Contents

Search

drug eruption; drug rash

Classification: - morbilliform drug eruption (erythematous drug eruption) most common - drug rash with eosinophilia & systemic symptoms (DRESS) - fixed drug eruption - urticaria - drug hypersensitivity syndrome - photosensitivity - erythema multiforme-like reaction - acneiform reaction - new onset psoriaform eruptions - subacute cutaneous lupus erythematosus - dermatomyositis-like eruptions - Sweet syndrome - eczema-like reactions Etiology: - morbilliform drug eruption (erythematous drug eruption) most common - penicillin & other beta-lactam antibiotics - carbamazepine - allopurinol - gold - all patients with Epstein-Barr virus or cytomegalovirus infection will develop rash if given ampicillin or amoxicillin - fixed drug eruption - phenolphthalein - tetracyclines - sulfonamides - metronidazole - non-steroidal anti-inflammatory drugs - barbiturates - oral contraceptives - quinine, including tonic water - peas, beans & lentils have been implicated - urticaria - antibiotics & most classes of other drugs - radiocontrast agents - hypersensitivity - anticonvulsants - minocycline - trimethoprim-sulfamethoxazole - allopurinol - dapsone - abacavir [1] - photosensitivity - amiodarone - thiazide diuretics - tetracyclines - sulfonamides, furosemide - phenothiazines - psoralins - can occur with light exposure through windows - erythema multiforme-like reaction - sulfonamides - phenytoin - barbiturates - penicillin - allopurinol - acneiform reaction (not true acne, follicular reaction) - EGF inhibitors - new onset psoriaform eruptions - TNF inhibitors, especially in patients with Crohn's disease or rheumatoid arthritis - subacute cutaneous lupus erythematosus - hydrochlorothiazide - terbinafine - calcium channel blockers - ACE inhibitors - dermatomyositis-like eruptions - hydroxyurea - statins - drug-induced Sweet syndrome is rare - imatinib - oral contraceptives - granulocyte colony-stimulating factor - all-trans retinoic acid - eczema-like reactions - calcium channel blockers [3,4] - metoprolol (vesiculobullous dermatitis, lichenoid dermatitis) * histopathological pattern may be unrelated to etiologic agent [3] Epidemiology: - drug eruptions most commonly caused by a) antibiotics 1] penicillins 2] beta-lactams 3] dulfonamides b) NSAIDs c) thiazide diuretics d) allopurinol Pathology: - histopathological pattern may be unrelated to etiologic agent [3] Clinical manifestations: - depends upon etiology, see a) morbilliform drug eruption b) fixed drug eruption c) urticaria d) photosensitivity - distribution generally includes trunk & often the extremities [2] - erythema multiforme-like reaction a) mucous membrane involvement common b) ocular involvement may lead to blindness - psoriaform eruptions a) often pustular b) involvement of palms & soles common - Grotton papules in dermatomyositis-like eruptions - severe drug eruption a) confluent erythema b) skin pain c) facial edema d) fever e) lymphadenopathy f) mucosal erosions g) widespread blistering h) purpura i) necrosis j) dyspnea k) hypotension Laboratory: - complete blood count (CBC) a) lymphocytosis b) eosinophilia - serum ALT & serum AST may be elevated - anti-SSA in serum (associated with lupus) - anti-histone antibodies generally negative Complications: - erythema multiforme-like reaction a) ocular involvement may lead to blindness b) severe reactions can be life-threatening Management: - morbilliform drug eruption a) antihistamines for pruritus b) topical glucocorticoids - fixed drug eruption: potent topical glucocorticoids - urticaria a) see urticaria b) antihistamines c) epinephrine for associated anaphylaxis d) systemic glucocorticoids for severe reactions - photosensitivity a) avoid sunlight, wear protect clothing, sunscreen b) antihistamines for pruritus c) topical glucocorticoids - erythema multiforme-like reaction a) antihistamines for pruritus b) systemic glucocorticoids for severe reactions (effectiveness not proven) - acneiform reaction a) topical antibiotics b) oral antibiotics - new onset psoriaform eruptions a) potent topical glucocorticoids b) methotrexate - subacute cutaneous lupus erythematosus a) topical glucocorticoids b) systemic glucocorticoids c) antimalarial agents - dermatomyositis-like eruptions: none - Sweet syndrome - eczema-like reactions

Specific

exanthematous drug eruption (morbilliform exanthem) fixed drug eruption

General

adverse drug reaction (ADR) rash

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16. American College of Physicians, Philadelphia 2009, 2012
  2. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  3. Summers EM, Bingham CS, Dahle KW, et al. Chronic eczematous eruptions in the aging: further support for an association with exposure to calcium channel blockers. JAMA Dermatol. 2013;149(7):814-818. PMID: 23636109
  4. Orme S, da Costa D. Generalised pruritus associated with amlodipine. BMJ. 1997;315(7106):463. PMID: 9284667