Non-follicular Pustules Research Articles

Ciprofloxacin-induced Acute Generalized Exanthematous Pustulosis

Acute generalized exanthematous pustulosis (AGEP) is a cutaneous eruption characterized by sterile non-follicular pustules located on erythematous skin. This case report describes a rare instance of ciprofloxacin-induced AGEP in a patient initially admitted to the hospital for treatment of acute diverticulitis.

Positive Nikolsky Sign and Pinpoint “Lakes of Pus”

A 54-year-old man with a past medical history of paraplegia, osteomyelitis, sacral decubitus ulcer, suprapubic catheter, and several reported drug eruptions was seen for evaluation of skin sloughing without any tenderness to palpation. He reported being on chronic oral antibiotics including amoxicillin/clavulanic acid and ciprofloxacin over the past two years for osteomyelitis. Two days prior to evaluation, he had been hospitalized for osteomyelitis of the left iliac bone and was treated with intravenous vancomycin and meropenem. Initial evaluation revealed widespread Nikolsky sign with extensive involvement of the back, abdomen, and extremities without any tenderness. Involving 30-40% body surface area were scattered deep red macules and patches. The histopathologic findings were consistent with the diagnosis of acute generalized exanthematous pustulosis (AGEP). Clinically, AGEP appears as diffuse erythema with several small, non-follicular pustules and possible peripheral neutrophilia or eosinophilia. A positive Nikolksy sign can be seen with AGEP, but is not specific, and has been referred to as a ‘pseudo-Nikolsky sign.’ Systemic involvement, such as renal insufficiency, has been reported in AGEP. There are few reports in the literature describing AGEP with TEN-like features. We present an interesting patient with AGEP and TEN-like features who improved after cessation of vancomycin and meropenem and a short course of systemic steroids.

Positive Nikolsky Sign and Pinpoint “Lakes of Pus”

A 54-year-old man with a past medical history of paraplegia, osteomyelitis, sacral decubitus ulcer, suprapubic catheter, and several reported drug eruptions was seen for evaluation of skin sloughing without any tenderness to palpation. He reported being on chronic oral antibiotics including amoxicillin/clavulanic acid and ciprofloxacin over the past two years for osteomyelitis. Two days prior to evaluation, he had been hospitalized for osteomyelitis of the left iliac bone and was treated with intravenous vancomycin and meropenem. Initial evaluation revealed widespread Nikolsky sign with extensive involvement of the back, abdomen, and extremities without any tenderness. Involving 30-40% body surface area were scattered deep red macules and patches. The histopathologic findings were consistent with the diagnosis of acute generalized exanthematous pustulosis (AGEP). Clinically, AGEP appears as diffuse erythema with several small, non-follicular pustules and possible peripheral neutrophilia or eosinophilia. A positive Nikolksy sign can be seen with AGEP, but is not specific, and has been referred to as a ‘pseudo-Nikolsky sign.’ Systemic involvement, such as renal insufficiency, has been reported in AGEP. There are few reports in the literature describing AGEP with TEN-like features. We present an interesting patient with AGEP and TEN-like features who improved after cessation of vancomycin and meropenem and a short course of systemic steroids.

Clinical features of von Zumbusch type of generalized pustular psoriasis in children: a retrospective study of 26 patients in southwestern China.

BackgroundVon Zumbusch type of generalized pustular psoriasis is a rare variant of psoriasis in children. It can occur in patients with or without psoriasis vulgaris.ObjectiveThe aim of the study was to discuss the precipitating factors, clinical manifestations, laboratory data and therapy of von Zumbusch type of generalized pustular psoriasis in children from southwestern China and to improve the diagnosis and treatment level.MethodsA retrospective analysis was conducted for inpatients aged 14 years old or less with von Zumbusch type of generalized pustular psoriasis in our department from 2005 to 2014.ResultsA total of 26 patients were included, of whom four (15.38%) had previous history of psoriasis vulgaris and one (3.85%) had previous history of psoriasis arthropathica. Mean onset age was 6.90 years. Gender distribution was equivalent. Incidence of the disease in summer and autumn was higher than that in winter and spring. Nineteen (73.08%) cases were triggered by infection, two (7.69%) cases were caused by sudden discontinuation of systemic use of corticosteroid. Twenty-four (92.31%) cases had concomitant fever. The initial lesion manifested as non-follicular sterile pustules on erythema. Sixteen patients responded well to acitretin, 11 to Tripterygium wilfordii Hook F (TwHF), two to cyclosporine, and one to methotrexate.Study limitationsThis study is a retrospective one and the number of cases is small.CONCLUSIONVon Zumbusch type of generalized pustular psoriasis is a rare disease in children, infection is the most common precipitating factor, acitretin is the first-line therapy, traditional Chinese medicine TwHF also can be used.

