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Giovannini S, Weibel L, Schittek B, Sinnberg T, Schaller M, Lemberg C, Fehrenbacher B, Biesemeier A, Nordin R, Ivanova I, Kurz B, Svilenska T, Berger C, Bourquin JP, Kulik A, Fassihi H, Lehmann A, Sarkany R, Kobert N, van Toorn M, Marteijn JA, French LE, Rocken M, Vermeulen W, Kamenisch Y, Berneburg M. Skin cancer induction by the antimycotic drug voriconazole is caused by impaired DNA damage detection due to chromatin compaction. J Invest Dermatol 2024:S0022-202X(24)01920-1. [PMID: 39047967 DOI: 10.1016/j.jid.2024.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 03/16/2024] [Accepted: 03/20/2024] [Indexed: 07/27/2024]
Abstract
Phototoxicity and skin cancer are severe adverse effects of the anti-fungal drug Voriconazole (VOR). These adverse effects resemble those seen in xeroderma pigmentosum (XP), caused by defective DNA nucleotide excision repair (NER), and we show that VOR decreases NER capacity. We show that VOR treatment does not perturb the expression of NER, or other DNA damage-related genes, but that VOR localizes to heterochromatin, in complexes containing histone acetyltransferase GCN5. Impairment of GCN5 binding to histone H3 reduced acetylation of H3, restricting damage-dependent chromatin unfolding, thereby reducing NER initiation. Restoration of H3 histone acetylation using histone deacetylase inhibitors (HDACi), rescued VOR-induced NER repression, thus offering a preventive therapeutic option. These findings underline the importance of DNA damage-dependent chromatin remodeling as an important prerequisite of functional DNA repair.
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Affiliation(s)
- Sara Giovannini
- Department of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany; Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany
| | - Lisa Weibel
- Department of Pediatric Dermatology and Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Birgit Schittek
- Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany
| | - Tobias Sinnberg
- Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany; Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Martin Schaller
- Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany
| | - Christina Lemberg
- Section of Immunology, Vetsuisse Faculty, University of Zurich, Winterthurerstr. 266a, Zurich, Switzerland
| | - Birgit Fehrenbacher
- Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany
| | - Antje Biesemeier
- Division of Experimental Vitreoretinal Surgery and Core Facility for Electron Microscopy, Center for Ophthalmology, Schleichstr. 12/1, 72076 Tuebingen, Germany; Luxembourg Institute of Science and Technology (LIST), MRT - Materials Research and Technology Department, 41, rue du Brill, L-4422 Belvaux, Luxembourg
| | - Renate Nordin
- Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany
| | - Irina Ivanova
- Department of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Bernadett Kurz
- Department of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Teodora Svilenska
- Department of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Christoph Berger
- Division of Infectious Diseases and Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Jean-Pierre Bourquin
- Department of Pediatric Oncology and Children's Research Center, University Children's Hospital Zurich, Switzerland
| | - Andreas Kulik
- Interfaculty Institute of Microbiology and Infection Medicine, Eberhard Karls University, Auf der Morgenstelle 28, 72076 Tuebingen, Germany
| | - Hiva Fassihi
- Guy's and St Thomas' NHS Trust, Guy's Hospital Great Maze Pond London SE1 9RT, UK
| | - Alan Lehmann
- Genome Damage and Stability Centre, University of Sussex, Falmer, Brighton BN1 9RQ, UK
| | - Robert Sarkany
- Guy's and St Thomas' NHS Trust, Guy's Hospital Great Maze Pond London SE1 9RT, UK
| | - Nikita Kobert
- ICB Institute for Chemical and Bioengineering, ETH Zurich, Switzerland
| | - Marvin van Toorn
- Department of Molecular Genetics, Oncode Institute, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurgen A Marteijn
- Department of Molecular Genetics, Oncode Institute, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, Ludwig Maximilan University Munich, Munich, Germany; Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Martin Rocken
- Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany
| | - Wim Vermeulen
- Department of Molecular Genetics, Oncode Institute, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - York Kamenisch
- Department of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany; Department of Dermatology, Eberhard Karls University, Liebermeisterstrasse 25, 72076 Tuebingen, Germany
| | - Mark Berneburg
- Department of Dermatology, University Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany.
