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A three-year photopatch study in Thailand
Journal of Dermatological Science, 2 (1991) 311-375 0 1991 Elsevier Science Publishers B.V. All rights reserved 0923-181 l/91/$03.50
371
DESC 00107
A three-year photopatch study in Thailand Pimonpun Gritiyarangsan Instituteof Dermatology, Bangkok, Thailand (Received 9 October
Key words: Photopatch
1990; accepted
test; Photosensitizers;
11 May 1991)
Photocontact
dermatitis
Abstract
Photopatch testing was performed on 274 patients who had history of photosensitivity at the Institute of Dermatology Thailand from 1987 through 1989, A total of 92 positive photocontact reactions and 71 positive contact reactions were seen. The most frequent positive photopatch test reactions were to sulfanilamide (18.2%) followed by Jadit (4.4%) chlorpromazine (3.6%) promethazine (3.6%) and fenticlor (3.2%). The most common photodermatoses was polymorphous light eruption (60.9%). Photocontact dermatitis was established in 28 patients (10.2%) while other skin diseases aggravated by sunlight were seen in 47 patients (17.2%).
Introduction The most wide spread of photoallergic contact dermatitis resulted from the use of soaps containing halogenated salicylanilides and related compounds [ 11. Since then, several topical agents such as PABA [ 2,3] 6-methylcoumarin [ 41, musk ambrette [5] etc. have been reported to cause photoallergic contact dermatitis. Therefore, it is important to perform photopatch test in patients with suspected photodermatoses. At the Institute of Dermatology, Thailand, all photopatch testing results performed in patients from 1987 through 1989 were analyzed and the most frequent positive photosensitizers were discussed in order to Correspondence to: P. Gritiyarangsan, Institute of Dermatology, 42017 Rajavithi Road, Bangkok 10400, Thailand.
know the incidence and causes of photocontact dermatitis and also to determine the occurrence of other photosensitive skin diseases in Thailand. Patients and Methods A total of 274 patients who had history and clinical features suggesting photosensitivity were photopatch tested using 18 test substances comprising mainly of antimicrobial agents, cosmetic ingredients, therapeutic agents and sunscreens. The age, sex and clinical diagnosis of all patients were recorded before the test. Photopatch testing was performed using the International Contact Dermatitis Research Group (ICDRG) test subtances. These were applied in duplicate on the lower back of the patients using Finn Chamber and covered with
312
light opaque black paper. After 24 h one set was uncovered and evaluated for the presence of any reaction and was then irradiated with 5 Joules/cm2 of UVA. Dermaray M-DMR-1 which contained 10 UVA fluorescent lamp (Toshiba Fl-20S-BLB 300-430 nm) with an intensity of 7 mW/cm2 (TOREX, UV-radiometer UVR 305/365-D) served as the UVA light source. After 30 min the irradiated site was read for any immediate reaction. Then the photopatch test site was covered again with light opaque black paper. After 48 h both sets were uncovered and were read based on the following standard scoring: ?+ - doubtful reaction + - weak reaction - non-vesicular ++ - strong reaction - edematous or vesicular +++ - extreme reaction - markedly bullous or ulcerative IR - irritant reaction Photopatch and patch testing results were then evaluated. If only the irradiated site shows a positive reaction the photocontact dermatitis is present. However, if both sites show equally positive reaction then contact dermatitis is present. If the irradiated site shows more severe positive reaction than the non-irradiated site, then photocontact dermatitis and contact dermatitis are both present. Besides the photopatch test, a photoprovocation test by repeated irradiation with UVA (PUVA 3001, Waldmann, 3 consecutive irradiations with 60 J/cm2 of UVA) and UVB (Dermaray M-DMR-1, Toshiba FL 20s E-30, 3 consecutive irradiations with 2 MED of UVB) were also carried out. Urinary porphyrin, skin biopsy for histopathology examination and direct immunofluorescence were performed when indicated. The clinical diagnosis was made after consideration of all laboratory results. Results
