Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor - Case Letter
2016:82:1;101-103
doi: 10.4103/0378-6323.172899
PMID: 26728829

Pirfenidone induced phototoxic reaction in an elderly man

Rohini Pradip Gaikwad1 , Samipa S Mukherjee2
1 Department of Dermatology, Venereology and Leprosy, MIMER Medical College, Talegaon Dabhade, Maharashtra, India
2 Department of Dermatology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Correspondence Address:
Rohini Pradip Gaikwad
Flat Number 5, Hindustan Arcade, Tingrenagar Road, Vishrantvadi, Pune - 411 015, Maharashtra
India
How to cite this article:
Gaikwad RP, Mukherjee SS. Pirfenidone induced phototoxic reaction in an elderly man. Indian J Dermatol Venereol Leprol 2016;82:101-103
Copyright: (C)2016 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Pirfenidone is an antifibrotic and anti-inflammatory agent used in the treatment of idiopathic pulmonary fibrosis. It reduces fibroblast proliferation, inhibits transforming growth factor-β stimulated collagen production and reduces the production of fibrogenic mediators. Although photosensitivity and rash are reported side effects in clinical trials, we were able to find only a few previously published reports of this adverse effect.[1]

A 70-year-old man presented with burning sensation and a rash for 20 days. He had intense erythema with desquamation involving the face, scalp [Figure - 1], V area of the chest, shoulder area and upper back [Figure - 2] extending to the dorsum of the hands along with involvement of the dorsa of feet upto the ankles. Fissuring was noted over the preauricular area. Characteristic sparing of the periorbital area (patient was using spectacles) and vest covered area was noted. Hair, nail, and mucosae were normal. Skin biopsy was not undertaken.

Figure 1: Erythema and scaling involving face, neck, shoulder sparing vest covered area, and periorbital region
Figure 2: Intense erythema involving upper back, nape of neck, and shoulders sparing the vest covered region

He had interstitial lung disease and was on treatment with bronchodilators (formetrol, once a day), mucolytics (N-acetylcysteine, 2 teaspoons thrice a day), and pirfenidone for the last 6 months. He had been started on 600 mg/day of pirfenidone 5 months back and the dose was gradually increased to 1200 mg/day. Ten days after escalation of the dose, the patient developed the rash suggesting a dose dependency of the phototoxic reaction. He was managed with oral prednisolone 0.75 mg/kg body weight in a tapering dose along with antihistamines, topical corticosteroids, broad spectrum sunscreens and strict photoprotection.

A diagnosis of drug-induced phototoxic reaction with pirfenidone was made based on clinical examination and history. The differential diagnosis of allergic contact dermatitis, irritant contact dermatitis, and subacute cutaneous lupus erythematosis were excluded on clinical grounds.

Costabel et al. stated that the cutaneous adverse effects of pirfenidone include phototoxic burn-like skin rash on the sun exposed body areas.[2] Skin related photosensitivity reactions were observed in 12.2% and rash was noted in 32.2% of pirfenidone treated patients as reported in the CAPACITY studies.[3] Our patient can be categorized as Grade 3 (erythema with desquamation) which was reported in 0.2% of the drug cohort in the CAPACITY studies. Photosensitivity and rash led to the discontinuation of therapy in approximately 1% of the patient.[3]

The mechanism of pirfenidone-induced photosensitivity is likely to be phototoxic and is related to the drug's ability to absorb ultraviolet A and ultraviolet B. Absorption of ultraviolet light in the skin tissue could result in skin lesions due to generation of reactive oxygen species and lipid peroxidation.[4] Animal studies have shown the use of sunscreens with higher sun protection factor significantly reduce the severity of skin reactions.[5]

The standard approach for preventing and managing skin-related adverse effects include avoiding direct sun exposure, use of broad spectrum sunscreens, physical protection, and avoiding other phototoxic drugs. Costabel et al. have expanded the above guidelines by suggesting behavioral avoidance of indirect sunlight as well as intense artificial light sources, wearing of thick woven cloth and broad brimmed hats and avoiding sun exposure for a few hours following the intake of pirfenidone.[2] The management of the rash includes reduction of the drug dose and discontinuation of the drug in case of persistence of rash for more than 15 days. Slow re-introduction of the drug can be attempted once the symptoms have resolved.

As pirfenidone is also associated with gastrointestinal and neurological side effects, these also need to be carefully monitored. Dose reduction can lessen the gastrointestinal and dermatological side effects.[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors have obtained appropriate patient consent for the information published in this article.

References
1.
Koulelidis A, Zacharis G, Dolios P, Zouvelekis AT. Pirfenidone photosensitivity rash in a patient with idiopathic pulmonary fibrosis. Pneumon 2013;26:92.
[Google Scholar]
2.
Costabel U, Bendstrup E, Cottin V, Dewint P, Egan JJ, Ferguson J, et al. Pirfenidone in idiopathic pulmonary fibrosis: Expert panel discussion on the management of drug-related adverse events. Adv Ther 2014;31:375-91.
[Google Scholar]
3.
Noble PW, Albera C, Bradford WZ, Costabel U, Glassberg MK, Kardatzke D, et al. Pirfenidone in patients with idiopathic pulmonary fibrosis (CAPACITY): Two randomised trials. Lancet 2011;377:1760-9.
[Google Scholar]
4.
Seto Y, Inoue R, Kato M, Yamada S, Onoue S. Photosafety assessments on pirfenidone: Photochemical, photobiological, and pharmacokinetic characterization. J Photochem Photobiol B 2013;120:44-51.
[Google Scholar]
5.
Pharmaceuticals and Medical Devices Agency Japan. Pirfenidone Report. Available from: http://www. pmda.go.jp/english/service/pdf/drugs/pirespa_oct2008_e.pdf. [Last accessed on 2014 Mar 18]
[Google Scholar]
6.
Jiang C, Huang H, Liu J, Wang Y, Lu Z, Xu Z. Adverse events of pirfenidone for the treatment of pulmonary fibrosis: A meta-analysis of randomized controlled trials. PLoS One 2012;7:e47024.
[Google Scholar]

Fulltext Views
4,569

PDF downloads
2,140
Show Sections