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Isaacs T, Lehloenya R. HIV-associated photodermatitis in African populations. FRONTIERS IN ALLERGY 2023; 4:1159387. [PMID: 37216149 PMCID: PMC10192905 DOI: 10.3389/falgy.2023.1159387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/14/2023] [Indexed: 05/24/2023] Open
Abstract
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.
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Shen K, Gu Y, Wang Y, Lu Y, Ni Y, Zhong H, Shi Y, Su X. Therapeutic drug monitoring and safety evaluation of voriconazole in the treatment of pulmonary fungal diseases. Ther Adv Drug Saf 2022; 13:20420986221127503. [PMID: 36225945 PMCID: PMC9549188 DOI: 10.1177/20420986221127503] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 09/04/2022] [Indexed: 11/07/2022] Open
Abstract
Aims: The gene polymorphism of voriconazole metabolism–related liver enzyme is
notable in East Asia population. It casts a significant influence on the
rational use of voriconazole. We conducted this study to investigate the
relationship between steady-state voriconazole trough concentration
(Ctrough) and adverse effects (AEs), especially
hepatotoxicity. Methods: We conducted a real-world study in the Jinling Hospital from January 2015 to
June 2020. A total of 140 patients receiving voriconazole were enrolled in
this study. The determination and scoring of voriconazole-associated
hepatotoxicity were performed according to the Roussel Uclaf Causality
Assessment Method scoring scale and the severity of hepatotoxicity was
graded according to the Common Terminology Criteria for Adverse Events
(CTCAE). Results: Elevated steady-state voriconazole Ctrough with concomitant AEs
are the most common reason for dose adjustments during treatment. Compared
with the group without any AEs, voriconazole Ctrough was
significantly higher in the hepatotoxicity and neurotoxicity groups, and the
incidence of both events showed an overall increasing trend with increasing
voriconazole Ctrough. Hepatotoxicity occurred in 66.7% of
patients within 7 days of the first dose of voriconazole and 94.4% within
15 days of the dose. Steady-state voriconazole Ctrough
>3.61 mg/l was associated with an increased incidence of hepatotoxicity
(area under the curve = 0.645, p = 0.047). Logistic
regression analysis showed that timely voriconazole dose adjustment was a
predictor of attenuated hepatotoxicity after adjustment for confounders, but
hepatotoxicity was not associated with voriconazole Ctrough
measured at a single time point. Conclusion: Hepatotoxicity and neurotoxicity correlate with voriconazole
Ctrough, and dose reduction in patients with elevated
steady-state voriconazole Ctrough may prevent hepatotoxicity. In
patients with early occurrence of hepatotoxicity, initial therapeutic drug
monitoring (TDM) might predict the risk of hepatotoxicity. Follow-up TDM may
be necessary to predict late onset hepatotoxicity. Plain Language Summary Safety of voriconazole for the treatment of pulmonary fungal
diseases Introduction: Several studies have suggested an association
between the concentration of voriconazole in the blood and liver damage, but
the evidence is weak. This study aimed to investigate relationships between
voriconazole drug concentration and side effects and to analyze the factors
affecting liver damage caused by voriconazole. Methods: We conducted a study at the Jinling Hospital from
January 2015 to June 2020, in which a total of 140 patients were finally
enrolled. Results: Voriconazole doses were adjusted in 44 patients due to
abnormal voriconazole drug concentration or side effects, 32 patients
reduced the dose and 8 patients increased the dose. An elevated liver enzyme
level was the most common cause for dose adjustment. After the first dose
adjustment, most patients achieved the target drug concentration. A total of
18 patients were determined as probable or highly probable to have
drug-induced liver injury from voriconazole. Voriconazole drug concentration
was significantly higher in the liver damage and nervous system damage
groups as compared with the group without any side effects, and most liver
damage events occurred within 14 days of the first dose. Voriconazole drug
concentration >3.61 mg/l was associated with an increased incidence of
liver damage. Conclusion: In this study, approximately one-third of patients
with pulmonary fungal disease needed to adjust their dose after the standard
dose of voriconazole treatment. The incidence of liver damage and nervous
system damage showed an overall increasing trend with increasing
voriconazole baseline concentrations. Initial therapeutic drug monitoring
may be predictive of liver damage. Follow-up monitoring of liver enzymes may
be needed.
