UV-B phototoxic effects induced by atorvastatin

Atorvastatin-Associated Eosinophilic Spongiosis: A Case Report and a Relevant Literature Review of Dermatological Manifestations

Atorvastatin, a widely prescribed 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor (HMG-CoA reductase inhibitor), is associated with various adverse effects, including many dermatologic manifestations. We present the case of a 73-year-old man who developed eosinophilic spongiosis shortly after initiating atorvastatin therapy, an adverse effect which to our knowledge has not yet been reported in association with atorvastatin. Our investigation explores the clinical and histopathologic characteristics of eosinophilic spongiosis induced by atorvastatin, delving into potential mechanisms behind statin-induced eosinophilia. A literature review, focusing on atorvastatin's dermatological side effects, revealed a limited number of relevant studies, emphasizing the scarcity of documented cases. Our aim is to raise awareness of eosinophilic spongiosis as a potential side effect of atorvastatin, emphasizing its impact on patients' quality of life. This case prompts further research into the mechanisms underlying such dermatologic reactions, contributing to a better understanding of atorvastatin's diverse adverse effects.

Incidence of radiodermatitis and factors associated with its severity in women with breast cancer: a cohort study

BACKGROUND

One of the main adverse reactions of adjuvant radiotherapy for breast cancer is radiodermatitis.

OBJECTIVE

To assess the incidence of radiodermatitis in women with breast cancer, identify factors associated with its severity and determine the time at which this event occurs.

METHODS

Prospective cohort study in 113 women with breast cancer who were evaluated before radiotherapy and at every fifth session until the end of treatment. Logistic regression and Cox proportional regression model were used for the assessment of risk factors; P values < 0.05 were considered significant.

RESULTS

The incidence rate of radiodermatitis was 98.2% and it was demonstrated that for each additional point of the Body Mass Index (BMI), the chance of occurrence of grades II to IV radiodermatitis increases by 14% (OR=1.14 [95% CI 1.04-1.26]; p=0.004) and statin use increases the risk of more severe skin lesions by four-fold (OR=4.27 [95% CI 1.11-16.42]; p=0.035). The exclusive use of hydrogel for skin hydration was an independent factor in delaying the onset of radiodermatitis (HR=0.55 [95% CI 0.36-0.82]; p=0.004).

STUDY LIMITATIONS

The main limitation of this study was its external validity. The identified factors should be considered for services and populations similar to those in this study.

CONCLUSIONS

There was a high incidence of radiodermatitis and its severity was related to higher BMI, statin use; there was a protective effect of hydrogel use.

Statin Use and Skin Cancer Risk: A Prospective Cohort Study

Epidemiological studies on statin use in relation to skin cancer risk are scarce and yielded conflicting results. We explored this association in Etude Epidémiologique auprès de femmes de l'Education Nationale, a prospective cohort of French women born in 1925-1950. Health and lifestyle data were self-reported biennially and matched with drug reimbursement data, allowing the identification of participants' statin use since 2004. Multivariable cause-specific hazards regression models adjusted for skin cancer risk factors estimated hazard ratios with 95% confidence intervals. Over 2004-2014, 455 cutaneous melanoma, 1,741 basal cell carcinoma, and 268 squamous cell carcinoma cases were ascertained among 62,473 women. Compared with never use, there were no associations between ever use of statins and melanoma (hazard ratio = 1.16, 95% confidence interval = 0.94-1.44) or squamous cell carcinoma (hazard ratio = 0.89, 95% confidence interval = 0.66-1.19) risks and a decrease in basal cell carcinoma risk with ever use of statins (hazard ratio = 0.89, 95% confidence interval = 0.79-0.996). We found no trend of increasing or decreasing risks with dose, duration of use, time since first use, or age at first use and no statistically significant effect modification by pigmentary traits or residential UVR exposure. Because of the limited number of studies evaluating the associations between the use of statins and the risks of melanoma, basal cell carcinoma, and squamous cell carcinoma, these findings would deserve further investigation in other settings.

