ARTICLE
Topical non steroidal anti-inflammatory drugs (NSAIDs) are widely used
in Italy and in other Mediterranean countries in the treatment of inflammatory
lesions and musculo-tendinous injuries, because of their compliance, efficacy
and low risk of systemic adverse reactions [1].
However, many cases of photo-allergic and allergic dermatitis to NSAIDs
have been reported in the literature. Among these compounds, topical ketoprofen
is frequently responsible for contact and photocontact allergy especially
in Italy where it is widely used [2, 3]. Cross-reactions are also possible
between various arilcarbossilic acid derived-NSAIDs [4]. Once sensitized
by the application of topical drugs patients may develop severe cutaneous
reactions with the systemic use of the same drug.
We present the case of an 18 year-old Caucasian male who came to our
clinic in the summer of 1997 presenting a papulovesicular eruption on
the left foot. He reported that he had applied a ketoprofen-base gel some
hours earlier on the site of the lesion for a sprained ankle. The patient
was treated with topical and systemic steroids and sent home after being
advised not to use anti-inflammatory creams in the future. In the summer
of 1998, after a prolonged sun exposure, the patient was again referred
to our clinic by the emergency department with a limited number of vesicles
on edematous-erythematous skin, localized on the neck and on the dorsum
of the left foot, the same site as the previous eczematous eruption. The
patient denied the use of any topical or systemic NSAIDs medication. He
was again treated with topical steroids and 1 month later agreed to undergo
a photopatch test on the dorsum with ketoprofen using an appropriate UVA
dose as described in the literature [5].
The patient developed a strong vesicular reaction to ketoprofen 24 hrs
after irradiation and did not accept any further investigation.
The reaction described in this patient seems to be a "persistent light
reactor" phenomenon, that is to say, an abnormal sensitivity to sunlight
that can last from a month to a several years after the last contact with
the photosensitizing agent [6]. This phenomenon is common with other photoallergens,
such as: chlorpromazine, prometazin, tar and alogenate salicilamids containing
soaps, and it has also been recently described for fenofibrate [7]. Ketoprofen
and fenofibrate have a common diphenylketone group (double benzenic ring
linked to a ketonic group) which could explain the photo-reactivity expressed
by both these compounds.
Exaggerated light sensitivity in subjects with the persistent light
reactor phenomenon could be linked to the persistence of small quantities
of the photosensitizing substance in the skin for long periods of time,
usually months but in some cases a year or more. The deposit must be in
the dermis, because the whole epidermis is normally replaced in 28 days.
In a highly sensitized subject, very small quantities of the compound
and exposure to long-wave ultraviolet light are sufficient to elicit the
reaction [8]. Other mechanisms proposed include: photochemical alteration
of the allergen that can thus exert long term reactions [9], autosensitization
to skin proteins that become photoaptens and cellular sensitivity to ultraviolet
radiation [10].
To our knowledge, this is the second report of prolonged photosensitivity
to ketoprofen [11], thus we think that an additional warning should be
given to people photosensitized to ketoprofen and cross-reacting compounds.
Moreover, particular caution should be used in the prescription of topical
ketoprofen in view of the risk of severe allergic or photoallergic contact
dermatitis and more complex photoreactions after solar irradiation.
REFERENCES
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1993; 29: 57-64.
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prolonged photosensitivity induced by ketoprofen and associated with sensitivity
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