Non-follicular Pustules Research Articles

Acute generalized exanthematous pustulosis secondary to spider bites: Clinico-dermoscopic findings and review of literature

Acute generalized exanthematous pustulosis (AGEP) or toxic pustuloderma is a febrile adverse cutaneous reaction, characterized by small non-follicular sterile pustules. AGEP can occur in any age group and is found to be more common in women. A large proportion (>90%) of cases are triggered by medications, particularly macrolides and aminopenicillins. The occurrence of AGEP following spider bite has been rarely documented in the literature.We report two cases who presented to us with AGEP following spider bite along with dermoscopic findings and also present a brief review of literature on the same.

Acute Generalized Exanthematous Pustulosis (AGEP): Case Report

Acute generalized exanthematous pustulosis (AGEP) is a clinical and rare condition characterized by the sudden development of multiple non-follicular sterile pustules that are pruritic, primarily appearing in intertriginous areas. This study reports a case of AGEP during pregnancy in a 24-year-old patient, at a gestational age of 35 weeks and 3 days. She was admitted to the obstetric ward with a presentation of pustular exanthematous lesions on the lips, chest, abdomen, face, and upper limbs. The treatment was initiated with a pulse therapy of methylprednisolone at 1 gram per day for 3 days, and albendazole for 5 days. The patient remained hospitalized until she reached 37 weeks of gestation, and a cesarean section was eventually recommended due to failed induction, and the procedure occurred without complications.

Acute generalized exanthematous pustulosis induced by isoniazid and pyrazinamide in a child

An 8-year-old female with cervical lymph node tuberculosis, received rifampicin, isoniazid, pyrazinamide, and ethambutol. Two weeks later, she developed a fever and a generalized erythematous rash covered with pustules. Acute generalized exanthematous pustulosis diagnosis was confirmed by a skin biopsy. Antitubercular therapy was discontinued. Drug causality was found using oral provocation tests and patch tests. Cutaneous adverse drug reactions to first-line antituberculosis drugs are common. However, acute generalized exanthematous pustulosis is rare. It is a severe form of cutaneous drug reaction, primarily associated with beta-lactam antibiotics, and clinically characterized by non-follicular pustules on erythematous skin.

Severe Acute Genital Ulcer: An Unusual Presentation of Behçet’s Disease: A Case Report

Introduction: Genital ulcers are among the main manifestations of Behçet’s disease (BD); however, large severe acute genital ulcers are not common. Case Presentation: A 29-year-old unmarried woman with a history of recurrent oral aphthae presented with a genital ulcer developed 2 weeks before admission. On clinical examination, there were two large painful ulcerations on the right labia majora, painful oral ulcerations, non-follicular pustules on the face and limbs, and painful edema on the left leg with positive Homan’s sign. The D-dimer level was elevated, and a Doppler ultrasound showed deep venous thrombosis of the right common femoral, femoral, and popliteal veins. The BD was diagnosed according to the International Criteria for Behçet’s Disease. The patient was treated with prednisone 40 mg/day and colchicine 1 mg/day, and the lesions developed well and healed within 2 weeks, leaving scarring lesions in the genital area. Conclusions: Behçet's disease is an important nonvenereal cause of genital ulceration. A high index of suspicion in a patient with mucocutaneous lesions might result in the early diagnosis, management, and prevention of complications.

Dermoscopy of Acrodermatitis Continua of Hallopeau.

