Sun-Sensitive Drugs (Photosensitivity to Drugs)

  • Medical Author:
    John P. Cunha, DO, FACOEP

    John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

Sun-sensitizing drugs (photosensitivity) definition and facts

  • Sun-sensitive or photosensitive drugs are drugs that cause a moderate to severe skin reaction that is similar to a bad sunburn when the exposed to the sun (UV rays), usually the forehead, nose, hands, arms, and lips. Many common medications cause this reaction in some people.
  • Usually, the allergic reaction appears within 24 hours of sun exposure and resolves when the blisters from the rash peel and slough off.
  • Symptoms of sun sensitivity are similar to those of a sunburn, and may include:
  • The photoallergic reactions may happen after several days of exposure to sun. Ultraviolet exposure causes the body's immune system to see a drug as an invader (antigen). The immune system initiates an allergic response and causes inflammation of the skin in the sun-exposed areas. Photoallergic reactions resemble eczema and are generally chronic.
  • Common types of phototoxic drugs include:

What is photosensitivity (sun sensitivity)?

Photosensitivity (or sun sensitivity) is inflammation of the skin induced by the combination of sunlight and certain medications or substances. This causes redness of the skin and may look similar to sunburn. Both the photosensitizing medication or chemical and light source have to be present in order for a photosensitivity reaction to occur.

Generally, these reactions can be divided into two mechanisms:

  • Phototoxic reactions
  • Photoallergic reactions. 

Phototoxic drugs are much more common than photoallergic drugs.

Find out how to choose the best sunscreen.

Making Sense of Sunscreen Products

Most people are understandably confused when it comes to choosing a sunscreen because of the baffling array of available choices. Common questions about sunscreens include

  • How high should the SPF be?
  • Should it block UVA or UVB?
  • Does it matter whether it is a gel, cream, or spray?
  • Should it be water-resistant or waterproof?

SPF stands for sun protection factor. The SPF numbers on a product can range from as low as 2 to as high as 60. These numbers refer to the product's ability to screen or block out the sun's burning rays. The SPF rating is calculated by comparing the amount of time needed to produce sunburnon protected skin to the amount of time needed to cause a sunburn on unprotected skin. The higher the SPF, the greater the sun protection.

What is the difference between a photoallergic and a phototoxic reaction?

Phototoxic reactions

In phototoxic reactions, the drug may become activated by exposure to sunlight and cause damage to the skin. The skin's appearance resembles sunburn, and the process is generally acute (has a fast onset). Ultraviolet A (UVA) radiation is most commonly associated with phototoxicity, but ultraviolet B (UVB) and visible light may also contribute to this reaction.

Rash from a phototoxic reaction is mainly confined to the sun-exposed area of the skin. A phototoxic reaction typically clears up once the drug is discontinued and has been cleared from the body, even after re-exposure to light.

Photoallergic reactions

In photoallergic reactions, the ultraviolet exposure changes the structure of the drug so that is seen by the body's immune system as an invader (antigen). The immune system initiates an allergic response and cause inflammation of the skin in the sun-exposed areas. These usually resemble eczema and are generally chronic (long-lasting). Many drugs in this family are topical drugs.

This type of photosensitivity may recur after sun exposure even after the drug has cleared from the system and can sometimes spread to areas of the skin unexposed to the sun.

Photoallergic and phototoxic reaction pictures

Picture of photoallergic and phototoxic dermatides
Picture of photoallergic and phototoxic dermatides
Picture of a phototoxic drug induced photosensitivity
Picture of a phototoxic drug induced photosensitivity

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What are the signs and symptoms of sun sensitivity (photosensitivity)?

Symptoms of phototoxic reaction

Individuals with phototoxic reactions may initially complain of a burning and stinging sensation. Redness typically occurs within 24 hours of the exposure to sun in the exposed areas of the body such as the forehead, nose, hands, arms, and lips. In severe cases, sun protected areas of skin may be also be involved.

The range of skin damage may vary from mild redness to swelling to blister formation in more severe cases. The rash from this photosensitivity reaction usually resolves with peeling and sloughing of (shedding) skin in the affected area within several days.

Symptoms of photoallergic reactions

Individuals with photoallergic reactions may initially complain of itching. This is then followed by redness and possibly swelling and eruption in the involved area. Because this is considered type of an allergic reaction, there may be no symptoms for many days when the drug is taken for the first time. Subsequent exposure to the drug and the sun may cause a more rapid response in 1-2 days.

