Photodermatoses, including phototoxic and photoallergic reactions (internal and external)

JAK inhibitors as a promising therapy for immune-mediated photodermatoses

Immune-mediated photodermatoses (IMPs) are skin diseases caused by altered immune responses triggered by sunlight, including polymorphous light eruption (PMLE), actinic prurigo (AP), solar urticaria (SU), chronic actinic dermatitis (CAD), and hydroa vacciniforme (HV). Managing IMPs is challenging because of the need for rigorous sun protection and the poor response to conventional therapies, particularly in moderate-to-severe patients. Researchers are exploring new targeted therapies for IMPs, including Janus kinase (JAK) inhibitors, a novel class of small molecules that block the JAK-STAT signaling pathway. Several case reports and series show promising results. This study reviews the evidence-based rationale for using JAK inhibitors in IMP treatment, assessing their efficacy and safety.

The assessment of the phototoxic potential of drugs forming complexes with melanin - Screening in vitro studies using normal skin cells with varying pigmentation irradiated by a sunlight simulator

Phototoxic reactions are among the most common skin-related adverse effects induced by drugs. It is believed that the binding of chemicals to melanin biopolymers is a significant factor influencing skin toxicity. The formation of drug-melanin complexes can lead to the accumulation of drugs or their photodegradation products in pigmented cells, potentially affecting phototoxic reactions. Current procedures for assessing the phototoxic potential of drugs are based on tests using immortalized mouse fibroblasts. This study aimed to assess the phototoxic potential of selected drugs that form complexes with melanin (chloroquine, chlorpromazine, doxycycline) using human melanocytes with varying degrees of pigmentation. Parallel research was conducted on human dermal fibroblasts. To induce phototoxicity, cell cultures were irradiated using a sunlight simulator (5 J/cm2 for UVA spectrum). To account for the process of drug accumulation, two experimental models with different incubation times of cells with drugs before irradiation were used. The photo-irritation factor (PIF) was calculated based on NRU and WST-1 screening tests. Additionally, cell viability was examined cytometrically, and analyses of the cell cycle and reduced glutathione levels were conducted. The results indicated that drugs binding with melanin exhibited different levels of cytotoxicity and phototoxicity towards fibroblasts and melanocytes. These observed differences impact the values of PIF, potentially complicating the interpretation of the studies. Additional analyses, such as examining cell subpopulations in the sub-G1 phase and determining the level of reduced glutathione, can enhance the assessment of the phototoxicity of drugs on pigmented cells.

The phenomenon of phototoxicity and long-term risks of commonly prescribed and structurally diverse drugs

Photosensitivity to structurally diverse drugs is a common but under-reported adverse cutaneous reaction and can be classified as phototoxic or photoallergic. Phototoxic reactions occur when the skin is exposed to sunlight after administering topical or systemic medications that exhibit photosensitizing activity. These reactions depend on the dose of medication, degree of exposure to ultraviolet light, type of ultraviolet light, and sufficient skin distribution volume. Accurate prediction of the incidence and phototoxic response severity is challenging due to a paucity of literature, suggesting that phototoxicity may be more frequent than reported. This paper reports an extensive literature review on phototoxic drugs; the review employed pre-determined search criteria that included meta-analyses, systematic reviews, literature reviews, and case reports freely available in full text. Additional reports were identified from reference sections that contributed to the understanding of phototoxicity. The following drugs and/or drug classes are discussed: amiodarone, voriconazole, chlorpromazine, doxycycline, fluoroquinolones, hydrochlorothiazide, nonsteroidal anti-inflammatory drugs, and vemurafenib. In reviewing phototoxic skin reactions, this review highlights drug molecular structures, their reactive pathways, and, as there is a growing association between photosensitizing drugs and the increasing incidence of skin cancer, the consequential long-term implications of photocarcinogenesis.