Drug-Induced Photosensitivity-From Light and Chemistry to Biological Reactions and Clinical Symptoms

Photosensitivity is one of the most common cutaneous adverse drug reactions. There are two types of drug-induced photosensitivity: photoallergy and phototoxicity. Currently, the number of photosensitization cases is constantly increasing due to excessive exposure to sunlight, the aesthetic value of a tan, and the increasing number of photosensitizing substances in food, dietary supplements, and pharmaceutical and cosmetic products. The risk of photosensitivity reactions relates to several hundred externally and systemically administered drugs, including nonsteroidal anti-inflammatory, cardiovascular, psychotropic, antimicrobial, antihyperlipidemic, and antineoplastic drugs. Photosensitivity reactions often lead to hospitalization, additional treatment, medical management, decrease in patient's comfort, and the limitations of drug usage. Mechanisms of drug-induced photosensitivity are complex and are observed at a cellular, molecular, and biochemical level. Photoexcitation and photoconversion of drugs trigger multidirectional biological reactions, including oxidative stress, inflammation, and changes in melanin synthesis. These effects contribute to the appearance of the following symptoms: erythema, swelling, blisters, exudation, peeling, burning, itching, and hyperpigmentation of the skin. This article reviews in detail the chemical and biological basis of drug-induced photosensitivity. The following factors are considered: the chemical properties, the influence of individual ranges of sunlight, the presence of melanin biopolymers, and the defense mechanisms of particular types of tested cells.

Photosensitizing Medications and Skin Cancer: A Comprehensive Review

(1) The incidence of skin cancer is increasing in the United States (US) despite scientific advances in our understanding of skin cancer risk factors and treatments. In vitro and in vivo studies have provided evidence that suggests that certain photosensitizing medications (PSMs) increase skin cancer risk. This review summarizes current epidemiological evidence on the association between common PSMs and skin cancer. (2) A comprehensive literature search was conducted to identify meta-analyses, observational studies and clinical trials that report on skin cancer events in PSM users. The associated risks of keratinocyte carcinoma (squamous cell carcinoma and basal cell carcinoma) and melanoma are summarized, for each PSM. (3) There are extensive reports on antihypertensives and statins relative to other PSMs, with positive and null findings, respectively. Fewer studies have explored amiodarone, metformin, antimicrobials and vemurafenib. No studies report on the individual skin cancer risks in glyburide, naproxen, piroxicam, chlorpromazine, thioridazine and nalidixic acid users. (4) The research gaps in understanding the relationship between PSMs and skin cancer outlined in this review should be prioritized because the US population is aging. Thus the number of patients prescribed PSMs is likely to continue to rise.

Enhanced phototransformation of atorvastatin by polystyrene microplastics: Critical role of aging

Reactive oxygen species (ROS) generated from light irradiation of microplastics (MPs) can potentially affect the environmental fate of organic contaminants when they coexist in the same environment. This study investigated the effect of polystyrene (PS) MPs with different aging degrees on the phototransformation of atorvastatin (ATV) under simulated sunlight. Results showed that the presence of PS MPs facilitated the phototransformation of ATV, and the degradation rate was linearly correlated with the aging degree (i.e., carbonyl index) of MPs. The enhanced effects mainly depended on the contents of oxygen-containing functional groups of PS MPs, which increased the absorption of light energy and the generation of ROS (e.g., singlet oxygen (¹O₂) and triplet-excited state PS (³PS*)). Quenching experiments indicated that ¹O₂ generated from photosensitization of PS was the major contributor to the increased phototransformation of ATV. Additionally, the role of ³PS* became more important in the photodegradation mediated by higher degree aged MPs because much more ¹O₂ was generated from the ³PS* . PS MPs also increased the types and yields of degradation products, especially for higher degree aged MPs, despite the low effect on leachate toxicity. The findings provide a novel insight into the critical role of MPs in the fate of organic contaminants in aquatic environments.