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Affiliation(s)
- Kunlu Shen
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, The First School of Clinical Medicine, Southern
Medical University, Nanjing, China
| | - Yu Gu
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Yu Wang
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yajie Lu
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yueyan Ni
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Huanhiuan Zhong
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
| | - Yi Shi
- Department of Respiratory and Critical Care
Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing,
China
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da Silva JWV, Ribeiro JI, de Souza LX, da Silva Aquino KA, Kishishita J, Sobrinho JLS, Leal LB, de Santana DP, de Castro WV, Bedor DCG. Development of the stability-indicating method, structural elucidation of new photodegradation products from terconazole by LC-MS TOF, and in vitro toxicity. J Pharm Biomed Anal 2022; 216:114794. [DOI: 10.1016/j.jpba.2022.114794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/06/2022] [Accepted: 04/20/2022] [Indexed: 11/15/2022]
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Phototoxic and Photoallergic Contact Reactions. Contact Dermatitis 2021. [DOI: 10.1007/978-3-030-36335-2_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Blakely KM, Drucker AM, Rosen CF. Drug-Induced Photosensitivity-An Update: Culprit Drugs, Prevention and Management. Drug Saf 2020; 42:827-847. [PMID: 30888626 DOI: 10.1007/s40264-019-00806-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Photosensitive drug eruptions are cutaneous adverse events due to exposure to a medication and either ultraviolet or visible radiation. In this review, the diagnosis, prevention and management of drug-induced photosensitivity is discussed. Diagnosis is based largely on the history of drug intake and the appearance of the eruption primarily affecting sun-exposed areas of the skin. This diagnosis can also be aided by tools such as phototesting, photopatch testing and rechallenge testing. The mainstay of management is prevention, including informing patients of the possibility of increased photosensitivity as well as the use of appropriate sun protective measures. Once a photosensitivity reaction has occurred, it may be necessary to discontinue the culprit medication and treat the reaction with corticosteroids. For certain medications, long-term surveillance may be indicated because of a higher risk of developing melanoma or squamous cell carcinoma at sites of earlier photosensitivity reactions. A large number of medications have been implicated as causes of photosensitivity, many with convincing clinical and scientific supporting evidence. We review the medical literature regarding the evidence for the culpability of each drug, including the results of phototesting, photopatch testing and rechallenge testing. Amiodarone, chlorpromazine, doxycycline, hydrochlorothiazide, nalidixic acid, naproxen, piroxicam, tetracycline, thioridazine, vemurafenib and voriconazole are among the most consistently implicated and warrant the most precaution by both the physician and patient.
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Affiliation(s)
- Kim M Blakely
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aaron M Drucker
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Cheryl F Rosen
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada. .,Division of Dermatology, Toronto Western Hospital, Toronto, ON, Canada.