Hyperpigmentation after reaction

Hyperpigmentation (darkening) of the affected area of the skin may develop after the resolution of a phototoxicity reaction, but it is rare in a photoallergic reaction. In phototoxic reactions, high doses of the drug and long exposures to light may be required to cause the reaction.

Can tanning beds cause a sun sensitive reaction?

Yes. Ultraviolet (UV) light is radiation energy in the form of invisible light waves. UV light is emitted by the sun and by tanning lamps. The sun discharges three types of ultraviolet radiation,

  1. ultraviolet A (UVA)
  2. ultraviolet B (UVB)
  3. ultraviolet C (UVC)

Only UVA and UVB rays reach earth. (UVC does not penetrate the earth's upper atmosphere.) Tanning lamps also produce UVA and/or UVB. These artificial rays affect the skin in the same way as do UVA and UVB from the sun.

List of examples of medications that cause phototoxicitcy

Common phototoxic drugs include:

Antibiotics

Antihistamines

Malaria medications

Cancer chemotherapy drugs

Other cancer drugs

  • Epidermal growth factor receptor inhibitors, for example, cetuximab (Erbitux), panitumumab (Vectibix), erlotinib (Tarceva), gefitinib (Iressa), lapatinib (Tykerb), vandetanib (Caprelsa)
  • BRAF inhibitors, for example, vemurafenib (Zelboraf), sorafenib (Nexavar)

Cardiac drugs

What are other examples drugs that cause phototoxicity?

BRAF inhibitors, for example, vemurafenib (Zelboraf), sorafenib (Nexavar)

Cardiac drugs

  • amiodarone (Cordarone)
  • nifedipine (Procardia)
  • quinidine (Quinaglute, Quinidex)
  • diltiazem (Cardizem, Dilacor, Tiazac)

HMG-CoA reductase inhibitors

For example, statins:

  • atorvastatin (Lipitor)
  • fluvastatin (Lescol, Lescol XL)
  • lovastatin (Altoprev)
  • pravastatin (Pravachol)
  • simvastatin (Zocor, Flo Lipid)

Diuretics

  • furosemide (Lasix)
  • thiazides [hydrochlorothiazide (Hydrodiuril)

Drugs that treat diabetes

  • sulfonylureas, for example, chlorpropamide (Diabinese), and glyburide (Micronase, DiaBeta, Glynase)

Painkillers

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), for example, naproxen (Naprosyn, Naprelan, Anaprox, Aleve) and piroxicam (Feldene).

Skin medications

  • Photodynamic therapy for skin cancer, for example, ALA or 5-aminolevulinic acid (Levulan), Methyl-5-aminolevulinic acid, verteporfin (Visudyne), and porfimer sodium (Photofrin).
  • Acne medications
  • isotretinoin (Accutane)
  • acitretin (Soriatane)

Psychiatric drugs

  • Phenothiazines, for example, chlorpromazine (Thorazine)
  • Triyclicantidepressants, for example, desipramine (Norpramin) and imipramine (Tofranil)

Antifungals

  • terbinafine (Lamisil), itraconazole (Sporanox), voriconazole (Vfend), and griseofulvin (Gris-PEG), for example

List of examples of drugs that cause photoallergic reactions

Examples of some of the common photoallergic drugs include:

Sunscreens

  • Para-aminobenzoic acid (PABA) - PABA has been phased out of sunscreen preparations because of the high rate of allergic reactions to this chemical.
  • oxybenzone
  • cyclohexanol
  • Benzophenones
  • Salicylates
  • cinnamate

Anti-microbials

Painkillers

Cancer chemotherapy drugs

  • 5-fluorouracil (5-FU, Efudex, Carac, Fluoroplex)

Fragrances

  • Musk
  • 6-methylcoumarine

These are only some of the common sun-sensitizing drugs.

What foods and plants cause sun sensitivity (photosensitivity) reactions?