Cardiovascular Drug Use and Risk of Actinic Keratosis: A Case-Control Study

INTRODUCTION

Actinic keratosis (AK) is a precancerous skin lesion. Currently, many experts treat actinic keratosis as squamous cell carcinoma in situ. It is well established that exposure of the skin to ultraviolet radiation is a major risk factor for the development of actinic keratosis. Some studies suggest an association between keratinocyte cancers and photosensitizing cardiovascular drugs. The aim of this study was to establish an association between cardiovascular drug use and the presence of AK.

METHODS

A total of 400 patients were enrolled into the study (200 with AK; 200 healthy persons in the control group). The group of patients with AK consisted of 106 women and 94 men (mean age 71 years). The control group included 102 women and 98 men (mean age 69 years). An analysis of the risk factors for developing actinic keratosis was performed in all patients with AK on the basis of a detailed, standardized interview.

RESULTS

The statistical analysis showed that features independently associated with increased risk of AK included: age > 80 years (OR 4.14; 95% CI 2.4-7.3), positive cancer history (OR 1.94; 95% CI 1.0-3.6), positive history of sunburns when < 18 years old (OR 2.18; 95% CI 1.3-3.7) and taking angiotensin-converting enzyme inhibitors (OR 2.28; 95% CI 1.2-4.3), angiotensin receptor AT1 blockers (OR 2.90; 95% CI 1.1-7.9) and calcium channel blockers (OR 2.4; 95% CI 1.0-5.3).

CONCLUSION

In conclusion, our study presented an association between cardiovascular drug use and the risk of developing AK.

Drug-Induced Photosensitivity-An Update: Culprit Drugs, Prevention and Management

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.

Photosensitivity reactions in the elderly population: questionnaire-based survey and literature review

Purpose

Older people are at risk of developing adverse drug reactions, including photosensitivity reactions. Therefore, the aim of the study was to assess the use of potentially photosensitizing medications and photoprotection in the elderly population.

Patients and methods

Three hundred and fifty-six respondents (223 [63%] women and 133 [37%] men) aged ≥65 years filled in the original questionnaire concerning photosensitivity reactions to drugs. The diagnosis of drug-induced photosensitivity was based on medical history and clinical examination.

Results and conclusion

We found that drugs potentially causing phototoxic/photoallergic reactions comprised more than one fifth of all drugs used by the participants. The most numerous group was patients treated with 3–5 drugs potentially causing phototoxic/photoallergic reactions simultaneously. Of all drugs, ketoprofen was found to cause the highest number of photosensitivity reactions. Cutaneous adverse reactions were also observed for hydrochlorothiazide, atorvastatin, simvastatin, telmisartan, and metformin. Moreover, it was found that the incidence of photosensitivity reactions can be significantly reduced by using proper photoprotection.

Drug-induced photosensitivity: Photoallergic and phototoxic reactions

Drug-induced photosensitivity refers to the development of cutaneous disease due to the interaction between a given chemical agent and sunlight. Photosensitivity reactions can be classified as phototoxic or photoallergic. Sometimes, there is an overlap between these two patterns, making their distinction particularly difficult for the clinician. We review the drugs that have been implicated as photosensitizers, the involved mechanism, and their clinical presentations. The main topical agents that cause contact photosensitivity are the nonsteroidal antiinflammatory drugs, whereas the main systemic drugs inducing photosensitivity are antimicrobials, nonsteroidal antiinflammatory agents, and cardiovascular drugs. Drug-induced photosensitivity remains a common clinical problem and is often underdiagnosed.

Health outcomes associated with illicit prescription opioid injection: A systematic review

