Photosensitivity


Article Author:
Amanda Oakley


Article Editor:
Talel Badri


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
3/26/2019 11:24:16 PM

Introduction

Photosensitivity refers to various symptoms, diseases, and conditions (photodermatoses) caused or exacerbated by exposure to sunlight[1]. It is classified into five categories: primary photodermatosis, exogenous photodermatosis, photo-exacerbated dermatoses, metabolic photodermatosis, and genetic photodermatosis.

Primary or autoimmune photodermatoses

  • Polymorphic light eruption[2]
  • Juvenile spring eruption
  • Actinic folliculitis
  • Actinic prurigo[3]
  • Solar urticaria[4]
  • Chronic actinic/photosensitivity dermatitis[5]
  • Hydroa vacciniforme (associated with Epstein-Barr virus)[6]

Exogenous or drug/chemical-induced photodermatoses[7][8]

  • Drug-induced photosensitivity: common photosensitizing drugs are thiazides, tetracyclines, non-steroidal anti-inflammatory drugs (NSAIDs), phenothiazines, voriconazole, quinine, vemurafenib, and many others[7]
  • Photocontact dermatitis: due to phototoxic chemicals such as psoralens in plants, vegetables, fruit; fragrances in cosmetics; sunscreen chemicals; dyes and disinfectants[9]
  • Pseudoporphyria: induced by drugs and/or renal insufficiency[10]

Photo-exacerbated or photo-aggravated dermatoses

Usually:

  • Cutaneous lupus erythematosus (acute, subacute and chronic variants)[11]
  • Dermatomyositis[12]
  • Sjogren syndrome
  • Darier disease[13]
  • Rosacea[14]
  • Melasma[15]

Sometimes:

  • Pemphigus vulgaris
  • Pemphigus foliaceus[16]
  • Atopic dermatitis[17]
  • Seborrhoeic dermatitis[18]
  • Psoriasis[19]
  • Lichen planus (actinicus)[20]
  • Erythema multiforme[21]
  • Mycosis fungoides[22]

Metabolic photodermatoses (rare)

  • Porphyria cutanea tarda[23]
  • Erythropoietic protoporphyria
  • Variegate porphyria[24]
  • Erythropoietic porphyria (Gunther disease)[25]

Genetic photodermatoses (very rare disorders due to genomic instability)

  • Xeroderma pigmentosum[26]
  • Cockayne syndrome[27]
  • Trichothiodystrophy[28]
  • Bloom syndrome[29]
  • Rothmund Thomson syndrome[30]

Etiology

The etiology of a photodermatosis depends on its classification (see individual topic articles). Some are due to autoimmune reactions, drugs, connective tissue disease, and abnormal inherited biochemical pathways.

Epidemiology

Photosensitivity may be observed in both males and females at all ages and in all ethnic groups. Different types of photosensitivity may be prevalent at different times of life. Genetic and environmental factors intervene in the occurrence of photosensitivity.

Pathophysiology

Photosensitivity is caused by an abnormal reaction to a component of the electromagnetic spectrum of sunlight and a chromophore (reactive compound) within the skin. Patients can be sensitive to one kind of sunlight, for example only to ultraviolet radiation, ultraviolet A or B (UVA, UVB), or visible light, or to a wider range of radiation. The most common photosensitivity is to UVA. Mainly, exposure to visible light triggers porphyria.

History and Physical

The clinical features depend on the specific photodermatosis.

  • Photodermatoses affect areas exposed to sunlight, usually the face, neck, hands, and do not affect areas not exposed to the light (covered at least by underwear), or are less severe in covered areas.
  • Sometimes they spare areas that habitually are exposed to the light, for example, the face of a polymorphic light eruption.
  • Sometimes they only affect certain parts of the body, for instance, juvenile spring eruption is confined to the tops of the ears.
  • Photodermatoses may also occur following indoor exposure to artificial sources of UVR like fluorescent lamps or visible radiation.
  • Genomic instability due to DNA repair deficiency disease causes pigmentary changes and high risk (1000 times normal) of skin tumors including basal cell carcinoma, squamous cell carcinoma, and melanoma.
  • Children with the photosensitive genodermatoses have characteristic cutaneous features and abnormalities of other organs.

Clues to photosensitivity include: 

  • Summer exacerbation; although, note that many photodermatoses are present year round
  • Sharp cut-off between affected area and skin covered by clothing or jewellery (e.g., watch strap, ring)
  • Sparing of folds of upper eyelids
  • Sparing of deep furrows on face and neck
  • Sparing of skin covered by hair
  • Sparing of skin shadowed by the ears, under the nose and the chin
  • Sparing of the web spaces between the fingers.

Evaluation

Medical practitioners diagnose photosensitivity by a history of a skin problem arising from exposure to sunlight. They determine the specific type by taking a careful history, examining the skin and performing specific tests. Photosensitivity is sometimes confirmed by photosets, which only is available in specialized centers.

