JAAD ONLINE

CASE LETTER

Bullous fixed drug eruption caused by

flecainide
To the Editor: Fixed drug eruption (FDE) is a diag-
nosis that is commonly encountered by dermatology
practices today. Recent studies have shown that the
most common locations for such eruptions include
the lip and genitalia, with the foot being least
common.1
Although a number of drugs have been implicated
in the development of FDE, no observations to date
have reported flecainide as a causative agent. We
report the case of a patient with bullous FDE of the Fig 1. Bulla on the dorsal surface of the foot.
dorsal surface of the foot caused by flecainide.
A 69-year-old white male presented to our de-
as urticaria, flushing, pruritus, and psoriasis.2
partment with a 4-month history of a recurrent blister
However, there have been no reports to date of
on the dorsal surface of his left foot (Fig 1). The
FDE caused by flecainide. We report the case of a 69-
patient’s medical history was significant for narrow
year-old male with a history of a recurrent foot blister
complex tachycardia, for which he was being treated
which arose several weeks after beginning oral
with oral flecainide 50 mg twice daily.
flecainide treatment. Our clinical suspicions of FDE
Three weeks after starting flecainide, the patient
were confirmed histologically. The patient was pre-
reported the development of multiple small, pruritic
scribed clobetasol ointment and advised to continue
vesicles on the dorsal surface of his left foot which
using the flecainide despite the eruption, given the
coalesced to form a single large bulla. The patient’s
importance of the medication in treating his
family practitioner initially aspirated the bulla with
arrhythmia.
a needle and advised the patient to subsequently
apply mupirocin ointment to the lesion. Several Charles F. Knapp III, BS,a Elizabeth R. Cooke, MD,b
weeks later, the bulla recurred despite this therapy, and Daniel J. Sheehan, MDb
notably in the exact same location, and the patient
University of South Florida College of Medicine,a
was referred to our clinic.
Tampa, Florida, and the Department of Medi-
On physical examination, a 3.3-cm tense bulla
cine, Section of Dermatology,b Medical College of
was noted on the dorsal surface of the patient’s left
Georgia, Augusta, Georgia
foot. Two punch biopsies of the lesion were taken
(one for hemtoxylineeosin staining and one for Funding sources: None.
direct immunofluorescence), and the roof of the
Conflicts of interest: None declared.
bulla was sent for periodic acideSchiff staining. The
specimen was periodic acideSchiff negative and Reprint requests: Elizabeth R. Cooke, MD, Depart-
negative for direct immunofluorescence of immuno- ment of Medicine, Section of Dermatology, Med-
globulin G (IgG), IgM, IgA, and C3. Histopathologic ical College of Georgia, 1004 Chafee Ave,
evaluation of the hematoxylineeosin-stained speci- Augusta, GA 30904
men revealed a subepidermal bulla with foci of
E-mail: ecooke@mail.mcg.edu
epidermal necrosis and scattered dyskeratotic kerat-
inocytes. The bullous cavity contained ample fibrin- Published online November 17, 2008.
ous material and a scant infiltrate consisting of
prominent eosinophils. Superficial and mid perivas- REFERENCES
cular infiltrate consisting of lymphocytes, plasma 1. Özkaya-Bayazit E. Specific site involvement in fixed drug
eruption. J Am Acad Dermatol 2003;49:1003-7.
cells, and eosinophils were also noted. The diagnosis
2. Frishman WH, Brosnan BD, Grossman M, Dasgupta D, Sun DK.
of FDE was confirmed on the basis of clinical and Adverse dermatologic effects of cardiovascular drug therapy:
histologic findings. part I. Cardiol Rev 2002;10:230-46.
A number of reports have been published regard-
ing the various cutaneous effects of flecainide, such doi:10.1016/j.jaad.2008.09.041

J AM ACAD DERMATOL FEBRUARY 2009 e3