Do antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Tricyclic Antidepressants (TCAs), increase photosensitivity?

Antidepressants and Photosensitivity

Yes, certain antidepressants can increase photosensitivity, with tricyclic antidepressants (TCAs) having the highest risk, followed by some selective serotonin reuptake inhibitors (SSRIs). 1, 2, 3

Types of Antidepressants and Their Photosensitivity Risk

Tricyclic Antidepressants (TCAs)

• Highest photosensitivity risk among antidepressants
• Imipramine is associated with 81% of TCA-induced photosensitivity cases 3
• Other TCAs with documented photosensitivity: amitriptyline (9.5%), desipramine (4.8%), and clomipramine 4, 3
• Can cause photo-distributed hyperpigmentation, particularly after long-term use (average 10.4 years) 3
• Characteristic presentation: asymptomatic blue-gray or brownish discoloration of sun-exposed skin 3

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Moderate photosensitivity risk
• Documented cases with:
  • Citalopram (can cause subacute cutaneous lupus erythematosus) 5
  • Fluvoxamine and paroxetine (photoallergic reactions with possible cross-reactivity) 6
• Photosensitivity reactions typically present as:
  • Sunburn-like responses
  • Eczematous or lichenoid eruptions
  • Occasionally bullous lesions resembling porphyria cutanea tarda 2

Other Antidepressants

• Mirtazapine has been reported in 4.8% of antidepressant-induced photosensitivity cases 3
• Bupropion has documented photosensitivity reactions in post-marketing reports 7

Clinical Presentation and Diagnosis

Photosensitivity reactions can manifest as:

• Exaggerated sunburn reactions
• Itching erythema with infiltrations and blisters on sun-exposed areas
• Photo-distributed hyperpigmentation
• Dermatitis or lichenoid eruptions
• Subacute cutaneous lupus erythematosus (rare) 5, 2

Diagnosis requires:

• Detailed medication history
• Examination of skin lesions (distribution pattern limited to or accentuated in light-exposed areas)
• Histological examination (may show golden-brown or brownish granules in dermis for TCAs)
• Phototesting to confirm photosensitivity 2, 3

Management Recommendations

For patients requiring antidepressants with history or risk of photosensitivity:

1. Medication selection:

   • Choose antidepressants with lower photosensitivity risk when possible
   • Consider bupropion or SNRIs as alternatives if appropriate for the patient's condition 8, 7

2. For patients already on photosensitizing antidepressants:

   • Discontinue the medication if severe photosensitivity occurs 5
   • Switch to an antidepressant from a different class 5
   • Monitor for improvement (symptoms typically improve within 2 weeks after discontinuation) 5

3. Preventive measures for patients on photosensitizing antidepressants:

   • Seek shade when outdoors, especially around midday 1
   • Wear protective clothing, sunglasses, and broad-brimmed hats 1
   • Use broad-spectrum sunscreens with SPF 30 or higher 1
   • Be aware that radiation can be stronger when reflected by water, sand, or snow 1
   • Consider stopping the medication before phototherapy or prolonged sun exposure 6

Special Considerations

• Risk factors: Female gender and older age appear to increase risk (mean age at presentation: 55 years) 3
• Timing: While some reactions occur quickly (within days of starting medication), hyperpigmentation typically develops after prolonged use (average 10.4 years for TCAs) 5, 3
• Cross-reactivity: Possible cross-reactivity between different SSRIs has been reported 6
• Systemic complications: Rarely, photosensitivity reactions may be associated with systemic problems such as liver involvement, thrombocytopenia, or hepatic injury 4, 3

By understanding the photosensitizing potential of antidepressants and implementing appropriate preventive measures, clinicians can minimize the risk of photosensitivity reactions while effectively treating depression.