Exanthematous Pustulosis Research Articles

Acute Localized Exanthematous Pustulosis Due to Alendronate.

Acute Localized Exanthematous Pustulosis Due to Alendronate.

Mechanism of Lethal Skin Toxicities Induced by Epidermal Growth Factor Receptor Inhibitors and Related Treatment Strategies.

Epidermal growth factor receptor (EGFR) inhibitors are widely used to treat various types of cancers such as non-small cell lung cancer, head and neck cancer, breast cancer, pancreatic cancer. Adverse reactions such as skin toxicity, interstitial lung disease, hepatotoxicity, ocular toxicity, hypomagnesemia, stomatitis, and diarrhea may occur during treatment. Because the EGFR signaling pathway is important for maintaining normal physiological skin function. Adverse skin reactions occurred in up to 90% of cancer patients treated with EGFR inhibitors, including common skin toxicities (such as papulopustular exanthemas, paronychia, hair changes) and rare fatal skin toxicities (e.g., Stevens–Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis). This has led to the dose reduction or discontinuation of EGFR inhibitors in the treatment of cancer. Recently, progress has been made about research on the skin toxicity of EGFR inhibitors. Here, we summarize the mechanism of skin toxicity caused by EGFR inhibitors, measures to prevent severe fatal skin toxicity, and provide reference for medical staff how to give care and treatment after adverse skin reactions.

Safety of Favipiravir for Treatment of COVID-19: Latest Systematic Review

Background: Adverse event studies of favipiravir use in treating COVID-19 have been ongoing since it was established as a treatment option. A better understanding of the side effects of favipiravir from recent studies is important in developing and assessing the recognition of effective treatments for COVID-19. Method: This was a systematic review based on studies and case reports on favipiravir monotherapy in COVID-19. Access to the included studies was gained via PubMed, SCOPUS, Science Direct, SpringerLink, and MedRxiv. Results: Twelve studies consisting of eight studies and four case reports were reviewed. The most common side effects were diarrhea, elevated liver enzyme levels, and hyperuricemia. None of which were significantly different from the comparison. Currently, various adverse event were reported in case reports such as drug fever,acute generalized exanthematous pustulosis (AGEP), and transient increase in viral load. The side effects would mostly be subsided after the treatment was discontinued.Conclusion: The use of favipiravir to treat COVID-19 caused dose-related side effects such as diarrhea, changes in liver enzymes, and increased level of uric acid. There were no serious side effectscompared to other antiviral drugs. To improve the efficacy and safety of COVID-19 therapy, it is important to prepare an incidence report of antiviral adverse events in special populations such as children, pregnant women, and patients with organ dysfunction.

Linagliptin-induced acute generalized exanthematous pustulosis.

Linagliptin-induced acute generalized exanthematous pustulosis.

POS-903 ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI) OF COVID-19 VACCINES IN KIDNEY PATIENTS- A CASE SERIES

Patients with kidney diseases have been prioritised for covid 19 vaccination due to their higher risk for worse outcomes from covid 19 infections. Data on vaccine efficacy and safety have generally been inferred from studies of non-CKD population. The immune response from vaccinations may trigger various diseases with an immunopathogenesis. We report a series of 3 patients with kidney diseases who developed adverse events worth noting following vaccination Case 1: 67 years old, Male, with underlying primary membranous nephropathy, treated with oral cyclophosphamide and steroids and was in partial remission with proteinuria of 1.1g/24H. He came with relapsed nephrotic range proteinuria of 5.3g/24H 2 weeks after the 1stdose of Pfizer–BioNTech COVID-19 vaccine. Anti- PLA2R titre repeated was 41.8 RU/ml from 1574 RU/ml. Proteinuria self-reduced to 1.6g/24H about 1 month post vaccination with conservative management. Case 2: 60 years old, male, with underlying ESRF on regular haemodialysis and diabetes mellitus, became acutely delirious with Glasgow Coma Scale (GCS) ranging 10 to 13, 3 days after 1stdose Sinovac CoronaVac covid-19 vaccine. Multiple investigations ruled out organic causes. Patient did not respond to empirical treatment of meningo-encephalitis but responded with intravenous methylprednisolone and recovered full GCS on day 2 of methylprednisolone. Cerebrospinal fluid was normal. MRI brain showed non-specific finding with focus T2W/ FLAIR hyperintensity at splenium of corpus callosum. Patient likely had Acute Disseminated Encephalomyelitis post- vaccination with rapid response to steroids. Case 3: 28 years old, female, with underlying Systemic Lupus Erythematosus (SLE) with renal, muco-cutaneous, and joint involvement had been in remission on maintenance therapy of Myfortic and low dose steroids; developed progressive generalised pustular lesions immediately day 3 post second dose Sinovac CoronaVac covid-19 vaccine. Skin biopsy done suggestive of acute generalised exanthematous pustulosis (AGEP). She had no history of concomitant medications, viral infections, or drug allergies either before or after the COVID-19 vaccination. Skin lesions improving with steroids and potassium permanganate wet dressing with emollients. Even though benefits from vaccination far outweighs potential risks, health professional should be alert to the various adverse events that may occur following covid-19 vaccination. Patients with kidney diseases may experience different adverse events post vaccination unique to their underlying kidney diseases. Further studies are needed for better understanding of the effects of vaccination in the CKD population.