Some vegetables and plants may cause sun sensitivity if they come into contact with the skin. Mango peel, lime juice, parsnips, or celery, for example, may cause temporary discoloration (darkening) of the skin contact area when in the sun. Common phototoxic fruits and vegetables include:

  • Lime
  • Celery
  • Carrots
  • Figs
  • Parsley
  • Parsnips
  • Mango peel

Pictures of food and plant sun-sensitivity (photosensitivity) reactions

Picture of phytophotodermatitis hyperpigmentation
Picture of phytophotodermatitis hyperpigmentation
Picture of photodermatitis
Picture of photodermatitis
Picture of photodermatitis with blisters
Picture of photodermatitis with blisters

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What diseases or other health problems cause photosensitivity?

Some medical conditions are known to cause sensitivity to sun exposure.

Systemic lupus erythematosus (SLE) often causes a rash on the face which can be very sensitive to sunlight. This rash is typically seen on the nose and cheeks, called a malar rash, and is considered one of the hallmarks of lupus.

Porphyria is another medical condition that may cause photosensitivity reactions. This is a hereditary condition with skin manifestation (cutaneous porphyria) causing rashes and blisters in reaction to exposure to sunlight.

Vitiligo is a relatively common disorder that causes patches of white de-pigmented skin. These patches lack melanin and are extremely sensitive to UV rays.

Xeroderma pigmentosum is a disorder that appears to result from an inherited hypersensitivity to the cancer-causing (carcinogenic) effects of ultraviolet light. Sunlight causes DNA damage that is normally repaired. Individuals with xeroderma pigmentosum have defective inability to repair the DNA after UV damage. Affected individuals are hundreds of times more vulnerable to developing skin cancer than other people. Their extreme skin photosensitivity predisposes them to pronounced skin damage and scarring and also to the early onset of skin cancer (basal cell and squamous cell carcinomas and malignant melanoma).

Individuals with classic oculocutaneous albinism lack melanin in their skin and eyes - the term oculocutaneous" comes from "oculo" for eyes, and "cutaneous" for skin. Without the protection of this pigment, their white skin and pink eyes are both highly sensitive to UV and susceptible to the rays' damage.

How is sun sensitivity (photosensitivity) diagnosed?

The diagnosis of sun sensitivity is mainly made by a thorough history, examination, and review of medications and duration of exposure to sun. It is important to ask when the medication was started and for how long the symptoms persisted.

There are no diagnostic tests available, although a photo-patch test may be performed. This test is typically performed by a dermatologist (a doctor who specializes in diseases of the skin) by shining light onto different areas of the skin to see how long it will take for the light to cause redness. This test may be useful in evaluating photosensitivity to topical medications causing a photoallergic response. In cases of phototoxicity reactions, this test is generally not useful.

What is the treatment for a photosensitizing drug reaction?

Recognizing and discontinuing the photosensitizing drug is the most important step in treatment. In general, the usual sunburn prevention methods such as the use of sunscreens and avoidance of prolonged exposure to sun are important steps to take. Keeping the area of skin eruption moist and applying wet dressings may help relieve the symptoms. The reaction may last up to a few weeks.

Topical steroid creams may be helpful in treating the redness, and antihistamines are generally helpful in minimizing the itching. In severe cases, a short course (10-14 days) of oral steroids, under the direction of a doctor, may be used.

Is anyone taking these drugs at risk for developing sunburn?

Not everyone taking any of these drugs will develop photosensitivity reactions. Certain individuals have more susceptibility to these medications than others.

Are there any medical applications of sun sensitivity (photosensitivity)?

Photodynamic therapy utilizes the concept of sun or light sensitivity to treat some skin conditions including skin pre-cancers (actinic keratosis), skin cancers, and acne. Briefly, this treatment takes advantage of activating a photosensitizing drug (such as 5-aminolevulinic acid) by shining light directly onto it for a short time. The drug is first applied to the area of the skin where the cancer or pre-cancer is found. With light-induced activation of the drug, the abnormal cells (cancer or pre-cancer) are destroyed preferentially.

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Medically Reviewed on 4/26/2018
References
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Arndt, K. et al. Cutaneous Medicine and Surgery: An integrated program in dermatology. N Engl J Med 1996; 335:826 September 12, 1996

New England Journal of Medicine 2004;350:1111-1117. Photosensitivity by Morrison, MD.

Poh-Fitzpatrick, MB, MD. "Porphyria Cutanea Tarda." Medscape. Updated: Ma 08, 2017.
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Zhang, AY, MD. "Drug-Induced Photosensitivity." Medscape. Updated: Jun 14 June 2017.
<https://emedicine.medscape.com/article/1049648-overview>
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