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Diagnosis of Photosensitization Reactions by the Scotch Tape® Provocative Patch Test*
Vol. 51 No. 2 Pr(nted in U.S.A.
TirE JOURNAL OF INVESTIGATIVE DERMATOLOGY
Copyright
1968 by The Wifliams & Wilkins Co.
DIAGNOSIS OF PHOTOSENSITIZATION REACTIONS BY THE SCOTCH TAPE® PROVOCATIVE PATCH TEST* ISAAC WILLIS, M.D.t AND A. M. KLIGMAN, M.D., PHD.
Two experiences have caused clinicians to acquire a practical knowledge of drug photosensitization: 1) The induction of photocontact allergy by halogenated salicylanilides and related compounds incorporated as bacteriostats in soap (1, 2). The occurrence of phototoxie reactions in patients taking widely used drugs,
the long ultraviolet region, between 330—400 nm, extending somewhat into the visible range (4, 5). This simplifies interpretation by making it possible to filter out the sunburning rays, 290—310 nm.
notably certain tetracyclines and phenothi-
lamp with a Schott WG1 filter to obtain a con-
azines (3).
Iii neither instance was the potentiality for photosensitization suspected before use. We have concerned ourselves with methods for identification of phototoxic and photoallergic chemicals by bioassay in humans. A problem which arose in the course of the studies and which was also obvious in the data of others was that of false negative reactions, i.e. the failure to verify the existence of photosensiti zation by the conventional methods of photo-
testing. It became clear that the ordinary techniques were not sufficiently sensitive. We
propose to show in this paper that stripping the horny layer prior to irradiation markedly enhances the recognition of drug photosensiti
zation. This method is advantageous in the diagnosis of photosensitivity reactions in clini— cal practice. MAflRTALS AND METHODS
The latter produces redness which may mask positive responses or complicate accurate evaluation (6). Ordinary window glass prevents sunburn by cutting out radiation below 320 nrn. We utilized a 1600 watt high pressure xenon arc
tinuous spectrum closely resembling summer sunlight based On Urbach's model (7). With window glass in the light path, six minutes of irradiation contains an amount of long ultraviolet radiation equivalent to about two hours of mid-day summer
sunlight at our latitude, 45° N. This was the
standard dose; it never produced redness on nor-
mal skin and had no intensifying effect, histologically or clinically on the mild reaction produced by the stripping.
3. Experimental Models of Photosensitization a. Oral Drug Phototoxicity.—Three phototoxic drugs were given orally; demethylchlorotetracydine, chlorpromazine and sulfisoxizole. These were given daily for six days. Normal and stripped sites were irradiated after the morning dose on the last day. A control site was stripped and not irradiated. In addition, three non-phototoxic drugs were given
to groups of three men as follows: penicillin G, 4.8 million units daily I.M.; erythromycin, 2 gm daily; and aspirin, 3 gm daily.
b. Topical Application of Phototoxic Agents.— The phototoxic agents studied included chlorpromazine, demethylchlorotetracycline, sulfonilarnide,
1. Subjects Young white adult male prisoners served as sub-
griseofulvin, tolbutamide and chlorothiazide. The control substances, to which no stigma of phototoxicity is attached, included neomycin, penicillin,
stripped to the glistening layer with Scotch Tape®
chloromycetin and aspirin. The crystalline chemicals were finely ground and
jects. The back was the test site. The skin was till no more horny cells could be removed.
blended into yellow petrolaturn at 5% concentra-
2. Light Source
Investigation of photosensitization reactions,
tion. Occlusive applications under an impermeable plastic film were made for 24 hours on normal skin and for one hour on stripped skin, following which
whether of the photoallergic or phototoxic variety, the test sites, squares 2 cms on the sides, were has established the major action spectrum to be in immediately irradiated. The sites were examined This study was supported in part by the U.S. at two, six, twenty-four and forty-eight hours, Army Medical Research & Development Comc. Pho tocont act Allergy—Because hexachloro-
mand, Department of the Army, under research Contract No. DA-49-193-MD-.2 137 and in part by a grant from the Public Health Service Contract No. UI 00483-06. Accepted for publication March 25, 1968.
phene is usually not found to cross react with halogenated salicylanilides (8), the demonstration of this phenomenon upon provocative testing was
deemed to furnish a particularly convincing in-
* From the Department of Dermatology, TJni-
versity of Pennsylvania School of Medicine, Pluladelphia, Pennsylvania.
t Post-Doctoral Trainee on NIH T1AM 05479-
02, 116
stance of increased sensitivity.