Drug Triggers and Clinic of Acute Generalized Exanthematous Pustulosis (AGEP): A Literature Case Series of 297 Patients.

Acute generalized exanthematous pustulosis (AGEP) is a rare skin reaction, commonly caused by drugs. Available evidence mostly relies on small studies or case reports. We collected published AGEP case reports and, subsequently, described the patient characteristics, suspect and concomitant drugs, time to onset, disease management, and clinical prognosis. This study included 297 AGEP patients (64.3% women) obtained from 250 published case reports or case series with individual patient data. AGEP affected patients of all ages, but the majority of patients (88.2%) were ≥25 years old. The most frequently reported suspect drugs were anti-infectives for systemic use (36.5%), particularly antibacterials for systemic use (31.0%), and especially beta-lactam antibacterials (18.3%) and macrolides (4.3%). Other frequent suspect drugs were antineoplastics (12.2%), and anti-inflammatory/anti-rheumatic products (5.2%) plus hydroxychloroquine (12.8%). Mean time to onset was 9.1 days (standard deviation SD 13.94). Some patients developed fever (64.3%) and systemic involvement (18.9%), and most patients (76.4%) received pharmacological treatment for AGEP. Seven patients died, although five of them were already critically ill prior to AGEP. In conclusion, antibiotics remain the most common suspected cause of AGEP. While case mortality rate may be up to 2.5%, disentangling the role of AGEP on the fatal outcome from the role of the preexisting health conditions remains challenging.

Clinical Characteristics, Disease Course, and Outcomes of Patients With Acute Generalized Exanthematous Pustulosis in the US

Acute generalized exanthematous pustulosis (AGEP) is a rare, severe cutaneous adverse reaction associated with systemic complications. Currently available data are largely limited to small retrospective case series. To describe the clinical characteristics, disease course, and outcomes of a heterogeneous group of patients with AGEP across the US. A retrospective review of a case series of patients was conducted from January 1, 2000, through July 31, 2020. All 340 included cases throughout 10 academic health systems in the US were scored retrospectively using the EuroSCAR scoring system, and patients with a score corresponding to probable or definite AGEP and aged 18 years or older were included. Patient demographic characteristics, clinical course, suspected causative agent, treatment, and short- and long-term outcomes. Most of the 340 included patients were women (214 [62.9%]), White (206 [60.6%]), and non-Hispanic (239 [70.3%]); mean (SD) age was 57.8 (17.4) years. A total of 154 of 310 patients (49.7%) had a temperature greater than or equal to 38.0 °C that lasted for a median of 2 (IQR, 1-4) days. Of 309 patients, 263 (85.1%) developed absolute neutrophilia and 161 patients (52.1%) developed either absolute or relative eosinophilia. Suspected causes of AGEP were medications (291 [85.6%]), intravenous contrast agents (7 [2.1%]), infection (3 [0.9%]), or unknown (39 [11.5%]). In 151 cases in which a single medication was identified, 63 (41.7%) were β-lactam antimicrobials, 51 (33.8%) were non-β-lactam antimicrobials, 9 (6.0%) were anticonvulsants, and 5 (3.3%) were calcium channel blockers. The median time from medication initiation to AGEP start date was 3 (IQR, 1-9) days. Twenty-five of 298 patients (8.4%) had an acute elevation of aspartate aminotransferase and alanine aminotransferase levels, with a peak at 6 (IQR, 3-9) days. Twenty-five of 319 patients (7.8%) experienced acute kidney insufficiency, with the median time to peak creatinine level being 4 (IQR, 2-5) days after the AGEP start date. Treatments included topical corticosteroids (277 [81.5%], either alone or in combination), systemic corticosteroids (109 [32.1%]), cyclosporine (10 [2.9%]), or supportive care only (36 [10.6%]). All-cause mortality within 30 days was 3.5% (n = 12), none of which was suspected to be due to AGEP. This retrospective case series evaluation of 340 patients, the largest known study cohort to date, suggests that AGEP onset is acute, is usually triggered by recent exposure to an antimicrobial, may be associated with liver or kidney complications in a minority of patients, and that discontinuation of the triggering treatment may lead to improvement or resolution.

