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Fitzpatrick's Dermatology, 9th Edition (Chapter-based Decks) > 97: Phototoxicity & Photoallergy > Flashcards

97: Phototoxicity & Photoallergy Flashcards

1
Q

What is the likely diagnosis for a patient with burning and stinging on sun-exposed areas after taking a new medication?

A

The likely diagnosis is acute phototoxicity.

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2
Q

What is the mechanism behind acute phototoxicity?

A

The mechanism involves direct tissue injury caused by the phototoxic agent and radiation, leading to erythema, edema, and in severe cases, vesicles and bullae.

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3
Q

What is the likely explanation for hyperpigmentation lasting for months after PUVA therapy?

A

PUVA therapy involves psoralen-induced phototoxicity, where the acute response peaks at 48-72 hours and resolves with hyperpigmentation that can last for months.

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4
Q

What condition is indicated by separation of the distal nail from the nail bed after starting doxycycline?

A

The condition is photoonycholysis.

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5
Q

How does photoonycholysis occur?

A

It occurs due to the nail plate acting as a lens to focus UV energy on the nail bed. Doxycycline and other tetracyclines are common culprits.

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6
Q

What is the diagnosis for pruritic, eczematous eruptions confined to sun-exposed areas after using a new sunscreen?

A

The diagnosis is photoallergy.

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7
Q

What is the mechanism behind photoallergy?

A

The mechanism involves a type IV delayed hypersensitivity response to a photoallergen modified by photon absorption.

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8
Q

What are the two main types of photosensitivity?

A

Phototoxicity and photoallergy.

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9
Q

What is phototoxicity?

A

Direct tissue injury caused by the phototoxic agent and radiation, occurring in all individuals exposed to adequate doses of the agent and activating wavelengths of radiation.

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10
Q

What is the difference between exogenous and endogenous photosensitizers?

A

Exogenous photosensitizers are administered systemically or applied topically, while endogenous photosensitizers are related to cutaneous porphyrias with enzymatic defects in heme biosynthetic pathways.

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11
Q

What is the prevalence range of positive responses in patients who had photopatch testing?

A

1.5% to 74%.

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12
Q

What are the symptoms of acute phototoxicity?

A

Burning and stinging on exposed areas, erythema, edema, and in severe cases, vesicles and bullae.

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13
Q

What is photoonycholysis?

A

Separation of the distal nail from the nail bed, which may be asymptomatic and can manifest as acute phototoxicity.

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14
Q

What factors influence acute phototoxicity?

A

It is drug-dose and UV-dose dependent, with symptoms appearing within hours of exposure to the phototoxic agent and UV radiation.

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15
Q

What is the role of the nail plate in phototoxicity?

A

The nail plate can serve as a lens to focus UV energy on the nail bed, potentially leading to phototoxic effects.

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16
Q

What is the clinical significance of the difference between phototoxicity and photoallergy?

A

Most photosensitivity induced by systemic medications is phototoxicity, while that induced by topical agents is photoallergy.

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17
Q

What are the common drugs associated with slate-gray pigmentation on sun-exposed areas?

A

Common drugs include Amiodarone, Chlorpromazine, Clozapine, Imipramine, Desipramine (less common), and Minocycline (can also affect non-sun-exposed areas).

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18
Q

What is the most common causative agent of pseudoporphyria?

A

The most common causative agent of pseudoporphyria is Naproxen.

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19
Q

What are the chronic effects associated with long-term PUVA treatment?

A

Chronic effects associated with long-term PUVA treatment include premature aging of the skin, lentigines, squamous cell carcinomas, basal cell carcinomas, and melanoma.

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20
Q

What is the relationship between voriconazole use and photosensitivity?

A

In immunosuppressed patients receiving voriconazole for longer than 12 weeks, the following effects may occur: photosensitivity, pseudoporphyria, photoaging, lentigines, and premature dermatoheliosis.

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21
Q

What are the systemic agents commonly reported to induce photosensitivity?

A

Common systemic agents that induce photosensitivity include Vemurafenib, Voriconazole, Doxycycline, Hydrochlorothiazide, Amiodarone, and Chlorpromazine.

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22
Q

What is the likely cause of asymptomatic blue-gray pigmentation on sun-exposed areas after prolonged use of a medication?

A

The condition is slate-gray pigmentation, often caused by drug metabolite-melanin complexes.

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23
Q

What is the underlying mechanism for squamous cell carcinoma development in a patient on voriconazole for over a year?

A

Voriconazole can cause accelerated photo-induced changes, leading to photosensitivity, pseudoporphyria, photoaging, lentigines, and premature dermatoheliosis.

