Concise Communication
Fixed Drug Eruption Induced by Levocetirizine
A 45‑year‑old woman presented to our
clinic with itchy erythematous lesions
distributed on the left wrist, right
knee, and back. The patient had been
prescribed levocetirizine 5 mg/day due
to allergic rhinitis. One day after taking
the first dose of levocetirizine, the
patient noticed a burning sensation and
itching, followed by patchy plaques.
Patient history revealed that, within the
last two years, the patient had developed
similar lesions four times after using
levocetirizine for allergic rhinitis.
Skin examination revealed multiple
well‑defined erythematous patchy
lesions distributed on the dorsum of the
right hand, left hand wrist, and right
knee [Figures 1 and 2]. Skin biopsy was
performed from the lesions on the left
arm. Histopathologic examination showed
eosinophilic spongiosis in the epidermis,
vacuolar changes in the basal layer, and
perivascular infiltrate of lymphocytes,
accompanied by eosinophil leukocytes
in the upper dermis [Figure 3]. The
diagnosis of FDE was established based
on the clinical findings, clinical history
of the patient, and the histopathologic
findings.
Fixed drug eruption (FDE) is a common
drug reaction that often recurs at the same
location after exposure to the same drug
and is characterized by erythematous
and edematous plaques.[1] More than one
hundred drugs have been blamed in the
pathogenesis of FDE, predominantly
including tetracyclines, sulfonamides, and
barbiturates. Rarely, antihistamines such
as cetirizine, levocetirizine, and laratadine,
being antiallergic drugs, paradoxically
produce FDE lesions.[1‑5] Lesions in FDE
typically occur within a few hours or
days after exposure to the offending drug.
These lesions may be localized in any part
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276
of the body, glans penis, and the sacral Isa An,
region.[2] Vasfiye Demir1,
Diagnosis of FDE is often established Ibrahim Ibiloglu2,
clinically. However, histopathologic Sedat Akdeniz
analysis can be helpful for the diagnosis. Departments of Dermatology,
Oral provocation tests can be performed 1
Family Medicine and
2
Pathology, Dicle University
to confirm the diagnosis of FDE; however,
Medical Faculty, Diyarbakır,
these tests are not recommended because Turkey
they have a risk of generalized bullous
eruption. Patch testing is particularly used
as a first step in the diagnosis of children
and common bullous fix drug eruptions.[3,4]
In our patient, no oral provocation test
and patch test was performed as the idea
was rejected by the patient. The causal
relationship between levocetirizine and the
FDE was found to be definite according
to the objective causality assessment by
the Naranjo probability scale (Naranjo
score = 10). According to the World
Health Organization‑Uppsala Monitoring
Center (WHO‑UMC) criteria, which
were used for the evaluation of adverse
drug reaction for causality assessment,
the assigned causality category for this
adverse drug reaction was revealed as
“certain.”
Levocetirizine, which is a derivative
of piperazine, is a second‑generation
antihistamine agent. It is commonly
prescribed for the treatment of allergic
rhinitis. Although it is known to be a
safe drug, levocetirizine may lead to
Address for correspondence:
cutaneous side effects, including itching,
Dr. Isa An,
urticaria, and angioneurotic edema.[4,5]
Department of Dermatology,
In the literature, only a few cases of Dicle University Medical
FDE caused by levocetirizine have been Faculty, Diyarbakır, Turkey.
E‑mail: is_an89@hotmail.com
reported.[2‑5]
In this report, we presented a patient
with levocetirizine‑induced fixed drug Access this article online
eruption whose diagnosis was confirmed Website: www.idoj.in
by histopathologic findings. Although
DOI: 10.4103/idoj.IDOJ_348_16
levocetirizine‑induced FDE is a rare entity, Quick Response Code:
How to cite this article: An I, Demir V, Ibiloglu I,
Akdeniz S. Fixed drug eruption induced by
levocetirizine. Indian Dermatol Online J 2017;8:
276-8.
Received: September, 2016. Accepted: November, 2016.
© 2017 Indian Dermatology Online Journal | Published by Wolters Kluwer - Medknow
 An, et al.: Fixed drug eruption

Figure 1: Sharply marginated, erythematous patches of varying sizes are

seen on the extensor surface of right hand, left wrist, and right knee

Figure 2: Sharply marginated, erythematous patches of varying sizes are

seen on the left extensor surface of forearm

clinicians should be aware of this side effect during the

levocetirizine therapy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest

Figure 3: Eosinophilic spongiosis in the epidermis, vacuolar changes in
the basal layer, and perivascular infiltrate of lymphocytes accompanied by
eosinophil leukocytes in the upper dermis (HE; ×400)
References
1. Ruiz‑Genao  DP, Hernández‑Nüñez A, Sánchez‑Pérez J,
García‑Díez A. Fixed drug eruption due to loratadine. Br J
Dermatol 2002;146:528‑9.
2. Guptha SD, Prabhakar SM, Sacchidanand S. Fixed drug eruption
due to levocetirizine. Indian J Dermatol Venereol Leprol

Indian Dermatology Online Journal | Volume 8 | Issue 4 | July‑August 2017 277

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2005;71:361‑2. 4. Cravo M, Gonçalo M, Figueiredo A. Fixed drug eruption to

3. Kim MY, Jo EJ, Chang YS, Cho SH, Min KU, Kim SH. cetirizine with positive lesional patch tests to the three piperazine
A  case of levocetirizine‑induced fixed drug eruption derivatives. Int J Dermatol 2007;46:760‑2.
and cross‑reaction with piperazine derivatives.  Asia Pac 5. Gupta LK, Agarwal N, Khare AK, Mittal A. Fixed drug eruption
Allergy 2013;3:281‑4. to levocetirizine and cetirizine. Indian J Dermatol 2014;59:411‑3.

278 Indian Dermatology Online Journal | Volume 8 | Issue 4 | July‑August 2017