Fact-checked by Grok 2 weeks ago

Photodermatitis

Photodermatitis is an inflammatory skin condition triggered by the interaction between ultraviolet (UV) radiation from sunlight or artificial sources and certain exogenous substances, resulting in a rash confined to light-exposed areas such as the face, neck, hands, and forearms.^[1] Unlike simple sunburn, it involves a heightened sensitivity where the substance acts as a photosensitizer, leading to either a non-immunologic phototoxic reaction or an immunologic photoallergic response.^[2] This condition affects individuals of all ages and ethnicities, with prevalence influenced by environmental exposure to triggers and genetic predispositions.^[3] Photodermatitis is classified into two primary types based on its mechanism: phototoxic, which resembles an exaggerated sunburn with direct cellular damage from the photosensitizer and UV light, often causing immediate redness, edema, and blistering; and photoallergic, which involves a delayed immune-mediated hypersensitivity reaction, typically presenting 24 to 48 hours after exposure as eczematous patches with papules, vesicles, or lichenification.^[2] Common causes include medications like tetracyclines, nonsteroidal anti-inflammatory drugs (NSAIDs), and diuretics; plant-derived psoralens (e.g., from limes or figs); and topical agents such as fragrances, sunscreen chemicals, or dyes.^[1] In photoallergic cases, the reaction requires prior sensitization, making it more akin to allergic contact dermatitis but activated by light, particularly UVA wavelengths.^[3] Symptoms generally include intense itching, burning, or stinging, accompanied by erythematous plaques that may evolve into hyperpigmentation, scaling, or scarring if recurrent; severe episodes can lead to complications like secondary infections or, rarely, increased skin cancer risk due to chronic inflammation.^[1] Diagnosis relies on a detailed patient history of recent exposures, physical examination of the rash's distribution, and confirmatory tests such as photopatch testing—where suspected substances are applied to the skin and irradiated—to differentiate it from other photodermatoses like polymorphous light eruption or lupus-related photosensitivity.^[2] Management focuses on trigger avoidance, broad-spectrum sun protection with clothing and high-SPF sunscreens, and symptomatic relief using topical corticosteroids or oral antihistamines for acute flares, while chronic cases may require desensitization phototherapy.^[3]

Definition and Classification

Definition

Photodermatitis is an inflammatory skin reaction triggered by exposure to ultraviolet (UV) or visible light, often in combination with endogenous or exogenous photosensitizing agents, resulting in abnormal cutaneous eruptions confined to sun-exposed areas.^[4]^[3] This condition encompasses phototoxic and photoallergic responses, where light activates the sensitizer to produce reactive species that damage skin cells, leading to dermatitis-like manifestations. Photodermatitis is distinct from other photodermatoses, such as idiopathic conditions like polymorphous light eruption, as it specifically involves photosensitizing agents.^[5]^[3] Unlike simple sunburn, which arises from direct cytotoxic effects of UV radiation on keratinocytes and DNA without requiring additional agents, photodermatitis specifically involves photosensitizers that amplify light-induced damage, affecting only sensitized individuals and often presenting with eczematous or exaggerated inflammatory features.^[3]^[4] The historical naming of photodermatitis evolved from early descriptions of light-related skin conditions, with "eczema solare" first documented in 1798 by Robert Willan, though the modern term and its classification gained prominence in early 20th-century medical literature amid growing recognition of photoallergic and phototoxic mechanisms.^[6]^[7]

Types

Photodermatitis is classified into two primary types based on the underlying reaction mechanisms: phototoxic and photoallergic.^[2] These categories are differentiated primarily by the presence or absence of immunologic involvement, the timing of onset after ultraviolet (UV) exposure, and the characteristic morphology of skin lesions.^[8] Phototoxic dermatitis represents a non-immunologic reaction that occurs in a dose-dependent manner, mimicking an exaggerated sunburn. It typically develops within hours of UV exposure in conjunction with a photosensitizing agent and manifests as erythema, edema, and sometimes blistering confined to sun-exposed areas.^[2] This type affects nearly anyone upon sufficient exposure and resolves without long-term sequelae once the irritant is removed.^[3] In contrast, photoallergic dermatitis is an immunologic delayed-type hypersensitivity reaction mediated by T-cells, requiring prior sensitization to the photoactive substance. Lesions appear 24 to 48 hours after exposure, presenting as pruritic, eczematous eruptions with papules, vesicles, or plaques that may spread beyond exposed sites and persist or recur with re-exposure.^[2] Differentiation from phototoxic reactions hinges on the delayed onset and immunologic basis, often confirmed through photopatch testing.^[3] Classification criteria emphasize clinical history, lesion timing (immediate for phototoxic versus delayed for photoallergic), morphology (sunburn-like versus eczematous), and immunologic testing to distinguish these types, guiding appropriate management.^[8]