Photocontact allergy to 3,3', 4', 5—tetrachlorosalicylanilide (TCSA) was induced in ten subjects by a modification of the maximization procedure for inducing ordinary contact allergy (9). A 10%
117
DIAGNOSIS OF PHOTOSENSITIZATION REACTIONS
TABLE I
concentration of the test agent was applied for five
forty-eight hour exposures to the same stripped site. After each application the site received 3 MED's of solar simulating radiation without window glass, i.e. erythemic radiation plus long UN. and visible light. Two weeks later, the subjects
Oral drug phototoxicity Normal skin
Drug
were challenged with 1% concentrations of 3,4',5tribrornosalicylanilide, bithionol, TCSA and hexachiorophene in petrolatum applied to normal and ____________
Daily dose
__________
Stripped skin
Re- In- Reac- Intenac- ten-. tors sity tors sity
sites for one hour, followed itmediately by three minutes of xenon-window glass radiation Demethylchlor- 1200 mgm 3/12 + 10/12 ++ tetracycline (long U.V.). The sites were read at six, twenty12 gm 3/3 + 3/3 ++ four, forty-eight and seventy-two hours. A similar Sulfisoxizole challenge procedure was carried out on six normal Chiorpromazine 800 mgm 3/3 + 3/3 +++ stripped
subjects not Previously exposed to TCSA.
TABLE II
RESULTS
Topically applied phototoxic drugs
1. Oral Phototoxic Drugs
Table I displays the results. The intensity of
the reaction was judged on a 0 to 4+ scale.
Normal skin
The control reaction on non-irradiated stripped
skin was regarded as 1+; 4+ was brilliant erythema and edema, rarely vesiculation.
Chiorpromazine
9/10
In every subject with each of the three agents the stripped site was clearly exacerbated, Demethylehiorstrikingly so in the case of chlorpromazine. The tetracycline dramatic finding, however, was with dernethylchlortetracycline; in twelve subjects, ten re- Sulfonilamide acted on stripped sites and only three on nor- Griseofulvin Tolbutamide mal skin. Irradiation of stripped sites of subjects re- Chlorothiazide ceiving full doses of penicillin, erythromycin and aspirin caused no intensification. 2. Topical Application of Phototoxic Agents
Stripped skin
Drug
+ to ++
Reactors
Intensity
10/10
+++ to
0/9
0
10/10
0/10
0 0 0 0
10/10 10/10 10/10 10/10
0/10 0/10
0/10
TABLE III
Cross reactions in subjects photoallergic to TCSA
The results are given in Table II. These
Normal skin
Stripped skin
constitute an impressive illustration of the enDrug Reac- Inten- Reactors hancement achieved by stripping. Of the six tors sity drugs studied, only one, chlorpromazine, produced any reaction on normal skin. On stripped 3,4',5 tribromo- 4/10 ++ 10/10 salicylanilide skin, however, all subjects reacted to all agents. The response to chlorprornazine was markedly 2/10 ++ 10/10 intensified. Under the same circumstances no Bithionol reactions occurred when stripped sites were treated with neomycin, chloromycetin, acetyl- Hexachioro10/10 0/10 salicylic acid and peiiicillin.
++++ ++ to +++ ++ ++ ++ ++
phene
Intensity
++ to
++ to
to
3. Cross Reactions in Subjects Photoallergic to TCSA
On normal skin a minority of the ten subjects exhibited cross reactions to tribromo-
contrast; every subject cross reacted briskly to
each of the three agents. The reactions resembled contact allergy. Six non-sensitized phene. This is what others have found (2, 8). controls were photopatch negative to those The results on stripped skin were in striking three chemicals. It is worthy of note that salicylanilide and bithionol, none to hexachloro-
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
118
TCSA sensitive subjects did not cross react to but to the toxicologist who is charged with certain other related compounds, p-amino- warranting the safety of drugs and the clinician benzoic acid, salicylanilide and salicylamide. DISCUSSION
The slenderest knowledge of the skin suffices to explain the enhanced sensitivity of provocative testing on stripped skin. The horny layer is not only a formidable barrier to the ingress of chemicals but is also a considerable obstacle to the transmission of light (10). On the back it consists of about fifteen layers of cells packed densely with fibrous protein. In addition, numerous melanin granules are dispersed throughout the horny cells. The removal of the horny layer necessarily greatly increases the quantity of light reaching the living regions of the skin.
who encounters photosensitivity in his practice.
With regard to phototoxicity to oral or parenterally administered drugs, we would urge the routine use of provocative testing. A complete work-up would entail: 1) irradiation of a
stripped site; 2) irradiation of a non-stripped site; and 3) a non-irradiated stripped site control. The second step is not strictly necessary.
Our results leave no doubt of the great enhancement of detecting phototoxicity to in-
ternally taken drugs. In practice few patients on such drugs as chlorpromazine and demethylchlortetracycline develop an adverse reaction to sunlight. With the latter the phototoxic reaction rate even in the hands of Moreover, not only light but the test agent experimenters using higher than usual doses
itself penetrates in much greater quantity under controlled conditions is usually less than through stripped skin. The dosage of both drug and light is increased.
30% (4). Even under our highly favorable circumstances with twice normal doses, only three of twelve subjects reacted. On stripped skin, however, ten were photopositive. Provocative
Our previous interest in the biology of the horny layer and especially with provocative patch testing in contact allergy had strongly testing invariably intensifies the responses. predisposed us toward exploiting this technique More intense reactions simplify interpretation, for photopatch testing (11). It was shown that especially for the novice. Provocative testing pre-treatment of the skin for one hour with may well prove decisive in the identification of 10% aqueous sodium lauryl sulfate enabled the weakly phototoxic drugs or in patients with diagnosis of contact sensitization to be made slight to moderate evidences of photosensiin many marginally sensitized subjects who tivity. would otherwise have been overlooked (12). With regard to photocontact allergy, proThis was especially true of water soluble, vocative photopatch testing may be of greater poorly penetrating chemicals which simply use to the experimentalist and the toxocologist could not pass the barrier in sufficient quan- than to the practicing clinician. tities to reach the target tissue. Earlier Spier The problem of establishing the spectrum of and Sixt had demonstrated that partial strip- cross reacting chemicals illustrates a particping of the horny layer resulted in at least a ularly valuable application of provocative photen-fold increase of sensitivity in patch testing topatch testirg. Although Wilkinson (1) in his for contact allergy (13).
We are not the first to utilize physical re-
classical study of tetrachlorosalicylanilide photoallergy observed four of his fourteen subjects
moval of the horny layer for photopatch to be photoreactive to hexachlorophene, retesting. As long ago as 1927 Guillume found that he could not demonstrate phototoxic reactions to dyes unless the skin was first scarified (14). These dyes, eosin, methyl violet and
searchers subsequently have generally not been able to verify this. Indeed, Vinson did not find cross reactivity to tribromosalicylanilide (16). With provocative testing we obtained complete cross reactivity to these agents in all subjects.
acridine, are water soluble and do not appreciably penetrate normal skin. Recently, We would emphasize that our observations
Burdick obtained reactions in each of ten ir- prove immunologic kinship but do not by any radiated subjects when Shaliniar perfume was means signify that cross reactivity will occur applied to stripped skin. There was no reac- or be detected under ordinary conditions in tion on normal skin under his coiditions (15) which the horny layer remains intact. MoreWe foresee that provocative photopatch test- over, our volunteers were strongly sensitized. ing will be useful not only to the experimenter
It seems probable that penetrating ability,
DIAGNOSIS OF PHOTOSENSITIZATION REACTIONS
119
more than intrinsic immunogenicity, determines which agents in this class will be clinical pho-
subjects orally treated with phototoxic drugs, in identifying phototoxic chemicals by topical tosensitizers. For example, a 1% solution of application to human skin and in establishing
TCSA in ethyleneglycol monomethyl ether the cross reacting spectrum of related subtakes about two hours to permeate the horny stances in subjects with photocontact allergy layer (17). We found that tribromosalicyl- to tetrachlorosalicylanilide. anilide required four to twelve hours in the REFERENCES
same vehicle. These two agents fluoresce brightly
under the Wood's light and their progress through the horny layer may be followed by Scotch Tape® stripping. Since hexachlorophene does not fluoresce, other methods must be used. With C14 labeled hexachlorophene applied under
occlusion for forty-eight hours and monitored at the surface by the gas flow chamber, we found
very little radioactivity after four strippings. Apparently, only trace quaiitities of hexachloro-
1. Wilkinson,
tetrachlorosalicylanilide. Brit. J. Derm., 73: 213, 1961.
