Drug Eruption Research Articles

Antitubercular drug-induced lichen planus: A case study with a mini literature review.

Drug-induced lichen planus is a cutaneous adverse effect that manifests as a systemic eruption of flat-topped, erythematous, or violaceous papules resembling lichen planus on the trunk and extremities. Although antitubercular therapy has been linked to cutaneous hypersensitivity reactions, the literature on such cases is scarce. Here, we present a case to contribute to this field, reporting on its presentation and management, and reviewing previous case studies. Our patient, a 63-year-old male, presented with black pigmented patches on the skin, having been diagnosed with pulmonary tuberculosis and on antitubercular therapy for the past two months. A diagnosis of ATT-induced lichen planus was made, and all ATT was stopped. The patient was treated with antihistamines, apremilast, tacrolimus, and corticosteroids, and rechallenge of each drug was performed consecutively. No new lesions appeared after rechallenge with isoniazid and rifampicin. However, ethambutol was not reintroduced due to strong suspicion, by exclusion, that it was the offending agent, whereas on rechallenge with isoniazid and rifampicin, the patient's skin lesions gradually improved with eventual resolution of hyperpigmentation. Lichenoid drug eruptions are characterized by type IV hypersensitivity reactions, and rechallenge is required to ensure safer treatment since the risk of disseminated and multi-drug-resistant tuberculosis increases with the cessation of antitubercular therapy.

Drug rash with eosinophilia and systemic symptoms syndrome in an elderly man on carbamazepine – A jeopardising clinical entity

Drug rash with eosinophilia and systemic symptoms syndrome (DRESS) is a rare but serious hypersensitivity drug reaction most frequently associated with antiepileptics. We report a case of carbamazepine-induced DRESS syndrome in a 61-year-old man who was recently initiated on carbamazepine (6 weeks back) and presented with a history of acute febrile illness of 10 days duration. General examination showed multiple erythematous coalescent papules and rash over the body with relative sparing of the face with lymphadenopathy. Laboratory results revealed eosinophilia, atypical lymphocytosis, transaminitis, and negative serology for hepatitis. Registry of severe cutaneous adverse reactions (RegiSCAR) scoring system case is categorized as a definite case with a score of 7. Carbamazepine was discontinued and with the initiation of intravenous steroids; the transaminitis improved, fever and rashes resolved. We report a case of carbamazepine induced DRESS syndrome in a 61-year-old man. He was recently initiated on carbamazepine (6 weeks back), who presented to with a history of acute febrile illness of 10 days duration. General examination showed multiple erythematous coalescent papule and rash over the body with relative sparing of face with lymphadenopathy. Laboratory results revealed an eosinophilia, atypical lymphocytosis, transaminitis and negative serology for hepatitis. RegiSCAR scoring system was used our case is categorized as definite case with a score of 7. Carbamazepine was discontinued and with initiation of intravenous steroids; the transaminitis improved, fever and rashes resolved.

Genital Ulcers Are Not Always Because of Sexually Transmitted Infections: A Case Report of an Unusual Presentation of Fixed Drug Eruption in a Pediatric Patient

Genital Ulcers Are Not Always Because of Sexually Transmitted Infections: A Case Report of an Unusual Presentation of Fixed Drug Eruption in a Pediatric Patient

Lichenoid Drug Eruption in the Setting of Lamotrigine and Amoxicillin: A Case Report

A 43-year-old female with a 5-week history of lamotrigine use presented with a rash over the neck and torso following 2 days of amoxicillin for acute pharyngitis. Despite antibiotic discontinuation, the rash progressed to confluent erythematous papules across the face, trunk, extremities, palms, and soles. Persistent fever, severe lymphadenopathy, and angioedema ensued, with leukocytosis, thrombocytosis, neutrophilia, elevated ESR and CRP. Punch biopsy revealed lichenoid drug eruption with prominent histiocytic components and rare eosinophils. Patient improved after lamotrigine discontinuation with prednisone 80 mg to 20 mg tapered over 8 days. This is the first report of a lichenoid drug eruption in the setting of lamotrigine. Lamotrigine is associated with many cutaneous reactions; this risk may be potentiated in the setting of antibiotic therapy.

