What medications can cause photosensitive skin?

Medications That Cause Photosensitive Skin

Multiple drug classes are well-established causes of photosensitivity, with tetracyclines (especially doxycycline), thiazide diuretics (particularly hydrochlorothiazide), fluoroquinolones, NSAIDs, and cardiovascular medications being the most consistently implicated culprits requiring sun protection counseling and potential medication adjustment. 1, 2

Major Drug Classes and Specific Agents

Antibiotics

• Tetracyclines: Doxycycline causes photosensitivity manifested by exaggerated sunburn reactions and is more photosensitizing than minocycline 1, 3
• Fluoroquinolones: Including nalidixic acid, consistently implicated in phototoxic reactions 1, 2
• Sulfonamides: Including trimethoprim-sulfamethoxazole (TMP/SMX), which causes photosensitivity reactions 1, 4
• Tetracycline class broadly: All members can cause photosensitivity, with demeclocycline being particularly problematic 5, 4

Cardiovascular Medications

• Thiazide diuretics: Hydrochlorothiazide triggers exaggerated sunburn reactions, dermatitis, and lichenoid eruptions, occurring in 1-2% of patients particularly after long-term sun exposure 1, 6, 2
• Loop diuretics: Bumetanide, furosemide, indapamide, and triamterene 1
• ACE inhibitors: Ramipril, enalapril, and quinapril 1
• Angiotensin receptor blockers: Candesartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan 1
• Anti-arrhythmics: Amiodarone and dronedarone (amiodarone is among the most consistently implicated) 1, 5, 2
• Calcium channel blockers: Amlodipine, diltiazem, and nifedipine 1
• Beta-blockers: Tilisolol 1

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• Ampiroxicam, celecoxib, diclofenac, ibuprofen, indomethacin, ketoprofen, meclofenamide, nabumetone, naproxen (consistently implicated), oxaprozin, piroxicam (consistently implicated), sulindac, and tiaprofenic acid 1, 5, 2

Statins

• Atorvastatin, pravastatin, and simvastatin 1

Psychotropic Medications

• Antipsychotics: Chlorpromazine (prototypical and consistently implicated), thioridazine, aripiprazole, clozapine, flupenthixol, haloperidol, olanzapine, and risperidone 1, 5, 2
• Antidepressants: Citalopram, clomipramine, escitalopram, fluoxetine, fluvoxamine, imipramine, paroxetine, sertraline, St. John's wort, and venlafaxine 1
• Anxiolytics: Alprazolam and chlordiazepoxide 1

Antineoplastic Agents

• BRAF kinase inhibitors: Vemurafenib (consistently implicated), dabrafenib 5, 2
• EGFR inhibitors, VEGFR inhibitors, MEK inhibitors, and Bcr-Abl tyrosine kinase inhibitors 5

Antifungals and Antimalarials

• Various anti-fungals, anti-malarials, anti-tuberculous drugs, and anti-retrovirals 1
• Voriconazole is consistently implicated 2

Clinical Recognition and Mechanism

Types of Reactions

• Phototoxic reactions (more common): Direct tissue damage from drug molecules absorbing UV/visible light, causing acute inflammatory response 4
• Photoallergic reactions (less common): Immunologically mediated damage 5, 4
• Drug-induced photosensitivity is generally believed to be a UVA phenomenon (315-400 nm), though UVB reactions can occur (as documented with hydrochlorothiazide at 308 nm) 6

Clinical Presentation

• Eruptions appear primarily on sun-exposed areas of skin 2
• Symptoms include erythema, swelling, blisters, exudation, peeling, burning, itching, and hyperpigmentation 7
• Pseudoporphyria can occur with fluoroquinolones, NSAIDs, tetracyclines, and diuretics, more likely after minor trauma on acral sites 1

Prevention and Management Algorithm

Step 1: Patient Counseling Before Prescribing

• Warn patients taking potentially photosensitive drugs about the possibility of skin reactions 5
• Advise avoiding direct sunlight exposure, particularly around midday 1
• Recommend seeking shade when outside, especially when UV radiation is reflected by water, sand, or snow 1

Step 2: Sun Protection Measures

• Apply broad-spectrum sunscreen with SPF ≥30 to all exposed skin 8
• Wear protective clothing covering as much body surface as possible, including broad-brimmed hats and sunglasses 1, 8
• For tetracyclines specifically: avoid prolonged direct sun exposure, use sunscreens that absorb long-wave UVA radiation, and take medication in the evening to minimize sun exposure risk 9
• Avoid sun exposure between 10 AM and 4 PM when UV radiation is most intense 8

Step 3: If Photosensitivity Reaction Occurs

• Discontinue the culprit medication immediately 8, 3
• Treat with corticosteroids for symptomatic relief 2
• For mild reactions (Grade 1): Continue medication with topical emollients and mild-moderate potency topical corticosteroids 1
• For moderate reactions (Grade 2): Hold medication, use medium-to-high potency topical corticosteroids, consider prednisone 0.5-1 mg/kg tapered over 4 weeks 1
• For severe reactions (Grade 3): Hold medication, consult dermatology, initiate prednisone 1 mg/kg/day tapered over at least 4 weeks 1

Step 4: Long-Term Surveillance

• For certain medications (amiodarone, chlorpromazine, vemurafenib), long-term surveillance is indicated due to higher risk of developing melanoma or squamous cell carcinoma at sites of earlier photosensitivity reactions 2

Critical Pitfalls to Avoid

• Do not underestimate delayed reactions: PUVA erythema may not peak until 96 hours post-exposure, requiring treatment intervals of at least 2-3 days 8
• Review complete medication lists: Any drug the patient is currently taking may cause photosensitivity, including long-term medications like NSAIDs and cardiovascular drugs 5
• Avoid drug combinations: Do not use tetracyclines with methoxyflurane due to potential drug interactions 10
• Consider alternative antibiotics: For patients with photosensitivity history, cephalexin is preferred over tetracyclines or fluoroquinolones when clinically appropriate 9
• Recognize that incidence may be low: Photosensitivity reactions may be too rare to detect in clinical trials and only become recognized post-marketing 4
• Do not automatically discontinue beneficial medications: If patients carefully protect themselves from the sun, it is often not necessary to stop treatments that include photosensitive drugs 5