Lamps used close to the skin could cause problems for
people who are extremely light-sensitive
3.5.2. Effects of fluorescence light vs. normal incandescent light on photosensitive skin related conditions
The photodermatoses are a group of skin conditions induced by
light which include the Idiopathic (of unknown mechanism)
photodermatoses, drug/chemical induced conditions, the
Fluorescent light has been identified as a risk factor (Rihner
and McGrath 1992, Sayre et al. 2004). This section also mentions
those disorders that are aggravated by sunlight.
188.8.131.52. Idiopathic photodermatoses
Although idiopathic, this group of conditions are believed to
have an immunological basis.
Polymorphic Light Eruption
This condition, which is the commonest of all the
photodermatoses presents in spring or early summer as a pruritic
erythematous papular rash on sunlight exposed sites. The skin
eruption usually develops within half to a few hours of sunlight
exposure. The condition usually remits over the winter months.
The prevalence increases with the distance from the Equator (5%
in Australia; 21% in Sweden; 15% in England)(Pao et al, 1994)
and also with altitude (Dang et al. 2006). The overall European
estimate is 10-20% (Stratigos et al. 2002, Bock et al. 2005,
Hönigsmann 2008). Age of onset is variable with 60% arising in
the first three decades, with a two to three fold
higherprevalence among females (Bock et al. 2005).
Polymorphic light eruption
is thought to be a delayed hypersensitivity response to
cutaneous neo-antigens induced in susceptible individuals by
UVB sunlight containing
exposure. It may be provoked by exposure to high output
It is possible that in the most severely affected, CFL could
produce the eruption [Evidence level C].
Chronic Actinic Dermatitis
Most of the patients have a long history of recurrent contact
allergy to defined
allergens with features of
dermatitis on photoexposed sites. Some have semi-translucent
nodules termed actinic reticuloid. It occurs mainly in males
over the age of 50 years with a prevalence in Scotland of
16.5:100,000 population (Dawe 2008). The skin is abnormally
sensitive to UVB/UVA and frequently also
visible radiation. A new
chronic actinic dermatitis
(also uncommon), associated with atopic dermatitis, has been
identified in patients in their teens and 20s. Photosensitivity
can be severe and broad extending from UVB to the visible
Degree of photosensitivity suggests there may be a problem
with CFL (Moseley 2008) [Evidence level C].
This is an uncommon condition that particularly affects
American Indians and less frequently Caucasian and Asian
populations. Age of onset is usually before 10 years and it
predominantly affects females. Patients complain of a perennial
problem with deterioration during spring and summer. Pruritic,
patchy, oedematous erythema with papules is evident following
exposure to sunlight. Repetitive
UVA provocation testing
usually induces lesions. Management of
actinic prurigo is more
difficult than that of
polymorphic light eruption.
Its prevalence is estimated at 3.3 per 100,000 of the general
population (Dawe 2008).
Severe cases may potentially be at risk from CFL (Moseley
2008) [Evidence level C].
This is an uncommon photosensitive skin disorder that affects
both males and females. It may arise in any age group but is
particularly common in the first four decades of life. The
condition is persistent and about one-third of patients show no
response to treatment. Its wavelength dependency is most
commonly in the UVA region
extending into the visible and occasionally also affecting the
UVB region. The prevalence
has been estimated to be 3.1 per 100,000 (Beattie 2003).
Provocation of the lesions is relatively easy in the most
It is possible that some patients could be at risk from CFL.
It should be noted that
incandescent light sources
also cause problems in some patients [Evidence level C].
184.108.40.206. Drug/chemical induced photosensitivity
Many drugs are recognised as capable of inducing
photosensitivity. They do so by a variety of mechanisms,
commonly phototoxicity, which means that any individual exposed
to a sufficient quantity of a drug and appropriate irradiation
will be affected. Other mechanisms of action result in only a
small number of individuals being affected. Some
photosensitising drugs are listed below (Ferguson 2002). Much
less common is the mechanism of drug-induced photoallergy which
involves a sensitised immune system.
Amiodarone is a cardiac antidysrhythmic agent that causes a
burning, prickling sensation with erythema in approximately 50%
of individuals on high dose. The wavelengths responsible are
visible light. Unsightly
slate-grey skin pigmentation may also develop.
