Photochem Photobiology - 2022 - Ezekwe - Visible Light and The Skin

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Photochemistry and Photobiology, 2022, 98: 1264–1269

Invited Review
Visible Light and the Skin
Nneamaka Ezekwe1,2, Jalal Maghfour2 and Indermeet Kohli2,3*
1
Department of Dermatology, University of Colorado, Aurora, CO, USA
2
Photomedicine and Photobiology Unit, Department of Dermatology, Henry Ford Hospital, Detroit, MI, USA
3
Department of Physics and Astronomy, Wayne State University, Detroit, MI, USA
Received 8 December 2021, accepted 31 March 2022, DOI: 10.1111/php.13634

ABSTRACT phototypes have been established (4,8). While the initial phases
of VL + UVA1 induced pigmentation, immediate pigment dark-
Visible light (VL, 400–700 nm) was previously regarded as ening (IPD, that occurs immediately after exposure and fades
nonsignificant with minimal to no photobiologic effects on the within 20 min to 2 h), and persistent pigment darkening (PPD,
skin. Recent studies have demonstrated that in dark-skinned that occurs and persists from 2 to 24 h) have been suggested to
individuals (skin phototypes IV–VI), VL can induce more result from oxidation and redistribution of pre-existing melanin,
intense and longer lasting pigmentation compared to ultravi- delayed tanning (DT, occurring 7–10 days after exposure and
olet A1 (UVA1, 340–400 nm). Additionally, long wavelength lasting from weeks to months) has been attributed to synthesis of
UVA1 (370–400 nm) has been shown to potentiate these new melanin (9–13).
effects of VL. The combination of VL and UVA1 Skin responses induced by VL and UVA1, and those by the
(VL + UVA1, 370–700 nm) was also able to induce erythema combination of VL and UVA1 have been reported in the litera-
in light-skinned individuals (skin phototypes I–III), which is ture; however, there is a lack of standardized VL phototesting
a novel finding since the erythemogenic spectrum of sunlight guidelines at this time (14). A number of studies have proposed
has primarily been attributed to ultraviolet B (UVB, 290– the use of in vitro methods in determining photoprotection
320 nm) and short wavelength UVA2 (320–340 nm) only. against VL (15,16,17,18,19,20). Although convenient for assess-
Although biologic effects of VL + UVA1 have been estab- ing optical photoprotection, the evaluation of protective effects
lished, there are no guidelines in any country to test for pho- of biologic agents, such as antioxidants, may be limited with
toprotection against this waveband. This invited perspective these in vitro methodologies. Herein, the focus of this article is
aims to present the evolution of knowledge of photobiologic to provide an overview on the evolution of knowledge of in vivo
effects of VL, associated phototesting methodologies, and cur- clinically relevant photobiologic effects of VL and UVA1 on
rent position on VL photoprotection. skin with an emphasis on associated phototesting methodologies.
The current in vivo VL phototesting methods including calcula-
INTRODUCTION tions for VL protection factor (VL-PF), and position on VL pho-
toprotection are also included.