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24
Q

What is the most common cause of pseudoporphyria with skin fragility and vesicles but normal porphyrin levels?

A

Naproxen is the most common cause.

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25
Q

What drugs are likely responsible for photodistributed telangiectasia in a patient on a calcium channel blocker?

A

Calcium channel blockers like nifedipine, amlodipine, felodipine, and diltiazem can cause photodistributed telangiectasia.

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26
Q

What is the likely mechanism for a lichenoid photosensitive eruption after starting doxycycline?

A

The mechanism involves phototoxicity or photoallergy induced by doxycycline.

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27
Q

What drugs are commonly associated with chronic actinic dermatitis?

A

Drugs like thiazides, quinidine, quinine, and amiodarone are associated with persistent photosensitivity evolving into chronic actinic dermatitis.

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28
Q

What is the diagnosis for exaggerated sunburn reactions after starting vemurafenib?

A

The diagnosis is phototoxicity.

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29
Q

What is the action spectrum for vemurafenib-induced phototoxicity?

A

The action spectrum for vemurafenib-induced phototoxicity is in the UVA range.

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30
Q

What are the likely culprits for a burning sensation and erythema on sun-exposed areas after using a topical agent?

A

Topical agents like fluorouracil, retinoids, and crude coal tar can cause phototoxicity.

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31
Q

What are the most commonly reported phototoxic agents after using a systemic medication?

A

Common agents include vemurafenib, voriconazole, doxycycline, hydrochlorothiazide, amiodarone, and chlorpromazine.

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32
Q

What is the typical action spectrum for most phototoxic agents?

A

The action spectrum for most phototoxic agents is in the UVA range.

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33
Q

What is the action spectrum for dyes like porphyrins and fluorescein?

A

The action spectrum for dyes like porphyrins and fluorescein is in the visible light range.

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34
Q

What are common sources of topical furocoumarins?

A

Common sources include limes, celery, figs, and parsnips.

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35
Q

What is the likely diagnosis for a burning sensation after exposure to crude coal tar?

A

The diagnosis is phototoxicity.

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36
Q

What is the mechanism of phototoxic reaction after using systemic fluorouracil?

A

The mechanism involves direct tissue injury caused by the phototoxic agent and radiation.

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37
Q

What are the most common systemic agents involved in phototoxic reactions?

A

Common agents include vemurafenib, voriconazole, doxycycline, hydrochlorothiazide, amiodarone, and chlorpromazine.

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38
Q

What skin condition is associated with chronic exposure to diltiazem?

A

Photodistributed, reticulated, slate-gray pigmentation.

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39
Q

What is the significance of the action spectra in phototoxic agents?

A

Most action spectra are in the UVA range, except for porphyrins and fluorescein which are in the visible light range.

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40
Q

What are the key steps involved in photodynamic processes leading to tissue injury?

A
  1. Absorption of radiation energy by the photosensitizer. 2. Formation of an excited molecule. 3. Generation of reactive oxygen species. 4. Resulting in tissue injury.
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41
Q

What are the histopathological findings associated with acute phototoxicity?

A
  • Individual necrotic keratinocytes; if severe, epidermal damage.
  • Epidermal spongiosis and dermal edema with mild infiltrate of neutrophils, lymphocytes, and macrophages.
  • Slate-gray pigmentation due to increased dermal melanin and drug deposits.
  • Lichenoid eruptions similar to idiopathic lichen planus with more spongiosis and necrotic keratinocytes.
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42
Q

What management strategies are recommended for acute phototoxicity?

A
  1. Identification and avoidance of the causative phototoxic agent. 2. Rigorous photoprotection: Seek shade, wear photoprotective clothing, wide-brimmed hats, and sunglasses. 3. Use broad-spectrum sunscreens with high SPF. 4. For acute phototoxicity, apply topical corticosteroids and compresses; consider systemic corticosteroids for severe cases.
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43
Q

What are the clinical features of photoallergy?

A
  • Sensitized individuals experience pruritic, eczematous eruptions within 24 to 48 hours after exposure.
  • Clinically indistinguishable from allergic contact dermatitis.
  • Predominantly affects sun-exposed areas, but may spread to covered areas.
  • Usually resolves without significant postinflammatory hyperpigmentation.
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44
Q

What are the potential long-term effects of UV radiation on photoallergens?

A
  • UV radiation can alter the carrier protein that binds the photoallergen, leading to the formation of a neoantigen.
  • This neoantigen can stimulate the immune system over the long term, potentially leading to chronic conditions.
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45
Q

What histopathological findings would confirm necrotic keratinocytes after exposure to a phototoxic agent?