Phenothiazine-derivative drugs have an antipsychotic action,
thought to act by blocking dopaminergic transmission within the
brain. They produce skin discomfort, erythema and blistering
elicited by exposure to UVA.
Unsightly skin discolouration may also occur.
This is a large group of drugs that exhibit variable degrees
of phototoxicity. Symptoms include erythema and blistering;
wavelengths responsible are mainly
Given the degree of photosensitivity, it is not anticipated
that drug induced photosensitivity to the above will be a
particular problem when patients are exposed to CFL vs.
incandescent sources [Evidence level C].
Photofrin and other
Photofrin and Foscan are potent intentional visible wavelength
dependent photosensitisers used in photodynamic therapy of
Photodynamic therapy can elicit skin phototoxic responses when
exposed to visible light
(Hettiaratchy et al, 2000).
Photosensitivity might be expected to arise with CFL to a
greater extent than that seen currently with
incandescent light sources
because of the greater amount of blue light. However, these
patients are closely managed because of their known temporary
phototoxicity, and so in practice this is not likely to
constitute a significant problem [Evidence level C].
from Plants and Diet
Phytophotodermatitis is a group of conditions which appear
following psoralen skin
contact from plants along with
UVA wavelength exposure.
This is unlikely to be a significant problem with CFL. Psoralens
are also present in foodstuffs.
The amount of psoralen in
the diet (celery, parsnip, limes, etc.,) when combined with
fluorescent lighting is unlikely to be either an acute or
chronic problem [Evidence
dermatitis is an uncommon delayed-type hypersensitivity reaction
elicited by low doses of UV radiation in susceptible
individuals. The main groups of photocontact
allergens current in the
environment are sunscreen chemicals, and topical non-steroidal
When the diagnosis is made, patients can quickly avoid the
provoking wavelengths, usually in the
CFL are unlikely to be a significant inducing factor in this
group of patients [Evidence level D].
This group of inherited photosensitive skin diseases include
Xeroderma Pigmentosum, Cockayne’s, Bloom’s and Rothmund-Thomson
Syndrome, which are quite rare. Xeroderma pigmentosum is
reported as occurring in 1 of 250,000 in Europe and the USA
(Robbins et al. 1974) while the other disorders are even rarer.
The best understood of these is xeroderma pigmentosum. In its
classical excision repair defective form, there is a marked
photosensitivity to UVB
wavelengths. Childhood development of
skin cancer makes
photoprotection against these wavelengths a priority.
It is possible that unfiltered CFL could be associated with
increased disease activity. Patients are currently advised to
avoid unfiltered fluorescent lighting. There could be assumed to
be a similar problem with other members of the group [Evidence
This group of mixed inherited and environmentally induced
photosensitivity skin diseases relates to an
accumulation of a
photosensitive porphyrin within the skin. Examples of these
diseases include erythropoietic protoporphyria, the main feature
of which is burning or prickling pain in the skin exposed to
sunlight. A few minutes of intense
visible light are usually
enough to elicit symptoms causing the individual to try to
escape from the light source and seek relief, for example, using
cold water compresses. Erythropoietic protoporphyria develops in
childhood, or even during infancy. It should be noted that
cutaneous porphyrias are
particularly sensitive to the blue light region so there would
be a theoretical argument when comparing tungsten bulbs (which
have less blue light). Porphyrias are rare disorders. For
example, the prevalence of congenital erythropoietic porphyria
(Günther’s disease) in the UK is approximately 2 per 3,000,000
live births. Erythropoietic protoporphyria prevalence has been
reported at around 1 to 2 per 100,000 inhabitants (Burns 2004,
Marco et al. 2007).
CFL in extremely sensitive patients could possibly produce a
slight increase in the problem compared to tungsten light
sources, although there is published evidence against this
(Chingwell et al, 2008, in press) [Evidence level C].
Porphyria Cutanea Tarda
The prevalence of porphyria cutanea tarda is estimated to be
1:5,000. It is caused by excessive alcohol intake,
chronic hepatitis infection
and other factors. It produces blisters, skin fragility and
hypertrichosis. It is mainly produced by visible wavelengths
rather than ultraviolet A.