Giant fixed drug eruption

Giant fixed drug eruption

A RETROSPECTIVE ANALYSIS OF REPORTED CUTANEOUS ADVERSE DRUG REACTIONS IN A TERTIARY CARE TEACHING HOSPITAL

Objectives: Analysis of adverse drug reactions (ADR) reports enriches and updates physician’s awareness about the pattern of cutaneous adverse reactions in the population studied and may play an important role to envision the frequency of appearance of reactions to specific drugs and morphological designs. This study intends to portray the clinical profile and causative agents of dermal ADRs in our population. Methods: All the ADR reporting forms received from February 2021 to February 2023 were scrutinized, and forms with cutaneous ADRs (CADRs) were analyzed. The data about the history of drug intake, names of the drug taken, time lag of appearance of reaction, and clinical examination details were collected from the reports. Demography, prevalence, reaction time morphological pattern, and causative agents of CADRs were evaluated. Results: Among the CADRs, acute urticaria 53.4 was the most common followed by acute exanthematous reaction 35.8% and lichenoid drug eruption 3.8%. Among the drugs causing CADRs, antibiotics top the list with 47% followed by ATT at 29.7% and iron sucrose 12.9%. Among the antimicrobials, fluoroquinolones 48% top the list followed by cephalosporins 21.6% and penicillins and vancomycin each 8.3%. Conclusion: Physician’s knowledge about pattern and causative agents of CADR in the specific population can aid in prevention and early management of ADRs and thereby reducing hospitalization.

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome following Ticagrelor administration leading to serious complications.

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is rarely reported with administration of Ticagrelor. We report a case, where such complication developed after 7 days of Ticagrelor administration, leading to acute severe complications requiring hospitalization. There was airway and renal involvement with elevated inflammatory markers. On withdrawing Ticagrelor, there was rapid resolution of symptoms.

Acute generalized exanthematous pustulosis caused by sulfasalazine

In the landscape of cutaneous adverse drug reactions (cADRs), acute generalized exanthematous pustulosis (AGEP) remains a pertinent dermatological manifestation. This research delineates a clinical presentation consistent with AGEP precipitated by the administration of sulfasalazine in a 68-year-old female. Drawing from the EuroSCAR study’s diagnostic parameters, the patient exhibited salient features such as facial erythema and a pervasive papular rash, concomitant with specific hematological perturbations, including leukocytosis and elevated hepatic enzymes. Utilizing the EuroSCAR AGEP validation score, a definitive diagnosis was ascertained, obviating the need for histological confirmation. Subsequent therapeutic interventions facilitated symptomatic resolution, leading to the patient’s discharge with a categorical advisory against future sulfasalazine exposure. This elucidation accentuates the causative potential of sulfasalazine in AGEP manifestation and underscores the imperativeness of vigilant diagnosis and timely intervention. Key words: sulfasalazine, AGEP, Drug hypersensitivity, Drug eruptions

Delayed drug hypersensitivity to anti-tuberculosis drug: a new desensitization scheme.