Acute localized exanthematous pustulosis: A novel side effect of piroxicam

Acute generalized exanthematous pustulosis (AGEP) is a rare yet well-known cutaneous reaction pattern, mostly caused by drugs. Acute localized exanthematous pustulosis (ALEP) is a localized variant of AGEP. A 42-year-old female presented with multiple erythematous pustules on the face, which appeared three days after the intramuscular injection of piroxicam. Histopathology revealed subcorneal pustules, epidermal spongiosis, and mixed inflammatory cell infiltration in the dermis. The pustules resolved within several days once the patient had discontinued the drug. Herein, we report the first case, as far as we know, of a female with a cutaneous drug reaction consistent with ALEP caused by piroxicam.

Acute generalized exanthematous pustulosis: A case highlighting the uncommon side effect of a common anti-Covid drug doxycycline in the era of Covid-19 pandemic

Acute generalized exanthematous pustulosis: A case highlighting the uncommon side effect of a common anti-Covid drug doxycycline in the era of Covid-19 pandemic

Acute localized exanthematous pustulosis (ALEP) due to itraconazole.

Acute localized exanthematous pustulosis (ALEP) due to itraconazole.

Management of drug allergy-clinical update

The new classification of drug hypersensitivity reactions (DHRs) is based on phenotypes, endotypes, and biomarkers. Immediate and delayed reactions are the clinical phenotypic presentation while endotypes are based on cellular, biological mediators, and biomarkers. Complement activation, cyclooxygenase-1 inhibition, Mas-Related G Protein-Coupled Receptor-X2 (MRGPRX2), Cytokine release syndrome (CRS) is also included in DHRs due to mast cell activation e.g., radio contrast media, nonsteroidal anti-inflammatory drugs, monoclonal antibodies, oxaliplatin and taxanes, etc. Genetic predisposition of specific human leukocyte antigen alleles has been associated with the development of T cell-mediated symptoms of severe cutaneous adverse reactions (SCAR), which includes acute generalized exanthematous pustulosis, drug rash with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, and toxic epidermal necroplasia, due to antibiotics, retrovirus and anti-convulsant drugs, etc., drug desensitization (Ds), is a personalized treatment approach for immunoglobulin E (IgE), and Non-IgE mediated DHRs, for example, antibiotics, biologicals, chemotherapy, etc. This review will update on the mechanism of DHRs, the clinical approach of alternative drugs, and Ds in a high-risk patient.

Localized Pustular Purpuric Eruption Associated with Propionic Acid NSAIDs: Acute Localized Exanthematous Pustulosis Accompanied with Leukocytoclastic Vasculitis.

Localized Pustular Purpuric Eruption Associated with Propionic Acid NSAIDs: Acute Localized Exanthematous Pustulosis Accompanied with Leukocytoclastic Vasculitis.

Patch Testing in Drug Eruptions: Practical Aspects and Literature Review of Eruptions and Culprit Drugs.

There is overwhelming evidence that many delayed cutaneous adverse drug reactions (beginning >6 hours after drug intake) are mediated by delayed-type (type IV) hypersensitivity, including maculopapular eruptions, erythroderma, symmetrical drug-related intertriginous and flexural exanthema/baboon syndrome, eczematous eruptions, fixed drug eruptions, acute generalized exanthematous pustulosis, and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome. Therefore, after resolution of the reaction, patch tests should be performed as first diagnostic method to identify the culprit drug(s). This article provides tools to perform drug patch tests properly and safely, discussing clinical history, indications, procedure, drug patch test materials, sensitivity, the meaning of negative patch tests, and safety of the procedure. In addition, a literature review of eruptions and culprit drugs is provided in tabular format.

Management of Psychiatric Disorders with HIV and Dermatological Disorders.

Management of Psychiatric Disorders with HIV and Dermatological Disorders.