220.127.116.11. Photo-aggravated Dermatoses
Ten percent of patients with atopic dermatitis are aware of
exacerbations triggered by sunlight. This may be due to
infrared exposure and
perspiration, but in other patients this does not seem to be the
It seems unlikely that CFL would contribute significantly to
this problem and might even be preferred to
incandescent light sources
[Evidence level D].
18.104.22.168. Lupus Erythematosus
Lupus erythematosus is a chronic
autoimmune disease that is
often exacerbated by sunlight exposure. Its prevalence is
estimated at 27.7 per 100,000 of the general population with a
much higher prevalence reported for females of Afro-Caribbean
ethnicity (Hopkinson et al. 1993, Johnson et al. 1995). Some
patients do describe artificial light causing problems.
Provoking wavelengths seem to be predominantly in the
UVB extending into UVA2. A
range of skin presentations include butterfly rash, a
polymorphic light eruption
presentation and lupus erythematosus tumidus are
Through their UV component,
chronic exposure to CFL
could possibly be a problem. Systemic
lupus is an important
condition in that skin flares can be associated with internal
disease activity [Evidence level C].
22.214.171.124. Skin Cancer
Ultraviolet radiation is a
major environmental risk factor for skin cancers. Hence, UV
radiation from artificial illumination sources should be reduced
to a minimum. The UVC and
UVB radiations are
especially effective in damaging
DNA, and in causing gene
mutations and cancerous
transformation of cells.
Although the carcinogenic UV dose from fluorescent lighting in
offices is minor (~ 1%) when compared to equal exposure times in
the summer sun, old risk assessments showed that actual annual
exposures of office workers could increase by 10 to 30% from the
fluorescent lighting, which over a lifetime was estimated to
increase the risk of squamous
cell carcinomas by around 4
% with a baseline risk much lower than that for outdoor workers
who dominate incidences (Lytle et al 1992). Some recent
measurements (see section 3.4) showed that some commercially
available CFL emit short wavelength UV radiation down to the UVC
(254 nm) which is
unnecessary and undesirable, and leaves room for improved lamp
engineering. The most effective wavelengths in causing or
stimulating skin melanoma –
the most aggressive
skin cancer – are not
known, but UVA and longer
wavelengths may be relatively more important than for skin
carcinomas. It should be noted that UVA exposure from
fluorescent lamps for
indoor illumination is still far lower than from the sun (or
artificial tanning lamps). A case-control study in a population
with low sun exposure showed that melanoma risk was not
associated with fluorescent lighting in the home or offices
(Swerdlow et al 1988).
Fluorescent lamps do not
contribute significantly to the
melanoma risk [evidence
level A] and by analogy CFL will not [Evidence level B].
Fluorescent lamps, including CFL, are estimated to contribute
insignificantly to UV doses effective in causing skin carcinomas
[Evidence level B].
126.96.36.199. Conclusions regarding skin diseases
Although good quality clinical data associating fluorescent
light induction (and by inference CFL) of these photosensitive
diseases, is lacking, there are some experimental data
supporting the belief that exposure to CFL (particularly when
the source is close to the skin) may induce problems in those
patients with severe photosensitivity in the ultraviolet B/A
spectrum namely, xeroderma pigmentosum, and other
well as the
(chronic actinic dermatitis,
severe solar urticaria,
polymorphic light eruption
and actinic prurigo). It
is also possible that in cutaneous
systemic lupus erythematosus
problems could be induced by the UV
mercury vapour lines
emitted by unfiltered CFL.
It is also feasible that in some skin conditions particularly
sensitive to blue light, e.g., photodynamic therapy administered
patients, there could be a marginally greater reaction with CFL
than seen with
sources. It does seem that these adverse reactions will occur in
a relatively small number of patients and could, to a degree, be
avoided by UV filtering of CFL.
Peer reviewed definitive test data comparing incandescent vs.
CFL in these diseases is required to provide a clear answer to
the question being asked in this report.
- There is sufficient evidence to show that UV and in
visible radiation from
lamps can provoke a clinically significant skin reaction in
light-sensitive patients [Evidence level A].
- Fluorescent lamps,
including CFL emit UV radiation that may be harmful to a
sub- set of particularly sensitive patients [Evidence level
- CFL may be harmful when in close proximity to the skin
(around 20 cm or less) [Evidence level B].