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\begin{document}

\title{Topical ketoprofen-induced photoallergic vasculitis: An uncommon side
effect}



\author[1]{Marwa THABOUTI}%
\author[1]{Nadia Ghariani Fetoui}%
\author[2]{Sana Mokni}%
\author[1]{Haifa Mkhinini}%
\author[1]{Najet Ghariani}%
\author[1]{Badreddine Sriha}%
\author[3]{Chaker Ben Salem}%
\author[2]{Mohamed Denguezli}%
\affil[1]{Farhat Hached University Hospital of Sousse}%
\affil[2]{Centre Hospitalier Universitaire Farhat Hached de Sousse}%
\affil[3]{Universite de Sousse Faculte de Medecine de Sousse}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
Drug-induced photosensitivity is a common problem that may be
encountered with a variety of medications. Non-steroidal
anti-inflammatory drugs (NSAIDs) such as naproxen and ketoprofen are
notable examples. Herein we describe an uncommon manifestation of
photosensitivity related to ketoprofen.%
\end{abstract}%



\sloppy


\textbf{Topical ketoprofen-induced photoallergic vasculitis: An uncommon
side effect}

\textbf{Authors:} \textbf{Marwa Thabouti
(MD)}\textsuperscript{a}\textbf{, Nadia Ghariani Fetoui
(MD)}\textsuperscript{a}\textbf{, Sana Mokni
(MD)}\textsuperscript{a}\textbf{, Haifa Mkhinini
(MD)}\textsuperscript{a}\textbf{, Najet Ghariani
(MD)}\textsuperscript{a}\textbf{, Badreddine Sriha
(MD)}\textsuperscript{b}\textbf{, Chaker Ben Salem
(MD)}\textsuperscript{c}\textbf{, Mohamed} \textbf{Denguezli
(MD)}\textsuperscript{a}

\textsuperscript{a} Dermatology Department, Farhat Hached Hospital,
Sousse, Tunisia.

\textsuperscript{b} Anatomopathology Department, Farhat Hached Hospital,
Sousse, Tunisia.

\textsuperscript{c} Pharmacology Department, Farhat Hached Hospital,
Sousse, Tunisia.

\textbf{Corresponding} \textbf{Auteur} : Marwa Thabouti. Phone number:
0021650553815. Mail Adress: hebek2011@live.com

\textbf{No conflicts of interest to disclose.}

\textbf{No financial support.}

\textbf{No aknowledgement}

\textbf{Keywords :} Ketoprofen, photoallergic vasculitis, side effect,
non-steroidal anti-inflammatory drugs

\textbf{Abstract :} Drug-induced photosensitivity is a common problem
that may be encountered with a variety of medications. Non-steroidal
anti-inflammatory drugs (NSAIDs) such as naproxen and ketoprofen are
notable examples. Herein we describe an uncommon manifestation of
photosensitivity related to ketoprofen.

Dear Editor;

Drug-induced photosensitivity is a common problem that may be
encountered with a variety of medications. Non-steroidal
anti-inflammatory drugs (NSAIDs) such as naproxen and ketoprofen are
notable examples. Herein we describe an uncommon manifestation of
photosensitivity related to ketoprofen.

An 85-year-old woman presented to our dermatology department with a
pruritic skin rash of the upper and lower extremities. Her medical
history revealed bilateral gonarthrosis, recently treated with topical
ketoprofen gel. Physical examination revealed multiple small non
blanchable erythematous necrotic and ulcerated papules only localized on
the back of the hands and extensor surface of the legs \textbf{(Figure
1a, 1b)} . Dermoscopic examination showed orange-brown globules on a
patchy red background\textbf{.} Personal and family medical history was
negative for photomediated diseases. Her laboratory parameters were
within normal limits. As the skin eruption was limited to sun-exposed
areas of the body where the ointment was applied, contact photosensivity
induced by ketoprofen was initially suspected and the drug was
withdrawn. Fresh lesions were biopsied showing a leukocytoclastic
vasculitis associated with fibrinoid necrosis and extravasation of red
blood cells \textbf{(Figure 1c)} . The diagnosis of contact photoinduced
leukocytoclastic vasculitis imputed to the use of topical ketoprofen was
made. The patient was treated with triamcinolone 0.1 per cent cream and
instructed to avoid sun exposure and sunscreens containing octocrylene.
Skin lesions gradually resolved within two weeks.