Non-dermatophyte Dermatoses Mimicking Dermatophytoses in Animals.

Dermatophytoses in animals are fungal diseases of the skin caused by dermatophyte fungi of the genus Microsporum or Trichophyton. Because the infection is generally follicular, the most common clinical sign is one or many circular areas of alopecia with variable erythema, scaling and crusting, and the primary differential diagnoses are follicular infections, such as bacterial folliculitis and demodicosis. Although dermatophyte folliculitis or ringworm is the most commonly observed lesion of dermatophytoses in animals, other presentations may be observed according to the host species and the dermatophyte involved: dermatophyte folliculitis or ringworm, scaling and crusting in dermatophytosis due to Microsporum persicolor, nodule in case of kerion or mycetoma, matted hairs, seborrheic dermatosis or miliary dermatitis in cats, generalized exfoliative dermatoses in dogs, cats and horses, superficial non-follicular pustules, papules and macules in the Devon Rex cat, pruritic dermatophytoses in dogs, cats and horses, and onychomycosis in dogs, cats and horses. Since manifestations of dermatophytosis are highly variable, particularly in the cat, dermatophytosis should be considered in case of any annular, papular, nodular or pustular dermatoses, alopecic or not, sometimes pruritic, and nodular dermatoses as well.

Acute Generalized Exanthematous Pustulosis: Pathogenesis, Genetic Background, Clinical Variants and Therapy.

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. Systemic involvement occurs in about 20% of cases. The course is mostly benign, and only in rare cases complications lead to life-threatening situations. Recent studies highlight the importance of genetic variations in interleukin-36 receptor antagonist gene (IL-36RN) in the pathogenesis of this disease. The physiopathology of AGEP remains unclear, but an involvement of innate and acquired immune cells together with resident cells (keratinocytes), which recruit and activate neutrophils via production of cytokines/chemokines such as IL-17, IL-36, granulocyte-macrophage colony-stimulating factor (GM-CSF), tumor necrosis factor alpha (TNFα) and chemokine (C-X-C motif) ligand 8 (CXCL8)/IL-8, has been postulated. Treatment is based on the removal of the causative drug, supportive care, infection prevention and use of potent topical or systemic steroids.

Acute Generalized Exanthematous Pustulosis Induced by Fexofenadine.

Acute generalized exanthematous pustulosis (AGEP) is a skin eruption, frequently drug induced and characterized by the acute development of multiple sterile minute pustules on an erythematous base. There is no case of fexofenadine-induced AGEP in literature (PubMed search). A 40-year-old female presented to us with fever and sudden onset development of multiple discrete to coalescent 1–2 mm nonfollicular pustules on an erythematous base present mainly on her trunk and upper extremities for past 2 days. She had a history of use of fexofenadine 180 mg OD for rhinitis for 2 days. Gram's stain showed no organism and pus culture showed no growth. Histopathological examination revealed subcorneal pustules with epidermal spongiosis. Scattered neutrophils and eosinophils were noted in the dermis. During this period, she took fexofenadine 180 mg unknowingly once following which she developed similar episode within 24–48 h. After withdrawal of the drug, the lesions subsided with scaling in 8–10 days. To the best of our knowledge, this is the first reported case of AGEP induced by fexofenadine. Recognition of such a rare entity is important given the frequent usage of fexofenadine for allergic disorders.

Terbinafine-induced acute generalized exanthematous pustulosis

Acute generalized exanthematous pustulosis (AGEP) is a diffuse pustular disorder, a member of the “neutrophilic dermatoses.” Histologically, it is represented by the presence of vasculitis, linked with nonfollicular subcorneal pustules. Majority of cases is related to medication administration. In this article, we are reporting a case of AGEP caused by terbinafine, an antifungal agent.

Residents'corner October 2015. DeRmpath&Clinic: Acute generalised exanthematous pustulosis.

