Guidance on minimising photosensitivity / phototoxicity

reactions between medication and sunlight.

(v2 October 2013)
Everyone should be protected from excess exposure to the sun by avoiding the sun at
midday and covering up to include wearing a hat and utilising appropriate
sunscreen. Some medicines can sensitise patients to greater reaction to sunlight.
These patients should be even more cautious in avoiding direct exposure to the sun,
and they should always use a high factor sunscreen.
How likely are photosensitising reactions to occur?
The table below identifies drugs that are known to have the potential to cause
photosensitising reactions. Some of them, (mostly newer ones), have been evaluated
regarding the likelihood of occurrence. In these cases the following words have been
used to specify how many patients are likely to be affected:

very common:
common:
uncommon:
rare:
very rare:

more than 1 in 10
more than 1 in 100, but less then 1 in 10
more than 1 in 1000, but less than 1 in 100
more than 1 in 10000, but less than 1 in 1000
less than 1 in 10000

Please note, however, that these data mostly stem from voluntary reporting systems,
which may be biased and inaccurate 1. This means that drugs for which no data exist
cannot be assumed to be less likely to cause a reaction when the patient is exposed
to sunlight. Where data are more reliable, drugs are required to carry a cautionary
label: Avoid exposure of skin to direct sunlight or sun lamps.
Which drugs are involved?
Major drug groups that can be expected to cause photosensitivity are: phenothiazinebased antipsychotics (chlorpromazine, thioridazine)2, sulfonamides, tetracyclines
(such as doxycycline)2, and quinolone antibacterials. Some diuretics, amiodarone2 and
some anti-inflammatory drugs have also been associated with these types of
reaction1.

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What is the worst that could happen?

The following reactions can occur in response to drugs: phototoxicity, photoallergy,
planus lichenoid reaction, pseudoporphyria, and subacute cutaneous lupus
erythematosus3. Phototoxic reactions usually present as an exaggerated sunburn
response minutes to hours after exposure to the sun, whereas photoallergic reactions
manifest after 24 to 48 hours, usually as a pruritic eczematous eruption4.
Mortality is rare and generally only occurs in individuals exposed to large doses of
psoralens, (a specialist drug used to treat psoriasis not listed in the table below), and
large amounts of sunlight. Even so, drug-induced photosensitivity can cause
significant morbidity in some individuals, who must severely limit their exposure to
natural or artificial sunlight, (e.g. in persistent light reactivity after photoallergy).
It has also been suggested that prolonged exposure to photosensitising drugs has
carcinogenic potential3. In most patients, however, the prognosis is excellent, once the
offending agent has been removed, although complete resolution of the
photosensitivity may take several weeks, or even several months with some
compounds.

DRUG CLASS
ACE inhibitors5
and ARBs6

GROUP

DRUGS
6

Losartan
6
Valsartan
6
Lisinopril
Quinapril
5
Captopril
6
Fosinopril
6
Enalapril
6

Antibiotics

Quinolones

2,5

Sulphonamides
Tetracyclines5

Others

Antidepressants

Tricyclics5

Ramipril
6
Moxifloxacin
6
Ciprofloxacin
6
Levofloxacin
Nalidixic acid
6
Ofloxacin
5,6
Co-trimoxazole
6
Azithromycin
6
Lymecycline
6
Oxytetracycline
Demeclocycline
Doxycycline
Minocycline
Tetracycline
Gentamicin
Isoniazid
Nitrofurantoin
5,6
Trimethoprim
Amoxapine

FREQUENCY- IF REPORTED
Not known
2
Reports
Not known
2
Reports
6
Very rare
1
Reports
2
One case report ; part of complex
6
syndrome
2
6
One case report ; very rare
6

Rare
Very rare
BNF cautionary label
Very rare, BNF cautionary label
Very rare
Uncommon
Not known
Not known
BNF cautionary label
Common, BNF cautionary label
6
Rare. Reports
6
Reports; unknown
Reports

Others
SSRIs2,5

Antidiabetics
(oral)
Antiepileptics

Antifungals

Antihistamines5

Sulfonylureas6

Amitriptyline
2,6
Clomipramine
Desipramine
6
Doxepin
2,6
Imipramine
6
Lofepramine
6
Nortriptyline
St Johns Wort
2,5,6
Venlafaxine
2
Phenelzine
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
6
Glimepiride
2
Glibenclamide
6
Gliclazide
6
Glipizide
2
Carbamazepine
Lamotrigine
6
Phenobarbital
Phenytoin
2,5,6
Itraconazole
Terbinafine
2
Voriconazole
6
Chlorpheniramine
Cyproheptadine
(2)
Diphenhydramine
Loratadine

Common
Reports

Reports
6

Uncommon
6

Rare
6
Rare
6
Very rare
6
Rare reports
6
Not known
Reports
5

Rare
5,6
very rare
reports
Reports
6

Very rare , rare

5
Common
Reports

Malarone
Chloroquine and
6
hydroxychloroquine
Mefloquine
Pyrimethamine
5,6
Quinine