Visible light (VL, 400–700 nm), which accounts for approxi-
mately 44% of the electromagnetic radiation (1), was previously
regarded as having minimal to no photobiologic effects on the PHOTOBIOLOGIC EFFECTS INDUCED BY VL
skin. However, exposure to VL has recently been shown to AND UVA1
induce oxidative stress with increases in epidermal reactive VL was initially regarded as having no photobiologic effects;
oxidative species (ROS) in in vitro models, that results in the however, early research revealed the potential impact of VL in
release of inflammatory cytokines and upregulation of expression inducing skin pigmentation. In an in vivo experimental study
matrix metalloproteinases (MMP) in human epidermal equiva- conducted by Kollias et al. (5), a polychromatic light source with
lents (2). The downstream effect of these biologically active wavelengths ranging from 390 to 1700 nm was utilized to study
agents can contribute to premature photoaging in skin. VL is also skin responses in individuals with skin phototypes (SPT) I–VI. It
known to be an action spectrum of some photodermatoses such was reported that irradiation with VL and infrared radiation
as urticaria and the cutaneous porphyrias (1,3–7). induced pigmentary changes which were spectroscopically differ-
Pigmentation induced by VL has been shown to be relatively ent from those induced by UVA. No erythema was reported to
more persistent than that induced by ultraviolet A1 (UVA1, 340– be associated with this pigmentary change. A dose of
400 nm) (6). Additionally, synergistic effects of VL and long 720 J cm 2 (2) was shown to cause delayed pigment darkening,
wavelength UVA1 (VL + UVA1, 370–700 nm) in inducing ery- that persisted for up to 10 weeks. In another study conducted by
thema in light skin and pigmentation and erythema in dark skin Rosen et al. (13), a xenon-mercury arc lamp was used to emit
select wavelengths (334, 365, 405, 435, 549 nm). The SPT
*Corresponding author email: ikohli1@hfhs.org (Indermeet Kohli) included ranged from III–V. It was demonstrated that, for the
© 2022 The American Society for Photobiology.

1264
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Photochemistry and Photobiology, 2022, 98 1265

wavelengths investigated, the ability to induce IPD decreased meaningful in the field of photoprotection with this being rela-
with increasing wavelengths. Extrapolation of spectroscopic data tively more similar to outdoor sun exposure. Considering this
indicated no measurable IPD observed for wavelengths greater and the knowledge, shorter wavelengths of VL being relatively
than 470 nm. However, higher intensities and delayed responses more biologically effective in terms of hyperpigmentation, Kohli
were not investigated. Porges et al. (21) used a xenon-arc solar et al. (4) investigated the biologic effects induced by small
simulator, with a spectral distribution between 385 nm and changes in the spectral output of VL sources by including trace
700 nm, on subjects with SPT II-IV. It was demonstrated that amounts (< 0.5%) of UVA1 in one of the VL sources. A dose of
threshold dose for IPD ranged between 40 and 80 J cm 2 (2) 480 J cm 2 was administered with two light sources, pure VL
and that for delayed tanning between 80–120 J cm 2. In contrast (400–700 nm with 0.004% UVA1, 97.9% VL, and 2.05% IR)
to other studies, Porges et al. (21), reported erythema that and VL + UVA1 (370–700 nm with 0.44% UVA1, 99.4%VL,
resolved within 24 h. Although there were some variations in the and 0.15% IR) on opposite sides of the back of subjects with
results among the above-mentioned studies, biologic effects of SPT IV-VI. The UVA1 waveband of 370–400 nm was purpose-
VL were clearly demonstrated. The variations in the findings fully selected as 370 nm corresponded to the critical wavelength
could be attributed to the differences in the spectral distribution for broad-spectrum photoprotection, and protection offered by
of radiation source, SPT included and irradiance level used in broad-spectrum products reduces rapidly beyond this wavelength.