2. Jillson, 0. and Baughman, R. D.: Contact
photodermatitis from bithionol. Arch. Dorm., 88: 409, 1963.
3. Sams, W. M.: Photosensitizing therapeutic agents. J.A.M.A., 174: 2043, 1960. 4. Kligrnan, A. M. and Breit, R.: The identification
of phototoxic drugs by human assay,
J. Invest. Derm. In Press.
5. Epstein, S.: The photopatch test; its tech-
nique, manifestations and significance. Ann.
pheie permeate deeply into the coherent portion of the stratum corneum.
Finally, it should be noted that costly and elaborate light sources are not required in photoallergic testing. The energy required to elicit a response is very small with our set-up. The ordinary fluorescent "Black Lamp" emits a continuous spectrum in the long ultraviolet; six minutes at twelve inches is more than adequate. Or, a few minutes from the office variety
D. S.: Photodermatitis due to
Allergy, 22: 1964. 6.
Ison, A. E. and Blank, H.: Testing drug photo-
toxicity in hairless mice. J. Invest. Derm., 49: 508, 1967.
7. Urbach, F.: Solar simulation for phototesting of human skin, Presented at the 1966 Rutgers Conference on Biologic Effects of Ultraviolet Radiation. In Press.
8. Harber, L. C., Harris, H. and Baer, R. L.: 9.
Photoallergic contact dermatitis. Arch. Derm., 94: 255, 1966, Kligman, A. M.: The identification of contact
allergens by human assay: The maximiza-
tion test. J. Invest. Derm., 47: 393, 1966. of hot quartz lamp filtered through window 10. Bachem, A. and Reed, C. I.: The penetration glass will serve. Phototoxic reactions require of light through human skin. Am. J. Physiol.,
considerably more energy for their elicitation. More than an hour's exposure to fluorescent black light may be needed (4). The procedure
thus becomes burdensome without a high
97: 86, 1931.
11. Kligman, A. M.: The biology of the horny layer. P. 387, The Epidermis. Eds., Montagna, W. and Lobitz, W. C., Academic Press, New York, 1964.
A. M.: The SLS provocative patch energy source of long UV. Considerably less 12. Kligman, test in allergic contact sensitization. J. Inexpensive than the Xenon lamp and equally vest. Derm., 46: 573, 1966. 13. Spier, H. W. and Sixt, I.: Untersuchungen effective is the quartz-iodine lamp (4). SUMMARY
1. By stripping the stratum corneum with Scotch Tape®, the sensitivity of photopatch testiig can be greatly enhanced. Removal of
the horny layer barrier increases both the penetration of light and drugs into the liviig portion of the skin.
2. The value of the Scotch Tape® provocative patch test was demonstrated in studies of
uber die Abhãngigkeit des ausfallis der Ekzem-Lappchenproben von der Hornschichtdicke. das Hautartet 6: 152, 1955.
14. Guillume, H. C.: Les radiations lumineuses. Masson et Cie. Paris, 1927.
15. Burdick, K. H.: Phototoxicity of Shalimar perfume. Arch. Derm., 93: 424, 1966.
16. Vinson, L. S. and Flatt, R. S.: Photosensitization by tetrachlorosalicylanilide. J. Invest. Derm., 8: 327, 1962.
17. Baker, H. and Kligman, A. M.: A simple in vivo method for studying the permeability of the human stratum corneum. J. Invest. Derm., 48: 273, 1967.
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
94
linolenic acid extract. Arch. This pdf is a scanned copy UV of irradiated a printed document.