During a three-year period from 1987 through 1989, a total of 274 patients had undergone photopatch testing at the Institute of Dermatology,
Thailand. A total of 92 positive photocontact reactions and 71 positive contact reactions were seen. There were 148 females and 126 males. The ages of patients ranged from 9-90 years old. 68.6% were in the 21-50 years old group while 12.8% below 20 years old and the remaining 18.6% were above 50 years old (Table I). The main diagnoses of photopatch tested patients were listed in Table II. The most common diagnosis was polymorphous light eruption (60.9%). It is defined as recurrent skin eruptions involving sun exposed area with history of photosensitivity. There was no history of drug ingestion or contact to photosensitizers. Seborrheic dermatitis and atopic dermatitis who complained of worsening of skin lesions after exposure to sunlight, were seen in 47 patients (17.2%). All of them showed a negative result to photoprovocation test. The causes of photosensitivity could not be identified in 17 patients (6.2%). All of them had history of photosensitivity and developed skin eruptions localized in sun exposed areas. Phototesting showed normal MED and skin lesion could not be reproduced. There were 3 patients who developed photosensitivity to oral chlorpropamide, 2 to hydrochlorothiazide and one to unknown oral medication. Photocontact dermatitis was established in 28 patients (10.2 %) and contact dermatitis in 9 patients (3.3%). TABLE I Age distribution
Age
No. of
Sex
Percentage
patients M Below 10 1 l-20 21-30 3 l-40 41-50 5 l-60 Above 60 Total
F
-
0 6 23 29 28 25 15
1 28 50 31 21 7 4
1 34 13 60 55 32 19
126
148
214
0.4 12.4 26.6 21.9 20.1 11.7 6.9 100
313
TABLE II Main diagnosis No. of patients
Sex
Diagnosis
F
M Polymorphous light eruption Photocontact dermatitis Suspected but unconlirmed photosensitivity Seborrheic dermatitis Atopic dermatitis Photosensitivity from oral medication Contact dermatitis Total
Percentage
78 10 1 13 13 2 3
89 18 10 5 16 4 6
167 28 17 18 29 6 9
126
148
274
60.9 10.2 6.2 6.6 10.6 2.2 3.3 100
TABLE III Number of positive reactions Test substances
Antimicrobial Agents Tribromosalicylanilide Tetrachlorosalicylanilide Triclocarban Bithionol Hexachlorophene Fenticlor Triclosan Cosmetic Ingredients Fragrance mix Balsam of Peru 6-Methylcoumarin Musk Ambrette Therapeutic Agents Promethazine Chlorpromazine Sulfanilamide Jadit (4-chloro-2-hydroxybenzoic acid-n-butylamide) Sunscreen Agents p-Aminobenzoic acid Benzophenone Isobutyl-p-methoxycinnamate * Vehicle used was pet in all cases.
Cont.*
1% 0.1% 1% 1% 1% 1% 2%
8% 25% 1% 5%
1% 0.1% 5%
5% 5% 5%
No. of Pts tested
Positive reactions photocontact
274 274 274 274 214 274 274
1 (0.4%) 5 (1.8%) 2 (0.7%) 4 (1.5%) 6 (2.2%) 9 (3.2%) 0
195 195 214 274
5 4 3 2
(2.6%) (2.1%) (1.1%) (0.7%)
274 274 55 274
10 10 10 12
(3.6%) (3.6%) (18.2%) (4.4%)
214 127 274
5 (1.8%) 2 (1.6%) 2 (0.7%)
contact
0
2 (0.7%) 0 0 0 4 (1.5%) 2 (0.7%) 25 (12.8%) 22 (11.3%) 1 (0.4%) 2 (0.7%) 0
1 (0.4%) 4 (7.3%) I 2.6%)
1 (0.4%) 0 0
374
Table III shows the number of positive reactions to photopatch and patch testing. Sulfanilamide showed the highest positive photopatch reaction (18.2%) followed by Jadit (4.4%). Chlorpromazine and promethazine gave 3.6 % positive photocontact reaction each. Fragrance mix and balsam of Peru gave predominantly contact reactions. Among sunscreening agents tested, PABA produced both photocontact (1.8%) and contact reaction (0.4%) while benzophenone and isobutyl-p-methoxycinnamates produced only photocontact reactions. The antimicrobial agents which produced photocontact reactions were fentichlor (3.3x), hexachlorophene (2.2x), TCSA (1.8%) and bithionol (1.5%). 167 patients with polymorphous light eruptions showed 45 positive photocontact reactions and 51 positive contact reactions (Table IV).