Phototoxic Reactions Inducted by Hydrochlorothiazide and Furosemide in Normal Skin Cells-In Vitro Studies on Melanocytes and Fibroblasts

Hypertension is known to be a multifactorial disease associated with abnormalities in neuroendocrine, metabolic, and hemodynamic systems. Poorly controlled hypertension causes more than one in eight premature deaths worldwide. Hydrochlorothiazide (HCT) and furosemide (FUR), being first-line drugs in the treatment of hypertension, are among others the most frequently prescribed drugs in the world. Currently, many pharmacoepidemiological data associate the use of these diuretics with an increased risk of adverse phototoxic reactions that may induce the development of melanoma and non-melanoma skin cancers. In this study, the cytotoxic and phototoxic potential of HCT and FUR against skin cells varied by melanin pigment content was assessed for the first time. The results showed that both drugs reduced the number of metabolically active normal skin cells in a dose-dependent manner. UVA irradiation significantly increased the cytotoxicity of HCT towards fibroblasts by approximately 40% and melanocytes by almost 20% compared to unirradiated cells. In the case of skin cells exposed to FUR and UVA radiation, an increase in cytotoxicity by approximately 30% for fibroblasts and 10% for melanocytes was observed. Simultaneous exposure of melanocytes and fibroblasts to HCT or FUR and UVAR caused a decrease in cell viability, and number, which was confirmed by microscopic assessment of morphology. The phototoxic effect of HCT and FUR was associated with the disturbance of redox homeostasis confirming the oxidative stress as a mechanism of phototoxic reaction. UVA-irradiated drugs increased the generation of ROS by 10-150%, and oxidized intracellular thiols. A reduction in mitochondrial potential of almost 80% in melanocytes exposed to HCT and UVAR and 60% in fibroblasts was found due to oxidative stress occurrence. In addition, HCT and FUR have been shown to disrupt the cell cycle of normal skin cells. Finally, it can be concluded that HCT is the drug with a stronger phototoxic effect, and fibroblasts turn out to be more sensitive cells to the phototoxic effect of tested drugs.

Diseases from the Spectrum of Dermatitis and Eczema: Can "Omics" Sciences Help with Better Systematics and More Accurate Differential Diagnosis?

Researchers active in the field of inflammatory skin diseases from the spectrum of dermatitis and eczema are well aware of a considerable overlap in the clinical pictures and proposed sets of diagnostic criteria for these diseases, which can hardly be overcome through the clinical or epidemiological research. In effect, patients are included in studies based on vague and overlapping criteria, while heterogeneous study populations may, in turn, lead to non-representative outcomes and continued confusion. In this narrative review, a systematics of diseases from the spectrum of dermatitis and eczema is proposed based on the origins of causative factors and the pathomechanisms involved. Difficulties in differentiating between these diseases are discussed, and the extent to which advances in the "omics" sciences might help to overcome them is considered. Of all the "omics" research in this field, more than 90% of the published papers were devoted to atopic dermatitis, with a striking underrepresentation of other diseases from the spectrum of dermatitis and eczema, conditions which collectively exceed the rates of atopic dermatitis by far. A greater "omics" research effort is urgently needed to tackle other dermatitides, like allergic, irritant and protein contact dermatitis, as well as radiation, seborrheic, stasis or autoimmune dermatitis. Atopic dermatitis findings should be validated not only against healthy donors but also other dermatitides. A clinic-oriented approach is proposed for future "omics" studies in the field of dermatitis and eczema.

HIV-associated photodermatitis in African populations

Photosensitive dermatoses are seen in 5% of HIV-infected persons. These include drug- and chemical-induced photoallergic and phototoxic reactions, chronic actinic dermatitis of HIV, photo lichenoid drug eruptions, and porphyria. Data on photodermatitis in HIV are limited to case reports and series. The pathogenesis is not completely understood and includes a th2 phenotype in HIV which results in impaired barrier function and resultant allergen sensitisation as well as immune dysregulation. The objective of this manuscript is to review the literature on the clinical phenotype, pathogenesis, role of photo and patch testing, outcomes, and treatment of photodermatitis in HIV in an African population.