Pathophysiology

Phototoxic Mechanisms

Phototoxic reactions in photodermatitis arise from direct non-immune-mediated photochemical interactions between ultraviolet (UV) radiation and photosensitizing agents in the skin, leading to cellular toxicity without involving hypersensitivity mechanisms.^[9] These agents, which include exogenous chemicals like drugs (e.g., tetracyclines, nonsteroidal anti-inflammatory drugs) or plant-derived furanocoumarins (e.g., psoralens), absorb UV photons and transition to an excited state, typically a triplet state, initiating damaging reactions.^[10] This process primarily occurs in the epidermis and dermis, where the photosensitizer's chromophores—aromatic rings or conjugated double bonds—facilitate energy transfer to surrounding molecules.^[9] Upon photoactivation, the excited photosensitizer generates reactive oxygen species (ROS) through two main pathways: Type I reactions, which produce free radicals via electron or hydrogen transfer, and Type II reactions, which yield singlet oxygen.^[10] These ROS cause oxidative stress by attacking cellular components, notably inducing lipid peroxidation in cell membranes, which disrupts membrane integrity and triggers a cascade of inflammatory mediators like arachidonic acid derivatives.^[11] The resulting damage manifests as direct cytotoxicity, including epidermal cell necrosis and the formation of apoptotic keratinocytes, often described as "sunburn cells," due to DNA interstrand crosslinks or membrane lysis.^[9] In severe cases, this leads to widespread tissue necrosis, particularly when photosensitizers like 8-methoxypsoralen intercalate with DNA under UV exposure.^[11] The severity of phototoxic reactions exhibits a clear dose-response relationship, where higher concentrations of the photosensitizer or greater UV intensity amplify ROS production and cellular injury, often with a threshold below which no reaction occurs.^[10] For instance, systemic agents like doxycycline at doses of 100 mg/day or more increase risk proportionally with exposure.^[10] UVA wavelengths (320–400 nm) play the dominant role, penetrating deeper into the dermis to activate systemic photosensitizers, while UVB (290–320 nm) primarily affects superficial epidermal layers and contributes in cases involving agents like hydrochlorothiazide.^[9] This wavelength specificity underscores UVA's greater implication in phototoxicity from distributed drugs.^[11]

Photoallergic Mechanisms

Photoallergic reactions in photodermatitis involve the penetration of photoallergens into the skin, where exposure to ultraviolet A (UVA) radiation induces photochemical changes, leading to hapten formation. These low-molecular-weight photoallergens, upon absorbing UVA (320–400 nm), become reactive and covalently bind to carrier proteins in the epidermis, such as keratin or other cellular components, forming complete immunogenic antigens capable of triggering an adaptive immune response. This hapten-protein conjugation is a critical initial step, often mediated by reactive oxygen species generated during photoactivation.^[12]^[13] The immune cascade commences with antigen-presenting cells, primarily epidermal Langerhans cells, which internalize and process the photoantigens. These cells undergo maturation and migrate to draining lymph nodes, where they present the haptenated peptides via major histocompatibility complex class II molecules to naïve CD4+ T cells, initiating clonal expansion and differentiation into effector T cells. This activation is supported by the release of pro-inflammatory cytokines, including interleukin-2 (IL-2) for T-cell proliferation and interferon-gamma (IFN-γ) for enhancing macrophage activity and inflammation. CD8+ T cells may also contribute to the response in some cases, amplifying the cellular immunity.^[12]^[13] This process manifests as a delayed-type (Type IV) hypersensitivity reaction, characterized by T-cell-mediated inflammation that produces an eczematous eruption, typically peaking at 48 hours after re-exposure. The response involves infiltration of sensitized T cells into the skin, leading to cytokine-driven epidermal spongiosis and dermal edema, distinguishing it from immediate hypersensitivity types.^[12]^[14] Sensitization establishes immunological memory through long-lived memory T cells, which persist in the skin and lymphoid tissues, enabling rapid reactivation upon subsequent encounters with the same photoallergen and UVA. This persistence accounts for the recurrent nature of photoallergic photodermatitis, where symptoms can emerge more severely without an intervening asymptomatic period.^[12]^[13]