Ostra uogólniona osutka krostkowa w związku czasowym ze szczepieniem przeciw COVID-19

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Ozturk S, Ordu M. Acute generalized exanthematous pustulosis in temporal association with COVID-19 vaccine. Dermatology Review/Przegląd Dermatologiczny. 2022;109(6):464-468. doi:10.5114/dr.2022.126606. APA Ozturk, S., & Ordu, M. (2022). Acute generalized exanthematous pustulosis in temporal association with COVID-19 vaccine. Dermatology Review/Przegląd Dermatologiczny, 109(6), 464-468. https://doi.org/10.5114/dr.2022.126606 Chicago Ozturk, Simay Bayrak, and Melike Ordu. 2022. "Acute generalized exanthematous pustulosis in temporal association with COVID-19 vaccine". Dermatology Review/Przegląd Dermatologiczny 109 (6): 464-468. doi:10.5114/dr.2022.126606. Harvard Ozturk, S., and Ordu, M. (2022). Acute generalized exanthematous pustulosis in temporal association with COVID-19 vaccine. Dermatology Review/Przegląd Dermatologiczny, 109(6), pp.464-468. https://doi.org/10.5114/dr.2022.126606 MLA Ozturk, Simay Bayrak et al. "Acute generalized exanthematous pustulosis in temporal association with COVID-19 vaccine." Dermatology Review/Przegląd Dermatologiczny, vol. 109, no. 6, 2022, pp. 464-468. doi:10.5114/dr.2022.126606. Vancouver Ozturk S, Ordu M. Acute generalized exanthematous pustulosis in temporal association with COVID-19 vaccine. Dermatology Review/Przegląd Dermatologiczny. 2022;109(6):464-468. doi:10.5114/dr.2022.126606.

Acute generalized exanthematous pustulosis induced by sulfasalazine: Uncommon presentation of a common culprit

Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse drug reaction caused by drugs in the majority of cases. It is characterized by the sudden onset of nonfollicular sterile pustules, papules, and edematous plaques on an erythematous background, predominantly involving the flexures. Sulfa drugs have a notorious reputation of wide range of severe adverse reactions, including AGEP. However, nonantibiotic sulfonamides behave differently from antibiotic sulfonamides in the pattern of adverse drug reactions and seldom cause AGEP. Only one case of AGEP due to salazosulfapyridine has been documented, none due to sulfasalazine. We report a 40-year-old female patient with a known case of reactive arthritis who was started on tablet sulfasalazine 500 mg in escalating doses, 4 days before the onset of nonfollicular sterile pustules, on erythematous background predominantly over flexures. She was diagnosed as a case of definite AGEP with score of 12/12 on the European Study of Severe Cutaneous Adverse Reaction validation scale. As per the Naranjo causality scale, sulfasalazine was the probable drug with a score of 5.

The Confusion between Pustular Psoriasis and Acute Generalized Exanthematous Pustulosis as a Cause of Exfoliative Dermatitis: A Case Report

Background: Pustular psoriasis and Acute Generalized Exanthematous Pustulosis (AGEP) are grouped under pustular diseases, in which their clinical manifestations are similar. Those diseases can lead to exfoliative dermatitis. Purpose:To evaluate a specific histopathological examination in differentiating Pustular Psoriasis and AGEP. Case: A 55-year-old woman presented with sudden redness and diffused scaly skin with multiple pustules and also fever. She had taken Cefadroxil 2 days before the scales and pustules appeared. Leukocytosis and histopathological examination results from biopsy supported the diagnosis of AGEP. The patient was then hospitalized and received steroid therapy. Within the first week of tapering off, the scales disappeared but the pustules increased. After such clinical findings, the histopathological examination results were revisited and reassessed. Thus, we considered changing the diagnosis to Pustular Psoriasis, and the therapy was switched to Methotrexate. The patient had a better outcome, and the pustules slowly disappeared entirely. Discussion: It is often difficult to differentiate between the pustules in pustular psoriasis and AGEP unless by thorough history-taking and physical examinations. AGEP is characterized by a widespread of pustules with an acute febrile onset; while pustular psoriasis is an acute variant of psoriasis where pustules are spread over erythematous skin and accompanied by high fever and leukocytosis. Conclusion: Histopathological examination is the gold standard for the establishment of pustular psoriasis diagnosis. The histopathological characteristics of pustular psoriasis and AGEP are difficult to differentiate. Therefore, we need detailed history-taking and physical examination to establish the diagnosis.

Clinical characteristics and management of acute generalized exanthematous pustulosis with haemodynamic instability.