Tuberculosis is a communicable illness and one of the leading causes of death, especially in developing countries like Turkey. One of the problems that must be managed well in the treatment of tuberculosis is drug hypersensitivity. The first-line agents are very important for the success of treatment. Alternative drugs are more toxic and less successful in treatment. Therefore, it is very important to be able to include first-line drugs in the post-hypersensitivity regimen. At this point, the success of desensitization comes to the fore. There are fewer studies on rapid drug desensitization in delayed-type drug hypersensitivity to anti-tuberculosis drugs. The primary aim of the study was to determine the prevalence of delayed-type hypersensitivity reactions in drug-sensitive cases; the secondary aim was to determine the appropriate treatment management. This was a retrospective study. Demographic features, tuberculosis diagnostic indicator, clinical signs of developing a hypersensitivity reaction, reaction time, desensitization scheme and treatment were evaluated. A total of 41 tuberculosis cases were included in the study. Twenty-six of the cases were male; mean age (mean ± SD) 55.44 ±16.93 years; 70.7% of them were diagnosed bacteriologically; 70.7% of them were diagnosed with pulmonary tuberculosis. The most common skin finding was maculopapular drug eruption. The development time (mean ± SD) of the reaction in patients who developed a reaction was 34.93 ±39.62 days. The responsible agent could be identified in 15 reactions. The most common drug responsible for the reaction was rifampicin. Successful desensitization was achieved in 19 (46.3%) cases with the sensitive regimen. The duration of treatment was 8.97 ±3.44 months. When evaluated in terms of treatment results, cure and treatment completion were accepted as treatment success. In this case, 30 (73.2%) patients successfully completed the treatment. Our study is one of the largest series in which delayed-type hypersensitivity develops under tuberculosis treatment and the desensitization scheme is recommended. A practical, easy desensitization scheme had been shared in this paper.

Recurrent Pruritic Erythematous and Pigmented Plaques: Fixed Drug Eruption

Recurrent Pruritic Erythematous and Pigmented Plaques: Fixed Drug Eruption

A Clinico-Epidemiological Study of Fixed Drug Eruption with a Special Focus on the Causative Agent and the Clinical Patterns.

Fixed drug reaction (FDE) is characterized by the development of well-circumscribed, round, erythematous macules and plaques on cutaneous or mucosal surface following ingestion of the offending drug. To study the etiological agents responsible for FDE and to study the clinical patterns of FDE due to different drugs. It was a hospital-based observational cross-sectional clinical study. The study period was 24 months. Fifty patients were included. The study was done after a literature search, hypothesis generation, protocol write-up, ethical submission, ethical clearance, patient enrollment, data collection, data analysis, and research. The patients were selected on the basis of the Naranjo scoring system. The patients with a history of combination drug intake were not included in the study. A total of 0.11% patients presented with FDE in the study period. Out of them, 52% of the patients belonged to 20-39 years age group, having sex ratio of 1.6:1. About 64% of the patients presented with multiple lesions, whereas 36% had a single lesion. A total of 46% patients presented with first episode and 54% had recurrent episodes. The mean time intervals of first and subsequent episodes were 6.5 days and 4.3 hours, respectively. Also, 16% patients had a history of herpes infection. Extremities were more affected followed by trunk and mucosa. Fluoroquinolones were the most common etiological agent found in 56% patients having cutaneous (48%) and mucosal lesions (14%). The most common drug was norfloxacin (36%) followed by both paracetamol (12%) and metronidazole (12%). Fluoroquinolones were the most common drugs implicated in bullous lesions and generalized bullous FDE. The study population was small and the study was for a limited period of time. The patient should be aware of the offending drug and opt for any alternative agent after visiting the physician.

A Clinico-Epidemiological Study of Cutaneous Adverse Drug Reactions in a Tertiary Care Centre of Eastern India.

Adverse drug reactions (ADRs) are major problems in the drug therapy. Cutaneous adverse drug reactions (CADRs) are the most common ADRs. The pattern of CADRs differs among various drugs. To record various morphological patterns of CADRs and their causal relationships among patients attending in a tertiary care centre. An observational, cross-sectional, clinical study was conducted for a duration of one and a half years in a tertiary care centre in eastern India. Patients presenting with suspected CADRs were included if drug identity could be ascertained. Clinical profiling and drug history were recorded, and causality assessment was carried out as per the Naranjo scale. The commonest CADR in our study was fixed drug eruption (FDE) 48.61%, followed by SJS-TEN spectrum 16.66%, maculopapular rash 11.11% and so on. Severe cutaneous adverse drug reactions (SCARs) such as SJS, TEN, SJS-TEN Overlap, AGEP and DRESS accounted for 18 cases (25%). The most common culprit drugs were antimicrobials (54.16%), followed by nonsteroidal anti-inflammatory drugs (15.27%) and anticonvulsants (12.5%). Most of the CADRs were in probable category. The pattern of CADRs and the drugs causing them in our study population are similar to some previous studies but somewhat different from most of the previous Indian studies. The incidence of SCARs was significantly higher than in previous other studies in India and abroad.