Etiology

Exogenous Factors

Exogenous factors in photodermatitis encompass external agents from medications, plants, chemicals, and occupational environments that, upon interaction with ultraviolet radiation, trigger phototoxic or photoallergic skin reactions.^[5] Pharmaceuticals represent a primary category of exogenous triggers, with various classes known to induce photosensitivity through systemic or topical exposure. Antibiotics such as tetracyclines (e.g., doxycycline) and sulfonamides are common culprits, where they absorb UVA light and generate reactive oxygen species leading to epidermal damage.^[15] Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, can cause phototoxic eruptions resembling exaggerated sunburns, particularly in fair-skinned individuals.^[15] Diuretics like furosemide and thiazides similarly promote photosensitivity by forming photoproducts that damage keratinocytes upon UV exposure.^[15] Other classes, including antifungals such as voriconazole and targeted antineoplastic agents like vemurafenib, have been increasingly reported as causes in pharmacovigilance data as of 2023.^[16] Plants and natural substances containing phototoxic compounds, notably furocoumarins (psoralens), are significant exogenous inducers, especially in phytophotodermatitis. Citrus fruits such as lemons and limes harbor 5-methoxypsoralen (5-MOP), which penetrates the skin and, activated by UVA, causes linear blistering or hyperpigmentation in contact areas.^[11] Other plants like parsnips, celery, and hogweed (Heracleum mantegazzianum) contain imperatorin and 8-methoxypsoralen (8-MOP), resulting in severe inflammatory responses following plant sap contact and sunlight exposure.^[11] Figs (Ficus carica) also contribute via psoralen content, often affecting handlers through direct dermal application.^[11] Chemicals in consumer products frequently elicit photoallergic or phototoxic dermatitis via hapten formation under light exposure. Fragrances, such as musk ambrette in aftershaves and colognes, act as potent photoallergens by binding to skin proteins after UVA activation, leading to eczematous reactions on exposed sites.^[17] Sunscreens containing benzophenones (e.g., oxybenzone) can paradoxically induce photosensitivity, with the filters degrading into immunogenic compounds upon UV irradiation.^[13] Dyes in cosmetics, textiles, and hair products, including disperse blue dyes, similarly provoke persistent photoallergic contact dermatitis through photooxidation products.^[13] Occupational exposures heighten risk through repeated contact with these agents in professional settings. Bartenders handling limes for cocktails often develop phytophotodermatitis on hands and arms from juice splashes followed by UV exposure during outdoor service. Farm workers and gardeners encountering parsnips, hogweed, or celery during harvesting or weeding face heightened phytophototoxic risks, with sap-induced burns exacerbated by fieldwork sunlight. Industrial workers in dye or fragrance manufacturing may experience chronic photoallergic dermatitis from airborne or contact exposure to sensitizing chemicals.^[5]

Endogenous Factors

Endogenous factors in photodermatitis encompass intrinsic physiological, metabolic, and genetic conditions that heighten susceptibility to light-induced skin reactions without reliance on external agents. These factors alter the skin's ability to handle ultraviolet (UV) radiation, leading to exaggerated inflammatory or phototoxic responses. Common examples include inherited metabolic disorders and autoimmune conditions where UV exposure amplifies underlying defects. Porphyrias represent a group of genetic disorders characterized by the accumulation of porphyrins, which are photosensitizing intermediates in heme biosynthesis. In erythropoietic protoporphyria (EPP), a deficiency in the ferrochelatase enzyme results in protoporphyrin buildup in erythrocytes and skin, where it absorbs visible light (particularly 400-410 nm) and generates reactive oxygen species (ROS) through energy transfer to molecular oxygen. This ROS production damages vascular endothelium and keratinocytes, causing acute burning pain, edema, and erythema shortly after sun exposure, often beginning in childhood.^[18] Similarly, porphyria cutanea tarda (PCT), the most common porphyria, involves uroporphyrinogen decarboxylase deficiency, leading to uroporphyrin accumulation that triggers ROS-mediated cellular damage and chronic blistering on sun-exposed areas.^[18] Systemic lupus erythematosus (SLE) is an autoimmune disorder where photosensitivity affects up to 70% of patients, with UV radiation exacerbating cutaneous and systemic manifestations. UVB (290-320 nm) induces DNA damage in keratinocytes, promoting apoptosis and the release of autoantigens that stimulate autoantibody production, such as anti-Ro/SSA and anti-La/SSB, which deposit in the skin and trigger inflammatory flares. UVA (320-400 nm) contributes by generating ROS in mitochondria, further impairing apoptotic cell clearance and amplifying type I interferon signaling, which activates autoreactive T-cells and leads to erythematous rashes or discoid lesions on photoexposed sites. This UV-induced immune dysregulation can precipitate systemic flares, including arthritis and nephritis.^[19] Metabolic disorders like pellagra and Hartnup disease predispose individuals to light-exacerbated dermatitis through niacin (vitamin B3) deficiency or impaired synthesis. Pellagra, resulting from inadequate dietary niacin or its precursor tryptophan, manifests as a photosensitive dermatitis with hyperpigmented, scaly plaques on sun-exposed areas, driven by disrupted cellular energy metabolism and increased prostaglandin E2 production that heightens UV-induced inflammation; the exact photosensitizing mechanism remains incompletely elucidated but involves oxidative stress from niacin shortfall.^[20] Hartnup disease, an autosomal recessive disorder caused by mutations in the SLC6A19 gene encoding the neutral amino acid transporter B0AT1, impairs intestinal and renal absorption of tryptophan, leading to secondary niacin deficiency and pellagra-like photosensitive rashes characterized by erythema and scaling on UV-exposed skin.^[21] Genetic predispositions further modulate photodermatitis risk by influencing UV tolerance. Individuals with Fitzpatrick skin types I-II, characterized by fair skin, red or blond hair, and poor tanning ability, exhibit reduced melanin content, which normally absorbs UV and neutralizes ROS, resulting in heightened susceptibility to sunburn and phototoxic reactions.^[22] Defects in DNA repair enzymes, as seen in disorders like xeroderma pigmentosum (XP), arise from mutations in nucleotide excision repair genes (e.g., XPA-XPG), impairing the removal of UV-induced DNA lesions such as cyclobutane pyrimidine dimers; this leads to persistent genomic instability, chronic inflammation, and severe photosensitivity with freckling and early skin cancers upon minimal sun exposure.^[23]

