SECTION 10 PHOTOSENSITIVITY, PHOTO-INDUCED DISORDERS, AND DISORDERS BY IONIZING RADIATION

ACU TE SU N D AMAGE (SU NB U R N)

ICD-9 : 6 9 2 .7 1 ICD-1 0 : L 5 5

 Su nb u rn is an ac u te, delay ed, and transient inflammatory response of normal sk in after ex posu re to
UVR from su nligh t or artific ial sou rc es.
 By natu re it is a ph ototox ic reac tion.

EP ID EMIOL OGY
Sunburn depends on the amount of UVR
energy delivered and the susceptibility of the
individual (SPT). It will therefore occur more
often around midday, with decreasing latitude,
increasing altitude, and decreasing SPT. Thus,
the ideal setting for a sunburn to occur would
be an SPT I individual (highest susceptibility) on Mt. Kenya (high altitude, close to the
equator) at noon (UVR is highest). Of course,
sunburn can occur at any latitude, but the
probability for it to occur decreases with increasing distance from the equator. Sunburn is
seen more often in those who frequent beaches
or travel to sunny vacation areas. Sunburn also
increases with respect to other ambient conditions, such as UVR reflectance from snow,
water, or a glacier.
Age Very young children and elderly persons
are said to have a reduced capacity to sunburn,
although this has not been thoroughly documented.
P ATH OGENESIS
The chromophores (molecules that absorb
UVR) for UVB sunburn erythema are not
known, but damage to DNA may be the initiating event. The damage to DNA results
in excision of pyrimidine dimers, and that
itself initiates a protective tanning response.
The mediators that cause the erythema include histamine for both UVA and UVB.
In UVB erythema, other mediators include
tumor necrosis factor (TNF-), serotonin,
prostaglandins, nitric oxide, lysosomal enzymes, and kinins. The cytokine TNF- can
be detected as early as 1 h after exposure.
The resolution of erythema is associated with
interleukin (IL) 10, IL-4, and transforming
growth factor 1.

235

 

 Su nb u rn is c h arac teriz ed b y ery th ema (Fig. 1 0 -1 A)

and, if sev ere, b y v esic les and b u llae, edema,
tenderness, and pain (Fig. 1 0 -1 B).

CL INICAL MANIF ESTATION

E xposure to the sun or an artificial UV source.
Onset of symptoms depends on intensity of
exposure; erythema develops after 6 h and
peaks after 2 4 h.
Skin Sy mptoms Pruritus may be severe even in
mild sunburn; pain and tenderness occur with
severe sunburn.
Constitutional Sy mptoms H eadache, chills, feverishness, and weakness are not infrequent
in severe sunburn; some SPT I and II persons
develop headache and malaise even after short
exposures.
General Appearance In severe sunburn, the
patient is toxic with fever, weakness, lassitude, and a rapid pulse rate.
Skin L esions C onfluent bright erythema
always confined to sun-exposed areas and thus
sharply marginated at the border between
exposed and covered skin (Fig. 10-1A). E dema,
vesicles, and even bullae; always uniform
erythema and no rash, as occurs in most
photoallergic reactions. E dematous areas are
raised and tender. As edema and erythema fade
vesicles and blisters dry to crusts, which are
then shed (Fig. 10-1B).
Distribution Strictly confined to areas of
exposure; sunburn can occur in areas covered
with clothing, depending on the degree of UV
transmission through clothing, the level of
exposure, and the SPT of the person.
Mucous Membranes Sunburn of the tongue
can occur rarely in mountain climbers who
hold their mouth open panting; it is frequent
on the vermilion border of the lips.
L AB OR ATOR Y EX AMINATIONS
D ermatopath ology Sunburn cells in the
epidermis (apoptotic keratinocytes); also,