24. Wynn, C. H. and Iqbal, M.: Isolation of rat
skin lysosomes and a comparison with liver Path., 80: 91, 1965. and spleen lysosomes. Biochem. J., 98: lOP, 37. Nicolaides, N.: Lipids, membranes, and the 1966.
human epidermis, p. 511, The Epidermis
Eds., Montagna, W. and Lobitz, W. C. Acascopic localization of acid phosphatase in demic Press, New York. human epidermis. J. Invest. Derm., 46: 431, 38. Wills, E. D. and Wilkinson, A. E.: Release of 1966. enzymes from lysosomes by irradiation and 26. Rowden, C.: Ultrastructural studies of kerathe relation of lipid peroxide formation to tinized epithelia of the mouse. I. Combined enzyme release. Biochem. J., 99: 657, 1966. electron microscope and cytochemical study 39. Lane, N. I. and Novikoff, A. B.: Effects of of lysosomes in mouse epidermis and esoarginine deprivation, ultraviolet radiation and X-radiation on cultured KB cells. J. phageal epithelium. J. Invest. Derm., 49: 181, 25. Olson, R. L. and Nordquist, R. E.: Ultramicro-
No warranty is given about the accuracy of the copy.
Users should refer to the original published dermal cells. Nature, 216: 1031, 1967. version of1965. the material. vest. Derm., 45: 448, 28. Hall, J. H., Smith, J. G., Jr. and Burnett, S. 41. Daniels, F., Jr. and Johnson, B. E.: In prepa1967.
Cell Biol., 27: 603, 1965.
27. Prose, P. H., Sedlis, E. and Bigelow, M.: The 40. Fukuyama, K., Epstein, W. L. and Epstein, demonstration of lysosomes in the diseased J. H.: Effect of ultraviolet light on RNA skin of infants with infantile eczema. J. Inand protein synthesis in differentiated epi-
C.: The lysosome in contact dermatitis: A ration. histochemical study. J. Invest. Derm., 49: 42. Ito, M.: Histochemical investigations of Unna's oxygen and reduction areas by means of 590, 1967. 29. Pearse, A. C. E.: p. 882, Histochemistry Theoultraviolet irradiation, Studies on Melanin, retical and Applied, 2nd ed., Churchill, London, 1960.
30. Pearse, A. C. E.: p. 910, Histacheini.stry Thearetscal and Applied, 2nd ed., Churchill, London, 1960.
31. Daniels, F., Jr., Brophy, D. and Lobitz, W. C.: Histochemical responses of human skin fol-
lowing ultraviolet irradiation. J. Invest. Derm.,37: 351, 1961.
32. Bitensky, L.: The demonstration of lysosomes by the controlled temperature freezing section method. Quart. J. Micr. Sci., 103: 205, 1952.
33. Diengdoh, J. V.: The demonstration of lysosomes in mouse skin. Quart. J. Micr. Sci., 105: 73, 1964.
34. Jarret, A., Spearman, R. I. C. and Hardy, J. A.:
Tohoku, J. Exp. Med., 65: Supplement V, 10, 1957.
43. Bitcnsky, L.: Lysosomes in normal and pathological cells, pp. 362—375, Lysasames Eds., de Reuck, A. V. S. and Cameron, M. Churchill, London, 1953.
44. Janoff, A. and Zweifach, B. W.: Production of inflammatory changes in the microcirculation by cationic proteins extracted from lysosomes. J. Exp. Med., 120: 747, 1964.
45. Herion, J. C., Spitznagel, J. K., Walker, R. I. and Zeya, H. I.: Pyrogenicity of granulocyte lysosomes. Amer. J. Physiol., 211: 693, 1966.
46. Baden, H. P. and Pearlman, C.: The effect of ultraviolet light on protein and nucleic acid synthesis in the epidermis. J. Invest. Derm.,
Histochemistry of keratinization. Brit. J. 43: 71, 1964. Derm., 71: 277, 1959. 35. De Duve, C. and Wattiaux, R.: Functions of 47. Bullough, W. S. and Laurence, E. B.: Mitotic control by internal secretion: the role of lysosomes. Ann. Rev. Physiol., 28: 435, 1966. the chalone-adrenalin complex. Exp. Cell. 36. Waravdekar, V. S., Saclaw, L. D., Jones, W. A. and Kuhns, J. C.: Skin changes induced by
Res., 33: 176, 1964.