Case 1: A 55 year-old lady presented with diffuse oedematous erythema infiltrated with numerous small non-follicular pustules. This initially appeared over her face and axillae but subsequently spread to involve much of her torso and proximal limbs. There was associated fever and general malaise. Laboratory investigations also demonstrated an accompanying neutrophilia. Five days previously she had started oral flucloxacillin for a recurrent facial cyst.Case 2: A 48 year-old lady presented with multiple [...]

Acute Generalized Exanthematous Pustulosis Caused by Dihydrocodeine Phosphate in a Patient With Psoriasis Vulgaris and a HeterozygousIL36RNMutation

Acute generalized exanthematous pustulosis (AGEP) is a rare and severe type of drug eruption. Dihydrocodeine phosphate is a semisynthetic opioid analgesic. Recently, recessive mutations in IL36RN have been identified in generalized pustular psoriasis (GPP). To date, 4 cases of AGEP and IL36RN mutation without previous history of psoriasis vulgaris (PV) have been reported. A woman in her 60s with PV presented with diffuse erythema, nonfollicular pustules, and fever. She had been treated with dextromethorphan hydrobromide hydrate, amoxicillin hydrate, clarithromycin, dihydrocodeine phosphate, tipepidine hibenzate, and tulobuterol tape for a cough and common cold. Based on histopathologic results and a positive result in a drug provocation test with dihydrocodeine phosphate, she was diagnosed with AGEP. A heterozygous IL36RN mutation c.28C>T (p.Arg10X) was also confirmed by mutation analysis. This is the first report of dihydrocodeine phosphate-induced AGEP. In this case, helper T cells, type 17, might have been activated because of morphine and underlying PV, followed by increased production of interleukin (IL) 36. However, because of the IL36RN mutation, IL-36 signaling was uncontrolled, which might have resulted in the occurrence of AGEP. An IL36RN mutation might underlie several different pustular skin eruptions, including AGEP and GPP, and further accumulation of patient data is required.

Five-Year Retrospective Review of Acute Generalized Exanthematous Pustulosis.

Background. Acute generalized exanthematous pustulosis (AGEP) is an acute pustular eruption characterized by widespread nonfollicular sterile pustules. The aim of this study is to characterize the etiology, clinical features, laboratory findings, management, and outcome of patients with AGEP in Asians. Patient/Methods. A retrospective analysis was performed on patient who presented with AGEP between August 2008 and November 2012 in a tertiary center in Thailand. Results. Nineteen patients with AGEP were included. AGEP was generally distributed in seventeen patients (89.5%) and localized in two (10.5%). Fever and neutrophilia occurred in 52.6% and 68.4%, respectively. Hepatitis was found up to 26.3%. The most common etiology was drugs (94.7%), comprising of antibiotics (73.6%), proton pump inhibitors (10.5%), nonsteroidal anti-inflammatory drugs (5.3%), and herbal medicine (5.3%). Beta-lactams were the most common causal drug, particularly carbapenems and cephalosporins. This is the first report of Andrographis paniculata as an offending agent for AGEP. We found no differences between various treatment regimens (topical corticosteroid, systemic corticosteroid, and supportive treatment) regarding the time from drug cessation to pustules resolution (P = 0.171). Conclusions. We have highlighted the presentation of AGEP among Asians. We found high association with systemic drugs. Carbapenems were one of the leading culprit drugs. Finally, a localized variant was observed.

An Uncommon Side Effect of Bupropion: A Case of Acute Generalized Exanthematous Pustulosis.

Acute generalized exanthematous pustulosis (AGEP) is a rare inflammatory dermatosis characterized by multiple nonfollicular pustules that occur on erythematous skin. Despite its similarity to pustular psoriasis and association with fever and leukocytosis, AGEP typically heals quickly. Etiologically, drugs and viruses have been suspected in most cases. Here, we present a case of AGEP, in a woman, that developed 1 day after starting bupropion for smoking cessation, as a rare side effect of the treatment.

Leucomycin-induced acute generalized exanthematous pustulosis complicated with pitting edema of the legs

Abstract Acute generalized exanthematous pustulosis (AGEP) is characterized by fever, sterile nonfollicular pustules, and neutrophilia. More than 90% of cases of AGEP are induced by antibiotics such as aminopenicillins and macrolides. However, little is known about the side effects associated with leucomycin. To the best of our knowledge, the following case is the first one reporting leucomycin-induced AGEP. The case presented here is of a 43-year-old man who suffered from generalized pustulosis and severe leg edema 2 days after taking leucomycin for an upper respiratory tract infection. With discontinuation of leucomycin and a short course of systemic steroid treatment, these symptoms were gradually relieved.