BackgroundAcute generalized exanthematous pustulosis (AGEP) is a severe pustular drug eruption with rare reports of haemodynamic instability.ObjectiveTo describe the clinical characteristics, management, and outcomes of patients with AGEP‐associated haemodynamic instability.MethodsThis retrospective case series identified adult patients diagnosed with AGEP who had haemodynamic instability from November 2012 to February 2020 that were seen at two academic teaching hospitals with roles as a burn centre and tertiary referral centre at the University of Texas Southwestern Medical Center in Dallas, TX USA. Patients with a discharge diagnosis of AGEP that had haemodynamic instability during their eruption were included. Patients with a history of psoriasis, presentations thought to be a flare of generalized pustular psoriasis, or concurrent infection during eruption were excluded. AGEP with haemodynamic instability was characterized by degree of hypotension, dermatologic phenotype at time of dermatologic consultation, and management approach.ResultsThis study included 19 patients with AGEP‐associated haemodynamic instability (mean age, 52 years; age range, 29–76 years; 11 (58%) female). Patients were classified on a spectrum of haemodynamic instability; three had sustained hypotension, 10 had hypotension with organ dysfunction, and six had shock. Patients with AGEP‐associated haemodynamic instability had a range of dermatologic phenotypes at initial consultation: subtle exanthematous eruption with minimal pustules, typical eruption with pustules and flexural predominance, and severe eruption with features of Stevens–Johnson syndrome. Both topical and systemic corticosteroids were used for treatment of several patients. Of the patients that required vasopressors and received systemic steroids, the majority were off vasopressors within 24 h of steroid initiation.ConclusionApproximately 22% of patients presenting with AGEP to a tertiary referral center had haemodynamic instability. Clinicians should be aware that dermatologic phenotype of AGEP at presentation does not correlate with development of haemodynamic instability.

Drug triggered pruritus, rash, papules, and blisters \u2013 is AGEP a clash of an altered sphingolipid-metabolism and lysosomotropism of drugs accumulating in the skin?

Rash, photosensitivity, erythema multiforme, and the acute generalized exanthematous pustulosis (AGEP) are relatively uncommon adverse reactions of drugs. To date, the etiology is not well understood and individual susceptibility still remains unknown. Amiodarone, chlorpromazine, amitriptyline, and trimipramine are classified lysosomotropic as well as photosensitizing, however, they fail to trigger rash and pruritic papules in all individuals. Lysosomotropism is a common charcteristic of various drugs, but independent of individuals. There is evidence that the individual ability to respond to external oxidative stress is crosslinked with the elongation of long-chain fatty acids to very long-chain fatty acids by ELOVLs. ELOVL6 and ELOVL7 are sensitive to ROS induced depletion of cellular NADPH and insufficient regeneration via the pentose phosphate pathway and mitochondrial fatty acid oxidation. Deficiency of NADPH in presence of lysosomotropic drugs promotes the synthesis of C16-ceramide in lysosomes and may contribute to emerging pruritic papules of AGEP. However, independently from a lysosomomotropic drug, severe depletion of ATP and NAD(P)H, e.g., by UV radiation or a potent photosensitizer can trigger likewise the collapse of the lysosomal transmembrane proton gradient resulting in lysosomal C16-ceramide synthesis and pruritic papules. This kind of papules are equally present in polymorphous light eruption (PMLE/PLE) and acne aestivalis (Mallorca acne). The suggested model of a compartmentalized ceramide metabolism provides a more sophisticated explanation of cutaneous drug adverse effects and the individual sensitivity to UV radiation. Parameters such as pKa and ClogP of the triggering drug, cutaneous fatty acid profile, and ceramide profile enables new concepts in risk assessment and scoring of AGEP as well as prophylaxis outcome.

M011 HYPERSENSITIVITY TO AMOXICILLIN-CLAVULANATE MANIFESTING AS ACUTE LOCALIZED EXANTHEMATOUS PUSTULOSIS

In 2005, Prange and colleagues identified a localized variant of acute generalized exanthematous pustulosis (AGEP) they termed ‘acute localized exanthematous pustulosis’ (ALEP). ALEP is characterized by sterile pinhead-sized nonfollicular pustules over an erythematous base typically distributed on the face, neck, or chest. Over 80% of cases are in response to medications, with beta-lactam antibiotics being frequently implicated. We describe a case of facial ALEP that developed three days after initiating amoxicillin-clavulanate therapy.