Prescription opioid injection is a growing concern among people who use illicit drugs. Little is known about the potential health-related harms of injecting prescription opioids. Therefore, the authors undertook a systematic review to identify health outcomes associated with injecting prescription opioids. PubMed, Ovid MEDLINE®, EMBASE, Journals@Ovid, CINAHL, PsycInfo, Web of Science® Core Collection, CAB Direct, and ERIC databases were searched to identify English articles published between January 1990 and February 2015 that matched the inclusion criteria. Potentially relevant articles were those examining a clinical health outcome among people who use illicit drugs, in which a sub-group injects prescription opioids. The International Classification of Diseases (ICD-10) was used to clinically classify health outcomes. In total, 31 studies that met the inclusion criteria were identified and summarized. A modified version of the Downs and Black checklist was used to assess individual study quality and identify sources of bias. Findings supported associations between prescription opioid injection and hepatitis C infection, substance dependence and other mental health indicators, and lower general health. Associations with human immunodeficiency virus, overdose, and cutaneous infection were less consistent and varied according to prescription opioid type(s). Several potential sources of bias were identified as well as a need for more longitudinal research and more rigorous confounding adjustment. The current findings highlight a need to consider the growing popularity of prescription opioid injection in efforts to reduce drug-related harm among people who inject drugs.

Drug-induced photosensitivity: culprit drugs, management and prevention

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.

Erythromelalgia accompanying rosuvastatin-associated myopathy

BACKGROUND

Secondary erythromelalgia can occur due to various underlying medical disorders or drug toxicity.

MAIN OBSERVATIONS

A 75-year old male developed acute secondary erythromelalgia following the onset of rosuvastatin use and associated myopathy. The illness was reversible after discontinuation of the pharmacological agent.

CONCLUSION

Secondary erythromelalgia may occur after rosuvastatin use, but this and other dermatological toxicities are rare.

Potential phototoxicity of rosuvastatin mediated by its dihydrophenanthrene-like photoproduct

In this work, rosuvastatin has been used to gain insight into the molecular basis of statin photosensitization. This lipid-lowering drug, also known as "superstatin", contains a 2-vinylbiphenyl-like moiety and has been previously described to decompose under solar irradiation, yielding stable dihydrophenanthrene analogues. During photophysical characterization of rosuvastatin, only a long-lived transient at ca. 550 nm was observed and assigned to the primary photocyclization intermediate. Thus, the absence of detectable triplet-triplet absorption and the low yield of fluorescence rules out the role of the parent drug as an efficient sensitizer. In this context, the attention has been placed on the rosuvastatin main photoproduct (ppRSV). Indeed, the photobehavior of this dihydrophenanthrene-like compound presents the essential components needed for an efficient biomolecule photosensitizer i.e. (i) a high intersystem crossing quantum yield (Φ(ISC) = 0.8), (ii) a triplet excited state energy of ca. 67 kcal mol(-1), and (iii) a quantum yield of singlet oxygen formation (Φ(Δ)) of 0.3. Furthermore, laser flash photolysis studies revealed a triplet-triplet energy transfer from the triplet excited state of ppRSV to thymidine, leading to the formation of cyclobutane thymidine dimers, an important type of DNA lesion. Finally, tryptophan has been used as a probe to investigate the type I and/or type II character of ppRSV-mediated oxidation. In this way, both an electron transfer process giving rise to the tryptophanyl radical and a singlet oxygen mediated oxidation were observed. On the basis of the obtained results, rosuvastatin, through its major photoproduct ppRSV, should be considered as a potential sensitizer.

Statins in dermatology

Statins are competitive inhibitors of 3-hydroxy-3-methylyglutaryl-coenzyme A reductase and reduce low-density lipoprotein-C levels. Statins are well-tolerated drugs used for prevention of atherosclerosis and cardiovascular events. Statins possess anti-inflammatory, immunomodulatory, antioxidant, metabolic, and possible anticancer effects. Statins are reported to be effective against psoriasis, dermatitis, graft-versus-host disease, uremic pruritus, vitiligo, and hirsutism. Topical forms of statins are employed in the treatment of acne, seborrhea, rosacea, and rhinophyma. Animal studies show the beneficial effect of statins against contact dermatitis and wound healing. They have promising anti-HIV effects as well. This article succinctly reviews the various cellular and molecular effects of statins, their applications in cutaneous medicine and their side effects.

Erythema multiforme photoinduced by statins

We report two cases of systemic photosensitivity induced by simvastatin and pravastatin that presented as photodistributed erythema multiforme. One of them occurred in a 75-year-old woman who had been suffering recurrent eruptions following sun exposures over a period of 12 years. The other patient was a 54-year-old man who had a 1-week history of pruritic lesions on the face and the hands. They had no history of herpes simplex virus infection. In both cases, the close temporal relationship between drug ingestion and onset of the conditions suggested statin-induced photosensitivity. The diagnosis was confirmed by the marked reduction of UVB-MED or both UVA and UVB-MED while taking the drug and its normalization after discontinuing the statin intake.

Statin use and risk of basal cell carcinoma

OBJECTIVE

We examined the association between statin use and basal cell carcinoma (BCC) risk.

METHODS

We identified all members of a large integrated health care delivery system with a diagnosis of a histologically proven BCC in 1997. Subsequent BCCs were identified through 2006 from health plan electronic pathology records. Longitudinal exposure to statins and other lipid-lowering agents was determined from automated pharmacy records. We used extended Cox regression to examine the independent association between receipt of statin therapy (ever vs never, cumulative duration) and risk of subsequent BCC. To minimize confounding by indication, we conducted sensitivity analyses in the subset of individuals considered eligible for lipid-lowering therapy based on national guidelines.

RESULTS

Among 12,123 members given a diagnosis of BCC who had no prior statin exposure, 6381 developed a subsequent BCC during follow-up. Neither "ever use of statins" (adjusted hazard ratio 1.02, 95% confidence interval: 0.92-1.12) or cumulative duration of statin (adjusted hazard ratio 1.02/year, 95% confidence interval: 0.99-1.11) was associated with subsequent BCC after adjustment for age, sex, and health care use. Risk estimates did not change appreciably when the analysis was limited to the subset of individuals who met eligibility criteria for initiating statin therapy. There was also no significant association between use of non-statin antilipemics and subsequent BCC (adjusted hazard ratio 1.10, 95% confidence interval: 0.76-1.58).

LIMITATIONS

No information was available for BCC risk factors, such as sun sensitivity and sun exposure.

CONCLUSIONS

Among a large cohort of individuals with BCC, statin therapy was not significantly associated with risk of subsequent BCC.

A mechanistic study on the phototoxicity of atorvastatin: singlet oxygen generation by a phenanthrene-like photoproduct

Atorvastatin calcium (ATV) is one of the most frequently prescribed drugs worldwide. Among the adverse effects observed for this lipid-lowering agent, clinical cases of cutaneous adverse reactions have been reported and associated with photosensitivity disorders. Previous work dealing with ATV photochemistry has shown that exposure to natural sunlight in aqueous solution leads to photoproducts resulting from oxidation of the pyrrole ring and from cyclization to a phenanthrene derivative. Laser flash photolysis of ATV, at both 266 and 308 nm, led to a transient spectrum with two maxima at lambda= 360 and lambda= 580 nm (tau= 41 micro), which was assigned to the primary intermediate of the stilbene-like photocyclization. On the basis of the absence of a triplet-triplet absorption, the role of the parent drug as singlet oxygen photosensitizer can be discarded. By contrast, a stable phenanthrene-like photoproduct would be a good candidate to play this role. Laser flash photolysis of this compound showed a triplet-triplet transient absorption at lambdamax = 460 nm with a lifetime of 26 micro, which was efficiently quenched by oxygen (kq = 3 (+/-0.2) x 10(9) M(-1) s(-1)). Its potential to photosensitize formation of singlet oxygen was confirmed by spin trapping experiments, through conversion of TEMP to the stable free radical TEMPO. The photoreactivity of the phenanthrene-like photoproduct was investigated using Trp as a marker. The disappearance of the amino acid fluorescence (lambdamax = 340 nm) after increasing irradiation times at 355 nm was taken as a measurement of photodynamic oxidation. To confirm the involvement of a type II mechanism, the same experiment was also performed in D2O; this resulted in a significant enhancement of the reaction rate. On the basis of the obtained photophysical and photochemical results, the phototoxicity of atorvastatin can be attributed to singlet oxygen formation with the phenanthrene-like photoproduct as a photosensitizer.