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Background and aims: Acute generalized exanthematous pustulosis (AGEP) is characterized acute onset of widespread pustule eruption. Fever and leukocytosis may frequently accompany the disease but rapid spontaneous recovery is typical. This disease resembles pustular psoriasis clinically. Two pediatric patients with AGEP have been presented. Methods: CASE-1: A 10-year old male complaining of skin eruption for two days was brought to emergency department. He received anonymous cold medicine for sore throat two days ago. There were diffuse numerous small, primarily non-follicular pustules on a background of edematous erythema. White blood cell count (WBC) was 16500/µL (80% neutrophils). Punch biopsy results were consistent with AGEP. Supported treatment with analgesic and antihistaminic drugs was given. CASE-2: A 7-year old male patient was admitted to emergency department for diffuse redness. According to his history, sore throat and rashes started 3 days ago and then increased gradually. There were pharyngeal hyperemia and small vesiculopustular lesions on neck, axilla and genital area. WBC was 12300/µL (70% neutrophils). Antibiotics, antihistamines and topical steroids were started. On follow-up, reduction in lesions was observed and Group A Streptococcus was detected in throat culture. Conclusions: The patients were diagnosed with AGEP because of throat infection and suspected drug intake, presence of typical clinical findings and rapid improvement on follow-up. Differential diagnoses are important for treatment methods. If clinical improvement is not enough with supportive treatment, pustular psoriasis may be kept in mind. These cases were presented to avoid unnecessary treatment in AGEP which is seen rarely and has good prognosis in childhood.

Acute generalized exanthematous pustulosis: A retrospective study of 51 cases in Taiwan

Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse drug reaction characterized by fever and numerous sterile non-follicular pustules. It is mainly attributed to drugs, although other factors have been implicated. The objective of this study was to evaluate the clinical and histological features of AGEP in a Taiwanese population. In this retrospective study, we reviewed patients diagnosed with AGEP with a EuroSCAR (RegiSCAR) validation score more than 4 (>4, probable to definite cases), between 1992 and 2012 at the Chang Gung Memorial Hospital in Taiwan. Demographic, clinical and laboratory data, pathologic findings, and disease causality were analyzed. A total of 51 patients were included in this study, with 34 (66.7%) patients being diagnosed with AGEP with drug causality, and 17 (33.3%) patients being diagnosed with AGEP without drug causality. Cases of AGEP with drug causality showed an older average age, and a significantly higher rate of previous drug hypersensitivity history compared to cases of AGEP without drug causality ( p = 0.0018). None of the patients had a history of psoriasis or had developed psoriasis at the 1-year follow-up. A total of 12 cases (23.5%) had systemic involvement, including liver and kidneys. Penicillin or aminopenicillin (17.6%) and cephalosporins (17.6%) were the most common causative drug groups related to AGEP. In AGEP patients without drug causality, three cases of pathogen infections were identified (1 case of mycoplasma, Coxsackie virus, and Epstein-Barr virus, respectively). We found that beta-lactam antibiotics were the major drug class responsible for inducing AGEP in a Taiwanese population, but that some infectious pathogens may also contribute to AGEP development.

Acute Generalized Exanthematous Pustulosis

An 80-year-old woman presented with fever and a generalized, erythematous pruritic eruption of 3 days duration. Four days prior to the eruption, she was treated with terbinafine 250 mg po daily for onychomycosis. She denied any recent viral illness. There was no personal or family history of skin disease. On examination, her temperature was 38.50C. Dermatological examination revealed generalized, symmetrical erythematous macules/patches and multiple, scattered small nonfollicular pustules with surrounding erythema on the trunk and upper extremities. Mucosal surfaces were spared. Nikolsky sign was negative. Her white blood cell count was 17.6 x 109/L. Gram staining and bacterial culture of the pustule were negative. A punch biopsy taken from one of the lesions revealed subcorneal and intraepidermal pustules, widespread spongiosis, and neutrophilic perivascular infiltration. Acute generalized exanthematous pustulosis (AGEP) is a rare and potentially severe cutaneous adverse reaction most commonly in response to drug therapy. The main culprit drugs are antibiotics (macrolides, beta-lactam antibiotics, sulphonamides), calcium-channel blockers (diltiazem), antifungal agents (terbinafine, ketoconazole), antipyretics (paracetamol), and antimalarials (hydroxychloroquine, chloroquine). AGEP usually occurs within 5 days of starting the offending medication. AGEP is a type IV hypersensitivity reaction. Drug specific CD4+ and CD8+ T cells play a crucial role. Viral and bacterial infections and hypersensitivity reaction to mercury have also been incriminated. Clinically, AGEP manifests with an acute onset of widespread bilateral symmetrical edematous erythematous macules/patches studded with numerous small scattered non-follicular sterile pustules. The eruption is often pruritic or burning and accompanied by fever and leukocytosis. AGEP can occur at any age. The sex ratio is approximately equal. The disease is generally self-limited and resolves within 15 days once the offending agent is withdrawn. Treatment is mainly symptomatic. Mortality occurs mainly in elderly patients with significant comorbidities.