these studies. It was thus important to study potential effects caused by this
VL-induced effects were shown to be more intense and persis- waveband. Along with variation in spectral composition, the
tent compared to UVA1. In a clinical study, Mahmoud et al. (6) impact of irradiance was also investigated by administering the
evaluated the effects of visible light (98.3% VL (400–700 nm), dose at different irradiance levels (rate of delivery) ranging from
0.19% UVA1 (340–400 nm), and 1.5% IR (700–1800 nm)) on 100 to 250 mW cm 2. Skin responses, pigmentation and ery-
cutaneous pigmentary alterations in individuals with SPT IV–VI thema, were evaluated for a period of 2 weeks. Both clinical and
and compared to those induced by UVA1 (340–400 nm). Clini- instrumental data indicated stronger and more persistent pigmen-
cal and instrumental assessment for pigmentation, erythema and tation of all phases: IPD, PPD, DT and persistence of DT,
edema were performed from immediately after irradiation up to a induced with VL + UVA1 compared to pure VL. Additionally,
period of 2 weeks. The lowest dose to induce IPD was reported clinical erythema was observed only at the VL + UVA1 side for
to be 40 J cm 2 for VL, and 5 J cm 2 for UVA1. The skin the higher irradiances, but only subclinical erythema observed
responses were dose dependent for both VL and UVA1, with for the pure VL side for all irradiance levels investigated. Pig-
higher doses resulting in darker pigmentation. It was also shown mentary responses to pure VL did not change with change in
that VL-induced pigmentation had a sustained effect and was irradiance, whereas those to VL + UVA1 did with responses to
observed up to 2 weeks, which was the completion of the study. irradiances greater than 200 mW cm 2 being significantly stron-
In contrast, UVA1-induced pigmentation was associated with a ger than those below this level. As such, reciprocity, irradiance
lower intensity and progressively faded within 2 weeks. Finally, independence or skin response only being dose dependent, was
erythema was noted immediately after VL irradiation, whereas followed for pure VL but not for VL + UVA1. The minimal
no erythema was induced by UVA1 at any time point after irra- threshold doses for UVA (320–400 nm)-induced IPD, PPD and
diation. Interestingly, no VL-induced pigmentation was seen in DT to a single exposure, as demonstrated in a previous study,
SPT II. The clinical implications from this study further high- were 0.7  0.3, 11.0  3.4, and 18.2  4.1 J cm 2, respec-
lighted the importance of photoprotection beyond UV in tively (8). As such, the UVA1 dose used in this study (approx.
melanocompetent individuals, who have a high propensity to 2.4 J cm 2), with the VL + UVA1 light source, would have
develop hyperpigmentation on the skin such as melasma and been insufficient to induce PPD or DT. Altogether, this study
postinflammatory hyperpigmenation (6). yielded several important findings. First, potentiation of pigmen-
With sustained pigmentation resulting from VL being estab- tation by VL + UVA1, compared to pure VL, with such low
lished, knowledge on the contribution of the various wavelengths dose of UVA1 was suggestive of the synergistic relationship
within the VL spectrum began to emerge. Dutiel et al. (7), inves- between the two: VL and long wavelength UVA1. Second, ery-
tigated the impact of different wavelengths within VL in a study thema induced by VL + UVA1 and the absence of clinical ery-
on human subjects with SPT III and IV. It was demonstrated that thema with pure VL at similar irradiances again pointed toward
irradiation with blue/violet (415 nm) light induced a dose depen- synergism between the two. Third, reciprocity failure for
dent hyperpigmentation response, while red light (630 nm) VL + UVA1 irradiation suggested caution for selecting parame-
induced no hyperpigmentation at any of the investigated doses ters for VL + UVA1 phototesting as failure to do so may pro-
(maximum dose investigated 150 J cm 2) (7). In the same study, vide results that could not be accurately generalized to outdoor
it was shown that blue/violet-induced pigmentation was more sun exposure. Lastly, the need for photoprotection beyond
pronounced than that induced by UVB. In a subsequent ex vivo 370 nm and standardization of VL phototesting methodologies.
study, with normal human melanocytes and abdominoplasty skin Having established that trace amounts of long wavelength
from SPT IV, Regazzetti et al. (22), demonstrated that Opsin-3 UVA1 (<0.5%) within VL + UVA1 potentiated VL-induced
was the key sensor in melanocytes causing hyperpigmentation effects, efforts were then made to investigate changes induced by
induced by shorter wavelengths of VL (415 and 465 nm). These varying the UVA1 content while still keeping it low compared
findings demonstrated that different wavelengths within the VL to the corresponding waveband in sunlight. The effects of
waveband have different biologic effects. This catalyzed addi- VL + UVA1 [370–700 nm, 2.0% UVA1 (340–400 nm), 97.3%
tional efforts in understanding the differences in skin responses VL (400–700 nm) and 0.7% infrared (700–1600 nm)] were eval-
with variations of VL. uated in light-skinned individuals (SPT I-III) (8). Ten subjects of
The knowledge about impact of narrow wavebands within VL SPT I-III were irradiated with a dose of 480 J cm 2. A statisti-
is important; however, impact of broadband VL is more cally significant increase in erythema was observed immediately
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1266 Nneamaka Ezekwe et al.