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8
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9
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Gonçalo M. Phototoxic and Photoallergic Reactions. Contact Dermatitis 2019. [DOI: 10.1007/978-3-319-72451-5_18-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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10
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Ibbotson S. Drug and chemical induced photosensitivity from a clinical perspective. Photochem Photobiol Sci 2018; 17:1885-1903. [PMID: 30283959 DOI: 10.1039/c8pp00011e] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Drug photosensitivity is a relatively common occurrence and a range of mechanisms may be involved. Some of these mechanisms will be discussed, including the most common, that of drug phototoxicity. Different types of photosensitivity are addressed with respect to clinical presentation, mechanisms and additionally the contribution to our understanding through clinically directed investigations and regulatory requirements. Repeated controlled therapeutic use of drug phototoxicity, with psoralen-UVA (PUVA) photochemotherapy and photodynamic therapy (PDT) will also be discussed. Finally, the potential for drug-induced photocarcinogenesis will also be covered.
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Affiliation(s)
- Sally Ibbotson
- Photobiology Unit, Dermatology Department, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
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11
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Voriconazole photosensitivity causes apparent graft-versus-host disease exacerbation. Bone Marrow Transplant 2018; 54:323-325. [PMID: 30087464 DOI: 10.1038/s41409-018-0285-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 06/18/2018] [Accepted: 06/29/2018] [Indexed: 11/09/2022]
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12
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Monteiro AF, Rato M, Martins C. Drug-induced photosensitivity: Photoallergic and phototoxic reactions. Clin Dermatol 2016; 34:571-81. [PMID: 27638435 DOI: 10.1016/j.clindermatol.2016.05.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Ana Filipe Monteiro
- Department of Dermatovenereology, Hospital Distrital de Santarém EPE, Santarém, Portugal.
| | - Margarida Rato
- Department of Dermatovenereology, Hospital Distrital de Santarém EPE, Santarém, Portugal
| | - César Martins
- Department of Dermatovenereology, Hospital Distrital de Santarém EPE, Santarém, Portugal
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13
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Advances in the Diagnosis of Drug Eruptions. ACTAS DERMO-SIFILIOGRAFICAS 2013. [DOI: 10.1016/j.adengl.2012.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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de la Torre C, Suh Oh H. Novedades en el diagnóstico de las toxicodermias. ACTAS DERMO-SIFILIOGRAFICAS 2013; 104:782-8. [DOI: 10.1016/j.ad.2012.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 11/13/2012] [Accepted: 11/24/2012] [Indexed: 11/26/2022] Open
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Abstract
Skin toxicity due to voriconazole is well recognized. Recently, several series have reported skin cancer, particularly cutaneous squamous cell carcinoma (C-SCC), following photosensitivity reactions among patients receiving long-term voriconazole (>12 months). Almost all patients were immunosuppressed, including stem cell and solid organ transplant recipients. A case-control study of lung transplant recipients identified long-term voriconazole (median cumulative dose: 76 grams) and residence in areas of strong sun exposure as independent risk factors for C-SCC. The mechanism(s) by which voriconazole may predispose to skin cancer is not clear. Moreover, the relative contribution of voriconazole and other factors such as immunosuppression, ultraviolet exposure, advanced age and skin type is unknown. Until further data are available, voriconazole should be used carefully for durations >6-9 months, particularly among patients with risk factors for skin cancer. In patients requiring prolonged voriconazole, diligent skin examinations, avoidance of excess sunlight, and liberal use of UV protectants are advisable.