Objectively-Assessed Ultraviolet Radiation Exposure and Sunburn Occurrence

Ultraviolet radiation (UVR) exposure is the primary modifiable risk factor for melanoma. Wearable UVR sensors provide a means of quantifying UVR exposure objectively and with a lower burden than self-report measures used in most research. The purpose of this study was to evaluate the relationship between detected UVR exposure and reported sunburn occurrence. In this study, a UVR monitoring device was worn by 97 parent-child dyads during waking hours for 14 days to measure instantaneous and accumulated UVR exposure. The results showed that the participants' total UVR exposure was associated with reported sunburn after adjusting for Fitzpatrick skin type and geographic location. It was observed that one standard erythemal dose (SED) increase in the participants' daily total UVR exposure was associated with reported sunburn (an odds ratio (OR) of 1.26 with a 95% CI of 1.13 and 1.41, and p < 0.001 for parents and an OR of 1.28 with a 95% CI of 1.12 and 1.47, and p < 0.001 for children). A one-SED increase in the participants' UVR exposure from 10 am to 4 pm was also associated with reported sunburn (an OR of 1.31 with a 95% CI of 1.15 and 1.49, and p < 0.001 for parents and an OR of 1.33 with a 95% CI of 1.12 and 1.59, and p = 0.001 for children). We found that elevated UVR exposure recordings measured by the UVR sensor were associated with reported sunburn occurrence. Future directions for wearable UVR sensors may include their use as an intervention tool to support in-the-moment sunburn prevention.

NRF2 in dermatological disorders: Pharmacological activation for protection against cutaneous photodamage and photodermatosis

The skin barrier and its endogenous protective mechanisms cope daily with exogenous stressors, of which ultraviolet radiation (UVR) poses an imminent danger. Although the skin is able to reduce the potential damage, there is a need for comprehensive strategies for protection. This is particularly important when developing pharmacological approaches to protect against photocarcinogenesis. Activation of NRF2 has the potential to provide comprehensive and long-lasting protection due to the upregulation of numerous cytoprotective downstream effector proteins that can counteract the damaging effects of UVR. This is also applicable to photodermatosis conditions that exacerbate the damage caused by UVR. This review describes the alterations caused by UVR in normal skin and photosensitive disorders, and provides evidence to support the development of NRF2 activators as pharmacological treatments. Key natural and synthetic activators with photoprotective properties are summarized. Lastly, the gap in knowledge in research associated with photodermatosis conditions is highlighted.

A phototoxic drug reaction due to topical NSAIDs

We present a case with a phototoxic reaction following topical use of NSAID. The phototoxic reaction was initially mistaken for cellulitis which led to treatment with dicloxacillin, which led to an exanthematous drug eruption. The patient was treated with topical clobetasol propionate and oral non-sedating antihistamines. Follow-up revealed post-inflammatory hypopigmentation.

In vitro Assessment of Solar Filters for Erythropoietic Protoporphyria in the Action Spectrum of Protoporphyrin IX

Introduction: Subjects with erythropoietic protoporphyria rely on broad-spectrum sunscreens with high sun protection factor, which is not informative on efficacy in the absorption spectrum of protoporphyrin IX, spanning visible radiation and peaking around 408 nm. Photoactivation of protoporphyrin IX is responsible for painful skin photosensitivity in erythropoietic protoporphyria. The authors assessed the protective efficacy of six sunscreens in vitro in the absorption spectrum of protoporphyrin IX. Method: Transmittance measurements were performed in the 300-850 nm wavelengths on samples of six photoprotective products applied to polymethyl methacrylate plates. Porphyrin protection factor was calculated in the 300-700 nm region to provide a measurement for the efficacy of each product based on the action spectrum of protoporphyrin IX. Results: Product A showed the highest porphyrin protection factor among tested products with a median value of 4.22. Product A is a sunscreen containing organic filters, titanium dioxide and synthetic iron oxides, pigmentary grade active ingredients that absorb visible radiation. Other products showed inefficient protection in the visible, with transmittance between 75 and 95% at 500 nm. The low porphyrin protection factor of inorganic filter product B was attributed to particle micronization, as declared by the manufacturer. Conclusion: Adding porphyrin protection factor to sunscreen labeling could help patients with erythropoietic protoporphyria and other photosensitivity disorders identify products tailored on their specific needs. The development of sunscreens providing protection from visible radiation and excellent cosmetical tolerability could improve the lifestyle of patients with erythropoietic protoporphyria.

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.