  • Minimal erythema dose (MED) testing (broadband or monochromators) to determine threshold dose
  • Provocation photoset procedure using repeated exposures to UVA and/or UVB over four consecutive days in an attempt to reproduce the dermatosis
  • Photopatch tests in association with standard patch tests to determine photoallergy

Investigations may include:

  • Full blood count
  • Connective tissue antibodies including antinuclear antibodies (ANA), extractable nuclear antigens (ENA) if suspicious of lupus erythematosus
  • Porphyrins in blood, urine, and feces
  • Liver function and iron tests in patients suspected of porphyria
  • Skin biopsy for histopathology and direct immune fluorescence in primary and photo-exacerbated dermatoses
  • In cases suspicious of xeroderma pigmentosum, measurement of post-UV cell survival and DNA repair capacity in fibroblast assays
  • Tiger hair appearance on polarised microscopy of brittle hair (dark and light areas) should lead to chromatography to determine amino acid content, which shows reduced cysteine in trichothiodystrophy
  • Gene sequencing may confirm Bloom syndrome or Rothmund Thomson syndrome.

Treatment / Management

Management of photosensitivity involves sun protection and treatment of the underlying disorder. Mainly, photosensitivity reactions are prevented by careful protection from sun exposure and avoidance of exposure to artificial sources of UVR. Use of websites and smartphone apps that indicate local ultraviolet levels are helpful to understand when protection is most essential. There is more ultraviolet radiation in the tropics compared to temperate areas, in the Southern hemisphere compared to the Northern, during summer compared to winter, at high altitude compared to sea level, and in the middle of the day compared to the extremes of the day.

Protection involves:[31]

  • Avoiding exposure to direct sunlight
  • Staying indoors and away from windows, and seeking shade when outdoors
  • Dressing up in covering clothing and wearing a wide-brimmed hat when outdoors. Some clothing is labeled with ultraviolet protection factor (UPF). Best protection from clothing is obtained from thick, tightly woven, dry and dark colored polyester, denim or wool
  • Broad-spectrum sunscreen SPF 50 or higher, covering all exposed skin. Sunscreen should protect from UVB and UVA and be water resistant. It should be applied generously and reapplied every two hours while outdoors
  • Tanning products containing dihydroxyacetone provide modest photoprotection against UVA and to a lesser extent against UVB.

SPF is sun protection factor, defined as the dose of solar radiation needed to induce just perceptible erythema (minimal erythema dose, MED) on skin treated with 2 mg/cm sunscreen divided by the MED on untreated skin. SPF primarily describes protection from UVB, as it reflects protection from the erythema action spectrum.

The primary photodermatosis polymorphic light eruption may be paradoxically effectively treated by graduated, and cautious, exposure to ultraviolet radiation.[32]

Pearls and Other Issues

Patients with photodermatoses also may need to: 

  • Take vitamin D supplements and oral antioxidants
  • Wear a clear plastic mask to protect the face 
  • Choose gray-tinted laminated glass for automobile
  • Apply photoprotective UV films to windows at home, school work, and vehicles
  • Have regular skin checks to locate and treat skin cancers early.

Enhancing Healthcare Team Outcomes

The healthcare team, including nurses, pharmacists, and clinicians must work together to educate patients with photodermatoses as they need to be reminded to take vitamin D supplements and oral antioxidants, wear a clear plastic mask to protect the face, choose gray-tinted laminated glass for their automobile, and apply photoprotective UV films to windows at home, school work, and vehicles. The team should remind patients they need to have regular skin checks to locate and treat skin cancers early. [Level V]


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Photosensitivity - Questions

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An elderly gardener has an intensely pruritic chronic rash on his face, neck, and dorsum hands. It spares skin creases and covered skin. The rash is more prominent in summer than in winter. He is on no regular medications. Which of the following treatments are most likely to be effective?

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A man in his 70s develops a thickened, eczematous rash on face, neck, dorsum of hands and wrists. It spares eyelids, skin creases, the submental area, and under his watch. Which of the following statements is true?

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A man in his 60s had a cardiac event some weeks ago and was prescribed five new medicines including aspirin, hydrochlorothiazide, metoprolol, quinapril, and nitroglycerin. He presents with an itchy, blistering rash confined to his upper chest, extensor arms and dorsal hands. He attributes the rash to a fishing expedition the previous weekend. What is the most likely cause?

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A 31-year-old female presents with a 2-year history of facial burning sensation and erythema that occur even after short exposures to sunlight. Screening for antinuclear antibodies and extractable nuclear antigens is consistent with lupus erythematosus. What is the best photoprotection to use in this patient?



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A patient presents with a lifelong history of burning discomfort, erythema, and blistering on areas exposed to sunlight. Which of the following statements are true?