Clinical Manifestations

Signs and Symptoms

Photodermatitis presents with a range of cutaneous manifestations that vary by type and severity, primarily affecting sun-exposed areas such as the face, neck, hands, and arms.^[24] In acute phases, common features include erythema and edema, often accompanied by a burning or itching sensation that develops within hours to days following ultraviolet exposure.^[3] Vesicles or bullae may form in more severe cases, resembling exaggerated sunburn, with symptoms typically limited to the exposed skin.^[25] Chronic exposure can lead to persistent hyperpigmentation, scaling, or lichenification, where the skin becomes thickened and leathery due to repeated inflammation.^[5] These changes reflect ongoing dermal damage and may persist for weeks or longer without intervention.^[26] Characteristic distribution patterns aid in recognition: affected areas often spare covered regions, shadowed skin folds like under the chin or between fingers, and may show linear streaks or drip-like lesions in cases of phytophotodermatitis from plant contact.^[27] Symptom variation is influenced by whether the reaction is phototoxic, mimicking irritant dermatitis, or photoallergic, involving immune-mediated responses.^[3]

Complications

Untreated or recurrent photodermatitis can result in post-inflammatory hyperpigmentation, a common sequela in phototoxic reactions triggered by agents like tetracyclines, amiodarone, or psoralens, where melanin deposition leads to persistent brownish discoloration in affected areas.^[28] In severe cases involving bullous eruptions, such as phytophotodermatitis from plant-derived furanocoumarins, desquamation may progress to scarring, though this is rare and typically limited to deep dermal involvement.^[11] Repeated episodes heighten the risk of chronic actinic dermatitis, a lichenified, eczematous condition that extends photosensitivity and impairs quality of life through ongoing pruritus and skin thickening.^[28] Blistering lesions in photodermatitis, particularly from phototoxic mechanisms, carry a risk of secondary bacterial superinfection, which can escalate to cellulitis or more widespread dermatological complications if the breached skin barrier allows pathogen entry.^[29] Chronic or recurrent photodermatitis, especially drug-induced, is associated with an increased risk of non-melanoma skin cancers, such as squamous cell carcinoma, due to ongoing UV exposure and inflammation.^[30]^[31] Photoallergic photodermatitis often leads to persistent photosensitivity, with delayed-type hypersensitivity reactions causing lifelong avoidance of triggering photoallergens and potential progression to chronic photosensitivity syndromes.^[28] In patients with predisposing autoimmune disorders, such as systemic lupus erythematosus, recurrent photodermatitis can exacerbate disease activity, inducing subacute cutaneous lupus erythematosus flares characterized by widespread annular or papulosquamous lesions.^[32] In endogenous forms of photodermatitis, like porphyria cutanea tarda, accumulated porphyrins not only drive cutaneous fragility but also contribute to systemic risks, including hepatic siderosis, cirrhosis, and a markedly elevated incidence of hepatocellular carcinoma due to oxidative liver damage.^[33]^[34]

Diagnosis

Clinical Assessment

The clinical assessment of photodermatitis begins with a detailed patient history to identify potential triggers and patterns of exposure. Healthcare providers should inquire about the timeline of light exposure, including the duration, intensity, and type of ultraviolet (UV) radiation encountered, as symptoms often correlate with recent sun exposure or artificial UV sources. Recent use of medications known to cause photosensitivity, such as thiazides, tetracyclines, or nonsteroidal anti-inflammatory drugs, must be documented, along with contact with photosensitizing plants containing psoralens, like those in the Apiaceae family. Occupational history is crucial, particularly for individuals in outdoor professions such as farming or construction, where prolonged UV exposure is common. Additionally, a family history of photosensitivity disorders, such as xeroderma pigmentosum, should be explored to assess genetic predisposition.^[2]^[32]^[5] Physical examination focuses on inspecting the skin for characteristic distribution and morphology to support the diagnosis. Lesions typically appear on photo-exposed sites, including the face, neck, dorsal hands, and forearms, while sparing covered areas such as skin folds, under clothing, or beneath jewelry, creating sharp demarcation lines. Morphology varies by mechanism: phototoxic reactions often present with erythema, edema, vesicles, or bullae in bizarre, streaky patterns from plant contact, whereas photoallergic responses show pruritic eczematous papules or plaques. Severity is evaluated through visual assessment of lesion extent, inflammation, and associated features like hyperpigmentation or lichenification in chronic cases, though no standardized scoring system is universally applied; instead, clinical judgment guides the estimation of mild, moderate, or severe involvement based on surface area affected and symptom intensity.^[35]^[32]^[2] Risk stratification involves distinguishing acute from chronic presentations to inform urgency and follow-up. Acute photodermatitis is suggested by rapid onset within hours to days of exposure, often non-recurrent without re-exposure, whereas chronic forms exhibit recurrent episodes with seasonal patterns, such as worsening in spring or summer, indicating ongoing sensitization or endogenous factors. This assessment relies on the history of symptom recurrence and persistence to identify patients at higher risk for complications like persistent pigmentation.^[35]^[5]^[2] Differential considerations emphasize exposure patterns to rule out mimics, such as contact dermatitis, which may present similarly but lacks the strict photo-distribution and UV dependency. For instance, allergic contact dermatitis from plants might occur in non-exposed areas or without light history, whereas photodermatitis consistently aligns with UV-exposed sites and latency after combined exposure. Polymorphous light eruption or drug eruptions can be differentiated by timing and morphology, with history confirming the photoaggravated nature.^[35]^[32]^[5]