Fixed Eruptions: Drug, Food, and What More?

Abstract Fixed drug eruption (FDE) is a common entity encountered in our day-to-day clinical practice. It is a T-cell-dependent pathway with induction of interferon-gamma-producing CD8+ T-cells in the dermis and epidermis. It is not just a drug that causes a fixed eruption but has also been described with food known as fixed food eruption and also with other agents. The article describes the common causes and pathomechanism of FDE.

Ethambutol-induced Oral Lichenoid Drug Eruption: An Uncommon Occurrence

Ethambutol-induced Oral Lichenoid Drug Eruption: An Uncommon Occurrence

Variants of Fixed Drug Eruptions Following Covid-19 Vaccination: A Series of Three Cases.

Variants of Fixed Drug Eruptions Following Covid-19 Vaccination: A Series of Three Cases.

Pharmacological Treatment of Trigeminal Neuralgia

Although carbamazepine is the first-line treatment option for trigeminal neuralgia, it may not be sustained long-term. The benefits of carbamazepine are offset by adverse effects that lead to its withdrawal. The alternatives to carbamazepine include gabapentin, pregabalin, and microgabalin. Although used off-label in Japan, baclofen, lamotrigine, intravenous lidocaine, and botulinum toxin type A are also effective. Clinical experience has shown that alternative treatments are less effective than carbamazepine. Therefore, they can be used instead of or in addition to carbamazepine. The adverse effects of drugs include drowsiness, dizziness, rash, bone marrow suppression, and liver dysfunction. Carbamazepine and lamotrigine are particularly likely to cause severe drug eruptions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Low-dose titration is important to avoid the development of rashes and adverse effects.

Various Clinical Phenotypes and Approach to Patients with NSAID Hypersensitivity

Nonsteroidal anti-inflammatory drugs (NSAIDs) can induce hypersensitivity reactions with various clinical manifestations including acute/delayed reactions and three common phenotypes, NSAID/aspirin-exacerbated respiratory disease (NERD or AERD) with/without chronic rhinosinusitis (CRS) and nasal polyps, NSAID-exacerbated cutaneous disease (NECD). NSAID-induced urticaria/angioedema (NIUA). NIAU is commonly combined with anaphylaxis and named as NIUAA. The major pathogenic mechanism is the inhibition of cyclooxygenase-1 with a reduction in prostaglandin E2 levels, leading to the overproduction of cysteinyl leukotrienes and activation of inflammatory cells, including eosinophils and mast cells. To confirm the diagnosis, provocation testing via the oral route or inhalation remains the gold standard; in vitro diagnostic methods are still not available. Essential managements are: (1) avoidance of cross-reacting NSAIDs along with the use of alternative analgesics; (2) pharmacologic treatment should follow standard guidelines in patients with underlying asthma/rhinitis (NERD, CRS), and urticaria (NECD). Aspirin desensitization and biologic treatment can be done when indicated. Delayed reactions, including fixed drug eruptions, maculopapular eruptions, and severe cutaneous adverse reactions, are rare and mediated by T-cell responses. Symptomatic treatment with avoidance is essential. NSAID is a cofactor of food-dependent exercise-induced anaphylaxis. In this talk, we will update various clinical phenotypes and discuss practical issues faced in real clinical practice.