after irradiation compared with subjects’ baseline (nonirradiated harmful photobiological effects of VL + UVA1 highlight the
skin), and the erythema resolved within 24 h. This finding of importance of the development of means of photoprotection and
clinically perceptible erythema seen with VL + UVA1 was novel evaluation of associated efficacy with standardized protocols (in-
in photomedicine, as previously the erythemogenic spectrum of cluding irradiation and assessment methods) against this wave-
sunlight had only been attributed to UVB and short-wavelength band. Additionally, there is a need to establish the action spectra
UVA2 (8). Evaluation of exposure to the same light source was of long-wavelength UVA and VL.
done in darker skin types (SPT IV-VI); intense pigmentation was
observed at lower doses than those reported previously (unpub-
IN VIVO VL PHOTOTESTING
lished data).
METHODOLOGIES
Studies have demonstrated efficacy of tinted sunscreens, oral,
and topical antioxidants against VL-induced effects (23–27). Regulatory bodies throughout the world follow set methodolo-
However, irradiation and assessment methods vary. Commonly gies for testing product efficacy against UVB and UVA; how-
used assessment methods include photography, clinical scoring, ever, currently there are no such guidelines for VL in any
spectroscopy, histology, and immunohistochemistry. Photography country. There are very limited published in vivo methods for
ranges from standard to cross-polarized. Elimination of surface assessing VL protection. Duteil et al. (30) enrolled 20 healthy
reflectance resulting in improved visualization of sub-surface vas- subjects (SPT III-V) in a clinical study assessing VL protection.
culature and pigmentary changes makes cross-polarized photog- Irradiation was performed with a modified solar simulator with
raphy more suitable for assessing VL + UVA1-induced effects, spectral output containing 0.1% of long UVA1 (360–400 nm),
especially in skin types V–VI. Clinical scoring scales are used 95.1% VL (400–700 nm), and 4.8% of infrared radiation (700–
for pigmentation and erythema evaluation. Although useful, the 800 nm). A VL dose of 144 J cm 2 was administered for four
scales vary among studies and need to be validated and standard- consecutive days. Assessment, performed on all 4 days and on
ized. Noninvasive spectroscopic techniques including colorimetry day 5, included clinical photography, erythema and pigmentation
and diffuse reflectance spectroscopy (DRS) are objective with scoring, and colorimetry. Visible light protection factor (VL-PF)
relatively less user dependence. Colorimetry measured changes was proposed to be calculated as the ratio between untreated and
in L*a*b* parameters and individual typology angle (ITA), and treated site based on the slope of the linear regression of col-
DRS measured changes in chromophore concentrations (melanin orimetry measured change in ITA between day 1 and day 5.
and oxy-hemoglobin), and area under the curve (AUC, also ter- While multiple exposures are more physiological, this approach
med as relative dyschromia) of the absorption spectra have been involves product application for multiple days introducing addi-
shown to be sensitive to changes in skin color tional variables. Multiple visits may also result in higher number
(4,7,23,24,26,27,28). Change in AUC, between 400 and 700 nm, of subjects not willing or able to complete the evaluation. Addi-
is a relatively novel assessment method and has been shown to tionally, 5 days may be insufficient to observe delayed pigmenta-
correlate well with clinical findings (4,24,27–29). This can in tion resulting from first exposure, and pigmentation observed at
part be explained by the fact that this shows a combined effect all time points will be a mix of various phases of pigmentation
of erythema and pigmentary changes that result in overall dark- making it difficult to evaluate the actual efficacy against delayed
ness of the skin color. Oxy-hemoglobin and melanin changes tanning.