TABLE IV Number of positive reactions Test substance
in PLE patients Positive reactions photocontact
Antimicrobial Agents Tribromsalicylanilide Tetrachlorosalicylanilide Triclocarban Bithionol Hexachlorophene Fenticlor Triclosan
contact
0
0
3 1 3 3 4 0
2 0 0 0 1 0
Cosmetic ingredients Fragrance mix Balsam of Peru GMethylcoumarin Musk Ambrette
1 1 2 0
21 19 1 1
Therapeutic Agents Promethazine Chlorpromazine Jadit
6 8 7
0 0 6
Sunscreen Agents P-aminobenzoic Benzopheone Isobutyl-p-methoxycinnamate
3 2 1
0 0 0
Discussion
In this study, sulfanilamide showed the highest photocontact reactions (18.9%). This antibacterial agent can produce both phototoxic and photoallergic reactions. Topical application of sulfanilamide may produce photoallergic contact dermatitis. Of the 10 patients with positive photocontact reactions, 8 had relevant reactions. Since in Thailand this antimicrobial drug is still widely used topically, it could be responsible for the high incidence of positive reaction. Jadit (4-chlorohydroxybenzoic acid-n-butylamide), is an antifungal agent known to cause photoallergic contact dermatitis [ 61. In our study 4.4% showed positive photocontact reactions and 2.5% showed positive contact reactions. Of the 12 patients with positive photocontact reactions, 6 had relevant reactions. This high incidence could be due to wide use of this topical antifungal medication in Thailand. The phenothiazines could produce both phototoxic and photoallergic reaction [7]. In the present study, chlorpromazine and promethazine gave high positive photopatch reactions (3.6% each). But there was no relevance with any patient who showed positive results. The Scandinavian study also showed similar positive reactions [ 81. But the study from Mayo clinic using 2 % promethazine and 1% chlorpromazine gave higher positive reactions [ 91. Among the sunscreening agents tested, PABA gave the highest positive reactions which is in accordance with another report [lo]. It produced 5 positive photocontact reactions and 1 positive contact reaction. Recently, PABA has been replaced by octyl-dimethyl PABA which appears to be less sensitizing than PABA and many PABAfree formulations have appeared on the Thai market. Benzophenone and Cinnamates gave 2 positive photocontact reactions each, and none for contact reaction although there are reports on allergy to benzophenones [ 1l] and Cinnamates [ 121. All 9 patients who showed positive photocontact reactions to PABA, benzophenone, and cinnamate had history of using sunscreens. Since
375
more sunscreen preparations are recommended as protection against sunburn, photoaging and therapy for photodermatoses, suspicion of contact and photocontact allergy to different sunscreen preparations requires extensive investiConcomitant allergies to several gation. compounds are common and sunscreens, fragrances, antioxidants, dyes and preservatives could all be incriminated. Positive reactions were also seen to antiseptic agents such as halogenated salicylanilides, bithionol, fenticlor and hexachlorophene. But only a minority of the cases had relevant reactions. Cross reaction may have occurred among fentichar, bithionol and halogenated salicylanilides. In this study, hexachlorophene showed 6 positive photocontact reactions (2.2%); this high incidence could be due to the presence of this agent in antiseptic soap available on the Thai market. Photocontact dermatitis to perfumes may be due to the