TirE JOURNAL OF INVESTIGATIVE DERMATOLOGY
Copyright
1968 by The Wifliams & Wilkins Co.
DIAGNOSIS OF PHOTOSENSITIZATION REACTIONS BY THE SCOTCH TAPE® PROVOCATIVE PATCH TEST* ISAAC WILLIS, M.D.t AND A. M. KLIGMAN, M.D., PHD.
Two experiences have caused clinicians to acquire a practical knowledge of drug photosensitization: 1) The induction of photocontact allergy by halogenated salicylanilides and related compounds incorporated as bacteriostats in soap (1, 2). The occurrence of phototoxie reactions in patients taking widely used drugs,
the long ultraviolet region, between 330—400 nm, extending somewhat into the visible range (4, 5). This simplifies interpretation by making it possible to filter out the sunburning rays, 290—310 nm.
notably certain tetracyclines and phenothi-
lamp with a Schott WG1 filter to obtain a con-
azines (3).
Iii neither instance was the potentiality for photosensitization suspected before use. We have concerned ourselves with methods for identification of phototoxic and photoallergic chemicals by bioassay in humans. A problem which arose in the course of the studies and which was also obvious in the data of others was that of false negative reactions, i.e. the failure to verify the existence of photosensiti zation by the conventional methods of photo-
testing. It became clear that the ordinary techniques were not sufficiently sensitive. We
propose to show in this paper that stripping the horny layer prior to irradiation markedly enhances the recognition of drug photosensiti
zation. This method is advantageous in the diagnosis of photosensitivity reactions in clini— cal practice. MAflRTALS AND METHODS
The latter produces redness which may mask positive responses or complicate accurate evaluation (6). Ordinary window glass prevents sunburn by cutting out radiation below 320 nrn. We utilized a 1600 watt high pressure xenon arc
tinuous spectrum closely resembling summer sunlight based On Urbach's model (7). With window glass in the light path, six minutes of irradiation contains an amount of long ultraviolet radiation equivalent to about two hours of mid-day summer
sunlight at our latitude, 45° N. This was the
standard dose; it never produced redness on nor-
mal skin and had no intensifying effect, histologically or clinically on the mild reaction produced by the stripping.
3. Experimental Models of Photosensitization a. Oral Drug Phototoxicity.—Three phototoxic drugs were given orally; demethylchlorotetracydine, chlorpromazine and sulfisoxizole. These were given daily for six days. Normal and stripped sites were irradiated after the morning dose on the last day. A control site was stripped and not irradiated. In addition, three non-phototoxic drugs were given
to groups of three men as follows: penicillin G, 4.8 million units daily I.M.; erythromycin, 2 gm daily; and aspirin, 3 gm daily.
b. Topical Application of Phototoxic Agents.— The phototoxic agents studied included chlorpromazine, demethylchlorotetracycline, sulfonilarnide,
1. Subjects Young white adult male prisoners served as sub-
griseofulvin, tolbutamide and chlorothiazide. The control substances, to which no stigma of phototoxicity is attached, included neomycin, penicillin,
stripped to the glistening layer with Scotch Tape®
chloromycetin and aspirin. The crystalline chemicals were finely ground and
jects. The back was the test site. The skin was till no more horny cells could be removed.
blended into yellow petrolaturn at 5% concentra-
2. Light Source
Investigation of photosensitization reactions,
tion. Occlusive applications under an impermeable plastic film were made for 24 hours on normal skin and for one hour on stripped skin, following which
whether of the photoallergic or phototoxic variety, the test sites, squares 2 cms on the sides, were has established the major action spectrum to be in immediately irradiated. The sites were examined This study was supported in part by the U.S. at two, six, twenty-four and forty-eight hours, Army Medical Research & Development Comc. Pho tocont act Allergy—Because hexachloro-
mand, Department of the Army, under research Contract No. DA-49-193-MD-.2 137 and in part by a grant from the Public Health Service Contract No. UI 00483-06. Accepted for publication March 25, 1968.
phene is usually not found to cross react with halogenated salicylanilides (8), the demonstration of this phenomenon upon provocative testing was
deemed to furnish a particularly convincing in-
* From the Department of Dermatology, TJni-
versity of Pennsylvania School of Medicine, Pluladelphia, Pennsylvania.
t Post-Doctoral Trainee on NIH T1AM 05479-
02, 116
stance of increased sensitivity.