236

PART I DISORDERS PRESENTING IN THE SKIN AND MUCOUS MEMBRANES

exocytosis of lymphocytes, vacuolization of

melanocytes and Langerhans cells. Dermis: endothelial cell swelling of superficial blood vessels. More prominent with UVA erythema,
with a denser mononuclear infiltrate and more
severe vascular changes.
Serology and H em atology To rule out systemic
lupus erythematosus (SLE) obtain antinuclear
antibody (ANA) level. Leukopenia may be present in SLE.
D IAG NO SIS AND D IF F E RE NTIAL D IAG NO SIS
History of UVR exposure and sites of reaction
on exposed areas. Phototoxic erythema: obtain
history of medications that can induce phototoxic erythema. SLE can cause a sunburn-type
erythema. Erythropoietic protoporphyria causes
erythema, vesicles, edema, purpura, and, only
rarely, urticarial wheals.
C O U RSE AND PRO G NO SIS
Sunburn, unlike thermal burns, cannot be classified on the basis of depth, i.e., first-, second-,
and third-degree. Third-degree burns after UVR
do not occur, and none of the features of thirddegree thermal burns are seen: scarring, loss of
sensation, loss of sweating, hair loss. A perma-

D RU G -/ C H E MIC AL-IND U C E D PH O TO SE NSITIVITY

 This describes the interaction of UV R with a chemical/
drug within the skin.
 Two mechanisms are recogniz ed: phototoxic reactions, which are photochemical reactions leading to skin pathology, and
 photoallergic reactions, where a photoallergen is
formed that initiates an immunologic response

nent reaction from severe ultraviolet burns is

mottled depigmentation, probably related to
the destruction of melanocytes, and eruptive
solar lentigines (see F ig. 1 0 -22).
MANAG E ME NT
Prevention Persons with SPT I or II should
avoid sunbathing, especially between 1 1 A.M.
and 2 P.M. C lothing: UV-screening cloth garments. There are now many highly effective
topical chemical filters (sunscreens) in lotion,
gel, and cream formulations. It is still not clear
whether regular use of topical sunscreens can
prevent melanoma of the skin, but there is
reasonable proof that topical sunscreens reduce
the induction of solar keratoses and, probably,
sq uamous cell carcinoma.
Moderate Sunburn Topical C ool wet dressings, topical glucocorticoids.
Systemic Acetylsalicylic acid, indomethacin,
NSAIDs.
Severe Sunburn B ed rest. If very severe, a
toxic patient may req uire hospitalization for
fluid replacement, prophylaxis of infection, etc.
Topical C ool wet dressings, topical glucocorticoids.
Systemic O ral glucocorticoids are often given,
but their efficacy has not been established by
controlled studies. Indomethacin.

ICD-9 : 6 9 2 .7 9 ICD-1 0 : L 5 6 .0
and manifests in skin as a type IV immunologic
reaction.
 The main clinical difference between phototoxic
and photoallergic eruptions is that the former
manifests like an irritant (toxic) contact dermatitis
or sunburn and the latter like an allergic ecz ematous contact dermatitis (Table 1 0 -3 ).

SECTION 10 PHOTOSENSITIVITY, PHOTO-INDUCED DISORDERS, AND DISORDERS BY IONIZING RADIATION

237

B
F IG U R E 10-1 Acute sunburn A. Painful, tender, bright ery thema with mild edema of the upper back with
sharp demarcation between the sun-exposed and sun-protected white areas. B. 4 8 hours after acute sunburn.
Ery thema is fading and blisters hav e dried to crusts.

P AR T I DISORDERS PRESENTING IN THE SKIN AND MU COU S MEMB RANES

2 38

TABLE 10-3

Characteristics of Phototoxicity and Photoallergy

Clinical presentation

Histology

Pathophysiology

Occurrence after
first exposure
Onset of
eruption after
exposure
Dosage of agent
needed for eruption
Cross-reactivity
with other agents
Diagnosis

Phototoxicity

Photoallergy

Sunburn reaction: erythema,

edema, vesicles and bullae;
frequently resolves with
hyperpigmentation; burning,
smarting
Apoptotic keratinocytes,
sparse dermal infiltrate of
lymphocytes, macrophages,
and neutrophils
Direct tissue injury

Eczematous lesions,
papules, vesicles,
scaling, crusting;
usually pruritic

Yes

Spongiotic dermatitis,
dense, dermal
lymphohistiocytic
infiltrate
Type IV delayed
hypersensitivity
reponse
No

Minutes to hours

2448 h

Large

Small

Rare

Common

Clinical + phototests

Clinical + phototests
+ photopatch tests

Adapted from H Lim, in K Wolff et al (eds): Fitzpatrick's Dermatology in General Medicine, 7th ed. New York, McGraw-Hill, 2008.