fragrance or the fixative. Musk ambrette, a synthetic fragrance fixative contained in men’s aftershave lotions has been reported to cause photocontact dermatitis and persistent light reaction [ 13,141. In our study there were only two female patients who showed positive reactions and both of them could not be traced to a prior contact with this agent. It was reported that in order to produce a positive photopatch reaction to 6-methylcoumarin, the substance should be applied shortly after irradiation rather than 24 to 48 h [ 151. But in our study, 6-methylcoumarin showed 3 photocontact reactions and one contact reaction produced by a routine photopatch test. Fragrance mix and Balsam of Peru mainly gave contact reactions. In our series, 20.5 % of tested patients showed no photosensitivity (seborrheic dermatitis 6.6%) atopic dermatitis 10.6%, contact dermatitis 3.3 2) Photocontact dermatitis patients (10.2%) had a relevant positive photopatch test reaction. This indicates that the photopatch test is important in the investigation for photosensitive patients. Since other newly synthesized chemicals such as dibenzoylmethane which can produce photosensitivity [ 16,17 ] are being introduced in
the market, the photopatch revised periodically.
test battery should be
References 1 Epstein JH, Wuepper KD; Maibach HI: Photocontact dermatitis to halogenated salicylanilides and related compounds: a clinical and histologic review of 26 patients. Arch Dermatol 97: 236-244, 1968. 2 Horio T, Higuchi T: Photocontact dermatitis from p-aminobenzoic acid. Dermatologica 156: 124-128, 1978. MJ: Photodermatitis with 3 Marmelzat J, Rapaport PABA. Contact Dermatitis 6: 230-231, 1980. 4 Jackson RT, Nesbitt LT, Jr, De Leo VA: 6-Methylcoumarin photocontact dermatitis. J Am Acad Dermatol 2: 124-127, 1980. 5 Raugi GJ, Storrs FJ: Photosensitivity from men’s cologne. Arch Dermatol 115: 106, 1979. 6 Burry JM, Hunter GA: Photocontact dermatitis from Jadit, Br J Dermatol 82: 224-229, 1970. 7 Epstein S: Chlorpromazine sensitivity: phototoxic and photoallergic reactions. Arch Dermatol 98: 354-363, 1968. Jansen C, Wennersten G, Rystedt I, 8 Thune P, Brodthagen H, McFadden N: The Scandinavian multicenter photopatch study 1980-1985: final report. Photodermatology 5: 261-269, 1988. 9 Menz J, Muller SA, Connolly SM: Photopatch testing: a six-year experience. J Am Acad Dermatol 18: 1044-1047, 1988. 10 Thune P: Contact and photocontact allergy to sunscreens. Photodermatology 1: 5-9, 1984. 11 Ramsay DL, Cohen HJ, Baer RL: Allergic reaction to benzophenone. Arch Dermatol 105: 906-908, 1972. 12 Calnan CD: Cinnamon dermatitis from an ointment. Contact Dermatitis 2: 167-170, 1976. 13 Giovinazzo VJ, Harber LC, Bickers DR, Armstrong RB: Photoallergic contact dermatitis to musk ambrette: histopathologic features of photobiologic reactions observed in a persistent light reactor. Arch Dermatol 117: 344-348, 1981. 14 Burry JN: Persistent light reaction associated with sensitivity to musk ambrette. Contact Dermatitis 7: 46-47, 1981. 15 Jackson RT, Nesbit Jr LT, Deleo VA: 6-methylcoumarin photocontact dermatitis. J Am Acad Dermatol 2: 124-127, 1980. 16 Schauder S., Ippen H., Photoallergic and allergic contact dermatitis from dibenzoylmethanes. Photodermatology 3: 140-147, 1986. 17 Motley RJ, Reynolds AJ: Photocontact dermatitis due to isopropyl and butylmethoxydibenzoylmethanes (Eusolex 8020 and Parsol 1789). Contact Dermatitis 21: 109-110, 1989.