Photocontact allergy to 3,3', 4', 5—tetrachlorosalicylanilide (TCSA) was induced in ten subjects by a modification of the maximization procedure for inducing ordinary contact allergy (9). A 10%
117
DIAGNOSIS OF PHOTOSENSITIZATION REACTIONS
TABLE I
concentration of the test agent was applied for five
forty-eight hour exposures to the same stripped site. After each application the site received 3 MED's of solar simulating radiation without window glass, i.e. erythemic radiation plus long UN. and visible light. Two weeks later, the subjects
Oral drug phototoxicity Normal skin
Drug
were challenged with 1% concentrations of 3,4',5tribrornosalicylanilide, bithionol, TCSA and hexachiorophene in petrolatum applied to normal and ____________
Daily dose
__________
Stripped skin
Re- In- Reac- Intenac- ten-. tors sity tors sity
sites for one hour, followed itmediately by three minutes of xenon-window glass radiation Demethylchlor- 1200 mgm 3/12 + 10/12 ++ tetracycline (long U.V.). The sites were read at six, twenty12 gm 3/3 + 3/3 ++ four, forty-eight and seventy-two hours. A similar Sulfisoxizole challenge procedure was carried out on six normal Chiorpromazine 800 mgm 3/3 + 3/3 +++ stripped
subjects not Previously exposed to TCSA.
TABLE II
RESULTS
Topically applied phototoxic drugs
1. Oral Phototoxic Drugs
Table I displays the results. The intensity of
the reaction was judged on a 0 to 4+ scale.
Normal skin
The control reaction on non-irradiated stripped
skin was regarded as 1+; 4+ was brilliant erythema and edema, rarely vesiculation.
Chiorpromazine
9/10
In every subject with each of the three agents the stripped site was clearly exacerbated, Demethylehiorstrikingly so in the case of chlorpromazine. The tetracycline dramatic finding, however, was with dernethylchlortetracycline; in twelve subjects, ten re- Sulfonilamide acted on stripped sites and only three on nor- Griseofulvin Tolbutamide mal skin. Irradiation of stripped sites of subjects re- Chlorothiazide ceiving full doses of penicillin, erythromycin and aspirin caused no intensification. 2. Topical Application of Phototoxic Agents
Stripped skin
Drug
+ to ++
Reactors
Intensity
10/10
+++ to
0/9
0
10/10
0/10
0 0 0 0
10/10 10/10 10/10 10/10
0/10 0/10
0/10
TABLE III
Cross reactions in subjects photoallergic to TCSA
The results are given in Table II. These
Normal skin
Stripped skin
constitute an impressive illustration of the enDrug Reac- Inten- Reactors hancement achieved by stripping. Of the six tors sity drugs studied, only one, chlorpromazine, produced any reaction on normal skin. On stripped 3,4',5 tribromo- 4/10 ++ 10/10 salicylanilide skin, however, all subjects reacted to all agents. The response to chlorprornazine was markedly 2/10 ++ 10/10 intensified. Under the same circumstances no Bithionol reactions occurred when stripped sites were treated with neomycin, chloromycetin, acetyl- Hexachioro10/10 0/10 salicylic acid and peiiicillin.
++++ ++ to +++ ++ ++ ++ ++
phene
Intensity
++ to
++ to
to
3. Cross Reactions in Subjects Photoallergic to TCSA
On normal skin a minority of the ten subjects exhibited cross reactions to tribromo-
contrast; every subject cross reacted briskly to
each of the three agents. The reactions resembled contact allergy. Six non-sensitized phene. This is what others have found (2, 8). controls were photopatch negative to those The results on stripped skin were in striking three chemicals. It is worthy of note that salicylanilide and bithionol, none to hexachloro-
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
118
TCSA sensitive subjects did not cross react to but to the toxicologist who is charged with certain other related compounds, p-amino- warranting the safety of drugs and the clinician benzoic acid, salicylanilide and salicylamide. DISCUSSION
The slenderest knowledge of the skin suffices to explain the enhanced sensitivity of provocative testing on stripped skin. The horny layer is not only a formidable barrier to the ingress of chemicals but is also a considerable obstacle to the transmission of light (10). On the back it consists of about fifteen layers of cells packed densely with fibrous protein. In addition, numerous melanin granules are dispersed throughout the horny cells. The removal of the horny layer necessarily greatly increases the quantity of light reaching the living regions of the skin.
who encounters photosensitivity in his practice.