Latest Evidence Regarding the Effects of Photosensitive Drugs on the Skin: Pathogenetic Mechanisms and Clinical Manifestations

Photosensitivity induced by drugs is a widely experienced problem, concerning both molecule design and clinical practice. Indeed, photo-induced cutaneous eruptions represent one of the most common drug adverse events and are frequently an important issue to consider in the therapeutic management of patients. Phototoxicity and photoallergy are the two different pathogenic mechanisms involved in photosensitization. Related cutaneous manifestations are heterogeneous, depending on the culprit drug and subject susceptibility. Here we report an updated review of the literature with respect to pathogenic mechanisms of photosensitivity, clinical manifestations, patient management, and prediction and evaluation of drug-induced photosensitivity. We present and discuss principal groups of photosensitizing drugs (antimicrobials, nonsteroidal anti-inflammatory drugs, anti-hypertensives, anti-arrhythmics, cholesterol, and glycemia-lowering agents, psychotropic drugs, chemotherapeutics, etc.) and their main damage mechanisms according to recent evidence. The link between the drug and the cutaneous manifestation is not always clear; more investigations would be helpful to better predict drug photosensitizing potential, prevent and manage cutaneous adverse events and find the most appropriate alternative therapeutic strategy.

Reviewing the effects of thiazide and thiazide-like diuretics as photosensitizing drugs on the risk of skin cancer

BACKGROUND

Thiazide diuretics and particularly hydrochlorothiazide were recently linked to an increased risk of skin cancer, which was attributed to the photosensitizing properties of these drugs. Given the widespread use of thiazide diuretics, a potential skin cancer promoting effect would impose an important public health concern.

OBJECTIVE

To critically appraise in a narrative review, the association between use of thiazide and thiazide-like diuretics and risk of skin cancer.

METHODS

We evaluated chemical structures and photosensitizing potential of selected thiazide and thiazide-like diuretics. Moreover, we searched PubMed up to December 2018 for observational studies assessing the association between use of thiazide or thiazide-like diuretics and risk of skin cancer. Study quality was assessed for major methodological biases.

RESULTS

Commonly used thiazide and thiazide-like diuretics carry resonating structural components, such as sulfonamide groups that contribute to their photosensitizing activity. Overall, 13 observational (9 case-control, 4 cohort) studies assessed the association between use of different thiazide or thiazide-like diuretics and risk of several skin cancer types. Of those, nine studies showed positive associations ranging from 3% increased risk for bendroflumethiazide and basal cell carcinoma to 311% increased risk for thiazide diuretics and squamous cell carcinoma. All studies had important design-related methodological limitations including potential confounding by indication, detection bias, and time-window bias.

CONCLUSION

Commonly used thiazide and thiazide-like diuretics have photosensitizing potential, and some observational studies with important methodological limitations have linked their use to an increased risk of skin cancer. Well designed observational studies are needed to provide more solid evidence on this possible association.

[Cutaneous drug reactions]

Cutaneous drug reactions are a common reason for calls and visits. This term chiefly refers to hypersensitivity reactions ranging from benign rash without contraindication of treatment to severe life-threatening clinical pictures, such as anaphylactic shock and epidermal necrolysis. They should be carefully managed from the outset. Indeed, history taking and precise semiological description of the lesions are crucial to the formulation of recommendations for the patient. Allergological investigation of such reactions has developed greatly in recent decades and must now be carried out much more extensively. The arrival of new drug families such as biotherapies and the development of drug habituation protocols constitute the challenges of tomorrow for cutaneous drug reactions.

A case report of photodermatoses induced by the antifungal drug terbinafine

Terbinafine is an antifungaldrug(inhibitor of ergosterol synthesis) known to induce skin reactions. A 58-year-old female was treated with terbinafine for onychomycosis. On the fifth day of treatment a skin rash emerged on her sun-exposed areas. Biological testing did not find any allergic signs. Other skin reactions are well known with terbinafine, but we depict here, a case of photosensitisation induced by treatment, generally unknown for this antifungal. This side effect can be prevented by medication reconciliation and pharmaceutical advice from the clinical pharmacist.