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Epaulard O, Leccia MT, Blanche S, Chosidow O, Mamzer-Bruneel MF, Ravaud P, Thiebaut A, Villier C, Lortholary O. Phototoxicity and photocarcinogenesis associated with voriconazole. Med Mal Infect 2011; 41:639-45. [PMID: 22055586 DOI: 10.1016/j.medmal.2011.09.016] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 08/03/2011] [Accepted: 09/23/2011] [Indexed: 11/15/2022]
Abstract
The antifungal voriconazole was given its marketing authorization in 2002. Several kinds of adverse effects have been reported, including acute and chronic cutaneous adverse effects, mainly due to a phototoxicity mechanism. More recently, some authors have reported that voriconazole was involved in the occurrence of multiple and often-aggressive cutaneous squamous cell carcinomas if the treatment was maintained for a long time. According to safety data in studies assessing voriconazole effectiveness, 8% of outpatients may experience phototoxic events. An overview of the different types of phototoxicity and of the concerned population was given by the 61 published case reports of photo-induced voriconazole-related skin adverse events (including 18 cases of squamous cell carcinomas). The most likely mechanisms may be phototoxicity directly related to either voriconazole or to its N-oxide main metabolite, and an interaction with retinoid metabolism; moreover, immunodeficiency may enhance the risk of skin cancer. Several issues remain to be investigated, and studies are needed concerning the phototoxicity and photocarcinogenesis of voriconazole and the prognosis of chronic non-malignant skin lesions. Voriconazole prescription must be associated with strict photoprotection; in case of a phototoxic adverse event, another azole may be recommended.
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Affiliation(s)
- O Epaulard
- Service des maladies infectieuses et de médecine tropicale, CHU de Grenoble, France.
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Affiliation(s)
- J-L Schmutz
- Service de dermatovénérologie, hôpital de Brabois, bâtiment des spécialités médicales, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
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Multifocal aggressive squamous cell carcinomas induced by prolonged voriconazole therapy: a case report. Case Rep Med 2010; 2010:351084. [PMID: 21209800 PMCID: PMC3014742 DOI: 10.1155/2010/351084] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 11/15/2010] [Indexed: 11/18/2022] Open
Abstract
Voriconazole is a treatment for severe fungal infections. Prolonged voriconazole therapy may induce skin reactions, with 1% of severe photosensitivity accidents. Recently the imputability of voriconazole in skin carcinogenesis has been suggested. This report concerns a 55-year-old man suffering from pulmonary aspergillosis who presented a phototoxic reaction a few months after introduction of voriconazole, followed by multiple squamous cell carcinomas of sun-exposed skin areas. After voriconazole discontinuation, no new carcinoma was observed. The detection of EBV and HPV in skin lesions was negative. Exploration of gene mutations involved in skin carcinogenesis showed two variants of the MICR gene. The occurrence of multiple, recurrent, aggressive squamous cell carcinomas is rare with voriconazole, but its imputability is strongly suggested. A plausible hypothesis is that several factors including voriconazole uptake, immunosuppression, and genetic background could explain the phenotype of fast-developing skin carcinomas. Voriconazole therapy should be accompanied by stringent photoprotection and skin monitoring.
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Vöhringer S, Schrum J, Ott H, Höger PH. Severe phototoxicity associated with long-term voriconazole treatment. J Dtsch Dermatol Ges 2010; 9:274-6. [PMID: 21050383 DOI: 10.1111/j.1610-0387.2010.07563.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Voriconazole is a second-generation triazole antifungal approved for the treatment of invasive fungal infections, particularly with Aspergillus, Candida, Fusarium, and Scedosporium spp. Frequently reported adverse effects of voriconazole include visual disturbance (21 %), elevated liver enzymes (15.6 %) and rashes (7 %), which are largely attributable to drug-induced photosensitivity. We report a case of serious phototoxicity in a 8 year old boy who underwent chemotherapy for AML. He received voriconazole for the treatment and subsequent re-infection prophylaxis after pulmonary aspergillosis. One year after the start of therapy he developed blistering eruptions on his face after minimal sunlight exposure. Recent reports about the development of squamous cell carcinoma and melanoma, respectively, in children during and after oral therapy with voriconazole seem to warrant systematic follow-up investigations of all voriconazole-treated patients.