371
DESC 00107
A three-year photopatch study in Thailand Pimonpun Gritiyarangsan Instituteof Dermatology, Bangkok, Thailand (Received 9 October
Key words: Photopatch
1990; accepted
test; Photosensitizers;
11 May 1991)
Photocontact
dermatitis
Abstract
Photopatch testing was performed on 274 patients who had history of photosensitivity at the Institute of Dermatology Thailand from 1987 through 1989, A total of 92 positive photocontact reactions and 71 positive contact reactions were seen. The most frequent positive photopatch test reactions were to sulfanilamide (18.2%) followed by Jadit (4.4%) chlorpromazine (3.6%) promethazine (3.6%) and fenticlor (3.2%). The most common photodermatoses was polymorphous light eruption (60.9%). Photocontact dermatitis was established in 28 patients (10.2%) while other skin diseases aggravated by sunlight were seen in 47 patients (17.2%).
Introduction The most wide spread of photoallergic contact dermatitis resulted from the use of soaps containing halogenated salicylanilides and related compounds [ 11. Since then, several topical agents such as PABA [ 2,3] 6-methylcoumarin [ 41, musk ambrette [5] etc. have been reported to cause photoallergic contact dermatitis. Therefore, it is important to perform photopatch test in patients with suspected photodermatoses. At the Institute of Dermatology, Thailand, all photopatch testing results performed in patients from 1987 through 1989 were analyzed and the most frequent positive photosensitizers were discussed in order to Correspondence to: P. Gritiyarangsan, Institute of Dermatology, 42017 Rajavithi Road, Bangkok 10400, Thailand.
know the incidence and causes of photocontact dermatitis and also to determine the occurrence of other photosensitive skin diseases in Thailand. Patients and Methods A total of 274 patients who had history and clinical features suggesting photosensitivity were photopatch tested using 18 test substances comprising mainly of antimicrobial agents, cosmetic ingredients, therapeutic agents and sunscreens. The age, sex and clinical diagnosis of all patients were recorded before the test. Photopatch testing was performed using the International Contact Dermatitis Research Group (ICDRG) test subtances. These were applied in duplicate on the lower back of the patients using Finn Chamber and covered with
312
light opaque black paper. After 24 h one set was uncovered and evaluated for the presence of any reaction and was then irradiated with 5 Joules/cm2 of UVA. Dermaray M-DMR-1 which contained 10 UVA fluorescent lamp (Toshiba Fl-20S-BLB 300-430 nm) with an intensity of 7 mW/cm2 (TOREX, UV-radiometer UVR 305/365-D) served as the UVA light source. After 30 min the irradiated site was read for any immediate reaction. Then the photopatch test site was covered again with light opaque black paper. After 48 h both sets were uncovered and were read based on the following standard scoring: ?+ - doubtful reaction + - weak reaction - non-vesicular ++ - strong reaction - edematous or vesicular +++ - extreme reaction - markedly bullous or ulcerative IR - irritant reaction Photopatch and patch testing results were then evaluated. If only the irradiated site shows a positive reaction the photocontact dermatitis is present. However, if both sites show equally positive reaction then contact dermatitis is present. If the irradiated site shows more severe positive reaction than the non-irradiated site, then photocontact dermatitis and contact dermatitis are both present. Besides the photopatch test, a photoprovocation test by repeated irradiation with UVA (PUVA 3001, Waldmann, 3 consecutive irradiations with 60 J/cm2 of UVA) and UVB (Dermaray M-DMR-1, Toshiba FL 20s E-30, 3 consecutive irradiations with 2 MED of UVB) were also carried out. Urinary porphyrin, skin biopsy for histopathology examination and direct immunofluorescence were performed when indicated. The clinical diagnosis was made after consideration of all laboratory results. Results