Photosensitisation diseases of animals: Classification and a weight of evidence approach to primary causes

Clare's (1952) classification system for photosensitisation diseases (types I, II, III and Uncertain) has endured many years of use despite some confusion regarding his secondary, or type III, category, as well as the more recent discovery of two mechanisms (types I and II) of phototoxicity. Therefore, to reduce confusion in terminology, I propose that Clare's four groups be known as primary (or direct), secondary (indirect or hepatogenous), endogenous (aberrant porphyrin synthesis), and idiopathic. The use of the word type can then be reserved for the mechanisms of phototoxicity. Clare's (1952, 1955) papers listed three plants as primary photosensitisers and three as idiopathic. In the literature, several other plants have been associated with photosensitisation in farm animals. Most of these are likely to have a primary pathogenesis; however, the weight of evidence for all but a few is sparse. With respect to plants (and certain mycotoxins and insects) implicated in primary photosensitisation outbreaks, McKenzie's "toxicity confidence rankings" (Australia's Poisonous Plants, Fungi and Cyanobacteria, 2012) has been adapted to "phototoxic agent confidence rankings". Thus, plants, mycotoxins or insects can be categorised regarding phototoxicity, i.e. definite (A); some evidence (B); suspected (C); or phototoxin isolated but no field cases known (D), and weight of evidence, i.e. field cases (1); experimental feeding produces photosensitisation (2); phototoxin isolated (3); phototoxin produces photosensitisation experimentally (4); and/or correlation of the action spectrum/chromatogram in blood or skin with the absorption spectrum/chromatogram of the phototoxin (5). As a result, confidence rankings ranging from A5 to D1 can be allocated. From the available literature, at least seventeen plant species can be ranked as A5 (definite phototoxicity with a maximum weight of evidence). The relatively recent breakthrough regarding the discovery of phototoxic anthraquinones in Heterophyllaea spp. has led to the serendipitous association of the same and similar anthraquinones as the most likely phototoxins in alligator weed (Alternanthera philoxeroides).

Glutathione S-transferase polymorphisms in patients with photosensitive and non-photosensitive drug eruptions

BACKGROUND

Glutathione S-transferases (GSTs) play a critical role in cellular protection against oxidative damage. Polymorphisms in three major GST loci have been described. A number of studies have looked for an association between GSTs and skin diseases.

PURPOSE

To ascertain the possibility that polymorphisms in the GSTM1, GSTT1, and GSTP1 genes may predict the development of photo-induced and non-photo-induced drug eruptions.

METHODS

A cohort of 40 patients with drug eruptions, 10 of whom had developed a photo-induced drug reaction, and matched controls (116 for GSTM1 and GSTT1, 120 for GSTP1) were studied. Genotyping was conducted using direct sequencing and polymerase chain reaction.

RESULTS

The GSTP1 Val/Val genotype was significantly associated with non-photosensitive drug eruptions (OR = 3.64, P value = 0.038), whereas associations observed between GSTP1, GSTM1, GSTT1 polymorphisms and photosensitive drug eruptions did not reach statistical significance.

CONCLUSIONS

Variations in GSTP1 may affect the risk to develop non-photo-induced drug eruptions. These results warrant confirmatory studies in a larger patient sample.

Chlortetracycline and melanin biopolymer - The risk of accumulation and implications for phototoxicity: An in vitro study on normal human melanocytes

Tetracyclines belong to antimicrobial classes with the highest consumption in veterinary medicine and agriculture, which leads to the contamination of the environment and food products, as well as to antibiotic resistance and adverse drug reactions. Chloro-derivatives of tetracyclines are thought to be relatively more phototoxic than others and belong to the most frequently cited drugs as photosensitizers. Melanins are heterogenous biopolymers determining skin, hair and eye colour. They are biosynthesized in a multistep process in melanocytes. Melanins, besides photoprotective and antioxidant properties, may also contribute to adverse skin drug reactions, which involve e.g. hyperpigmentation disorders and phototoxic reactions. Furthermore, they have the ability to form a drug-melanin complex, which leads to deposition of the drug or its metabolites in pigmented tissues. The aim of the study was to examine the ability of chlortetracycline to form a complex with melanin, as well as the effect of the drug on viability, antioxidant defence system and melanogenesis in normal human epidermal melanocytes exposed to the UVA radiation. The obtained results show for the first time that chlortetracycline forms a complex with melanin polymers, which creates a possibility of the drug accumulation in pigmented tissues. A simultaneous exposition of normal melanocytes to chlortetracycline and to the UVA radiation decreases cell viability, proportionally to the drug concentration and the irradiation time. The phototoxic effect appears to be related to the induction of oxidative stress in melanocytes, mainly through an increase of SOD and a decrease of the CAT activity. Chlortetracycline itself does not influence the melanin content or the activity of tyrosinase. The UVA radiation appeared to be a conditioning factor stimulating melanogenesis, whereas the presence of the drug augmented this effect.