Diagnostic Tests

Diagnostic tests for photodermatitis are essential to confirm the diagnosis, differentiate between phototoxic and photoallergic mechanisms, and identify underlying triggers or associated conditions. These objective procedures complement clinical assessment by providing quantifiable evidence of photosensitivity and specific pathological changes. Common tests include phototesting, photopatch testing, laboratory investigations, and skin biopsy, each targeting different aspects of the condition.^[2] Phototesting involves controlled irradiation of the skin with specific wavelengths of ultraviolet (UV) or visible light using a monochromator or broadband source to evaluate photosensitivity. The procedure determines the minimal erythema dose (MED), defined as the lowest dose of UV radiation (typically 20-80 mJ/cm² for UVB) that produces perceptible erythema 24 hours after exposure, and identifies the action spectrum by testing incremental doses across wavelengths such as UVA (320-400 nm) or UVB (280-320 nm). This helps pinpoint the wavelengths provoking reactions, aiding in distinguishing idiopathic photodermatoses like polymorphic light eruption from exogenous causes. Provocation phototesting may involve repeated exposures over 3-4 days at 80% of the MED to reproduce lesions, confirming light-induced dermatosis.^[36]^[2]^[37] Photopatch testing is performed to detect photoallergic contact dermatitis by identifying photoactive substances that elicit reactions upon UV exposure. Suspected agents, such as fragrances, sunscreens, or medications, are applied to the skin (usually the back) in duplicate patches alongside standard patch testing. After 24-48 hours, one set of patches is irradiated with UVA (5-10 J/cm²), while the other remains unexposed; reactions are read at 48 and 96 hours post-irradiation. A positive response, indicated by erythema or vesicles confined to the irradiated sites, confirms photoallergy, with common allergens including ketoprofen or promethazine. This test differentiates photoallergy from simple contact allergy or phototoxicity.^[2]^[5]^[37] Laboratory investigations are targeted based on suspected endogenous factors contributing to photodermatitis. In cases of suspected porphyria, blood, urine, and fecal porphyrin levels are measured to detect elevated protoporphyrin or uroporphyrin, which can cause photosensitivity through accumulation in skin. For photoaggravated autoimmune conditions like lupus erythematosus, antinuclear antibody (ANA) testing is conducted, with positive results (e.g., titers >1:160) prompting further extractable nuclear antigen (ENA) panels. Additional tests may include complete blood count, liver function tests, and serum iron studies to rule out systemic involvement. These assays help identify underlying metabolic or immunological triggers.^[2] Skin biopsy provides histopathological confirmation by revealing distinct features of phototoxic versus photoallergic reactions. In phototoxicity, microscopy shows epidermal changes such as keratinocyte ballooning, scattered apoptotic (sunburn) cells, and necrosis in the upper epidermis, often with mild spongiosis and a sparse superficial dermal inflammatory infiltrate of lymphocytes and neutrophils; severe cases exhibit full-thickness epidermal necrosis resembling exaggerated sunburn. In contrast, photoallergy demonstrates epidermal spongiosis, acanthosis, and a superficial perivascular lymphocytic infiltrate with eosinophils, mimicking eczematous dermatitis. Direct immunofluorescence may be added to detect immune deposits in photoexacerbated autoimmune diseases. Biopsy is particularly useful when clinical features overlap with other dermatoses.^[38]^[2]

Management

Treatment

The treatment of photodermatitis primarily focuses on alleviating inflammation, relieving symptoms such as pruritus, and addressing underlying mechanisms specific to the type of photodermatosis. First-line interventions for most cases include topical corticosteroids, such as hydrocortisone 1% cream applied twice daily, to reduce inflammation and erythema in acute eruptions. Oral antihistamines, like cetirizine 10 mg daily, are commonly used to manage associated pruritus, providing symptomatic relief without targeting the photosensitive process directly.^[39]^[3] In severe or persistent cases, systemic corticosteroids such as prednisone 0.5-1 mg/kg/day for 5-7 days may be required to control widespread inflammation, with a gradual taper to prevent rebound. For chronic photoallergic dermatitis, immunosuppressants like azathioprine 1-2.5 mg/kg/day have demonstrated efficacy in achieving remission, particularly when topical therapies fail, by modulating immune responses to photoallergens. Desensitization phototherapy, such as narrowband UVB or PUVA administered in increasing doses during off-season months, is a prophylactic option for recurrent idiopathic photodermatoses like polymorphous light eruption (PMLE) and chronic actinic dermatitis to induce tolerance.^[40]^[41]^[3] Treatment strategies vary by photodermatosis type; for polymorphous light eruption (PMLE), topical mid-potency corticosteroids and oral antihistamines serve as initial management, while severe recurrent cases may benefit from antimalarials such as hydroxychloroquine 200-400 mg weekly to suppress eruptions. In porphyria-related photodermatitis, such as porphyria cutanea tarda, phlebotomy to reduce iron stores (typically 250-500 mL every 1-2 weeks until ferritin levels normalize) is a standard therapy that induces clinical remission by decreasing porphyrin accumulation; low-dose hydroxychloroquine (100-200 mg twice weekly) serves as an effective alternative or adjunct, particularly when phlebotomy is not feasible. As of 2025, Janus kinase (JAK) inhibitors like upadacitinib have shown promise in case series as monotherapy for severe chronic photodermatitis refractory to conventional treatments.^[42]^[43]^[44]^[45]^[46] Supportive care plays a crucial role across all cases, including cool compresses applied for 10-15 minutes several times daily to soothe irritated skin, emollients like petrolatum to maintain barrier function and prevent dryness, and vigilant monitoring for secondary bacterial infections, which may necessitate topical or oral antibiotics if signs of cellulitis emerge. The choice of therapy is influenced by the underlying etiology, such as exogenous photosensitizers or endogenous metabolic disorders.^[39]^[3]