Ketoprofen, 3-(3-benzoylphenyl) propionic acid, is a NSAID that is known
to cause photoallergic reactions, which is a cell-mediated immune
process. It seems that benzophenone moiety included in ketoprofen plays
a major role in this photosensitivity \textbf{(1)} . Despite being used
less than other NSAIDs, it remains one of the most frequent
photoallergens. It can cause erythema, oedema, papulovesicles, bullous,
itching lesions or erythema exsudativum multiforme-like eruption in
sun-exposed areas. The onset may spread to involve other sites due to
the systemic nature of the cell-mediated immune response, and can induce
the so-called systemic contact dermatitis, which can present as
generalized maculo-papular, papulo-vesicular, pustular or erythematous
eruption as well as urticarial rash \textbf{(2,3)} . Our patient,
presents a leukocytoclasic vasculitis which was limited to the back of
her hand and her legs, one week after applying ketoprofen gel, while the
rest of the covered skin was clinically unaffected despite the use of
this same ointment. \textbf{(4)} . Topical ketoprofen is known to induce
leukocytoclastic vasculitis \textbf{(4)} . However, no context of
photosensitivity was previously reported for this cutaneous side effect
with any type of NSAID. Only Thiamazole was described once to induce
leukocytoclastic vasculitis in photo-exposed areas mimicking
photosensitivity in a Tunisian patient \textbf{(5)} . Treatment of
ketoprofen-induced photoallergic dermatitis includes discontinuation of
ketoprofen, avoidance of sun exposure and agents known to exacerbate
dermatitis, notably, octocrylene in sunscreens (1) and prescribing
topical or systemic corticosteroids. Physicians should be aware of this
side effect, and educate patients using NSAIDs. To our knowledge, our
patient is the first case of Ketoprofen-induced photoallergic
leukocytoclastic vasculitis. there are no cases reported in literature
with NSAID. Further investigations are necessary to explain the
pathophysiology this side effect.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Loh T.Y., Cohen P.R. Ketoprofen-induced photoallergic dermatitis.
  Indian J. Med. Res. 2016; 144:803.
\item
  Cantisani, Carmen; Grieco, and al. Ketoprofen Allergic Reactions.
  Recent Patents on Inflammation \& Allergy Drug Discovery,2010, 4,
  58--64.
\item
  M Bastien 1, B Milpied-Homsi, S Baudot, Ketoprofen-induced contact
  photosensitivity disorders: 5 cases, Ann Dermatol Venereol. 1997;
  124:523-6.
\item
  F Peters, B Maessen-Visch, L Kho, Leukocytoclastic vasculitis induced
  by a nonsteroidal antiinflammatory drug, J Rheumatol. 1996; 23:2008-9.
\item
  O. Charfi, M. Daldoul, G. Lakhoua et al. Leukocytoclastic vasculitis
  mimicking photosensitivity induced by thiamazole. Therapie. 2021 Jul
  30; S0040-5957(21)00178-5
\end{enumerate}

\textbf{Figure:}

\textbf{Figure 1a, 1b:} erythematous necrotic and ulcerated papules
localized on the back of the hands and extensor surface of the legs

\textbf{Figure 1c:} HE*200: Perivascular infiltration of neutrophiles
and eosinophiles and leukocytoclastic vasculitis without fibrinoid
necrosis.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/ketoprofen-induced-vasculitis-(marwa-thabouti)-(marwa-thabouti)/ketoprofen-induced-vasculitis-(marwa-thabouti)-(marwa-thabouti)}

\end{center}
\end{figure}

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