Antimalarials

Azathioprine
Capecitabine
Epirubicin
Hydroxyurea
5
(hydroxycarbamide)
5
Imatinib
6
Paclitaxel
6
Fluorouracil
5,6
Methotrexate

Antineoplastics

Antipsychotics

Butyrophenones
Phenothiazines2

Thioxanthenes
Atypical
antipsychotics
Anxiolytics
Diuretics

Vinblastine
6
Sulpiride
6
Haloperidol
5,6
Chlorpromazine
6
Fluphenazine
6
Pipotiazine
1,6
Prochlorperazine
1
Promethazine
6
Trifluoperazine
2,6
Flupentixol
6
Zuclopenthixol
6
Aripiprazole
2
Olanzapine
2
Clozapine
Alprazolam
Chlordiazepoxide
Acetazolamide
Amiloride

Retinoids2,5

Other drugs

1,2

reports

Reports
2
Reports
-

Common
6
- Uncommon
2
Reports
Common but not real
2
photosensitivity
2
One case report
1

Reports rare
BNF cautionary label

Reports

Reports
6

Frequency not known

5,6
Uncommon
Reports
2
1

Bendroflumethiazide
5
Bumetanide
5
Hydrochlorothiazide
2,5,6
Indapamide
2,5,6
Furosemide
6
Spironolactone
2
Triamterene
6
Indometacin
2,6
Celecoxib
5,6
Diclofenac
2,6
Ibuprofen
6
Ketoprofen
6
Mefenamic acid
2,6
Naproxen
2,6
Piroxicam
6
Isotretinoin
Acitretin
Alitretinoin
Adapalene
Aciclovir
6
Alendronate
2,5
Amiodarone
2
Atorvastatin
Auranofin
6
Calcipotriol

Rare

Reports

5,6

NSAIDs5

Unknown

5,6

Reports rare
1
Reports
Uncommon
Reports
Common
Reports
Reports
1
Reports
1,2
5
Reports rare

Rare
BNF cautionary label
Uncommon
Reports
1
Reports
Very rare
Reports
Very rare, BNF cautionary label
BNF cautionary label
BNF cautionary label
6

Common
Rare
Very common, BNF cautionary label
Reports
BNF cautionary label
Very rare

(2)

Clopidogrel
5
Coal tar
Corticosteroids
2
Dapsone
2,5
Diltiazem
Disopyramide
2
Fibrates
Hydralazine
2
Leflunomide
2
Mesalazine
6
Metoprolol
2,5
Nifedipine and other
CCBs, including
6
amlodipine and
6
felodipine
Oral contraceptives
(oestrogens and
2
progestagens)
6
Oxybutinin
6
Oxycodone
Para-amino-benzoic
acid (preservative)
Pimecrolimus topical
2
Pravastatin
6
Proton pump inhibitors
omeprazole,
lansoprazole
2
Quinidine
2
Ranitidine
Simvastatin
Sodium aurothiomalate
Sulfasalazine
Tacrolimus
6
Vardenafil
Voriconazole
6
Zaleplon

Reports
Reports
1
Reports
One report
6
Uncommon; not known
1
Reports
5
Reports. Uncommon
1
Reports
Reports
Reports
Very rare
1

Reports - rare

Reports
Reports
Rare
Reports
BNF cautionary label
Reports
Rare
Reports
Reports
1
Reports
BNF cautionary label
1
5
Reports uncommon
6
BNF cautionary label; uncommon
Rare
BNF cautionary label
Uncommon

With groups of drugs please assume that all members cause photosensitivity unless
stated otherwise.
Please note that this list is not exhaustive. Consult your local pharmacy team or
Medicines Information department for specific information
References:
1. Moore DE. Drug-Induced Cutaneous Photosensitivity. Drug Safety 2002; 25 (5): p. 345372. Available from http://www.ncbi.nlm.nih.gov/pubmed/12020173?dopt=Abstract
(accessed 18 march 2013)
2. Drucker AM, Rosen CF. Drug-Induced Photosensitivity. Drug Safety 2011; 34(10):821-837.
st
Accessed 21 August 2013.
3. Zhang, A., Y., Craig, A., E. 2007. Drug-Induced Hypersensitivity. [Online] (Updated 19
March 2007) Available at: http://emedicine.medscape.com/article/1049648-print [accessed
29 April 2009]
4. MedicinesComplete Pharmaceutical Press. 2013. Martindale: The Complete Drug
Reference. [Online] Drug-induced photosensitivity (Latest modification 4-Feb-2008)
Available at: http://www.medicinescomplete.com [Accessed 18 March 2013].
5. BNF. Online edition. Individual monographs.
6. Datapharm Communications Ltd. 2013. electronic Medicines Compendium. [Online]
Available at: http://emc.medicines.org.uk Individual monographs. [first accessed 18 March
2013].

Principal authors:

Josef Elias Clinical Pharmacist

Gus Fernandez Clinical & MI Pharmacist

Supported by:

Jed Hewitt Chief Pharmacist

(Governance & Professional Practice)

Guidance issued:

March 2010

Review & update:

October 2013

Date of next review:

October 2015