Phytophotodermatitis: Treatment & Medication

Author: William P Baugh, MD, Assistant Clinical Professor of Dermatology, University of California Irvine School of Medicine and Western School of Medicine; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center Coauthor(s): David Barnette Jr, MD, Voluntary Associate Clinical Professor, University of California San Diego School of Medicine;Walter D Kucaba, DO, Private Family Practice, Simpsonville, South Carolina; Cynthia L Chen, Western University of Health Sciences College of Osteopathic Medicine of the Pacific Contributor Information and Disclosures Updated: Oct 16, 2009

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Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia
References Keywords

Treatment
Medical Care

Patient reassurance is essential once the diagnosis is made. Phytophotodermatitis (PPD) is a selflimited problem that resolves with removal of the offending agent. Patients should avoid the offending agent (furocoumarin). Cool wet compresses may be used for acute lesions. Topical steroids may be used if the eruption is severe and edematous. Indomethacin (50-75 mg PO qd) may be used for adults.

Consultations
Referral to a dermatologist may be useful.

Activity
Use of UV-A sunscreens may help prevent further phototoxic reactions from occurring when exposed to sunlight.

Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. Low-to-high potency topical steroids may be applied to affected areas to reduce local inflammation induced by the photoactivated psoralens. They may help to relieve the burning sensation associated with phytophotodermatitis as well as to reduce the associated postinflammatory hyperpigmentation.

Hydrocortisone valerate 0.2% cream (Westcort)

Treats inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult

Apply to affected areas bid; may be useful face or intertriginous areas for short periods
Pediatric

Apply as in adults
Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions

Prolonged use, applying over large surface areas, applying potent steroids, and using occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Clobetasol (Temovate)

Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.
Adult

Apply bid for up to 2 wk; not to exceed 50 g/wk

Pediatric

Not established; use with caution

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions

May suppress adrenal function in prolonged therapy; not recommended for face or intertriginous areas; can cause atrophy of groin, face, and axillae; if infection develops and is not responsive to antibiotic treatment, discontinue until infection under control
Betamethasone topical (Diprolene, Betatrex)

For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult

Apply thin film bid/qid until response

Pediatric

Not established; use with caution

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Can cause atrophy of groin, face, and axillae; if infection develops and is not responsive to antibiotic treatment, discontinue until infection under control

Nonsteroidal anti-inflammatory drugs

These agents are most commonly used for relief of mild to moderate pain. Indomethacin is an analgesic and NSAID medication that may offer some protection against acute UV-Ainduced epidermal apoptosis as well as provide some relief of skin discomfort.

Indomethacin (Indocin)

Has anti-inflammatory properties due to inhibition of prostaglandin synthesis and/or leukocyte migration into inflamed areas. Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation.
Adult

25 mg PO bid/qid with food

Pediatric

Not established; in general, should not be used in patients <14 y

Interactions:
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; may decrease effects of beta-blockers, hydralazine, and captopril; may decrease diuretic effects of furosemide and thiazides; coadministration with anticoagulants may prolong PT (monitor and watch for signs of bleeding); may increase risk of methotrexate toxicity, which can manifest as stomatitis, bone marrow suppression, or nephrotoxicity; coadministration may increase phenytoin levels; probenecid may increase toxicity of NSAIDs
Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur, (discontinue if leukopenia, granulocytopenia, or thrombocytopenia persists)