A 29-year-old female presented with recurrent episodes of painful pustules over the right thumb for the past 8 months. She was treated with oral antibiotics along with avulsion of the nail plate, but it did not improve her condition. She had no history of other skin disorders. On examination, the nail plate was absent. Erythematous plaque with scaling and few areas of crusting were present involving the nail bed and pulp of the right thumb [Figure 1a] along with a single pustule on the right thumb [Figure 1b]. Dermoscopy (Polarized contact light dermoscopy; Dermlite DL4; 10×) revealed yellowish-white scales and linear blood vessels over the nail bed along with few hemorrhagic spots [Figure 2a]. Additionally, yellow globules were seen on the lateral nail fold and dotted vessels arranged in a regular pattern were seen over the pulp area [Figure 2b]. A Gram stain was done from the pustule, which was sterile and showed only neutrophils. A diagnosis of acrodermatitis continua of Hallopeau (ACH) was made based on the clinical and dermoscopic correlation. She was treated with oral cyclosporine and topical calcipotriol with good improvement in 2 weeks [Figure 3a and b].Figure 1: (a) The nail plate is absent. Erythematous plaque with scaling and few areas of crusting is seen involving the nail bed and pulp of the right thumb. (b) A single pustule is seen on the right thumbFigure 2: (a) Dermoscopic image showing yellowish-white scales (black arrow) and linear blood vessels over the nail bed (blue arrow) along with few hemorrhagic spots (red arrow). (b) Dermoscopic image showing dotted vessels arranged in a regular pattern (yellow arrows) over the pulp area. (Polarized contact light dermoscopy; Dermlite DL4; 10×)Figure 3: Clinical (a) and dermoscopic (b) images showing near-complete resolution of the lesions after 2 weeks. (Polarized contact light dermoscopy; Dermlite DL4; 10X)ACH, a variant of pustular psoriasis, is a rare, sterile pustular eruption of the distal fingers and/or toes. It is a chronic and progressive condition and can lead to irreversible complications including onychodystrophy and osteitis, which may result in anonychia and distal phalanx osteolysis, respectively; hence, an early and prompt diagnosis is required.[1] Dermoscopy of pustular psoriasis reveals yellow globules and regularly distributed dotted vessels which on histology correspond to nonfollicular superficial pustules and dilated vessels in homogenously elongated dermal papillae, respectively.[2] E. Errichetti et al. described dermoscopic findings in two cases of ACH which showed whitish-yellowish hyperkeratosis/scaling along with single or multiple pustules, dotted and linear vessels, and hemorrhagic spots.[3] These findings aid in differentiating ACH from other localized conditions such as onychomycosis, nail lichen planus, acral hand eczema, and psoriatic onychopathy.[3] We report our case to highlight the dermoscopic features of ACH which can help in the preliminary evaluation, thus reducing the diagnostic delay. As biopsy over the distal digits is often distressing and difficult, dermoscopy can be considered a valuable tool in such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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.

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.

Steroid-resistant Acute Generalized Exanthematous Pustulosis Mimicking Generalized Pustular Psoriasis Successfully Treated by Methotrexate

Acute generalized exanthematous pustulosis is a rare drug-induced eruption that is characterized by sterile non-follicular pustules arising on an often edematous diffuse erythematous background. Generalized pustular psoriasis is an acute and severe clinical form of psoriasis presenting as pustular eruption with erythematous base. Differentiating both diseases is often challenging because of their clinical and histopathological similarities. A 62-year-old woman presented with pustular eruption and fever three days after taking propyphenazone. Laboratory findings revealed leukocytosis and neutrophilia. Histopathological findings revealed a subcorneal spongiform pustule filled with neutrophils and perivascular inflammatory cell infiltration with neutrophils in the dermis. She was initially treated with systemic steroids, however, the lesions showed insignificant improvement. Treatment was then shifted to methotrexate which resulted in a dramatic clinical improvement.

Pustular Psoriasis and Acute Generalized Exanthematous Pustulosis.