During a three-year period from 1987 through 1989, a total of 274 patients had undergone photopatch testing at the Institute of Dermatology,
Thailand. A total of 92 positive photocontact reactions and 71 positive contact reactions were seen. There were 148 females and 126 males. The ages of patients ranged from 9-90 years old. 68.6% were in the 21-50 years old group while 12.8% below 20 years old and the remaining 18.6% were above 50 years old (Table I). The main diagnoses of photopatch tested patients were listed in Table II. The most common diagnosis was polymorphous light eruption (60.9%). It is defined as recurrent skin eruptions involving sun exposed area with history of photosensitivity. There was no history of drug ingestion or contact to photosensitizers. Seborrheic dermatitis and atopic dermatitis who complained of worsening of skin lesions after exposure to sunlight, were seen in 47 patients (17.2%). All of them showed a negative result to photoprovocation test. The causes of photosensitivity could not be identified in 17 patients (6.2%). All of them had history of photosensitivity and developed skin eruptions localized in sun exposed areas. Phototesting showed normal MED and skin lesion could not be reproduced. There were 3 patients who developed photosensitivity to oral chlorpropamide, 2 to hydrochlorothiazide and one to unknown oral medication. Photocontact dermatitis was established in 28 patients (10.2 %) and contact dermatitis in 9 patients (3.3%). TABLE I Age distribution
Age
No. of
Sex
Percentage
patients M Below 10 1 l-20 21-30 3 l-40 41-50 5 l-60 Above 60 Total
F
-
0 6 23 29 28 25 15
1 28 50 31 21 7 4
1 34 13 60 55 32 19
126
148
214
0.4 12.4 26.6 21.9 20.1 11.7 6.9 100
313
TABLE II Main diagnosis No. of patients
Sex
Diagnosis
F
M Polymorphous light eruption Photocontact dermatitis Suspected but unconlirmed photosensitivity Seborrheic dermatitis Atopic dermatitis Photosensitivity from oral medication Contact dermatitis Total
Percentage
78 10 1 13 13 2 3
89 18 10 5 16 4 6
167 28 17 18 29 6 9
126
148
274
60.9 10.2 6.2 6.6 10.6 2.2 3.3 100
TABLE III Number of positive reactions Test substances
Antimicrobial Agents Tribromosalicylanilide Tetrachlorosalicylanilide Triclocarban Bithionol Hexachlorophene Fenticlor Triclosan Cosmetic Ingredients Fragrance mix Balsam of Peru 6-Methylcoumarin Musk Ambrette Therapeutic Agents Promethazine Chlorpromazine Sulfanilamide Jadit (4-chloro-2-hydroxybenzoic acid-n-butylamide) Sunscreen Agents p-Aminobenzoic acid Benzophenone Isobutyl-p-methoxycinnamate * Vehicle used was pet in all cases.
Cont.*
1% 0.1% 1% 1% 1% 1% 2%
8% 25% 1% 5%
1% 0.1% 5%
5% 5% 5%
No. of Pts tested
Positive reactions photocontact
274 274 274 274 214 274 274
1 (0.4%) 5 (1.8%) 2 (0.7%) 4 (1.5%) 6 (2.2%) 9 (3.2%) 0
195 195 214 274
5 4 3 2
(2.6%) (2.1%) (1.1%) (0.7%)
274 274 55 274
10 10 10 12
(3.6%) (3.6%) (18.2%) (4.4%)
214 127 274
5 (1.8%) 2 (1.6%) 2 (0.7%)
contact
0
2 (0.7%) 0 0 0 4 (1.5%) 2 (0.7%) 25 (12.8%) 22 (11.3%) 1 (0.4%) 2 (0.7%) 0
1 (0.4%) 4 (7.3%) I 2.6%)
1 (0.4%) 0 0
374
Table III shows the number of positive reactions to photopatch and patch testing. Sulfanilamide showed the highest positive photopatch reaction (18.2%) followed by Jadit (4.4%). Chlorpromazine and promethazine gave 3.6 % positive photocontact reaction each. Fragrance mix and balsam of Peru gave predominantly contact reactions. Among sunscreening agents tested, PABA produced both photocontact (1.8%) and contact reaction (0.4%) while benzophenone and isobutyl-p-methoxycinnamates produced only photocontact reactions. The antimicrobial agents which produced photocontact reactions were fentichlor (3.3x), hexachlorophene (2.2x), TCSA (1.8%) and bithionol (1.5%). 167 patients with polymorphous light eruptions showed 45 positive photocontact reactions and 51 positive contact reactions (Table IV).