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Photosensitivity - References

References

Lehmann P,Schwarz T, Photodermatoses: diagnosis and treatment. Deutsches Arzteblatt international. 2011 Mar;     [PubMed]
Blakely KM,Drucker AM,Rosen CF, Drug-Induced Photosensitivity-An Update: Culprit Drugs, Prevention and Management. Drug safety. 2019 Mar 19;     [PubMed]
Ibbotson S, Drug and chemical induced photosensitivity from a clinical perspective. Photochemical     [PubMed]
Lembo S,Raimondo A, Polymorphic Light Eruption: What's New in Pathogenesis and Management. Frontiers in medicine. 2018;     [PubMed]
Pile HD,Crane JS, Actinic Prurigo 2019 Jan;     [PubMed]
Photiou L,Foley P,Ross G, Solar urticaria - An Australian case series of 83 patients. The Australasian journal of dermatology. 2018 Dec 25;     [PubMed]
Paek SY,Lim HW, Chronic actinic dermatitis. Dermatologic clinics. 2014 Jul;     [PubMed]
Ahad T,Rhodes LE, Haemorrhagic vesicles and varioliform scarring: consider photosensitivity. Archives of disease in childhood. 2018 Nov 13;     [PubMed]
Snyder M,Turrentine JE,Cruz PD Jr, Photocontact Dermatitis and Its Clinical Mimics: an Overview for the Allergist. Clinical reviews in allergy     [PubMed]
Velander MJ,Þorsteinsdóttir S,Bygum A, [Clinical review of pseudoporphyria]. Ugeskrift for laeger. 2015 Feb 2;     [PubMed]
Foering K,Chang AY,Piette EW,Cucchiara A,Okawa J,Werth VP, Characterization of clinical photosensitivity in cutaneous lupus erythematosus. Journal of the American Academy of Dermatology. 2013 Aug;     [PubMed]
Auriemma M,Capo A,Meogrossi G,Amerio P, Cutaneous signs of classical dermatomyositis. Giornale italiano di dermatologia e venereologia : organo ufficiale, Societa italiana di dermatologia e sifilografia. 2014 Oct;     [PubMed]
Baba T,Yaoita H, UV radiation and keratosis follicularis. Archives of dermatology. 1984 Nov;     [PubMed]
Murphy G, Ultraviolet light and rosacea. Cutis. 2004 Sep;     [PubMed]
Suggs AK,Hamill SS,Friedman PM, Melasma: update on management. Seminars in cutaneous medicine and surgery. 2018 Dec;     [PubMed]
Igawa K,Matsunaga T,Nishioka K, Involvement of UV-irradiation in pemphigus foliaceus. Journal of the European Academy of Dermatology and Venereology : JEADV. 2004 Mar;     [PubMed]
Ellenbogen E,Wesselmann U,Hofmann SC,Lehmann P, Photosensitive atopic dermatitis--a neglected subset: Clinical, laboratory, histological and photobiological workup. Journal of the European Academy of Dermatology and Venereology : JEADV. 2016 Feb;     [PubMed]
Palmer RA,Hawk JL, Light-induced seborrhoeic eczema: severe photoprovocation from subclinical disease. Photodermatology, photoimmunology     [PubMed]
Wolf P,Weger W,Patra V,Gruber-Wackernagel A,Byrne SN, Desired response to phototherapy vs photoaggravation in psoriasis: what makes the difference? Experimental dermatology. 2016 Dec;     [PubMed]
Tiwary AK, Actinic Lichen Planus. Indian pediatrics. 2018 Aug 15;     [PubMed]
Rodríguez-Pazos L,Gómez-Bernal S,Rodríguez-Granados MT,Toribio J, Photodistributed erythema multiforme. Actas dermo-sifiliograficas. 2013 Oct;     [PubMed]
Haber R,Ram-Wolff C,Laly P,Bouaziz JD,Jachiet M,Rivet J,Bagot M, Photo-sensitive mycosis fungoides: a new variant? European journal of dermatology : EJD. 2017 Apr 1;     [PubMed]
Singal AK, Porphyria cutanea tarda: Recent update. Molecular genetics and metabolism. 2019 Jan 18;     [PubMed]
Wang B,Rudnick S,Cengia B,Bonkovsky HL, Acute Hepatic Porphyrias: Review and Recent Progress. Hepatology communications. 2019 Feb;     [PubMed]
Erwin AL,Desnick RJ, Congenital erythropoietic porphyria: Recent advances. Molecular genetics and metabolism. 2018 Dec 27;     [PubMed]
Lehmann J,Seebode C,Martens MC,Emmert S, Xeroderma Pigmentosum - Facts and Perspectives. Anticancer research. 2018 Feb;     [PubMed]
Hafsi W,Badri T, Cockayne Syndrome 2019 Jan;     [PubMed]
Yew YW,Giordano CN,Spivak G,Lim HW, Understanding photodermatoses associated with defective DNA repair: Photosensitive syndromes without associated cancer predisposition. Journal of the American Academy of Dermatology. 2016 Nov;     [PubMed]
Hafsi W,Badri T, Bloom Syndrome (Congenital Telangiectatic Erythema) 2019 Jan;     [PubMed]
Giordano CN,Yew YW,Spivak G,Lim HW, Understanding photodermatoses associated with defective DNA repair: Syndromes with cancer predisposition. Journal of the American Academy of Dermatology. 2016 Nov;     [PubMed]
Gozali MV,Zhou BR,Luo D, Update on treatment of photodermatosis. Dermatology online journal. 2016 Feb 17;     [PubMed]
Guarrera M, Polymorphous Light Eruption. Advances in experimental medicine and biology. 2017;     [PubMed]

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