The similarity between pustular psoriasis (PP) and acute generalized exanthematous pustulosis (AGEP) poses problems in the diagnosis and treatment of these two conditions. Significant clinical and histopathologic overlap exists between PP and AGEP. PP is an inflammatory disorder that has numerous clinical subtypes, but all with sterile pustules composed of neutrophils. AGEP is a severe cutaneous adverse reaction that is also characterized by non-follicular sterile pustules. Clinical features that suggest a diagnosis of PP over AGEP include a history of psoriasis and the presence of scaling plaques. Histologically, eosinophilic spongiosis, vacuolar interface dermatitis, and dermal eosinophilia favor a diagnosis of AGEP over PP. Importantly, PP and AGEP vary in clinical course and treatment. PP treatment involves topical steroids, oral retinoids, and systemic immunosuppressants. Newer therapies targeting IL-36, IL-23, IL-1, and PDE-4 have been investigated. The removal of the offending agent is a crucial part of the treatment of AGEP.

Une pustulose exanthématique aiguë généralisée infantile secondaire à la cétirizine

PAGE is a skin reaction secondary to various drugs, rarely reported in children. It is characterised by the rapid development of numerous sterile non-follicular pustules, often on an erythematous background. Cetirizine is a selective, second-generation H1 anti-histamine that is generally well tolerated. Due to its safety profile, tolerability and efficacy, cetirizine is widely used. To our knowledge, six cases of PEAG related to cetirizine have been reported in the literature and our paediatric case is added to these in order to raise awareness of the possible incrimination of antihistamines in the occurrence of toxidermia.

Acute Generalized Exanthematous Pustulosis Due to Cephalexin: A Case Report and Literature Review

Introduction: Acute Generalized Exanthematous Pustulosis (AGEP) is a cutaneous reaction that may appear after using certain medications, such as cephalexin. This disease is characterized by non-follicular sterile pustules, erythematous, urticaria, fever over , and leukocytosis. Cephalexin belongs to the family of β-lactam antibiotics, which are widely used to treat infections. However, cephalexin skin sensitivities have been reported rarely. Herein, in this case, we aimed to report a patient presented with AGEP due to cephalexin usage. Case Presentation: A 12-year-old boy presented with warm skin lesions that gradually appeared on the limbs, trunk, face, and neck after using cephalexin powder on his left leg injury. Because of his symptoms, acetaminophen, fexofenadine hydrochloride, loxoprofen sodium, and ointment, including difluprednate and hydrocortisone, were prescribed. Over time, the patient’s fever subsided, and 8 days later, the symptoms of AGEP, including urticaria, erythematous, and pustules in the neck and trunk, disappeared. Conclusions: Cephalexin is one of the antibiotics that doctors and patients consider when there is a possibility of infection. AGEP is a rare but severe reaction that can manifest as skin rashes in any age and sex following the use of cephalexin, so the patient should be careful when using this antibiotic.

Coexisting Pediatric Acute Generalized Exanthematous Pustulosis and Staphylococcal Scalded Skin Syndrome

Acute Generalized Exanthematous Pustulosis is a rare drug-induced skin disorder that can present at any age. It is typically noted by swelling and erythema, with numerous facial and/or anogenital nonfollicular pustules that quickly disseminate. Staphylococcal scalded skin syndrome presents with erythema and swelling that similarly favor the head and intertriginous sites with subsequent bullae formation. We present a case of a four-year-old female who presented with SSSS complicated by the development of AGEP and discuss the course of her condition and treatment.

Acute Generalized Exanthematous Pustulosis (AGEP) in 12 Patients Treated for SARS-CoV-2 Positive Pneumonia