TABLE IV Number of positive reactions Test substance
in PLE patients Positive reactions photocontact
Antimicrobial Agents Tribromsalicylanilide Tetrachlorosalicylanilide Triclocarban Bithionol Hexachlorophene Fenticlor Triclosan
contact
0
0
3 1 3 3 4 0
2 0 0 0 1 0
Cosmetic ingredients Fragrance mix Balsam of Peru GMethylcoumarin Musk Ambrette
1 1 2 0
21 19 1 1
Therapeutic Agents Promethazine Chlorpromazine Jadit
6 8 7
0 0 6
Sunscreen Agents P-aminobenzoic Benzopheone Isobutyl-p-methoxycinnamate
3 2 1
0 0 0
Discussion
In this study, sulfanilamide showed the highest photocontact reactions (18.9%). This antibacterial agent can produce both phototoxic and photoallergic reactions. Topical application of sulfanilamide may produce photoallergic contact dermatitis. Of the 10 patients with positive photocontact reactions, 8 had relevant reactions. Since in Thailand this antimicrobial drug is still widely used topically, it could be responsible for the high incidence of positive reaction. Jadit (4-chlorohydroxybenzoic acid-n-butylamide), is an antifungal agent known to cause photoallergic contact dermatitis [ 61. In our study 4.4% showed positive photocontact reactions and 2.5% showed positive contact reactions. Of the 12 patients with positive photocontact reactions, 6 had relevant reactions. This high incidence could be due to wide use of this topical antifungal medication in Thailand. The phenothiazines could produce both phototoxic and photoallergic reaction [7]. In the present study, chlorpromazine and promethazine gave high positive photopatch reactions (3.6% each). But there was no relevance with any patient who showed positive results. The Scandinavian study also showed similar positive reactions [ 81. But the study from Mayo clinic using 2 % promethazine and 1% chlorpromazine gave higher positive reactions [ 91. Among the sunscreening agents tested, PABA gave the highest positive reactions which is in accordance with another report [lo]. It produced 5 positive photocontact reactions and 1 positive contact reaction. Recently, PABA has been replaced by octyl-dimethyl PABA which appears to be less sensitizing than PABA and many PABAfree formulations have appeared on the Thai market. Benzophenone and Cinnamates gave 2 positive photocontact reactions each, and none for contact reaction although there are reports on allergy to benzophenones [ 1l] and Cinnamates [ 121. All 9 patients who showed positive photocontact reactions to PABA, benzophenone, and cinnamate had history of using sunscreens. Since
375
more sunscreen preparations are recommended as protection against sunburn, photoaging and therapy for photodermatoses, suspicion of contact and photocontact allergy to different sunscreen preparations requires extensive investiConcomitant allergies to several gation. compounds are common and sunscreens, fragrances, antioxidants, dyes and preservatives could all be incriminated. Positive reactions were also seen to antiseptic agents such as halogenated salicylanilides, bithionol, fenticlor and hexachlorophene. But only a minority of the cases had relevant reactions. Cross reaction may have occurred among fentichar, bithionol and halogenated salicylanilides. In this study, hexachlorophene showed 6 positive photocontact reactions (2.2%); this high incidence could be due to the presence of this agent in antiseptic soap available on the Thai market. Photocontact dermatitis to perfumes may be due to the fragrance or the fixative. Musk ambrette, a synthetic fragrance fixative contained in men’s aftershave lotions has been reported to cause photocontact dermatitis and persistent light reaction [ 13,141. In our study there were only two female patients who showed positive reactions and both of them could not be traced to a prior contact with this agent. It was reported that in order to produce a positive photopatch reaction to 6-methylcoumarin, the substance should be applied shortly after irradiation rather than 24 to 48 h [ 151. But in our study, 6-methylcoumarin showed 3 photocontact reactions and one contact reaction produced by a routine photopatch test. Fragrance mix and Balsam of Peru mainly gave contact reactions. In our series, 20.5 % of tested patients showed no photosensitivity (seborrheic dermatitis 6.6%) atopic dermatitis 10.6%, contact dermatitis 3.3 2) Photocontact dermatitis patients (10.2%) had a relevant positive photopatch test reaction. This indicates that the photopatch test is important in the investigation for photosensitive patients. Since other newly synthesized chemicals such as dibenzoylmethane which can produce photosensitivity [ 16,17 ] are being introduced in
the market, the photopatch revised periodically.
