Phototoxic dermatitis L56.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Dermatitis phototoxic; Eczema phototoxic; Photocontact dermatitis; Phototoxic contact eczema; Phototoxic dermatitis; Phototoxic eczema; Phototoxic reaction

Definition
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Acute or chronic photochemical light dermatosis of varying degrees of acuteity, induced by internal or external photosensitizers and sharply limited to the exposed skin areas, without immunological basis (important: no previous sensitization). See also Table 1.

Classification
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Depending on the clinical morphology and the time course of the reaction, 4 types of phototoxic reactions can be distinguished:

  1. Immediate or delayed reaction: Urticarial reaction, which is immediate or delayed. Clinical: immediate urticarial erythema with stinging and burning during exposure (smarting); erythema or urticae; triggers: tar, pitch, anthraquinone dyes, benoxaprofen, amiodarone, chlorpromazine.
  2. Sunburn-like reaction (corresponds to a dermatitis solaris): Trigger: quinolone, chlorpromazine, amiodarone, benoxaprofen, hydrochlorothiazide, quinidine, demethylchlortetracycline and other tetracyclines.
  3. Delayed erythema possibly with blistering: Often subclinical and only noticeable by hyperpigmentation. Trigger: Psoralene (phytophotodermatitis; see below dermatitis pratensis, Berloque dermatitis).
  4. Pseudoporphyria: Increased vulnerability of the skin with blistering after banal traumas. Triggers: Nalidixic acid, furosemide, tetracyclines, naproxen, amiodarone.

Clinical features
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The clinical symptoms vary with the triggering agent, its mode of application (external, internal) and the intensity of UV exposure. Various photosensitizers (e.g. coal tar, chlorpromazine) can trigger an immediate phototoxic reaction with an erythematous to urticarial local reaction sharply limited to the light-exposed areas, with stabbing or burning pain.

Other phototoxins induce a delayed, sunburn-like reaction (starting about 6-8 hours after exposure). These include: tetracyclines, non-steroidal anti-inflammatory drugs. Tetracyclines can induce distal phototoxic onycholysis.

In the case of furanocoumarins, dermatitis may occur after several hours or, less frequently, only after several days.

In various reactions the acute phase is regularly followed by sharply defined hyperpigmentations (stimulation of melanin synthesis) which can persist for years (e.g. amiodarone). Often it is only the "cosmetically disturbing" residual hyperpigmentations that lead to a visit to the doctor. Amiodarone leads to grey-blue colour changes of the skin. This is caused by degradation products of amiodarone which accumulate in the skin as a function of radiation and lead to toxic melanocyte damage with melanocyte damage(pigment incontinence).

Histology
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In the acute stage detection of dyskeratotic keratinocytes (see Dermatitis solaris). Subepidermal edema of the dermis, thin, perivascularly oriented lymphocytic infiltrate in the superficial dermis.

Differential diagnosis
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General therapy
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Avoid the agent.

External therapy
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Medium strength glucocorticoid creams such as 0.1% triamcinolone cream R259, 0.05% betamethasone V lotio R030, 0.25% prednicarbate cream (e.g. Dermatop), methylprednisolone cream (e.g. Advantan).

Internal therapy
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Only in severe cases initial therapy with acetylsalicylic acid and vitamin C (e.g. aspirin plus C, 2 times/day 1 tbl.) or systemic glucocorticoids in medium dosage such as prednisone 50-100 mg/day p.o. or i.v.

Tables
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Important phototoxic substances

Essential oils

Cedar oil

Lemon oil

Lavender oil

Linden oil

Antimycotics

isopropylamide bromosalicylic acid

Tetramethylthiuram disulfide

Disinfectants

Dichlorodioxydiphenylsulfide

Tetrachlorosalicylanilide

Dyestuffs

Acriflavin

Bengal Red

Eosin

Fluorescin

Methylene blue

Proflavin

Riboflavin

Rivanol

Thiopyronine

Trypaflavin

Phenothiazines

Alimemazine

Chlorpromazine

Levopromazine

Mepazine

Paracin

Prochlorperazine

Promazine

Thiopropazate

Thioridazine

Triflupromazine

Sulfonamides

Sulfanilamide

Sulphisoxazole

Tar and tar components

Acridine dyes

Cyclic hydrocarbons

Tetracyclines

Chlortetracycline

Dimethylchlortetracycline

Doxycycline

Methacycline

Oxytetracycline

Other

5-fluorouracil

Methoxsalene (Methoxypsoralene)

Resorcinol derivatives

Vinblastine

Dacarbazine

Vemurafenib

Amiodarone

Phenytoin

Clofazimine

Nifedipine

Plants with phototoxic ingredients (Furocumarins)

Field bindweed (Convolvulus arvensis L.), bergamot (Citrus aurantium L. ssp. bergamia), buckwheat (Fagopyrum esculentum M.), angelica (Angelica archangelica L.), figs, rue (Ruta graveolens L.), St. John's wort (Hypericum perforatum L.), lovage (Levisticum officinale K.), masterwort (Imperatoria ostruthium L.), parsley (Petroselinum crispum M.), pimpinella (Pimpinella saxifraga L.), pigeonweed (Achillea millefolium L.), hemlock, celery (Apium graveolens L.), meadow hogweed (Heracleum sphondylium L.)

Literature
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  1. Ferguson J, Addo A. A, Jones S et al (1985) A study of cutaneous photosensitivity induced by amiodarone. Br J Dermatol 113:537-549
  2. Hölzle E, Plewig G (1982) Photoallergic contact dermatitis caused by benzophenone-containing sunscreen preparations. Dermatologist 33:391-393
  3. Jackson R. T., Nesbitt L. T. Jr, DeLeo V. A (1980) 6-Methylcourmarin photocontact dermatitis. J Am Acad Dermatol 2:124-12
  4. Mahler V (2015) Contact eczema. Act Dermatol 40: 95-107
  5. Schauder S, Ippen H (1986) Photoallergic and allergic contact dermatitis from dibenzoylmethanes. Photodermatolgy 3:140-147

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020