone phototoxic dermatitis.
Collapse
Affiliation(s)
- H Hamanaka
- Department of Dermatology, Mie University, Faculty of Medicine, Tsu, Japan
| | | | | | | |
Collapse
|
16
|
Tokura Y, Seo N, Ohshima A, Yagi H, Furukawa F, Takigawa M. Lymphocyte stimulation test with drug-photomodified cells in patients with quinolone photosensitivity. J Dermatol Sci 1999; 21:34-41. [PMID: 10468190 DOI: 10.1016/s0923-1811(99)00011-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Quinolone antibacterial agents, known to elicit photosensitive dermatitis as an adverse effect, have both phototoxicity and photoallergenicity. The latter potency is mainly derived from their photohaptenic moiety; quinolones covalently bind to protein and cells upon exposure to ultraviolet A (UVA) light. Our previous study has shown the in vivo and in vitro antigenicity of quinolone-photomodified cells in mice. Here, we examined the presence of sensitized lymphocytes that react with quinolone-photomodified autologous cells in patients with photosensitivity to quinolones. A flow cytometric analysis using a monoclonal antibody specific to quinolone photoadducts demonstrated that peripheral blood mononuclear cells (PBMC) were successfully photomodified with quinolones upon exposure to UVA. PBMC from quinolone-photosensitive patients were cocultured with autologous PBMC photomodified with the causative drug. Modest but significant proliferative responses of responder lymphocytes were found in patients photosensitive to lomefloxacin, fleroxacin, and enoxacin, indicating photoallergic mechanism in these patients. On the other hand, sparfloxacin-photosensitive patients exhibited negative lymphocyte stimulation test, suggesting that its photosensitivity is mainly phototoxic. When UVA-preirradiated quinolones were used as stimulators, only fleroxacin exceptionally stimulated patients' PBMC, indicating its prohaptenic as well as photohaptenic properties. These findings suggest the presence of circulating sensitized T cells in patients with photosensitivity to certain quinolones.
Collapse
Affiliation(s)
- Y Tokura
- Department of Dermatology, Hamamatsu University School of Medicine, Japan.
| | | | | | | | | | | |
Collapse
|