Acute Generalized Exanthematous Pustulosis in a 51-Year-Old Patient under Etanercept Treatment for Psoriasis

Acute generalized exanthematous pustulosis (AGEP) is a cutaneous reaction mostly related to drug, which is characterized by a rapid appearance of fever, erythema, sterile pustules and neutrophilia. We report a 51-year-old female patient who had taken etanercept 50 mg/week for treatment of psoriasis. In the third month of pharmacotherapy, she interrupted the treatment on her own, and consequently, the lesions reappeared. When the drug was reintroduced, it was associated with prednisone 40 mg/day during 5 days. After this period, multiple erythematous and edematous lesions appeared with small non-follicular pustules. Oral corticosteroid was administered and a progressive and complete improvement was achieved. Histopathological findings revealed AGEP. Bacterioscopy of the pustules proved negative. The patient obtained the score 12 according to the EuroSCAR study group, which indicated a definitive diagnosis of AGEP. The criteria for diagnosis were based on morphology, course and histology of the skin reaction. The association between Etanercept and AGEP is an uncommon finding in the literature.

Acute generalized exanthematous pustulosis induced by parvovirus b19 infection.

Received June 20, 2012, Revised April 26, 2013, Accepted for publication May 29, 2013 Corresponding author: Jong Keun Seo, Department of Dermatology, Busan Paik Hospital, Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 614-735, Korea. Tel: 82-51-890-6135, Fax: 82-51-897-6391, E-mail: derma09@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Fig. 1. Multiple nonfollicular pustules with surround erythema on the trunk. Fig. 2. Histopathologic findings shows subcorneal pustules in the epidermis, perivascular and interstitial inflammatory cells infiltration in the dermis. The inflammatory cells are comprised of lymphohistiocytes, neutrophils and a few eosinophils (H&E, ×40). Acute Generalized Exanthematous Pustulosis Induced by Parvovirus B19 Infection

Acute Localized Exanthematous Pustulosis on Inguinal Area Secondary to Piperacillin/tazobactam

Acute generalized exanthematous pustulosis (AGEP) is a rare but well-known cutaneous reaction pattern mostly caused by drugs, i.e. aminopenicillins. Fever and erythema, followed by numerous tiny non-follicular pustules that usually appear within days after administering the medication, are characteristic. The reaction is self-limiting once the causative drug is withdrawn. The pathomechanisms of AGEP remain uncertain, but there is some evidence of underlying T-cell mediated process (1).

Acute Generalized Exanthematous Pustulosis Induced by Hydroxychloroquine: First Case Report in Canada and Review of the Literature

Acute generalized exanthematous pustulosis (AGEP) is a rare drug eruption presenting with an acute, extensive formation of nonfollicular sterile pustules on an erythematous and edematous base. Typically, the rash is accompanied by fever and leukocytosis, with spontaneous resolution in < 15 days. The incidence of AGEP is estimated at one to five cases per million people per year. Only 18% of these are from nonantibiotics. Hydroxychloroquine (HCQ) is an antimalarial agent that is also used to treat various dermatologic and rheumatologic conditions. We report the first observation in Canada of a patient with AGEP induced by HCQ. AGEP was diagnosed in a 48-year-old female who had been taking HCQ for 2 weeks and then developed a diffuse erythematous and edematous pustular eruption. Clinical and pathologic findings were consistent with a diagnosis of AGEP. The patient was treated with steroids and supportive measures. The rash resolved after 18 days and a complicated course in hospital. AGEP is a rare drug eruption, usually to antibiotics. We report the first case in Canada of AGEP as an adverse reaction to HCQ. Clinicians should keep in mind the possibility of this severe skin eruption.