Medications - Sun Photosensitivity & Autoimmune Disease in the COVID era

MedMaven

by Dr. C. H. Weaver M.D. updated 4/2020

Summer is coming and the COVID-19 pandemic has everyone anxious to get outside and get some sun and fresh air. Did you know that certain medications used for the treatment of rheumatoid arthritis (RA) and other autoimmune inflammatory conditions may make you more susceptible to sunburns and skin rashes?

Shielding your skin from the sun’s potentially harmful ultraviolet (UV) rays should be a concern for everyone, especially if you spend time outdoors, but if you’re undergoing treatment for an autoimmune condition, you may need to be especially vigilant when it comes to sun protection; some of the medications you’ve received may make your skin more vulnerable to UV damage and might also be associated with side effects that can worsen in hot, sunny conditions.

Photosensitivity, or extreme sensitivity to ultraviolet (UV) rays from the sun is a side effect of some medications. (1)

Two kinds of photosensitive reactions exist:

  1. Phototoxic: During a phototoxic reaction the drug becomes activated by UV rays from the sun and a skin rash similar to a “sunburn” occurs.
  2. Photoallergic: A photoallergic reactions is an actual allergic reaction to the medication that results from UV exposure which alters the structure of the drug so that the immune system views it as an antigen causing an allergic response.

Medications used to treat RA, AS, PsA and SLE that may cause photosensitivity

  • Methotrexate
  • Tetracyclines
  • Nonsteroidal anti-inflammatory drugs (NSAIDS)
  • Azathioprine
  • Cyclosporine
  • Dapsone
  • Leflunomide
  • Hydroxychloroquine

Preventive Measures to Protect Your Skin

  • Use sunscreen with a sun protection factor (SPF) of 30 or above
  • Use water-resistant sunscreen if swimming or sweating profusely
  • Reapply sunscreen very 3 hours
  • Apply sunscreen on the lips (some products are formulated for this use)
  • Limit time spent outside when the sun is at its peak around midday
  • Wear long pants, long sleeves, and a hat with a wide brim

Additional Summer Sun Safety Tips

By Justin Piasecki, MD

As summer arrives each year, I’m often asked about the balance between spending time outdoors enjoying all that summer has to offer and avoiding sun damage. My standard answer: know the rules to staying sun safe and then enjoy the season! The key to finding that balance is acknowledging a few basic facts that should guide our time outside this summer.

First, it is a myth that exposure to ultraviolet (UV) rays is justifiable in the name of vitamin D metabolism. The fact is we can get appropriate and healthy vitamin D through 15 minutes of direct sun exposure over the surface area of our hands.

Second, the incidence of skin cancer (cumulative sun exposure being the biggest risk factor) is on the rise. Basal and squamous cell carcinoma are now more common than all other cancers combined. They can be life threatening but are more commonly quality-of-life threatening—capable of destroying and deforming our skin if left untreated. If you have fair skin and live long enough, you are likely to get one of these cancer types.

So should we dive under a tree every time we see the sun? As an expert in the field, I say no. Most would argue—and I agree—that we should live life to the fullest and enjoy outdoor activities. Indeed, that is where many of our fondest experiences and memories occur.

That said, the key to living fully under the sun is to be smart. Be outdoors and be “sunsensical” at the same time. That means moderation and common sense. To that end here are five key lessons to live by.

  1. Say No to Tanning Beds. Tanning beds are to skin cancer what cigarettes are to lung cancer. A recent study estimated that regular use of tanning beds increased the risk of melanoma by 75 percent. Tanning beds deliver radiation— varying degrees of UVA and UVB rays, depending on the machine. Both forms of radiation cause skin cancer (and premature aging). Avoid them.
  2. Say Yes to Sunscreen. Put sunscreen on your body every day. Don’t forget your scalp and under your bathing suit. There is no evidence that one brand or product is better than another at preventing skin cancer. The best sunscreen out there is the one you will actually wear. If it is too expensive, too greasy, or too fragrant, you won’t wear it. My recommendation is to select a sunscreen with a sun protection factor (SPF) of 30 or greater and apply it every day (and reapply every two to three hours if you are outdoors because UV radiation will destroy the sunscreen on your skin over time). If you get in the water, assume the sunscreen is gone from your skin and reapply; if you can’t reapply to your whole body (the SPF of regular clothing is only 5 to 6), at least reapply to your face and hands, which are the most common body parts affected by skin cancer and the most cosmetically sensitive. Try several brands, and choose one that you like that is affordable and that you will use.
  3. Benefit from Early Detection. Examine your own skin every month on your birthday for an extra 10 minutes in the shower. A wound that bleeds with minimal trauma (like toweling), a wound that won’t heal over the course of a few weeks, a skin lesion that grows larger—all are signs of skin cancer. Additionally, any brown or black spot on the skin that is changing (shape, color, or size) is a red flag. Change is the most sensitive indicator of something you should have checked. At least once a year, have your skin checked by a dermatologist or primary care doctor.
  4. Don’t Cut Corners on Treatment. If you’re diagnosed with skin cancer, treat it right the first time. Be your own advocate, ask questions, and make sure you are treated by an expert in the removal of skin cancer (certified by the American College of Mohs Surgery) and an expert in reconstructive surgery (board certification by the American Board of Plastic Surgery or the American Board of Facial Plastic and Reconstructive Surgery).
  5. You Can Be Sun Safe and Still Look Great! For a variety of reasons, our society sees pale skin as less attractive than tan skin. As a board-certified plastic and cosmetic surgeon, I understand and appreciate the importance of cosmetics and looking attractive, youthful, and rejuvenated. But the reward has to justify the risk. Radiating your skin to look temporarily better is not worth the increased risk of cancer that prolonged and repeated intense sun exposure carries. If you feel more attractive with a tan complexion, keep in mind that there are several very effective and very safe spray-tanning options on the market today that do not increase the risk of cancer and that give fantastic cosmetic results.
**Are chemicals in sunscreens dangerous? Parabens, triethanolamine, and para-aminobenzoic acid (PABA)—all have been shown in mice studies to have some adverse effects. The risk in humans is unclear, however, and the risk of direct and cumulative UV exposure far outweighs the unclear and very small risks associated with the use of any sunscreen. Please wear it.
Justin Piasecki, MD*, practices Mohs, plastic, and reconstructive surgery at Harbor Plastic Surgery Center in Gig Harbor, Washington. Dr. Piasecki received his bachelor’s degree from Stanford University and his medical degree from Vanderbilt University. He completed a plastic and reconstructive surgery residency at the University of Wisconsin and a Mohs surgery fellowship at the University of British Columbia. Dr. Piasecki is also the only member of the American College of Mohs Surgery who is certified by the American Board of Plastic Surgery and the American Board of Facial Plastic and Reconstructive Surgery.*

References

  1. Cunha JP. Sun-sensitive drugs (photosensitivity to drugs). MedicineNet. Reviewed April 26, 2018. Accessed July 25, 2019.
  2. Levine B. Rheumatoid arthritis medication: beware of sunburn if you take these drugs. Everyday Health. Updated May 15, 2017. Accessed July 25, 2019.
  3. Sun allergy (photosensitivity). Harvard Health. Published October, 2018. Accessed July 25, 2019.
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