A

Histopathological findings include individual necrotic keratinocytes, epidermal spongiosis, dermal edema, and a mild infiltrate of neutrophils, lymphocytes, and macrophages.

46
Q

What alternative medications can be considered for a patient developing pseudoporphyria after using a nonsteroidal anti-inflammatory drug?

A

Switch to a different class of agents or less photosensitizing NSAIDs like indomethacin or sulindac.

47
Q

What histopathological findings would support a diagnosis of a lichenoid eruption after exposure to a photosensitizing agent?

A

Findings include spongiosis, dermal eosinophilic and plasma cell infiltrates, and a larger number of necrotic keratinocytes and cytoid bodies.

48
Q

What condition does dermal-epidermal separation at the lamina lucida indicate after exposure to a phototoxic agent?

A

This indicates pseudoporphyria, as seen in porphyria cutanea tarda.

49
Q

What is the underlying photodynamic process for a phototoxic reaction with reactive oxygen species formation?

A

The process involves absorption of radiation energy by the photosensitizer, formation of an excited molecule, and generation of reactive oxygen species leading to tissue injury.

50
Q

What is the mechanism and involved agent for a phototoxic reaction with DNA crosslinking?

A

The mechanism involves covalent binding of 8-methoxypsoralen to pyrimidine bases of DNA upon UVA exposure, forming crosslinks.

51
Q

What are the key contributors to a phototoxic reaction with inflammatory mediators?

A

Key contributors include complement activation products, mast cell-derived mediators, eicosanoids, proteases, and polymorphonuclear leukocytes.

52
Q

What is the role of reactive oxygen species in apoptosis after photodynamic therapy?

A

Reactive oxygen species generated during photodynamic therapy act as potent inducers of apoptosis.

53
Q

What histopathological findings are expected after phototoxicity leading to hyperpigmentation?

A

Findings include increased dermal melanin and dermal deposits of the drug or its metabolite.

54
Q

What are the key management steps for a phototoxic reaction with erythema and edema?

A

Key steps include identification and avoidance of the causative agent, rigorous photoprotection, and symptomatic treatment with topical or systemic corticosteroids.

55
Q

What is the expected histopathological finding for a phototoxic reaction with lichenoid eruptions?

A

Findings include spongiosis, dermal eosinophilic and plasma cell infiltrates, and necrotic keratinocytes.

56
Q

What histopathological findings are expected for pseudoporphyria after using a photosensitizing agent?

A

Findings include dermal-epidermal separation at the lamina lucida and immunoglobulin deposits at the dermal-epidermal junction.

57
Q

What is the expected histopathological finding in a patient with a phototoxic reaction and lichenoid eruptions?

A

Findings include spongiosis, dermal eosinophilic and plasma cell infiltrates, and necrotic keratinocytes.

58
Q

What histopathological findings are expected in a patient who develops pseudoporphyria after using a photosensitizing agent?

A

Findings include dermal-epidermal separation at the lamina lucida and immunoglobulin deposits at the dermal-epidermal junction.

59
Q

What are the photodynamic processes involved in tissue injury?

A

Absorption of radiation energy by the photosensitizer leads to the formation of an excited molecule and reactive oxygen species, causing tissue injury.

60
Q

What can stable photoproducts induced by radiation exposure cause?

A

They can be responsible for tissue injury.

61
Q

What is the role of inflammatory mediators in phototoxicity?

A

They contribute to the development of phototoxicity induced by certain drugs and agents.

62
Q

What is a significant management step for phototoxicity?

A

Identification and avoidance of the causative phototoxic agent, along with rigorous photoprotection.

63
Q

What is the typical treatment for acute phototoxicity?

A

Topical corticosteroids and compresses; systemic corticosteroids for severely affected individuals.

64
Q

How does photoallergy present in sensitized individuals?

A

It presents as a pruritic, eczematous eruption within 24 to 48 hours after exposure.

65
Q

How does UV radiation affect the immune system in relation to photoallergens?

A

It alters the carrier protein that binds the photoallergen, leading to the formation of a neoantigen that stimulates the immune system over the long term.

66
Q

What are some common topical photoallergens found in the United States and Europe?

A

UV filters such as benzophenone-3, octocrylene, and avobenzone, as well as topical nonsteroidal anti-inflammatory drugs like ketoprofen.

67
Q

What are the histopathological features associated with phototoxicity?

A
  • Similar to those of allergic contact dermatitis.
  • Epidermal spongiosis associated with infiltrate of mononuclear cells in the dermis.
68
Q

What is the pathophysiology of photoallergy?