Prevention

Prevention of photodermatitis primarily involves minimizing exposure to ultraviolet (UV) radiation and avoiding known triggers to reduce the risk of episodes. Photoprotection strategies are essential, including the application of broad-spectrum sunscreens with a sun protection factor (SPF) of at least 30 that include UVA-blocking agents such as avobenzone or zinc oxide, applied generously 15-30 minutes before sun exposure and reapplied every two hours or after swimming or sweating.^[47]^[24]^[48] Wearing protective clothing, such as long-sleeved shirts, wide-brimmed hats, and UV-blocking sunglasses, along with seeking shade during peak UV hours from 10 a.m. to 4 p.m., further limits skin exposure to sunlight.^[30]^[49] Avoiding triggers is crucial, particularly discontinuing or substituting photosensitizing medications like thiazide diuretics, tetracyclines, nonsteroidal anti-inflammatory drugs (NSAIDs), and certain antifungals under medical supervision to prevent drug-induced reactions.^[2]^[5]^[50] Similarly, opting for hypoallergenic cosmetics and topical products free of known photoallergens, such as fragrances or dyes, helps mitigate contact-related photodermatitis.^[4] Behavioral measures include immediate washing of skin with soap and water after contact with potentially photosensitizing plants like citrus fruits (e.g., limes) or wild parsnips to remove phytophototoxins before UV exposure, and wearing gloves or protective clothing during gardening or handling such plants.^[51]^[52]^[53] Occupational safeguards, such as using barrier creams and UV-protective gear for workers in agriculture or cosmetics industries, are recommended to prevent recurrent exposures.^[54] For high-risk groups, such as individuals with lupus erythematosus where photodermatitis manifests as part of cutaneous involvement, regular dermatologic monitoring and prophylactic use of antimalarials like hydroxychloroquine can reduce flare frequency and photosensitivity.^[55]^[56]^[57] Patient education on these strategies empowers adherence and long-term risk reduction.^[5]

