12/05/2018

There are 32 Zombieland rules but

ONLY ONE drug eruption rule……
• Always ask the patient if they have
Cutaneous Drug Eruptions any drug allergies and if you don’t
know prior to writing the
prescription ask them…..
Dr Paul Jarrett
Dermatologist. Middlemore Hospital
Clinical Lead for Dermatology, The University of Auckland
Paul.Jarrett@middlemore.co.nz

Drug eruptions: a detective story

Sometimes a mystery Sometimes obvious

1
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https://www.stuff.co.nz/the-press/news/69258944/
allergic-reaction-to-antibiotic-medication-kills-woman

Cutaneous Drug Eruptions Mild cutaneous drug eruptions

Most cutaneous drug eruptions occur within 10-21 days of starting a • Most common pattern Morbilliform(measles like)
medication • Due to
but not always… • Antibiotics
• Penicillins
• Cephalosporins
Mild Severe
• Non steroidal anti-inflammatory
S=Severe
• Allopurinol
C=Cutaneous
• Anti epileptics
A=Adverse • And many others…
R=Reaction 2

(Skin alone) (Skin and other organs)

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Mild cutaneous drug eruptions Mild cutaneous drug eruptions

Urticaria“Hives” Skin dyspigmentation Minocycline pigmentation
• Due to (colour change)
• Penicillins
• Non steroidal anti-inflammatory
• Angiotensin converting
• Due to
• Minocycline (blue)
enzyme inhibitors (ACE inhibitors) 1

• And many others… • Hydroxychloroquine

(grey)
• Amiodarone(Blue/grey)
2
• And many others…

Mild cutaneous drug eruptions Mild cutaneous drug eruptions

Skin dyspigmentation Vasculitis (inflammation of
(colour change) Melasma blood vessels) Vasculitis “Palpable purpura”
• Due to
• Combined oral • Due to
contraceptive • Antibiotics (eg penicillin)
• IUD/Contraceptive • Antiepileptics
• Allopurinol
implants
• NSAIDs
• (Also pregnancy) 3

(Can be systemic- watch kidney function)

2

Mild cutaneous drug eruptions Mild cutaneous drug eruptions

Photosensitivity Drug induced cutaneous
(sensitive to sunlight) disease
Due to • Acne
• Antibiotics • Systemic steroids
(eg doxycycline) • Anabolic steroids
• Diuretics • Lithium
(eg hydrochlorthiazide) • Contraceptives
• Oral hypoglycaemics 3-all photos
3

(glipizide)
• NSAIDs

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Mild cutaneous drug eruptions Mild cutaneous drug eruptions

• A 22 year old woman Drug induced cutaneous
• Every month gets a rash disease
at exactly the same • Peri-oroficial dermatitis
place on her skin. • Potent topical steroids
1

• Telangectasis
Diagnosis?
• (dilated blood vessels)
2

Fixed drug eruption due to

mefenamic acid
1

Severe Cutaneous Adverse Reactions “SCAR” Severe Cutaneous Adverse Reactions “SCAR”

• Drug hypersensitivity syndrome

• Drug Reaction with Eosinophilia and Systemic Symptoms
“DRESS”
• Stevens-Johnson Syndrome/Toxic Epidermal
Necrolysis (SJS/TEN)

Severe cutaneous adverse reactions Severe cutaneous adverse reactions

• 52 year old woman • OE

C/o: A rash and feeling generally unwell 4 days • Febrile 38.5 °C
PMH: • Rash
• Extensive - morbilliform & peel
Diabetes mellitus-retinopathy, nephropathy
Ischaemic heart disease
Hypertension Initial differential diagnosis?
Dylipidaemia
Infection ?viral ?bacterial
3

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Severe cutaneous adverse reactions Severe cutaneous adverse reactions

• Given IV antibiotics but
fever and rash did not
settle
• Infection screen –ve
• MSU
• Blood culture
• CXR

Severe cutaneous adverse reactions Severe cutaneous adverse reactions

Eosinophil Count
• Re took a drug history
• Started allopurinol
100mg od 2 weeks
prior to admission…

• Diagnosis:
Drug Reaction with Eosinophilia and
Systemic symptoms (DRESS)
3

Also: liver function can be deranged, lymphadenopathy

Severe cutaneous adverse reactions Severe cutaneous adverse reactions

Prednisone
Eosinophil Count

Liver function tests

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Erythema multiforme/Steven Johnson

Severe cutaneous adverse reactions
syndrome and Toxic Epidermal Necrolysis
Minor Infection

• DRESS Erythema Multiforme

Infection
• Stop allopurinol Major
(Mucosal involvement) +/- Drugs (rarely <10%)
• Give prolonged course of 2

systemic steroids
• Fever abruptly stops Stevens Johnson
<10% skin loss Drugs
Syndrome (SJS)
• Exclude infection (usually)

SJS/TEN overlap 10-30% skin loss

Toxic Epidemal Drugs

3 >30% skin loss 3
Necrolysis (TEN) (usually)

• 66 year old woman

• C/o
• 4 days of ulcers on lip and mouth
• Rash
• 16 days earlier started carbamazepine
• PMH
• Complex partial seizures 3

• Diagnosis
• Stevens Johnson syndrome secondary to carbamazepine (<10% epidermal loss)

• Treatment
• STOP Carbamazepine
• Supportive

• NB: Pharmacogenetics
• HLA-B*1502 confers a greater risk of SJS/TEN due to carbamazepine in all Asian
3

(esp Han Chinese) patients

• TEST FOR IT!

3

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• 15 year old boy.

• C/O
• 3 days of a rash and feeling unwell
• Hx of URTI symptoms
• Self medicated
• Took one of his brother’s amoxicillin/clavulanic acid tablets
• O/E
• Unwell
• Hypotensive
• Extensive rash
3

3
3

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Drug eruptions: a detective story

• Diagnosis Sometimes a mystery Sometimes obvious
• Toxic epidermal necrolysis secondary to penicillin (>30% epidermal loss)
• Treatment
• STOP Penicillin
• Burns unit
• Supportive mainly

Summary Summary
Culprits are often: • Think of the possibility of a drug eruption
• Antibiotics • Take a careful history
• Anti epileptics
• Anti gout- allopurinol
• Stop the drug ASAP
• Non steroidal anti-inflammatories • Use computer alerts or MedicAlert bracelet
• Timing: • Don’t let it happen again
• Significant medicolegal implications
• Usually but not always occur within 10-21 days
• Although….any drug at any time could be implicated
• Remember the only drug eruption rule….

There are 32 Zombieland rules but

ONLY ONE drug eruption rule……
• Always ask the patient if they have
any drug allergies and if you don’t
know prior to writing the
prescription ask them…..

https://www.stuff.co.nz/the-press/news/69258944/
allergic-reaction-to-antibiotic-medication-kills-woman

7
 12/05/2018

Photograph Attributions
• 1=Sourced from the internet
• 2=DermNet New Zealand (with permission)
Thank you • 3= Clinical photograph with patient’s consent