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Affiliation(s)
- Sabine Vöhringer
- Department of Pediatric Dermatology, Catholic Children's Hospital Wilhelmstift, Hamburg, Germany
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Miller DD, Cowen EW, Nguyen JC, McCalmont TH, Fox LP. Melanoma associated with long-term voriconazole therapy: a new manifestation of chronic photosensitivity. ACTA ACUST UNITED AC 2010; 146:300-4. [PMID: 20083676 DOI: 10.1001/archdermatol.2009.362] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Voriconazole is a triazole antifungal agent approved by the US Food and Drug Administration for serious fungal infections, including with Aspergillus, Fusarium, Pseudallescheria, and Scedosporium species. In initial clinical trials, approximately 2% of patients developed cutaneous reactions, including photosensitivity, cheilitis, and xerosis. Subsequent reports have implicated voriconazole as a cause of severe photosensitivity and accelerated photoaging, pseudoporphyria cutanea tarda, and aggressive squamous cell carcinoma. OBSERVATION We report 5 melanoma in situ lesions in the setting of extreme photosensitivity associated with long-term voriconazole therapy. CONCLUSIONS We recommend surveillance for skin cancer formation in all patients who require long-term voriconazole treatment, particularly those who manifest signs or symptoms of photosensitivity or chronic photodamage. Further study of the mechanism underlying voriconazole photosensitivity and oncogenesis is warranted.
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Affiliation(s)
- Daniel D Miller
- Department of Dermatology, University of California-San Francisco, 1701 Divisadero St., San Francisco, CA 94143, USA
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Hickman G, Duval A, Picard C, Petit A. Porphyrie cutanée tardive révélée par le voriconazole. Ann Dermatol Venereol 2010; 137:36-9. [DOI: 10.1016/j.annder.2009.10.179] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Accepted: 07/24/2009] [Indexed: 11/28/2022]
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Voriconazole-induced phototoxicity masquerading as chronic graft-versus-host disease of the skin in allogeneic hematopoietic cell transplant recipients. Biol Blood Marrow Transplant 2009; 15:370-6. [PMID: 19203729 DOI: 10.1016/j.bbmt.2008.12.491] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 12/09/2008] [Indexed: 11/20/2022]
Abstract
Systemic fungal infections pose a significant risk to patients following allogeneic hematopoietic cell transplantation (alloHCT). Voriconazole (Vfend, Pfizer) is an oral second-generation triazole antifungal agent that offers a broad spectrum of coverage against fungal species and is frequently utilized in the post-HCT setting. Herein, we describe 5 patients who were initially believed to be experiencing a flare of cutaneous chronic graft-versus-host disease (cGVHD), but who were actually exhibiting phototoxicity caused by voriconazole. A high index of suspicion for this adverse reaction in the post-alloHCT setting will prevent misdiagnosis and avoid inappropriate therapy for cGVHD.
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Berge M, Guillemain R, Boussaud V, Pham MH, Chevalier P, Batisse A, Amrein C, Dannaoui E, Loriot MA, Lillo-Le Louet A, Billaud EM. Voriconazole pharmacokinetic variability in cystic fibrosis lung transplant patients. Transpl Infect Dis 2009; 11:211-9. [PMID: 19302272 DOI: 10.1111/j.1399-3062.2009.00384.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aspergillosis is a high-risk complication in cystic fibrosis (CF) lung transplant patients. Azole antifungal drugs inhibit CYP3A4, resulting in significant metabolic drug-drug interactions. Voriconazole (VRZ) was marketed without therapeutic drug monitoring (TDM) recommendations, consistent with favorable pharmacokinetics, but regular determinations of plasma VRZ concentration were introduced in our center to manage interactions with calcineurin inhibitors and to document the achievement of therapeutic levels. METHODS VRZ TDM data analysis for trough concentration (C0) and peak concentration (C2) was carried out, using validated liquid chromatography assay with ultraviolet detection, for 35 CF lung transplant patients (mean age 25 