Exfoliative Dermatitis (Sodium Valproate Induced)

Abstract

Letters to the EditorExfoliative Dermatitis (Sodium Valproate Induced) Ghulam NabiMD Ghulam Nabi Chief Pediatrician, Civil Hospital, P.O. Box 737, Khamis Mushyat, Saudi Arabia Search for more papers by this author Published Online:1 Jul 1993https://doi.org/10.5144/0256-4947.1993.388SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor: Exfoliative dermatitis is an erythematous scaling eruption which involves most or all of the skin. The eruption can vary from slight scaling and minimal redness to generalized desquamation associated with systemic toxic symptoms [1]. Sodium valproate is being used for febrile convulsions with no particular toxic effect in young children [2]. We are reporting a case of recurrent febrile convulsions who was put on long term anticonvulsive therapy, sodium valproate, and developed one of the rare complications, exfoliative dermatitis, with this drug.A two-year-old Sudanese male presented with a history of recurrent convulsions since the age of nine months. He had five attacks of convulsions until he reported to our clinic. Each attack lasted from three to five minutes, tonic clonic type, always associated with respiratory tract infection and fever. The patient was getting the treatment for each episode from the local dispensary, syrup ampicillin and paracetamol. Antenatal, natal, and postnatal history were uneventful. There was no family history of convulsions or skin disease. On examination, the patient was of average build and undernourished; growth parameters were a weight of 10 kg (below the tenth percentile), length 85 cm and head circumference 48 cm, both normal. Vital signs were within normal limits. There was no neurological deficit and all other systems were clinically normal. Investigations: hemoglobin, total leucocyte count, total proteins, serum electrolytes, blood glucose, blood gases, x-ray of the skull, electroencephalography, and liver function tests were all normal. The patient was put on long term anticonvulsive therapy of Depakine syrup (sodium valproate) 20 mg/kg/day in two divided doses per oral for a period of two years.Six weeks after starting the treatment, he developed generalized redness of the skin with itching all over the body. The erythema was a bright red, classical allergic drug rash. The patient was taking only Depakine and no other medication. There was no fever, jaundice, lymphadenopathy, hepatosplenomegaly, or signs of congestive cardiac failure. The drug was stopped and the patient was put on chlorpheniramine maleate syrup 0.35 mg/kg/day in three divided doses per oral. Local application of calamine lotion was used as a soothing agent. Itching subsided and desquamation started; this lasted for a period of two weeks. In a total period of one month, skin was normal and the child was healthy. He is coming for follow-up regularly.Sodium valproate is a widely used drug for febrile convulsions. Usually in therapeutic doses, there are minimal side effects [2]. One of the rare complications of this drug is hepatotoxicity (one per 10,000 patients) [3]. Idiosyncrasy has been reported in some cases but exfoliative dermatitis due to this drug is very rare [4]. Exfoliative dermatitis is more common in adults than in children and males are affected more than females [5]. The patient developed skin rash and itching six weeks after starting the treatment. He was taking only this medication and there was no associated disease, so we presumed this was a delayed allergic drug reaction. After the drug was stopped, the patient was put on oral antihistamine and local application of calamine lotion. The itching stopped and desquamation started, which lasted for two weeks. In a total period of one month, the skin was normal. Our patient was undernourished and susceptibility to the infection in these cases is well known. Correlation between undernutrition and drug allergy is not known. Exfoliative dermatitis is associated with fever, lymphadenopathy, heart failure, dehydration, splenomegaly, bacterial infection, and partial or complete alopecia; none of these were present in our patient [5]. In conclusion, sodium valproate is being used widely for convulsive disorders. Besides known adverse side effects, there may be involvement of skin in the form of exfoliative dermatitis. Physicians who care for children who are on sodium valproate therapy should bear this complication in mind.ARTICLE REFERENCES:1. Thomas RM. "Drug eruptions" . Med Int’l, Middle Eastern Edition, Derm. 1992; 1(2):4273-7. Google Scholar2. Monaco F, Mele G, Meloni T, et al.. "A longitudinal study of valproate free fraction in the specific age group at greatest risk for febrile convulsions (children below three years)" . Epilepsia, 1984; 25(2):240-3. Google Scholar3. Murphy JV. "Valproate monotherapy in children" . Am J Med. 1988; 84(1A):17-22. Google Scholar4. Sharma M, Agrawal P. "Valproic acid" . Ind Pediatr. 1991; 28:921-4. Google Scholar5. Nicolis GD, Helwig EB. "Exfoliative dermatitis" . Arch Derm. 1973; 108:788-97. Google Scholar Previous article FiguresReferencesRelatedDetails Volume 13, Issue 4July 1993 Metrics History Published online1 July 1993 InformationCopyright © 1993, Annals of Saudi MedicinePDF download