can be useful for early time points (immediate to 24 h) and Ruvolo and colleagues used VL doses ranging from 40 to
7 days and beyond, respectively, whereas AUC comparisons can 157 J cm 2 to induce pigmentation in healthy volunteers (SPT
be made for all time points. VL + UVA1-induced histologic and IV-VI) (18). The VL source used included 0.002% UVA (320–
immunohistochemical changes in SPT IV–VI showed a signifi- 400 nm), 99.9% VL (400–700 nm), and 0.098% infrared radia-
cant increase in inflammation and proliferation, as assessed by tion (above 700 nm). The ratio of visually determined minimal
cyclooxygenase-2 (COX-2) and cyclin D1, respectively, for sites pigmentation dose, 2–3 h after irradiation, between protected and
irradiated with 480 J cm 2 of VL + UVA1 compared to nonirra- unprotected skin was used to calculate the VL-PF. The 2–3 h
diated control skin (28). Interestingly, despite evidence of clinical time point was used as the authors reported lack of consistent
pigmentation, which was confirmed by spectroscopic measure- delayed pigmentation responses after a single exposure. Of note,
ments, no changes in pigmentation were observed between irradi- although not used for VL-PF, in the same study authors reported
ated and nonirradiated skin with melanoma antigen recognized a delayed response after four consecutive VL exposures with
by T cells (MART)-1 (23). This could be attributed to the cur- 150 J cm 2.
rent lack of knowledge regarding optimal biopsy acquisition Jo et al. (31) utilized a blue light device (peak emission at
timeline after exposure, choice of appropriate biomarkers specific 456 nm, full width at half maximum 20 nm) to irradiate the back
to VL, and the limitation of relative subjectivity of the assess- of healthy subjects (SPT III–IV) with doses ranging from 45 to
ment of pigmentation, which relies on visual assessment of 270 J cm 2. Similar to Ruvolo et al., VL-PF was suggested to
change in the number of cells in high power fields and/or the be calculated as the ratio of visually determined minimal persis-
intensity of the staining. Altogether, this highlights the utility of tent pigment darkening dose, 2–4 h after irradiation, between
cross-polarized photography for visualization, and spectroscopic treated and untreated skin.
methods in quantifying VL + UVA1-induced changes. The protocol developed by Kohli et al. (4,8,19,22–24)
From the collective of the above-mentioned studies, involved the use of a single exposure with VL + UVA1 dose of
VL + UVA1 has been shown to induce erythema and persistent 320 or 480 J cm 2 depending on SPT. The output of the light
pigmentation in melanocompetent (SPT IV–VI) and erythema in source included <0.0001% below 370 nm, 0.5–4% long wave-
light skinned (SPT I–III) individuals, with histologic evidence of length UVA1 (370–400 nm), 96–99% VL (400–700 nm) and
inflammation and proliferation. As most photoprotective mea- (0–2%) IR. Clinical scoring, colorimetry, DRS and histology
sures to date only account for UV radiation, the discovery of the were performed to assess the induced changes and subjects were
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Photochemistry and Photobiology, 2022, 98 1267

followed for a period of 1–2 weeks (4,8,24,27–29). For VL-PF and Pfizer. IK has served as an investigator for Ferndale, Estee
calculation, the ratio of the DRS measured change in AUC Lauder, La Roche Posay Dermatologique, Unigen, Johnson and
between untreated and treated skin was proposed. The proposed Johnson, Allergan, Bayer and received support from American
waveband, 370–700 nm, should be used in VL phototesting Skin Association for a vitiligo project. IK has served as a consul-
because photoprotection from currently available broad-spectrum tant for Pfizer, Johnson and Johnson, Beiersdorf (previously
products drops significantly beyond 370 nm exposing human known as Bayer) and ISDIN. IK has received salary support
skin to these wavelengths even after application of broad- from the Dermatology Foundation through a research career
spectrum sunscreens when outdoors. Additionally, because syner- development award.
gistic effects between these long UVA1 wavelengths (370–
400 nm) and VL have been established.
