Photosensitive dermatitis caused by nintedanib in a patient of chronic fibrosing interstitial lung disease already on pirfenidone

Dear Editor,

Photosensitive dermatitis can be defined as an eczematous eruption occurring due to exposure to electromagnetic radiation (ultraviolet and visible rays mostly).[1] Lim and Hawk classified photodermatoses as:[2]

• Chemical and drug-induced photosensitivity

  • Endogenous: Cutaneous porphyrias
  • Exogenous: Phototoxicity and photoallergy.

• Immunologically mediated (idiopathic) photodermatoses

  • Solar urticaria
  • Polymorphic light eruption
  • Hydroa vacciniforme
  • Chronic actinic dermatitis.

• Photoaggravated dermatoses

  • Lupus erythematosus rosacea
  • Acne vulgaris
  • Dermatomyositis
  • Psoriasis
  • Dyskeratosis follicularis (Morbus Darier)
  • Atopic eczema
  • Reticular erythematous mucinosis lichen planus
  • Herpes simplex
  • Pemphigus foliaceus (erythematosus)
  • Bullous pemphigoid
  • Pellagra.

• DNA repair defect disorders

  • Rothmund–Thomson syndrome
  • Xeroderma pigmentosum
  • Cockayne syndrome
  • Bloom–Torre–Machacek syndrome
  • Bullous acrokeratotic poikiloderma of Kindler and Weary
  • UV-sensitive syndrome
  • Trichothiodystrophy.

Drug-induced photosensitivity is nonimmunologic, direct damage to the skin resulting from an interaction of the drug or chemical with electromagnetic radiation (ultraviolet or visible rays), and on substituting or drug withdrawal, it can be reversed. Commonly implicated drugs that are known to cause photosensitivity are anti-inflammatory, antibacterial, and nonsteroidal drugs.[1,3] Here, we present a case of photosensitivity due to the concomitant use of nintedanib with pirfenidone for lung fibrosis. The aim of this report is to underscore the significance of keeping up the doubt of drug-related reactions so as to advise patients for proper precautions and follow-up.

A 54-year-old male presented with complaints of an itchy and painful diffuse rash on his face and neck for 10 days. He was a known case of Systemic sclerosis (MRSS-20, Anti-Scl 70 positive) with interstitial lung fibrosis, on pirfenidone (well tolerated) for 7 years. One and a half months back, he was started on capsule nintedanib 150 mg once a day (IDOFNIB 150) on prescription from a local pulmonologist while continuing pirfenidone. A month later, he developed reddish oozy lesions over his face and neck and presented to the dermatology outpatient department for the same.

On examination, ill to well-defined erythematous eczematous patches over the sun-exposed sites, i.e., face, neck, and dorsal hands were present [Figure 1]. Laboratory workup including a complete hemogram, liver panel, renal function tests, lipid profile, fasting blood glucose, and urine examination revealed no abnormalities. Both C-reactive protein and erythrocyte sedimentation rates were mildly elevated.

Figure 1.

Ill to well-defined erythematous eczematous patches present over the sun-exposed sites, i.e., face (a), neck (b), and dorsal of hands (c)

After a complete laboratory workup, nintedanib was withheld and the patient was put on systemic steroids. Pirfenidone was continued. The patient was advised appropriate sun protection including the use of hats and two hourly sunscreen applications during the daytime. The eczematous patches resolved completely in a week. The oral corticosteroids were slowly tapered.

Nintedanib (a tyrosine kinase inhibitor) is used in the management of systemic sclerosis-associated interstitial lung disease (ILD) (as in this case), idiopathic pulmonary fibrosis, and ILD with progressive phenotype.[3] Conversely, pirfenidone is a novel anti-inflammatory and antifibrotic drug used for the treatment of idiopathic pulmonary fibrosis. The most common adverse effects of pirfenidone are hepatic dysfunction, gastrointestinal symptoms, photosensitivity, and rash.[4] The photosensitive rash due to pirfenidone most of the time appears by the first month of starting the therapy as has been reported previously in the literature.[4] Although most studies have showed photosensitivity as an adverse event common to pirfenidone, here the event occurred after nintedanib was coadministered. This needs the support of further studies and it is yet to be proven if nintedanib alone or in combination with pirfenidone aggravates the incidence of photo toxicity.

Both pirfenidone and nintedanib for the management of chronic fibrosing ILD have a good drug safety profile. However, few cases of eczematous photosensitivity rash have been seen with the use of pirfenidone. This is to add to the knowledge of respiratory physicians to keep in mind the necessity of photoprotection in patients taking either or both.[5]

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.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil