Stopping Doxycycline Before Sunny Travel

Doxycycline, Scarring Alopecia …. and Vacation

I’ve selected this question below for this week’s question of the week. It allows us to review the concept of photosensitivity with doxycycline.

Question

I use doxycycline and clobetasol for my scarring alopecia (lichen planopilaris). I am going on a trip with friends to a very sunny destination and I will need to be outside a lot!!!!!! I know that doxycycline can cause burns. Do you have any advice on what you recommend to patients?

Answer

Thanks for the great question. It’s difficult to give an exact answer for your situation as I don’t know all your story (or your skin type) but let me give you some important general points that I hope will help you.

Patients who use doxycycline for scarring alopecia have an importance difference compared to patients who use doxycycline for malaria prophylaxis or for treatment of an infection: they can stop it!

Stopping doxycycline for a week before leaving is often (though not always) the advice I give. It depends a bit on the skin type of the patient (light skin vs dark skin), the activity level of the scarring alopecia and how detrimental I think stopping doxycycline will be to a possible new flare of disease activity. For patients with light skin types, with stable scarring alopecia…stopping the doxycycline for short periods of time will be important to do.

Photosensitive Rashes from Doxycycline

Sun induced rashes can occur in 8-22 % of patients who use doxycycline. It is the UVA spectrum rather than UVB that seems responsible for the rash. The exact chances of a reaction depends a bit on dose. Patients who use 100 mg twice daily have a greater risk of rashes compared to those who use 100 mg once daily. This was nicely shown in a 1993 study by Layton and colleagues where the authors showed that 6 of 30 patients (20%) treated with 150 mg doxycycline per day and 32 of 76 subjects (42%) taking 200 mg per day developed a phototoxic reaction.

The rash happens within 12-24 hours of sun exposure. The patient develops redness and burning on the sun exposed areas like the nose, cheeks, lips, hands, forearms. Thicker red plaques can form as well. There is often pain and itching and it can be quite intense in severity for some patients. This is known as a photo-toxic reaction. Doxycycline-induced phototoxic reactions are more common in those with lighter skin types than darker skin types.

A completely different phototoxic reaction that can occur with doxycycline is photo-onycholysis. This refers to separation of the nail plate from the nail bed.

In some studies, there is no relation between severity of phototoxic reactions and sex, age and duration of therapy,

Treatment

I generally advise patients to stop doxycycline one week before leaving - if possible. If there is a history of severe reactions already, then 10-14 days may make more sense. Sunscreens that block the broad spectrum of UVA radiation will be helpful. Hats, long sleeve shirts, long pants are all part of the plan to consider as well as sun avoidance. In intensely hot places with a great deal of sun, wearing long sleeve shirts and long pants may not always be practical or easy. The same is true with avoiding sun while on vacation with friends.

In some cases, I may advise that patients increase the use of other supportive treatments while away including topical steroids, tacrolimus etc. For example, I may advise a patients who normally uses clobetasol three times per week to use it 4 or 5 times times week.

Conclusion

All in all, up to 1 out of 5 people can have photosensitive reactions with doxycycline when exposure to intense sun occurs. We do need to counsel patients about it and do everything we can to prepare and prevent these reactions. Stopping the medication before travel makes a lot of sense for those that are using doxycycline for its anti-inflammatory benefits. Clearly, those that use doxycycline for its anti-infective benefits such as a patient using doxycycline for malaria prevention, can not stop this medication when they head to a sunny marlaria endemic area

REFERENCE

Steven Goetze S et al. Phototoxicity of Doxycycline: A Systematic Review on Clinical Manifestations, Frequency, Cofactors, and Prevention. Skin Pharmacol Physiol. 2017;30(2):76-80.

Layton AM, Cunliffe WJ: Phototoxic eruptions due to doxycycline - a dose-related phenomenon. Clin Exp Dermatol 1993;18:425-427.