Molecular photoprotection of human keratinocytes in vitro by the naturally occurring mycosporine-like amino acid palythine

Background

Solar ultraviolet radiation (UVR) induces molecular and genetic changes in the skin, which result in skin cancer, photoageing and photosensitivity disorders. The use of sunscreens is advocated to prevent such photodamage; however, most formulations contain organic and inorganic UVR filters that are nonbiodegradable and can damage fragile marine ecosystems. Mycosporine‐like amino acids (MAAs) are natural UVR‐absorbing compounds that have evolved in marine species for protection against chronic UVR exposure in shallow‐water habitats.

Objectives

To determine if palythine, a photostable model MAA, could offer protection against a range of UVR‐induced damage biomarkers that are important in skin cancer and photoageing.

Methods

HaCaT human keratinocytes were used to assess the photoprotective potential of palythine using a number of end points including cell viability, DNA damage (nonspecific, cyclobutane pyrimidine dimers and oxidatively generated damage), gene expression changes (linked to inflammation, photoageing and oxidative stress) and oxidative stress. The antioxidant mechanism was investigated using chemical quenching and Nrf2 pathway activation assays.

Results

Palythine offered statistically significant protection (P < 0·005) against all end points tested even at extremely low concentrations (0·3% w/v). Additionally, palythine was found to be a potent antioxidant, reducing oxidatively generated stress, even when added after exposure.

Conclusions

Palythine is an extremely effective multifunctional photoprotective molecule in vitro that has potential to be developed as a natural and biocompatible alternative to currently approved UVR filters.

What's already known about this topic?

Mycosporine‐like amino acids (MAAs) are photoprotective molecules found in marine organisms but there are few data on their ability to protect skin cells from the adverse effects of solar ultraviolet radiation (UVR).

The European Chemicals Agency (ECHA) is concerned about the potential adverse health and ecotoxic effects of eight of 16 commonly used sunscreen filters in Europe. The Environmental Effects Assessment Panel (EEAP) of the United Nations Environment Programme has expressed similar concerns.

What does this study add?

Palythine, an MAA extracted from an edible seaweed, affords photoprotection against a wide range of adverse effects in HaCaT keratinocytes exposed to solar simulating and ultraviolet A radiation. Of note is protection against two types of DNA photolesions; cyclobutane pyrimidine dimers and 8‐oxo‐7,8‐dihydroguanine.

Palythine is also a potent antioxidant that offers protection even when added after UVR exposure.

What is the translational message?

MAAs should be considered for development as natural biocompatible sunscreens that may address the concerns of the ECHA and EEAP.

Linked Comment: https://doi.org/10.1111/bjd.16598.

https://goo.gl/Uqv3dl

Ketoprofen-induced photoallergic dermatitis

Drug-induced photosensitivity reactions are significant adverse effects. Ketoprofen is one of the most common drugs that can cause skin rash in sun-exposed areas. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ketoprofen, are often used for a variety of symptoms, including pain and fever. An understanding of the presentation and clinical course of ketoprofen-induced photosensitivity is necessary to correctly diagnose and manage this condition. Ketoprofen-induced photosensitivity reactions usually present as photoallergic dermatitis, which is a cell-mediated immune process. The benzophenone moiety in ketoprofen plays a major role in ketoprofen's ability to act as a photosensitizer. Several agents, such as fenofibrate and octocrylene have been found to be associated with aggravation of ketoprofen-induced photoallergic dermatitis or cross-photosensitization, and these reactions result from structural similarities with ketoprofen. Treatment of ketoprofen-induced photoallergic dermatitis includes discontinuation of ketoprofen, topical or systemic corticosteroids and avoidance of sun exposure and agents known to exacerbate dermatitis. In conclusion, photoallergic dermatitis is a significant adverse effect of ketoprofen. Some agents known to worsen dermatitis may be found in sun protection products (notably, octocrylene in sunscreen). Educating the patient to avoid these products is critical to treatment. Since NSAIDs, such as ketoprofen, are used commonly for a variety of illnesses, drug-induced photoallergic dermatitis should be high on the differential in individuals using these medications who present with acute onset of a rash in sun-exposed areas.