P H O TO TO X IC D R U G -/ C H EM IC AL-IN D U C ED P H O TO S EN S ITIVITY
 This describes an adverse reaction of the skin that
results from simultaneous exposure to certain
drugs (via ingestion, injection, or topical application) and to U VR or visible light.
 The chemicals may be therapeutic, cosmetic,
industrial, or agricultural.
 There are two types of reaction: (1 ) systemic
phototoxic dermatitis, occurring in individuals
systemically exposed to a photosensitizing agent

ICD-9 : 6 9 2.79 ICD-1 0 : L5 6 .0

(drug) and subsequent U VR; and (2) local phototoxic dermatitis, occurring in individuals topically
exposed to the photosensitizing agent and subsequent U VR.
 B oth are ex aggerated su nb u rn responses (erythema, edema, vesicles, and/or bullae).
 Systemic phototoxic dermatitis occurs in all UVRex posed sites; local phototoxic dermatitis only in
the topical application sites.

SECTION 10 PHOTOSENSITIVITY, PHOTO-INDUCED DISORDERS, AND DISORDERS BY IONIZING RADIATION

TAB L E 10-4

Systemic Phototoxic Agentsa

Property

Generic Name

Property

Generic Name

Antianxiety drugs

Alprazolam
Chlordiazepoxide
Adriamycin
Dacarbazine
Fluorouracil
Methotrexate
Vinblastine
Tricyclics
Amitriptyline
Desipramine
Imipramine
Griseofulvin
Chloroquine
Quinine
Quinolones
Ciprofloxacin
Enoxacin
Gemifloxacin
L omefloxacin
Moxifloxacin
Nalidixic acid
Norfloxacin
Ofloxacin
Sparfloxacin
Sulfonamides
Tetracyclines
Demeclocycline
Doxycycline
Minocycline
Tetracycline
Trimethoprim
Voriconazole
Phenothiazines
Chlorpromazine
Perphenazine
Prochlorperazine
Thioridazine
Trifluoperazine
Amiodarone
Quinidine
F urosemide
Thiazides
Bendroflumethiazide
Chlorothiazide

Diuretics

Hydrochlorothiazide
Dyazide
Fluorescein
Methylene blue
Psoralens
5-Methoxypsoralen
8-Methoxypsoralen
4, 5', 8-Trimethylpsoralen
Sulfonylureas:
Acetohexamide
Chlorpropamide
Glipizide
Glyburide
Tolazamide
Tolbutamide
Acetic acid derivative
Diclofenac
Anthranilic acid derivative
Mefenamic acid
Enolic acid derivative:
Piroxicam
Propionic acid derivatives
Ibuprofen
Ketoprofen
Naproxen
Oxaprozin
Tiaprofenic acid
Salicylic acid derivative
Diflunisal
Others
Celecoxib
Nabumetone
Porfimer
V erteporfin
Acitretin
Isotretinoin
Flutamide
Hypericin
Pyridoxine (vitamin B6)
Ranitidine

Anticancer drugs

Antidepressants

Antifungals
Antimalarials
Antimicrobials

Antipsychotic
drugs

Cardiac
medications
Diuretics

Dyes
Furocoumarins

Hypoglycemics

NSAIDs

Photodynamic
therapy agents
Retinoids
Other

Commonly reported drugs are printed in bold.

Source: Adapted from H L im, in K W olff et al (eds): Fitzpatrick's Dermatology in General Medicine, 7 th ed. New York , McGraw -Hill, 2 0 0 8 .

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