References

[1]
Photodermatitis: Rash Characteristics and Treatment - Verywell Health
Aug 4, 2025 · Photodermatitis is a condition that causes a rash on the skin. It occurs when the skin is exposed to both an irritant and ultraviolet (UV) light.Missing: definition | Show results with:definition
[2]
Photosensitivity - StatPearls - NCBI Bookshelf - NIH
Photosensitivity refers to various symptoms, diseases, and conditions (photodermatoses) caused or exacerbated by exposure to sunlight.Missing: reliable | Show results with:reliable<|control11|><|separator|>
[3]
Photodermatoses: Diagnosis and Treatment - PMC - PubMed Central
Mar 4, 2011 · Photodermatoses are caused by an abnormal reaction to sunlight, usually to its ultraviolet component. They are divided into phototoxic and photoallergic ...Missing: reliable sources
[4]
Photodermatitis | 5-Minute Clinical Consult
### Summary of Photodermatitis
[5]
Historical perspective on sunscreens: Shift towards worldwide ...
Although eczema solare was first described in 1798 by Wilan [5], there was a general rise in cases of photodermatitis from the mid-20th century, especially ...<|control11|><|separator|>
[6]
Photodermatology over the past 125 years - Wiley Online Library
Nov 19, 2014 · An example is polymorphous light eruption, a term first used by Rasch in 1900,1 although the same condition was described earlier, before ...
[7]
Assessment of sunscreen effects in photosensitivity under UV ...
The prevalence of photosensitivity across Europe is 10–20 % of the population. Excessive contact with UV rays also leads to skin cancer (Kim and Chong, 2013). A ...Missing: photodermatitis | Show results with:photodermatitis
[8]
Classification and evaluation of photodermatoses - PubMed
Photodermatoses can be classified into five general categories: 1) idiopathic photodermatoses, including polymorphic light eruption (PMLE), actinic prurigo, ...
[9]
https://doi.org/10.3389/falgy.2022.876695
[10]
https://doi.org/10.1016/j.jpap.2023.100221
[11]
Phytophotodermatitis: Background, Pathophysiology, Etiology
Jul 17, 2025 · Phytophotodermatitis (PPD) is a cutaneous phototoxic inflammatory eruption resulting from contact with light-sensitizing botanical substances.
[12]
Drug photoallergy - Tokura - 2018 - Wiley Online Library
May 16, 2018 · This review aims to highlight the mechanism of drug photoallergy, focusing on the assessments of photoallergenicity as well as phototoxicity of chemicals.
[13]
Innovative Strategies for Photoallergy Assessment - MDPI
Mar 25, 2024 · In a first exposure or sensitization phase (Figure 1), the photoallergen will form the complete hapten by binding to skin proteins. These events ...
[14]
Phototoxic and photoallergic cutaneous drug reactions - PubMed
In contrast, photoallergic reactions are type IV hypersensitivity reactions, and therefore resemble eczema. They usually develop within days and are less common ...
[15]
Photosensitivity (sun allergy) - DermNet
Photosensitivity refers to various symptoms, diseases and conditions caused or aggravated by exposure to sunlight.Polymorphic light eruption · Solar urticaria · Juvenile spring eruption · Actinic prurigo
[16]
Drug-induced Photosensitivity - DermNet
What causes drug-induced photosensitivity? Table 1. Common photosensitising agents. Phototoxic drugs. Photoallergic drugs. Antibiotics. Fluoroquinolones (eg ...
[17]
Photoallergy - an overview | ScienceDirect Topics
The most common photoallergens are chemicals used as sunscreens. Three fragrance materials not found in essential oils, musk ambrette, 6-methylcoumarin and 7- ...
[18]
[PDF] Update on Photodermatoses
1 In this review we will discuss the clinical features, pathogenesis, photobiologic evaluation, prognosis, and ther- apies of the more commonly encountered ...
[19]
New concepts on abnormal UV reactions in systemic lupus ... - NIH
Mar 6, 2023 · Photosensitivity (PSN) is an abnormal reaction to sunlight/UVR exposure that leads to a rash or lesion formation as determined by a practitioner.
[20]
Pellagra: a review with emphasis on photosensitivity - PubMed
However, the pathogenetic mechanism for the photosensitivity caused by niacin deficiency has yet to be determined. This review seeks to update the ...
[21]
Hartnup Disease - StatPearls - NCBI Bookshelf
Feb 13, 2023 · Hartnup disease is an autosomal recessive disorder resulting in impaired functioning of transport proteins in the intestines and kidneys.
[22]
Skin phototype (Fitzpatrick skin type) - DermNet
Fitzpatrick skin phototype is a constitutional characteristic present at birth. Note that people with photosensitivity may burn easily on exposure to the sun ...
[23]
Understanding photodermatoses associated with defective DNA repair
Photodermatoses associated with defective DNA repair are a group of photosensitive hereditary skin disorders. In this review, we focus on diseases and ...Missing: endogenous factors porphyrias lupus pellagra Hartnup Fitzpatrick
[24]
Photosensitivity: What it is, Symptoms & Rash, Causes
Mar 24, 2025 · Photosensitivity is an extreme skin sensitivity to sunlight or other sources of UV radiation. It commonly appears as an itchy, painful rash.Missing: reliable | Show results with:reliable
[25]
Photosensitivity Reactions - Skin Disorders - Merck Manuals
people have pain and develop redness, inflammation, and sometimes brown or blue-gray discoloration in areas of skin that have been exposed to sunlight for a ...Solar Urticaria · Some Medications And... · Polymorphous Light EruptionMissing: signs | Show results with:signs
[26]
Sun allergy - Symptoms and causes - Mayo Clinic
Jul 19, 2024 · It describes several conditions that cause an itchy rash to form on the skin after being in sunlight or other sources of ultraviolet (UV) ...Missing: reliable | Show results with:reliable
[27]
Phytophotodermatitis - DermNet
Phytophotodermatitis, a form of plant dermatitis, is a skin reaction that occurs after natural photosensitising chemicals (furanocoumarins) present within ...
[28]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3063367/
[29]