Phototoxic effect of oxytetracycline on normal human melanocytes

Oxytetracycline is a broad-spectrum antibiotic, used in dermatology and veterinary medicine. Like other tetracyclines, it may evoke skin phototoxic reactions related to generation of reactive oxygen species (ROS). Melanins are biopolymers synthesised in melanocytes - highly specialised cells, localised in the basal layer of epidermis. Production of melanin is a defence mechanism against harmful effects of UV radiation, ROS and many chemical substances, including drugs. In the present study the influence of oxytetracycline and UVA radiation on darkly pigmented melanocytes viability, the melanogenesis process and the activity of antioxidant enzymes were analysed. The obtained results show that oxytetracycline decreases cell viability in a dose-dependent manner. It has also been stated that UVA radiation as well as simultaneous exposure to oxytetracycline and UVA radiation reduce melanocytes viability. The tested drug alone exhibits little effect on antioxidant enzymes activity and has no influence on the synthesis of melanin. However, simultaneous exposure of the cells to oxytetracycline and UVA radiation causes an increase of SOD and GPx activity, a decrease of CAT activity as well as stimulates melanogenesis. The obtained results suggest that phototoxicity of oxytetracycline towards normal human melanocytes depends on both time of UVA exposure and the drug concentration.

Photodermatitis for the Allergist

PURPOSE OF REVIEW

The photodermatoses represent a group of disorders of sensitivity to light that continue to pose difficulties in diagnosis and management. Photodermatoses are of interest to allergists because many photosensitive skin disorders have immunologic underpinnings, and patients often present to clinic complaining of "allergy" to the sun. We provide a concise reference for allergists on the clinical recognition and management of photodermatitis.

RECENT FINDINGS

New developments in the understanding of immunomodulatory effects of light have demonstrated normally immunosuppressive responses in the skin to light exposure, and a blunted immunosuppressive response in the pathogenesis of many photodermatoses. Vitamin D plays an important role in immunomodulation and itself may be affected by photodermatoses due to the impact of photoprotective treatment strategies on circulating vitamin D levels. The elucidation of the immunological basis of many photodermatoses may provide guidance for developing new treatment modalities. Further research is necessary to determine the optimal management of vitamin D metabolism in patients with photodermatoses.

Effect of tetracycline and UV radiation on melanization and antioxidant status of melanocytes

Tetracycline is a semisynthetic antibiotic and is used in several types of infections against both gram-positive and gram-negative bacteria. This therapy is often associated with phototoxic reactions that occur after exposure to UV radiation and lead to photo-onycholysis, pseudoporphyria, solar urticaria and the fixed drug eruption in the skin. The phototoxic reactions may be related to the melanin content which, on one side may bind drugs - leading to their accumulation, and on the other side, they have photoprotective and antioxidant properties. In this study the effect of tetracycline and UVA irradiation on cell viability, biosynthesis of melanin and antioxidant defense system in cultured normal human epidermal melanocytes (HEMn-DP) was analyzed. The viability of the cells treated with tetracycline and exposed to UVA radiation decreased in a drug concentration-dependent manner. At the same time, the induction of the melanization process was observed. The significant alterations in antioxidant defense system, on the basis of changes in SOD, CAT and GPx activities, were stated. The obtained results may give explanation for the phototoxic effects of tetracycline therapy observed in skin cells exposed to UVA radiation.

Quantitative assessment of photostability and photostabilisation of Fluvoxamine and its design for actinometry

Wavelength-dependent forwardand reverseFluvo quantum yields have been reported.

Cutaneous manifestations of infection in returning travelers

Dermatologic problems are common in returning travelers who seek medical care. Some common illnesses such as cellulitis or abscesses occur in travelers but are not unique to this patient group. Additionally, dermatologic illnesses not due to infection such as drug eruptions or phototoxicity are seen. Skin manifestations occur in many tropical illnesses such as dengue, schistosomiasis, and leishmaniasis. This article reviews the common causes of cutaneous illnesses associated with travel including non-infectious causes, infections that are not limited to travelers, and infections that are almost exclusively seen in travelers.