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length UVA1-induced effects with topical antioxidants. Photochem. dermatology residency at
Photobiol. 98, 455–460. the University of Color-
25. Mann, T., K. Eggers, F. Rippke, M. Tesch, A. Buerger, M. E. Dar- ado Denver Department
vin, et al. (2020) High-energy visible light at ambient doses and of Dermatology. She is
intensities induces oxidative stress of skin-protective effects of the passionate about skin of
antioxidant and Nrf2 inducer Licochalcone a in vitro and in vivo. color dermatoses and
Photodermatol. Photoimmunol. Photomed. 36, 135–144. areas of research interests
26. Mohammad, T. F., I. Kohli, C. L. Nicholson, G. Treyger, S. include photomedicine,
Chaowattanapanit, A. F. Nahhas, et al. (2019) Oral polypodium Leu- lasers, hidradenitis suppu-
cotomos extract and its impact on visible light-induced pigmentation rativa, vitiligo, and alope-
in human subjects. J. Drugs Dermatol. 18, 1198–1203. cia.
27. Nnmeaka, E. (2021) Efficacy evaluation of topical sunscreens against
long wavelength ultraviolet a1 and visible light induced biological
effects: Preliminary findings. Ann Meet Photodermatol Virtual.
28. Kohli, I., T. L. Braunberger, A. F. Nahhas, F. N. Mirza, M. Mokh-
tari, A. B. Lyons, et al. (2020) Long-wavelength ultraviolet A1 and Jalal Maghfour MD is
visible light photoprotection: A multimodality assessment of dose currently a clinical
and response. Photochem. Photobiol. 96, 208–214. research fellow at the
29. Kohli, I., A. F. Nahhas, T. L. Braunberger, S. Chaowattanapanit, T. photomedicine photobiol-
F. Mohammad, C. L. Nicholson, et al. (2019) Spectral characteristics ogy research unit at
of visible light-induced pigmentation and visible light protection fac- Henry Ford Health Hospi-
tor. Photodermatol. Photoimmunol. Photomed. 35, 393–399. tal dermatology depart-
30. Duteil, L., J. Esdaile, Y. Maubert, A. C. Cathelineau, A. Bouloc, C. ment. He has completed
Queille-Roussel, et al. (2017) A method to assess the protective effi- his undergraduate degree
cacy of sunscreens against visible light-induced pigmentation. Photo- at the University of
dermatol. Photoimmunol. Photomed. 33, 260–266. Wisconsin-Stout. Subse-
31. Jo, H. L., Y. Jung, B.-F. Suh, E. Cho, K. Kim and E. Kim (2020) quently, he moved to
Clinical evaluation method for blue light (456 nm) protection of New Orleans, LA where
skin. J. Cosmet. Dermatol. 19, 2438–2443. he completed his Master’s
degree in biochemistry
and molecular biology as
well as his undergraduate
medical education. He
completed a preliminary
year in Internal Medicine
at Tulane University
School of Medicine. Inter-
ests include exploring and eradicating health disparities within dermatol-
ogy, community volunteerism and skin of color research. His current
research encompasses pigmentary skin disorders (e.g. post-inflammatory
hyperpigmentation), sunscreen, photoprotection, vitiligo and hidradenitis
suppurativa.
17511097, 2022, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/php.13634 by Nat Prov Indonesia, Wiley Online Library on [28/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Photochemistry and Photobiology, 2022, 98 1269

Indermeet Kohli PhD


is an Associate scientist
in the Department of
Dermatology at Henry
Ford Hospital, Detroit,
MI. She joined Derma-
tology research at Henry
Ford in 2014 after grad-
uating with her PhD in
Physics from Wayne
State University. Her
research interests
include photoprotection,
vitiligo, hidradenitis
suppurativa, post inflam-
matory hyperpigmenta-
tion, and Basal cell
carcinoma. She serves
as the imaging commit-
tee chair for the Global
Vitiligo Foundation
(GVF) and as a member
of the board of directors
of the Photodermatology
Society. Dr. Kohli received the American Society for Photobiology
Young Investigator Award in 2020, and the Dermatology Foundation
Research Career-Development-Award in 2021.

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