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rapidly spreading throughout the world. The study describes 12 patients with SARS-CoV-2 pneumonia, who developed an acute erythematous rash with nonfollicular pinhead-sized pustules, without mucosal involvement. The clinical differential diagnosis was viral rash, acute generalized exanthematous pustulosis (AGEP), or multiform erythema. computed tomography with a diagnosis of interstitial pneumonia and a respiratory tract sample positive for SARS-CoV-2 in a reverse transcriptase polymerase chain reaction assay. Patients had signs of respiratory distress and were treated with hydroxychloroquine, darunavir, ritonavir, heparin, ceftriaxone, and azithromycin. Punch biopsies showed subcorneal pustules typical of AGEP. Dermal microvascular injury and thrombosis as described in skin damage by SARS-CoV-2 infection was not observed. The direct immunofluorescence for IgG, IgA, IgM, and C3 was negative in 8 patients investigated. A polymerase chain reaction for RNA SARS-CoV-2 performed on frozen skin was negative in 5 of 6 patients. Most of our patients were treated with systemic corticosteroids. After some days (4-10), the diffuse erythema and pustules had improved. AGEP is classified as a severe cutaneous adverse reaction, provoked by drugs and acute infections. Characteristically, removal of the offending agent leads to spontaneous resolution typically in less than 15 days. The recognition of AGEP is important, in order to avoid confusion with a systemic infection and consequently to avoid incorrect treatment. Cutaneous adverse reactions to drugs are common and are major health problems worldwide causing considerable costs for health care systems. We suggest that in the patients with AGEP during SARS-CoV-2 pneumonia, viral infection is a risk factor for developing drug reaction.

A Case of Acute Generalized Exanthematous Pustulosis by Cefixime with Oral Mucosal Involvement

Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous adverse reaction characterized by the development of numerous sterile and non-follicular pustules on an erythematous base with no or minimal mucous membrane involvement associated with fever and leucocytosis. Cefixime is a cephalosporin-type beta-lactam antibiotic commonly used for the management of several infections. The Cefixime-induced AGEP cases are known to be rare. Here, we present the case report of a 26-year old female who developed Cefixime-induced AGEP with mucosal membrane involvement. To the best of our knowledge, this is the first case to report the mucosal membrane involvement in Cefixime-induced AGEP. We are presenting this case report to draw the attention on the existence and plethora of symptoms of Cefixime-induced AGEP hoping that the clinicians will reckon these in their differential diagnosis and implement the appropriate management strategies for this rare adverse event in their clinical practice.

Acute generalized exanthematous pustulosis induced by hydroxychloroquine prescribed for COVID-19

Acute generalized exanthematous pustulosis (AGEP) is a rare drug reaction characterized by acute, extensive formation of numerous nonfollicular sterile pustules on a background of edematous erythema.1 Hydroxychloroquine (HCQ) is widely used to treat rheumatic and dermatologic diseases, and is well known to cause AGEP.1 At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, city of China. It rapidly spread in China and outside, and on March 12, 2020, the World Health Organization declared a pandemic.

Positive nikolsky sign and “pinpoint lake of pus” in acute generalized exanthematous pustulosis: a case report

Introduction: Acute generalized exanthematous pustulosis (AGEP) is a severe, usually drug-related reaction, characterized by an acute onset of mainly small non-follicular pustules on an erythematous base and spontaneous resolution usually within two weeks. Current report aims to present management of AGEP in our center at Singaraja Regional Hospital, Bali-Indonesia.Case: A 78 years old woman with a history of acute coronary syndrome, was reported to have a severe allergic drug reaction. Patients reported taking cefixime medication for the past 2 days because of acute bronchitis. The patient was hospitalized because of the complaint, and diffuse miliary pustules were found above the base of erythematous skin. On examination of lesions, the Nikolsky sign was positive on lesions in the back and abdomen without any tenderness. Histopathological examination was suitable for the diagnosis of acute generalized exanthema pustulosis (AGEP). Systemic intravenous corticosteroid with oral antihistamines was choosen as a primary treatment for this patient.Conclusion: Treatment is based on the removal of the causative drug, supportive care, infection prevention and use of potent topical or systemic steroids

Pustulosis exantemática generalizada aguda inducida por meropenem

Presentamos el caso de una paciente mujer de 91 años, hospitalizada por infección de herida operatoria secundaria a cirugía de cadera. Se administró tratamiento antibiótico con meropenem, presentando a los 4 días: fiebre, astenia y una erupción eritematosa diseminada con pústulas no foliculares a predominio de tronco, extremidades y áreas de pliegues; además, se observó leucocitosis con neutrofilia. Al estudio histopatológico de biopsia de piel, se evidenciaron pústulas subcorneales con exocitosis de neutrófilos. Se suspendió antibiótico, con mejoría clínica a los 5 días posteriores de la suspensión de meropenem. Existen pocos reportes de casos de pustulosis exantemática generalizada aguda producido por meropenem.