Insights into Mefenamic Acid-Induced Allergic Reactions: A Comprehensive Clinical and Research Review

This study investigates the incidence of Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome associated with the over-the-counter non-steroidal anti-inflammatory drug (NSAID) mefenamic acid. Approximately 10% of individuals exposed to mefenamic acid experience DRESS syndrome, a severe and potentially fatal allergic reaction characterized by fever, skin rash, lymphadenopathy, hematological abnormalities, and internal organ involvement. Leukocytosis with eosinophilia (90%) and mononucleosis (40%) has been linked to certain cases, emphasizing the diversity of clinical presentations. The causative medication must be promptly discontinued upon identification of DRESS syndrome, with documented evidence indicating improved prognosis with early drug removal. Despite the severity of these reactions, the study sheds light on the alarming accessibility of mefenamic acid and other banned medications in developing nations, particularly exemplified by the Indian Pharmacopoeia Commission’s alert on mefenamic acid issued on December 7, 2023. The lack of effective law enforcement and medical awareness poses significant challenges, allowing banned drugs, including Nimesulide and Rofecoxib, to persist in the market despite being banned by the USFDA. This research underscores the critical need for global collaboration to address regulatory gaps, enhance medical awareness, and enforce stringent measures to restrict the availability of harmful medications in developing nations. Urgent attention to these issues is imperative to safeguard public health and ensure the effective implementation of drug regulations on a global scale.

Multi‐institutional retrospective review of acute generalized exanthematous pustulosis (AGEP) induced by hydroxychloroquine

AbstractBackgroundAcute generalized exanthematous pustulosis (AGEP) is a rare and severe cutaneous drug eruption. Hydroxychloroquine (HCQ) is one of the known culprit drugs with less than 60 cases reported in the literature, and may have a more severe clinical presentation compared to AGEP induced by other drugs. There are no standardized management strategies for HCQ‐induced AGEP outside of drug discontinuation.ObjectivesCharacterize the clinical presentation of HCQ‐induced AGEP and management strategies.MethodsRetrospective chart review of nine patients clinically diagnosed with HCQ‐induced AGEP using the EuroSCAR score from 2017 to 2022 at four academic medical centres in the United States.ResultsAll patients in our series were female and the median age was 52. Four patients initially presented with fever, and eight patients had neutrophilia. Median time to rash was 15 days. Biopsies obtained in six patients showed typical characteristics of AGEP. In most patients, rash morphology consisted of generalized pinpoint pustules atop atypical targetoid lesions and annular plaques. Five patients were hospitalized for AGEP. All patients were treated with methylprednisolone and/or prednisone, and the average days treated with systemic corticosteroids was 35.ConclusionsOur case series is the largest to date describing HCQ‐induced AGEP. Clinicians should be wary that HCQ‐induced AGEP may present with a longer latency period after drug initiation and with atypical targetoid and annular lesions. Early initiation of systemic corticosteroids should be considered due to the severity of this drug reaction with addition of cyclosporine in refractory cases.

Prevalence and spectrum of infectious and inflammatory dermatologic conditions occurring in pediatric heart transplant patients on a predominantly mTOR-based immune suppressive regimen: A retrospective chart review.

Pediatric heart transplant patients are routinely followed in dermatology clinics due to elevated risk of cutaneous malignancy. However, transplant patients may experience other, non-cancer-related dermatologic conditions including skin infections, inflammatory diseases, and drug eruptions that can cause significant medical and psychosocial comorbidity. A retrospective chart review of all pediatric heart transplant patients at Mayo Clinic Children's Center in Rochester, MN, was performed to determine the prevalence and spectrum of non-cancer dermatologic conditions. Statistical analysis was conducted to look for associations between episodes of rejection and skin condition development. Of the 65 patients who received heart transplants under the age of 18 and were followed at Mayo Clinic, 69% (N = 45) were diagnosed with at least one skin condition between transplant and the time of most recent follow-up. Sixty-two percent (N = 40) of patients were diagnosed with an inflammatory skin condition (most commonly acne and atopic dermatitis), 45% (N = 29) with an infectious skin condition (most commonly warts and dermatophyte infection), and 32% (N = 21) with a drug eruption (most commonly unspecified rash and urticaria). No association was found between presence of skin disease and number of rejection episodes. Non-cancer dermatologic conditions are prevalent within pediatric heart transplant recipients and may directly impact their medical needs and quality of life. Dermatologist involvement in the care of post-transplant pediatric patients is important, not only for cancer screening but also for diagnosis and treatment of common infectious and inflammatory skin conditions.