A
  • It involves a type IV delayed hypersensitivity response requiring both photoallergen and UVA radiation.
  • The photoallergen is converted to an excited state and may conjugate with a carrier protein to form a complete antigen.
  • Mechanisms include:
    • Halogenated salicylamides, chlorpromazine, and para-aminobenzoic acid.
    • Formation of a stable photoproduct that conjugates with a carrier protein.
  • Antigen is processed by epidermal Langerhans cells and presented to T lymphocytes, leading to cutaneous lesions.
69
Q

What management strategies are recommended for phototoxicity?

A
  • Identification and avoidance of the photoallergen.
  • Implementation of sun-protective measures.
  • Symptomatic therapy to alleviate symptoms.
70
Q

How can photosensitivity be evaluated in patients?

A
  • Similar to evaluations for other photosensitivity disorders, focusing on:
    • History of exposure to known photosensitizers.
    • Assessing if window glass-filtered sunlight induces cutaneous eruptions.
  • Widespread eruptions suggest systemic photosensitizers, while localized lesions indicate topical sensitizers.
  • Vesicular and bullous eruptions are commonly associated with phototoxicity, while eczematous eruptions suggest photoallergy.
71
Q

What are the key differences between phototoxicity and photoallergy based on clinical presentation?

A

Feature | Phototoxicity | Photoallergy |
|———|—————|————–|
| Sensation | Associated with a burning sensation | Associated with pruritus |
| Skin Reaction | Necrotic keratinocytes commonly seen | Spongiotic dermatitis associated |
| Erythema | Well-defined erythema that resolves promptly indicates irritant dermatitis | Erythema indicates photoallergy or allergic contact dermatitis |

72
Q

What does a reaction only at the irradiated site in photopatch testing indicate?

A

A reaction only at the irradiated site indicates photoallergy.

73
Q

What is the likely diagnosis for a patient with well-defined erythema that resolves promptly after photopatch testing?

A

The diagnosis is irritant dermatitis.

74
Q

What is the underlying mechanism for spongiotic dermatitis after exposure to a photoallergen?

A

The mechanism involves a type IV delayed hypersensitivity response, where the photoallergen conjugates with a carrier protein to form a complete antigen, leading to an inflammatory response.

75
Q

What are common photoallergens in the category of topical NSAIDs?

A

Common photoallergens include ketoprofen and etofenamate.

76
Q

What is the role of Langerhans cells in the process of a pruritic eruption after exposure to a photoallergen?

A

Langerhans cells take up and process the antigen, migrate to regional lymph nodes, and present the antigen to T lymphocytes, initiating an inflammatory response.

77
Q

What histopathological findings are expected in a patient with chronic actinic dermatitis?

A

Findings include epidermal spongiosis, dermal edema, and infiltrates of mononuclear cells in the dermis.

78
Q

What is the role of UVA in photopatch testing?

A

UVA is used as a light source in photopatch testing to activate the photoallergen and assess the reaction.

79
Q

What type of hypersensitivity response is involved in photoallergy?

A

Type IV delayed hypersensitivity response.

80
Q

What is the mechanism of photoallergy induced by certain drugs?

A

It involves the absorption of UV light, converting the photoallergen to an excited state molecule that can form a complete antigen.

81
Q

What are the common histopathological features of photoallergy?

A

Similar to those of allergic contact dermatitis, with epidermal spongiosis and infiltrate of mononuclear cells in the dermis.

82
Q

What management strategies are recommended for photoallergy?

A

Identification and avoidance of the photoallergen, sun-protective measures, and symptomatic therapy.

83
Q

What does widespread eruption suggest in the evaluation of photosensitivity?

A

It suggests systemic photosensitizers.

84
Q

What type of eruptions are most commonly associated with phototoxicity?

A

Vesicular and bullous eruptions.

85
Q

What is the significance of necrotic keratinocytes in phototoxicity?

A

They are commonly seen in phototoxicity, indicating damage to the skin.

86
Q

What does a reaction only at an irradiated site indicate in photopatch testing?

A

It indicates photoallergy.

87
Q

What is the role of epidermal Langerhans cells in the mechanism of photoallergy?

A

They process the antigen and migrate to regional lymph nodes to present it to T lymphocytes.

88
Q

What is the clinical significance of well-defined erythema that resolves promptly in photopatch testing?

A

It indicates an irritant dermatitis.

89
Q

What are some examples of systemic phototoxic agents classified as antibiotics?

