Transcript - Abdel Hamid Derm Atlas

Antibiotics &
photosensitivity
Abdel Hamid M . Abdel Aziz
Professor pf Dermatology &
Venereology , Al Azhar University
Skin reactions to antibiotics
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1. Exanthema tic reactions:
-Ampicillin & penicillin
-Sulphonamides
-Gentamycin
-Isoniazid
2. Exfoliative dermatitis:
-Ampicillin & penicillin -Griseofulvin
-Streptomycin
-Sulphonamides
3. Urticaria or anaphylaxis:
- Penicillin
-Cephalosporins
- Amino glycosides
-Tetracyclines
-Sulphonamides
-Ketaconazole
4. Photosensitivity : Discussed seperately
5. Pigmentation:
- Minocyclin
-Antimalarial
6. Pemphigus:
- Penicillin & its derivatives – Rifampicin
-Cephalexin
- Cefadroxil
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7. Erythema multiformis or Steven -johnson syndrome:
- Sulphonamides
- Sulphones
-Penicillin & ampicillin -Cephalosporins
-Rifampicin
-Tetracyclines
-Erythromycin
-Thioacetazone
8 Toxic epidermal necrolysis:
-Sulphonamides
-Tetracyclines
-Penicillin
-Isoniazid
-Streptomycin
-Thiacetazone.
9. Fixed drug eruption:
-Sulphonamides
- Tetracyclines
-Penicillin & ampicillin -Erythromycin
-Nystatin
-Griseofulvin
-Dapsone
-Quinine
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1O. Lichenoid eruption:
- Antimalarials
- Isoniazid
-Streptomycin
-Ketaconazxole
-Tetracyclines
-Dapsone.
11. Vasculitis:
-Ampicillin, penicillin
-Griseofulvin
-Streptomycin
- Sulphonamides
- Tetracycline
12. Lupus erythematosus –like syndromes:
-Griseufulvin
-Isoniazid
- Penicillin
-Streptomycin
-Sulphonamides
-Tetracyclines
13. Hypertrichosis:
- Streptomycin
- Minoxidil
14. Onycholysis:
-Minocycline
- Tetracyclines
-Chloranphenicol
-Doxycycline
-Cloxacillin
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15: Porphyria cutanea tarda or varigata:
-Griseofulvin
- Rifampicin
-Sulphonamides
16. Systemic drugs that can reactivate allergic contact dermatitis to topical
nystatin sulphate:
-Streptomycin
-kanamycin
-Gentamycin.
17. Acneiform & pustular eruption:
-Penicillin, ampicillin -Macrolides
-Cephalosporin's
-Chloranphenicol
-Streptomycin
-Isoniazid
-Doxycycline
-septrin
18. Photo recall reactions:
-Cefazolin
-Gentamycin
19 Photo onycholysis:
-Tetracycline
-Ofloxacin
Antibiotics & Photosensitivity
• Antibacterial agents:
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@ Beta lactam antibiotics:
- Ampicillin
- Cephalosporins:
e.g. cephazolin, gentamycin: photo-recall like phenomenon (eruption restricted to
previous sunburn)
@Tetracyclines: All tetracyclines ( phototxicity + onycholysis)
Methacycline (minocycline) photosensitive lichenoid pigmentation.
@Sulphonamides & trimethoprim: e.g. .septrin, sulphasalazine, sulphadoxine:
(phototoxic & photoallergic eruption).
@ Quinolonees; ciprofloxacin, ofloxacine: (phototoxicity + onycholysis)
Antileprotic drugs: clofazimine (phototoxicity)
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Antifungal drugs: Griseofulvin ( photo patch test positive,& photo cross reaction
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with penicillin
• Antimalarial drugs:
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Chloroquine & hydrochloroquine, pyrimethaminr
Topical Antibiotics
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@ Antibacterial agents:
- Tetracyclines
-Neomycin
-Sodium fusidate
-Gentamycin sulphate
-Polymyxin B
-Clindamycin
-E rythromycin
-Bactericin
The risk of topical antibiotics:
1. Emergence of resistant bacterial strains
2. Topical sensitization: This prevents its use systemically in future.
Penicillin, sulphonamides, streptomycin, chloranphenicol should not be
used topically
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@ Antifungal
-Imidazoles
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@ Antiviral agents:
Aciclovir
-idoxuridine
-Podophyllin
- flurouracil -Monochloracetic acid
agents:
-allylamines
Antibiotics
& photocontact dermatitis
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1. Photo toxic reaction:
-Non immunological mechanism
-Can be provoked on first exposure
-It is a sunburn provoked by wave lengths not normally provoke it.
Examples:
- Sulphonamides
-Dimethyl chlor tetracycline
-Other tetracyclines -Griseofulvin
-Nalidixic acid.
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2. Photo allergic reactions:
It is an immunological mechanism
-Can be provoked by UV radiation only in small number of individuals who have been sensitized
previously.
Examples:
-Sulphonamides used for topical treatment
- Tetra chloro salicylamilide: used previously as anti bacterial.
-Buclosamide (Jadit cream, antifungal); induce persistant light reaction even without contact with
the offending agent.
