Aphthous stomatitis induced by piroxicam

Abstract

Piroxicam is a nonsteroidal anti-inflammatory drug that may cause adverse mucocutaneous reactions. The most frequent manifestation is photodermatitis, but maculopapular or lichenoid eruptions, urticaria, erythema multiforme, toxic epidermal necrolysis, and pruritus are also reported.1Lisi P. Stingeni L. Reazioni cutanee da farmaci antinfiammatori non steroidei dati etio-patogenetici e revisione della letteratura.Ann Ital Dermatol Clin Sper. 1991; 45: 193-213Google Scholar A case of aphthous stomatitis that recurred after oral rechallenge with piroxicam is described. A 49-year-old medical doctor was initially seen with an acute aphthous stomatitis rash that had occurred 4 weeks previously. The erosions and ulcers were sharply delimited, circular, 2 to 3 mm in diameter, surrounded by a red border, and covered by a yellowish white pseudomembrane. They were very painful and occurred in crops, but often the lesions coalesced to form larger erosions on the lateral borders of the tongue and oral mucosa. They were associated with dysphagia and sialorrhea. Spontaneous healing occurred after 10 to 15 days. The family history was not positive for allergic diseases, and the patient reported only occasional low back pain treated orally with piroxicam. Laboratory investigations, instrumental examinations, ocular examinations, and psychologic examinations showed no abnormalities. In particular, there was no Behçet disease, anemia, or gastrointestinal disorders. A patch test with piroxicam 10% in petrolatum was negative on days 2 and 4. No reaction to prick test with piroxicam 2% in dimethylformamide was observed at 20 minutes, 24 hours, or 48 hours. Because the patient's history left us several doubts and because the lesion extension was narrow, after the patient's consent, an oral provocation test was performed with increasing doses of piroxicam. The respective doses (0.02, 0.2, 2, and 20 mg, resulting in a cumulative dose of 22.22 mg) were administrated at 20-minute intervals. Aphthous stomatitis relapsed 48 hours from the last dose (Fig 1). The patient was asymptomatic during the 24-month follow-up. Among the undesirable reactions affecting the oral mucosa from systemic medication, erosive and ulcerative stomatitis is frequent. However, aphthous stomatitis is rather rare2Boulinguez S. Cornée-Leplat I. Boyssou-Gauthier M.-L. Bedane C. Bonnetblanc J.-M. Aphtes induits par les medicaments analyse de la littérature.Ann Dermatol Venereol. 2000; 127: 155-158PubMed Google Scholar and mainly provoked by antihypertensives3Boulinguez S. Reix S. Bedane C. Debrock C. Bouyssou-Gauthier M.L. Sparsa A. et al.Role of drug exposure in aphthous ulcers a case-control study.Br J Dermatol. 2000; 143: 1137-1139Crossref PubMed Scopus (38) Google Scholar and antiangina drugs.4Marquart-Elbaz C. Lipsker D. Grosshans E. Cribier B. Ulcérations buccales induites par le nicorandil prévalence et aspects clinicopathologiques.Ann Dermatol Venereol. 1999; 126: 587-590PubMed Google Scholar Only 1 case of aphthous ulcers from piroxicam5Siegel M.A. Balciunas B.A. Medication can induce severe ulcerations.J Am Dent Assoc. 1991; 122: 75-77Abstract Full Text PDF PubMed Scopus (15) Google Scholar has been described, but a patch test, prick test, and challenge test with the drug have not been performed. Differential diagnosis between drug stomatitis and recurrent oral aphthae is not always easy, even if the presence of numerous and simultaneous lesions of uniform size (2-3 mm) without sites of predilection, the tendency to coalesce into large ulcers (0.5-2 cm), the absence of evolutive polymorphism, the severe pain, the longer duration of lesions, and their anamnestic recurrence after intake of medications are indicative of aphthous stomatitis induced by drugs. Histologically, this condition is characterized by a dense inflammatory infiltrate rich in eosinophils, which is not present in recurrent oral aphthae. Skin testing with nonsteroidal anti-inflammatory drugs often provides unreliable results, even if they are performed in patients with sure adverse mucocutaneous reactions. Thus, in these patients, an exposure test with the suspected drug should be performed but only in the hospital and specialized centers equipped for emergency and not in patients with severe diseases, such as anaphylaxis, angioedema, erythema multiforme, and Stevens-Johnson syndrome.1Lisi P. Stingeni L. Reazioni cutanee da farmaci antinfiammatori non steroidei dati etio-patogenetici e revisione della letteratura.Ann Ital Dermatol Clin Sper. 1991; 45: 193-213Google Scholar