years, mean weight 47 kg, balanced sex ratio) since 2003. Therapeutic range (C0: 1.5 +/- 0.5 - C2 : 4.0 +/- 1.0 mg/L) was expressed relative to pivotal pharmacokinetic trial data. RESULTS The duration of VRZ treatment ranged from 9 days to 22 months. The recommended standard dose of VRZ (200 mg twice a day, following the loading dose) resulted in significant plasma concentrations (>0.5 mg/L) in 20% of CF lung transplant patients. Therapeutic concentrations were obtained using higher doses (average 570 +/- 160 mg/day, +43%, P<0.01). Despite adaptation, C0 remained <0.5 mg/L (11%), even when the drug was administered intravenously, highlighting the variability of VRZ pharmacokinetics, possibly enhanced by CYP2C19 polymorphism. The risk of inefficacy during periods of underdosage was overcome by treatment with antifungal drug combinations (caspofungin, n=10). The therapeutic index was limited by neurologic effects (14%) and hepatic abnormalities (30%). VRZ concentrations correlated significantly (P<0.01) with aspartate aminotransferase levels but not with bilirubin levels. VRZ acted as a metabolic inhibitor of tacrolimus (C0 to dose ratio 5.8 +/- 2.6, n=31/VRZ versus 1.7 +/- 0.9 alone, P<0.001). Large changes in azole concentration affected the magnitude of the drug-drug interactions and adjustment requirements. CONCLUSIONS TDM is required because VRZ levels are often undetectable in treated CF lung transplant patients, supporting the use of antifungal drug combinations until achievement of VRZ C0 at a steady state between 1 and 2 mg/L. Plasma VRZ concentrations should be determined for the quantitative, individualized management of drug-drug interactions in lung transplant patients, in particular immunosuppressant such as tacrolimus, considering VRZ to be both a target and an inhibitor of CYP3A4.
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Affiliation(s)
- M Berge
- Department of Pharmacology, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Européen Georges Pompidou (HEGP), Faculté de Médecine, Université Paris Descartes, Paris, France
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Les photosensibilisations graves. Ann Dermatol Venereol 2009; 136:76-83. [DOI: 10.1016/j.annder.2008.05.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Accepted: 05/30/2008] [Indexed: 11/22/2022]
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Multifocal squamous cell carcinomas in an HIV-infected patient with a long-term voriconazole therapy. AIDS 2008; 22:905-6. [PMID: 18427212 DOI: 10.1097/qad.0b013e3282f706a9] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Bonamigo RR, Auler A, Duro KM, Cartell A. Infecção por Scedosporium apiospermum e tratamento com Voriconazol. An Bras Dermatol 2007. [DOI: 10.1590/s0365-05962007000600011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A infecção pelo Scedosporium apiospermum pode tornar-se grave quando afeta pacientes imunodeprimidos, contexto em que diagnóstico e tratamento são geralmente difíceis. Os autores apresentam caso de paciente diabética usuária de ciclosporina, metotrexato e corticoesteróide sistêmico para o tramento de artrite reumatóide e que apresentou úlceras cutâneas pelo S. apiospermum. Após uso de itraconazol, sem sucesso, ocorreu resolução do quadro com o uso de voriconazol, nova alternativa para determinadas infecções fúngicas.
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Affiliation(s)
- Renan Rangel Bonamigo
- Universidade Federal do Rio Grande do Sul; Hospital Mãe de Deus; Fundação Faculdade Federal de Ciências Médicas, Brasil
| | - Alexandre Auler
- Hospital Mãe de Deus; Hospitalar Conceição de Porto Alegre, Brasil
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Serra Soler G, Delgado Sánchez O, Esteban Marcos E, Martínez-López I, Femenías Sureda M. [Voriconazole-associated phototoxicity]. FARMACIA HOSPITALARIA 2007; 30:386-7. [PMID: 17298198 DOI: 10.1016/s1130-6343(06)74012-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Torrelo A, Hernández-Martín A, Scaglione C, Madero L, Colmenero I, Zambrano A. Primary Cutaneous Aspergillosis in a Leukemic Child. ACTAS DERMO-SIFILIOGRAFICAS 2007. [DOI: 10.1016/s1578-2190(07)70443-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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