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Voriconazole and Sunlight Don't Mix

Summary and Comment |
December 19, 2013

Voriconazole and Sunlight Don't Mix

  1. Craig A. Elmets, MD

Patients prescribed this medication should be counseled about strict adherence to sun-protective measures.

  1. Craig A. Elmets, MD

Voriconazole is employed for the treatment and prevention of Aspergillosis and other serious fungal infections. Side effects include acute and chronic phototoxicity, and some reports link it to aggressive squamous cell carcinomas (SCCs) of the skin. Physicians throughout France were asked to identify voriconazole recipients who had benign and malignant skin diseases.

They identified 61 drug recipients with a dermatological problem. Among these were 17 with cutaneous SCCs that had an intermediate or high likelihood of being attributable to voriconazole (age range at first SCC, 20 to 80 years). The mean time from initiation of voriconazole therapy to first SCC was 46±18 months; time to first SCC was accelerated in immunosuppressed patients. In 14 of the 17 patients, SCCs were preceded by erythema in sun-exposed areas occurring, on average, within the first year after voriconazole therapy. In general, erythema progressed to actinic keratoses (AKs) in the second or third year and subsequently evolved into SCCs. Nine of the 17 patients developed more than one SCC. An additional five patients without SCCs developed AKs 11 to 80 months after beginning voriconazole. No melanomas were detected, although melanomas associated with voriconazole therapy have been reported by others (NEJM JW Dermatol Feb 19 2010). Benign complications of voriconazole therapy were reported in 37 other subjects, including pseudoporphyria and phototoxic erythema, alone or with blistering, lentigines, or cheilitis (mean time to development, 107 days; range 14–421 days). In most instances, discontinuation of voriconazole led to improvement in cutaneous side effects.

Comment

The introduction of voriconazole has been an important advance in antifungal therapy. Adverse cutaneous effects complicate its use and have been reported in 8% of patients. Patients prescribed this medication should be counseled about strict adherence to sun-protective measures. Because there is an apparent progression from phototoxic erythema to cutaneous pre-malignancies and cancers, patients with signs of phototoxicity should be followed closely by a dermatologist for skin cancers. In some instances, patients may need to be changed to another antifungal medication.

  • Disclosures for Craig A. Elmets, MD at time of publication Consultant / Advisory board Astellas Pharmaceuticals Grant / research support NIH; NIH/NCI; Veteran’s Administration; Abbott Laboratories; Biogen; Clinuvel; Covan Basilea Pharmaceutica; Genentech; TenX Biopharma; University of California Editorial boards Cancer Prevention Research; Journal of the American Academy of Dermatology; Photodermatology, Photoimmunology, & Photomedicine; UpToDate Leadership positions in professional societies American Academy of Dermatology (Psoriasis Guidelines Subcommittee and Chair Designate, Clinical Guidelines and Research Committee); Photomedicine Society (Board of Directors)

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