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Photo toxic reaction
Photo allergic dermatitis
from hair dye
Clinical evaluation of a patient
with suspected photosensitivity
• History:
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- Age, sex
-Course: intermittent, persistent.
generalized or localized
-Site affected ( ? contact)
-History of drug or chemical exposure (? Drug eruption)
• Clinical examination:
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-Appears precisely in exposed areas
-Areas of exempt ( upper eye lid, under chin , retro auricular areas, skin creases of
neck)
• Investigations:
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-ANA, anti RO& anti La (?L.E.)
-Blood, urine ,stool ,porphyrin concentration (porphyria).
-Biopsy ( photo toxicity, photo allergy or underlying disease aggravated by light)
-Patch & photo patch test ( ?contact or drug eruption)
-If negative: investigation for gene photo dermatoses (DNA repair) (Xeroderma
pigmontosum), sister chromatid frequency ( ? Cockayane syndrome)
Phototoxic
dermatitis
Everyone
Yes
Yes
Photo allergic
dermatitis
uration of photoreaction
stology
No
Short
Sunburn
bsequent exposure to untreated site
Similar to treated site
Yes
Long
Eczema
No reaction
xamples
Tetracycline
sulphonamides
rson affected with dermatitis
ose related response
citation after initial exposure to UV
diation
ssive transfer with lymphocyte
A few individuals
No
No
Ultraviolet Radiation Can:
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1. Produce skin disease:
-Solar urticaria
– Polymorphic light eruption
-Actinic prurigo
-Actinic reticuloid
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2 Aggravate skin disease:
- Herpes simplex
-Lichen planus
-L. E.
-Psoriasis
-Pityrasis rubra pilaris
–Rosacea
-Dermtomyositis
-Pemphigus foliaceous
-Erythema multiformis
-Pemphigus vulgaris
-Pemphigoid
-Darier’s disease
-Haily & Haily disease
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3. Help skin diseases:
-mycosis fungoides
-Vitiligo
-Psoriasis
- Alopecia arearta
- Atopic dermatitis
- Urticaria pigmentosa
-Hydroa vacciniformis
Photopatch test
• 1. Test material: moistened with tap water. Apply on skin of back in 2
sites.
• 2. Vehicle: Petrolatum.
• 3. The stability of test material: Occlude with filter paper disks with
plastic coated aluminum foil. Mark the test site with marker pen.
• 4. Photo provocation: On day 1 , one test series was irradiated with
5O% minimal erythema dose of UVA.
• 5. Application time:
• Tests reaction were read on day 2 & 3 . The case is positive (+,++,
+++, ) if irradiated site shows a reaction but not the control site.
• Other tests on systemic application:
• 1. Oral photo provocative testing
• 2. Photo hemolytic test
Photo patch test for terbinafine
hydrochloride . On the left, the
control test
Mechanism of photo allergy
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Absorption spectrum:
Molecules absorb energy of different wave lengths with varying efficiency.
Action spectrum:
The wavelength absorbed by a molecule that induce the specific photo biologic event.
Gotthum- Draper law:
1. The light or UV energy must be absorbed to produce the photo biologic reaction.
2. The action spectrum must be included in the absorption spectrum of the
photosensitizing molecule.
3, The photo sensitizing molecule must be present at time of irradiation to initiate the
photo biologic response
Photo activation will result into photo toxic (non immunologic, similar to sunburn) or
photo allergic (immunologic action).
The photo activated antibiotic molecules may be transformed into a new substance
capable of acting as irritant or haptens.
New formed haptens are able to combine with other substances e,g protein to
produce full antigen . The hapten may be :
1. stable photo product of the drug.
2. or short lived free radical
Their shadow is less than their length
Skin Photo type
Skin type
Characteristics
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Always burn, never tan.
II
IV
Always burn ,but
sometimes tan
Sometimes burn, but
always tan.
Never burn, always tan
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Moderately pigmented
VI
Black
III
Treatment
• 1. Prevention is better than cure. Drugs
incriminated in previous reactions should be
avoided.
• 2. Withdrawal of suspected drug in established
case.
• 3. If the patient is receiving multiple drugs, it is
wise to withdraw all but the essential medication.
• 4. Substitute by non cross reacting drugs
• 5.Apply moderate potent topical corticosteroid.
• 6. Systemic antihistamine
• General measures:
• 1. Being out doors only before9 A.M. & after 4 P.M
• 2,Wearing clothing & broad brand brimmed hat that
does not allow light to penetrate.
• 3, Avoid exposure to fluorescent lamps.
• 4. Sitting & walking on shady side of street
• 5. Wearing glasses
• 6. Changing out doors jobs ( farmers, building worker) to
in doors jobs (Door keeper, clerk)
• 7. Plastic UV opaque sheets on the inside of car window.
• 8. Patients must be taught that celery , carrots, figs &
parsnips contain phototoxic chemicals.
Treatment ( Continue)
• 9. Patient needs to know that oil of the skin of
citreous fruits, the herpes of shampoos &the
fragrance of colognes & after shave lotions are
potentially photo sensitizers.
• 1O. Soap should be perfume free.
• 11. Avoid other drugs which are known to be
photo sensitizers e.g. thiazides, sunscreens…
• 12. Alcohol should be avoided, since it is hepato
toxic & could be associated with the formation of
the metabolic photo sensitizer
In ancient Egypt, The sun was a god,
but it may be to the skin a hill