A

Common Name (U.S. Trade Name) | Generic Name |
|———————————-|————–|
| Plicamycin | Mithramycin |
| Doxycycline | Vibramycin |
| Minocycline | Minocin |
| Tetracycline | Sumycin |

90
Q

Which class of drugs includes immunosuppressants that can cause phototoxicity?

A

Class | Common Name (U.S. Trade Name) | Generic Name |
|—————————————–|——————————–|————–|
| Immunosuppressants, nonsteroidal anti-inflammatory drugs | Acetic acid derivative | Diclofenac |
| | Penicillin | Penicillin |
| | Salicylate | Aspirin |

91
Q

What are some examples of oncologic drugs that can induce phototoxicity?

A

Common Name (U.S. Trade Name) | Generic Name |
|———————————-|————–|
| Dactinomycin | Dactinomycin |
| Docetaxel | Taxotere |
| Fluorouracil | Adrucil |
| Methotrexate | Trexall |

92
Q

What are systemic phototoxic agents?

A

They are drugs that can cause phototoxic reactions when exposed to sunlight.

93
Q

What class of drugs includes Tetracyclines and Sulfonamides?

A

Antimicrobials.

94
Q

Which class of drugs is known for its immunosuppressive properties?

A

Immunosuppressants.

95
Q

What is a common side effect of Cardiac drugs like Amiodarone?

A

Phototoxic reactions.

96
Q

Which class of drugs includes Furosemide and Hydrochlorothiazide?

A

Diuretics.

97
Q

What type of agents are used in photodynamic therapy?

A

Photodynamic therapy agents.

98
Q

What is the common name for the drug Doxycycline?

A

Vibramycin.

99
Q

Which drug is known as a nonsteroidal anti-inflammatory drug (NSAID)?

A

Ibuprofen.

100
Q

What is the generic name for the drug known as Taxol?

A

Paclitaxel.

101
Q

What is the common name for the drug Desipramine?

A

Norpramin.

102
Q

What are some examples of systemic photoallergens and their generic names?

A

Property | Generic Name (U.S. Trade Name) |
|———-|——————————-|
| Antifungal | Griseofulvin (Fulvicin, Grifulvin G, Gris-PEG) |
| Antimalarial | Quinine |
| Antimicrobials | Quinolone |
| Cardiac medication | Quinine (Quinaglute, Quindex) |
| Nonsteroidal anti-inflammatory drugs | Ketoprofen (Feldene) |
| Vitamin | Pyridoxine hydrochloride (vitamin B6) |

103
Q

What are some common topical photoallergens and their chemical names?

A

Group | Chemical Name (Trade Name) |
|——-|—————————-|
| Sunscreens | Benzophenone-3 (oxybenzone), Benzophenone-4 (sulisobenzone), Para-aminobenzoic acid (PABA) derivatives |
| Fragrances | 6-Methylcoumarin, Musk ambrette, Sandalwood oil |
| Antiinfective agents | Dibromolutehron (DBS), Triclosan (Microban, Lexol 300) |
| Others | Balsam of Peru, Etonamate, Ketoprofen (Invaul gel, Powergel, Tiloket gel) |

104
Q

What are systemic photoallergens and provide an example?

A

Systemic photoallergens are substances that can cause allergic reactions when exposed to sunlight. An example is Griseofulvin (Fulvicin, Grifulvin, Gris-PEG).

105
Q

What is a common topical photoallergen found in sunscreens?

A

Benzophenone-3 (oxybenzone) is a common topical photoallergen found in sunscreens.

106
Q

What type of medication is Quinidine classified as in the context of photoallergens?

A

Quinidine is classified as a cardiac medication that can act as a systemic photoallergen.

107
Q

Name a nonsteroidal anti-inflammatory drug that is a systemic photoallergen.

A

Ketoprofen is a nonsteroidal anti-inflammatory drug that is a systemic photoallergen.

108
Q

What is the role of PABA derivatives in topical photoallergy?

A

PABA derivatives, such as Ethylhexyl dimethyl PABA, are used in sunscreens and can act as topical photoallergens.

109
Q

What is a common ingredient in personal care products that can be a photoallergen?

A

Triclosan is a common ingredient in personal care products that can be a photoallergen.

110
Q

What is the significance of the chemical name ‘Octocrylene’ in relation to photoallergens?

A

Octocrylene is a chemical used in sunscreens that can act as a topical photoallergen.

111
Q

What type of agents are salicylanilides and their relevance to photoallergens?

A

Salicylanilides are antinfective agents that can act as topical photoallergens.

Fitzpatrick's Dermatology, 9th Edition (Chapter-based Decks) (48 decks)

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