With regard to phototoxicity to oral or parenterally administered drugs, we would urge the routine use of provocative testing. A complete work-up would entail: 1) irradiation of a
stripped site; 2) irradiation of a non-stripped site; and 3) a non-irradiated stripped site control. The second step is not strictly necessary.
Our results leave no doubt of the great enhancement of detecting phototoxicity to in-
ternally taken drugs. In practice few patients on such drugs as chlorpromazine and demethylchlortetracycline develop an adverse reaction to sunlight. With the latter the phototoxic reaction rate even in the hands of Moreover, not only light but the test agent experimenters using higher than usual doses
itself penetrates in much greater quantity under controlled conditions is usually less than through stripped skin. The dosage of both drug and light is increased.
30% (4). Even under our highly favorable circumstances with twice normal doses, only three of twelve subjects reacted. On stripped skin, however, ten were photopositive. Provocative
Our previous interest in the biology of the horny layer and especially with provocative patch testing in contact allergy had strongly testing invariably intensifies the responses. predisposed us toward exploiting this technique More intense reactions simplify interpretation, for photopatch testing (11). It was shown that especially for the novice. Provocative testing pre-treatment of the skin for one hour with may well prove decisive in the identification of 10% aqueous sodium lauryl sulfate enabled the weakly phototoxic drugs or in patients with diagnosis of contact sensitization to be made slight to moderate evidences of photosensiin many marginally sensitized subjects who tivity. would otherwise have been overlooked (12). With regard to photocontact allergy, proThis was especially true of water soluble, vocative photopatch testing may be of greater poorly penetrating chemicals which simply use to the experimentalist and the toxocologist could not pass the barrier in sufficient quan- than to the practicing clinician. tities to reach the target tissue. Earlier Spier The problem of establishing the spectrum of and Sixt had demonstrated that partial strip- cross reacting chemicals illustrates a particping of the horny layer resulted in at least a ularly valuable application of provocative photen-fold increase of sensitivity in patch testing topatch testirg. Although Wilkinson (1) in his for contact allergy (13).
We are not the first to utilize physical re-
classical study of tetrachlorosalicylanilide photoallergy observed four of his fourteen subjects
moval of the horny layer for photopatch to be photoreactive to hexachlorophene, retesting. As long ago as 1927 Guillume found that he could not demonstrate phototoxic reactions to dyes unless the skin was first scarified (14). These dyes, eosin, methyl violet and
searchers subsequently have generally not been able to verify this. Indeed, Vinson did not find cross reactivity to tribromosalicylanilide (16). With provocative testing we obtained complete cross reactivity to these agents in all subjects.
acridine, are water soluble and do not appreciably penetrate normal skin. Recently, We would emphasize that our observations
Burdick obtained reactions in each of ten ir- prove immunologic kinship but do not by any radiated subjects when Shaliniar perfume was means signify that cross reactivity will occur applied to stripped skin. There was no reac- or be detected under ordinary conditions in tion on normal skin under his coiditions (15) which the horny layer remains intact. MoreWe foresee that provocative photopatch test- over, our volunteers were strongly sensitized. ing will be useful not only to the experimenter
It seems probable that penetrating ability,
DIAGNOSIS OF PHOTOSENSITIZATION REACTIONS
119
more than intrinsic immunogenicity, determines which agents in this class will be clinical pho-
subjects orally treated with phototoxic drugs, in identifying phototoxic chemicals by topical tosensitizers. For example, a 1% solution of application to human skin and in establishing
TCSA in ethyleneglycol monomethyl ether the cross reacting spectrum of related subtakes about two hours to permeate the horny stances in subjects with photocontact allergy layer (17). We found that tribromosalicyl- to tetrachlorosalicylanilide. anilide required four to twelve hours in the REFERENCES
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