Iohexol-Induced Acute Generalized Exanthematous Pustulosis (AGEP): Case Report

Acute generalized exanthematous pustulosis (AGEP) is a rare adverse drug reaction characterized by numerous non-follicular sterile pustules overlying edematous, erythematous plaques. The majority of AGEP cases are associated with antimicrobial medications, although other agents and etiologies have also been implicated. Here, we report a patient with recurrent angioimmunoblastic T-cell lymphoma (AITL) who presented with a pruritic and widespread pustular eruption one week following computed tomography (CT) with iohexol contrast administration. Notably, she had a documented prior mild reaction to contrast medium and was appropriately pre-medicated with diphenhydramine and prednisone before imaging. Biopsy revealed intra-epidermal pustules, epidermal spongiosis, and dermal infiltrate of lymphocytes, neutrophils, and some eosinophils – histological findings consistent with AGEP. Systemic and topical corticosteroids plus topical mupirocin resulted in complete resolution of symptoms. While cutaneous reactions to iodinated contrast are common and often self-limited, severe manifestations such as AGEP must be considered particularly in patients with a history of prior contrast allergy.

Hidroksiklorokinin tetiklediği akut generalize ekzantematöz püstülozis: Literatür eşliğinde bir olgu

Acute generalized exanthematous pustulosis (AGEP) is a clinical reaction pattern that is generally drug induced and characterized by acute, nonfollicular sterile pustules on a background of edematous erythema. Hydroxychloroquine (HCQ) is an antimalarial drug which is widely used in dermatologic and rheumatologic diseases and reported as a rare cause of AGEP. A 44 years old female patient developed AGEP while recieving HCQ for rheumatoid arthritis and resolved after cessation of HCQ and starting steroid therapy. The aim of this case is to raise the awareness about AGEP which is an uncommon and undesired effect of HCQ; a widely used drug in rheumatology practice.

THE PEPCID PUSTULOSIS PROBLEM

Introduction Acute Generalized Exanthematous Pustulosis (AGEP) is a dermatologic condition characterized by non-follicular sterile pustules on a background of edematous erythema. The most common offending drugs are antibiotics; however, we report a case of Pepcid (Famotidine) -induced AGEP. An 82-year old African American female with a known medical history of HTN, GERD, eczema, and glaucoma was brought to the ER after being found to be lethargic and difficult to arouse. Chief complaints included chills, fatigue, and dry skin with accompanying rash. The patient was hospitalized for treatment of pneumonia with Vancomycin and Rocephin. She was hospitalized two months prior for diffuse dermatitis with exfoliation and diagnosed with Eczema status post skin biopsy. Increasing her Famotidine dosage showed an exacerbation in her condition. Famotidine was discontinued, however her rash persisted and developed over time, leading to her present condition. The skin rash was found on the trunk, extremities, face, and scalp, soles, and mucosal membranes of the mouth. There was marked neutrophilia and light eosinophilia. The Anti-SSA and SSB came back negative ruling out Sjogren Syndrome as well as a negative skin biopsy ruling out bacterial infection. The patient is currently being treated with ammonium lactate lotion and prednisone. The pustules had disappeared by the 8th day of admission leaving dry skin and some scarring with continuing improvement. Discussion This case brings attention to an uncommon skin manifestation caused by a drug that does not have many documented cases of causing AGEP. Though rare, AGEP should be considered in patients that develop cutaneous manifestations with Famotidine treatment.