test battery should be
References 1 Epstein JH, Wuepper KD; Maibach HI: Photocontact dermatitis to halogenated salicylanilides and related compounds: a clinical and histologic review of 26 patients. Arch Dermatol 97: 236-244, 1968. 2 Horio T, Higuchi T: Photocontact dermatitis from p-aminobenzoic acid. Dermatologica 156: 124-128, 1978. MJ: Photodermatitis with 3 Marmelzat J, Rapaport PABA. Contact Dermatitis 6: 230-231, 1980. 4 Jackson RT, Nesbitt LT, Jr, De Leo VA: 6-Methylcoumarin photocontact dermatitis. J Am Acad Dermatol 2: 124-127, 1980. 5 Raugi GJ, Storrs FJ: Photosensitivity from men’s cologne. Arch Dermatol 115: 106, 1979. 6 Burry JM, Hunter GA: Photocontact dermatitis from Jadit, Br J Dermatol 82: 224-229, 1970. 7 Epstein S: Chlorpromazine sensitivity: phototoxic and photoallergic reactions. Arch Dermatol 98: 354-363, 1968. Jansen C, Wennersten G, Rystedt I, 8 Thune P, Brodthagen H, McFadden N: The Scandinavian multicenter photopatch study 1980-1985: final report. Photodermatology 5: 261-269, 1988. 9 Menz J, Muller SA, Connolly SM: Photopatch testing: a six-year experience. J Am Acad Dermatol 18: 1044-1047, 1988. 10 Thune P: Contact and photocontact allergy to sunscreens. Photodermatology 1: 5-9, 1984. 11 Ramsay DL, Cohen HJ, Baer RL: Allergic reaction to benzophenone. Arch Dermatol 105: 906-908, 1972. 12 Calnan CD: Cinnamon dermatitis from an ointment. Contact Dermatitis 2: 167-170, 1976. 13 Giovinazzo VJ, Harber LC, Bickers DR, Armstrong RB: Photoallergic contact dermatitis to musk ambrette: histopathologic features of photobiologic reactions observed in a persistent light reactor. Arch Dermatol 117: 344-348, 1981. 14 Burry JN: Persistent light reaction associated with sensitivity to musk ambrette. Contact Dermatitis 7: 46-47, 1981. 15 Jackson RT, Nesbit Jr LT, Deleo VA: 6-methylcoumarin photocontact dermatitis. J Am Acad Dermatol 2: 124-127, 1980. 16 Schauder S., Ippen H., Photoallergic and allergic contact dermatitis from dibenzoylmethanes. Photodermatology 3: 140-147, 1986. 17 Motley RJ, Reynolds AJ: Photocontact dermatitis due to isopropyl and butylmethoxydibenzoylmethanes (Eusolex 8020 and Parsol 1789). Contact Dermatitis 21: 109-110, 1989.