A Case Study of Photosensitivity Associated with Anaplasma spp ...
... photodermatitis. Dermatitis with alopecia mainly affected the forehead, the ... Microscopic examination also revealed a secondary bacterial infection.
[30]
Drug-Induced Photosensitivity Clinical Presentation
Mar 4, 2025 · Drug-induced photosensitivity may result in phototoxicity, photoallergy, lichenoid reactions, subacute cutaneous lupus erythematosus (SCLE; see the image below ...
[31]
Porphyria - NIDDK
Porphyria cutanea tarda can damage the liver and increase the chance of developing cirrhosis and liver cancer. Some people with protoporphyria also develop ...
[32]
Porphyria cutanea tarda increases risk of hepatocellular carcinoma ...
Apr 3, 2019 · Liver cancer risk is increased in patients with porphyria cutanea tarda in comparison to matched control patients with chronic liver disease.
[33]
Photodermatoses - Knowledge @ AMBOSS
Jun 1, 2023 · Careful history-taking is usually sufficient to establish a clinical diagnosis; further studies are reserved for diagnostic uncertainty. The ...
[34]
Phototesting - DermNet
Photopatch testing aids the diagnosis of suspected contact ... Laboratory investigations can help formulate a diagnosis in patients with photosensitivity.
[35]
Sun allergy - Diagnosis and treatment - Mayo Clinic
Jul 19, 2024 · Photopatch testing. This test ... With these tests, a blood sample or a skin sample (biopsy) is taken for examination in a laboratory.
[36]
Investigations and treatment of photodermatoses
May 3, 2024 · The photodermatoses comprise of a miscellaneous set of photosensitive disorders with abnormal cutaneous response to sunlight.
[37]
Phytophotodermatitis Treatment & Management: Medical Care, Diet ...
Jul 17, 2025 · Topical steroids may be administered if the eruption is severe and edematous. ... Topical antihistamines may be considered for skin irritation.Missing: guidelines | Show results with:guidelines
[38]
Treatment of chronic actinic dermatitis with azathioprine - PubMed
Fourteen patients with severe unremitting chronic actinic dermatitis were treated with oral azathioprine in a dosage of 100-200 mg daily for a mean 11.5 months.
[39]
Azathioprine Treatment in Chronic Actinic Dermatitis - PubMed
Oral azathioprine therapy is an effective and usually well tolerated treatment in chronic actinic dermatitis.
[40]
Polymorphous Light Eruption Treatment & Management
Aug 20, 2025 · Other studies have supported the use of UVA blockers to help prevent PMLE, including a report that described a lower percentage of PMLE (0% at 2 ...Missing: calcium channel
[41]
Porphyria Cutanea Tarda - StatPearls - NCBI Bookshelf - NIH
Apr 17, 2023 · Porphyrin elevation is also seen in liver disease, advanced renal disease, and other porphyrias. However, they will not show the typical ...
[42]
Porphyria cutanea tarda: a unique iron-related disorder - PMC
Dec 6, 2024 · Treatment includes therapeutic phlebotomy to decrease total body iron levels and low-dose hydroxychloroquine, which reduces hepatic porphyrin ...
[43]
Sun Allergy (Photosensitivity) - Harvard Health
May 7, 2024 · It is an immune system reaction in the skin triggered by sunlight, most often causing an itchy red rash.Missing: definition | Show results with:definition
[44]
Photosensitivity - Dermatologic Disorders - Merck Manuals
Photosensitivity is a cutaneous overreaction to sunlight. It can be related to photoallergy or phototoxicity and may be idiopathic or occur after exposure ...Missing: photodermatitis definition
[45]
Photosensitivity - The Skin Cancer Foundation
Photosensitivity is heightened skin sensitivity or an unusual reaction when your skin is exposed to UV radiation from sunlight or a tanning bed.What Causes Photosensitivity... · If You Have A Reaction · Safeguard Against Skin...Missing: photodermatitis reliable sources
[46]
Photosensitive dermatitis: Causes, symptoms, and treatments
Aug 19, 2021 · Photosensitive dermatitis is a condition that causes skin inflammation, or an eczematous reaction, after exposure to sunlight or some types of artificial light.Missing: reliable | Show results with:reliable
[47]
Drug-Induced Photosensitivity: Background, Pathophysiology, Etiology
Mar 4, 2025 · Photosensitivity reactions may result from systemic medications and topically applied compounds (see Etiology). Drug-induced photosensitivity is ...<|separator|>
[48]
What You Should Know About Phytophotodermatitis - WebMD
Apr 24, 2024 · You can get phytophotodermatitis if your skin absorbs psoralen from certain plants, fruits, or vegetables and is then exposed to UVA light.What Is Phytophotodermatitis... · Featured · Suggested Questions<|separator|>
[49]
Phytophotodermatitis symptoms and treatment
Sep 17, 2021 · Phytophotodermatitis can cause painful swelling and severe blisters. Basic sun safety is important for phytophotodermatitis prevention. But it ...
[50]
Sun-related Skin Condition Triggered by Chemicals in Certain ...
Aug 12, 2011 · To prevent phytophotodermatitis, wash your hands after handling any citrus fruits, particularly limes. You should also wear long pants and ...Missing: prevention | Show results with:prevention
[51]
New Insights Concerning Phytophotodermatitis Induced by ...
The term “phytophotodermatitis” gained prominence in the 20th century as cases were documented in the medical literature, particularly among individuals ...
[52]
Lupus and your skin: Diagnosis and treatment
Sep 23, 2022 · Antimalarial medication: Used to treat malaria, this medication can also clear skin rashes due to lupus and prevent lupus flares. Antimalarial ...
[53]
Treating Lupus with Anti-Malarial Drugs
Anti-malarials can protect against UV light and sometimes even improve skin lesions that do not respond to treatment with topical therapy (ointments).Missing: photodermatitis | Show results with:photodermatitis
[54]
Cutaneous Lupus (Skin Lupus): Symptoms & Treatment
Oral medications: Disease-modifying anti-rheumatic drugs (DMARDs) treat autoinflammatory diseases like lupus. Hydroxychloroquine and chloroquine are most often ...Discoid Lupus · Chilblain Lupus · Skin Lesions