A D V ER S E C U TA N EO U S

D R U G R EA C TIO N S

Muh. Eko Irawanto

Bag/SMF Ilmu Kesehatan Kulit dan Kelamin
FK UNS/ RS dr Moewardi Surakarta
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5 Nov 2015

FB: Eko Kepik - HP: 08122914685

5 Nov 2015

FB: Eko Kepik - HP: 08122914685

5 Nov 2015

FB: Eko Kepik - HP: 08122914685

5 Nov 2015

FB: Eko Kepik - HP: 08122914685

5 Nov 2015

Urtikaria

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5 Nov 2015

Acute generalized exanthem atous pustulosis (AG EP)

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5 Nov 2015

D rug Reaction w ith Eosinophilia and System ic

Sym ptom s (D rug-Induced Hypersensitivity Syndrom e)/D RESS /D IH S

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5 Nov 2015

FB: Eko Kepik - HP: 08122914685

5 Nov 2015

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5 Nov 2015

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Angioedem a

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Vasculitis

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EX A N TH EM ATO U S D R U G
R EA C TIO N S

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5 Nov 2015

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EX A N TH EM ATO U S D R U G
R EA C TIO N S

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 EPIDEMIOLOGY
Age of Onset
Less common in the very young.
Incidence
Most common type of cutaneous drug
reaction

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 ETIOLOGY
Drugs with a high probability of reaction (3

5%): penicillin and related antibiotics,

carbamazepine, allopurinol, gold salts (10
20%).
Medium probability : sulfonamides
(bacteriostatic, antidiabetic, diuretic),
nonsteroidal anti-inflammatory drugs (NSAIDs),
hydantoin derivatives, isoniazid,
chloramphenicol, erythromycin, streptomycin.
Low probability (<1%): barbiturates,
benzodiazepines, phenothiazines, tetracyclines
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5 Nov 2015

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 PATHOGENESIS
Exact mechanism unknown.
Probably delayed hypersensitivity.

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CLIN ICA L M A N IFESTATIO N S

Onset
Early Reaction In previously sensitized patient,

eruption starts within 2 or 3 days after

readministration of drug.
Late Reaction Sensitization occurs during
administration or after completing course of
drug; peak incidence at ninth day after
administration.
However, ACDR may occur at any time between
the first day and 3 weeks after the beginning of
treatment.
Reaction to penicillin can begin 2 weeks after
drug is discontinued.
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5 Nov 2015

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 Skin Symptoms
Usually quite pruritic, disturbs sleep.
Painful skin lesions suggest development

of a more serious ACDR, such as TEN.

Systems Review
Fever, chills.

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5 Nov 2015

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 Skin Lesions
Macules and/or papules, a few millimeters to 1

cm in size (Figs. 22-1 and 22-2).

Bright or drug red.
Resolving lesions have hues of tan and purple.
In time, lesions become confluent forming large
macules, polycyclic/ gyrate erythema, reticular
eruptions, sheetlike erythema (Fig. 22-1),
erythroderma; alsoerythema multiformelike.
Scaling and/or desquamation may occur with
healing.
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5 Nov 2015

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 Distribution
Symmetric (Fig. 22-1).
Almost always on trunk and extremities.
Confluent lesions in intertriginous areas,

i.e., axilla, groin, inframammary area.

Palms and soles variably involved.
In children, may be limited to face and
extremities.

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5 Nov 2015

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 Exanthematous drug eruptions. Numerous pink papules on the trunk

due to a cephalosporin (A). Confluence of lesions on the trunk (B) and

annular plaques on the forehead (C) secondary to phenobarbital.
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5 Nov 2015

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 Mucous Membranes
Enanthem on buccal mucosa.

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 LABORATORY EXAMINATIONS
Hemogram
Peripheral eosinophilia.
Dermatopathology
Perivascular lymphocytes and eosinophils.

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 MANAGEMENT
The definitive step in management is to identify

the offending drug and discontinue it.

Symptomatic Treatment
Oral antihistamine to alleviate pruritus.
Glucocorticoids
Potent Topical Preparation
May help speed resolution of eruption.

Oral or IV Provides symptomatic relief.

If offending drug cannot be substituted or omitted,
systemic glucocorticoids can be administered to treat
the ACDR; also, to induce more rapid remission.
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5 Nov 2015

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FIX ED D R U G ER U P TIO N

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FIX ED D R U G ER U P TIO N

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 PATHOGENESIS
Unknown.

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 CLINICAL MANIFESTATION
Drug History Patients frequently give a

history of identical lesion(s) occurring at

the identical location.
Skin symptoms :
Usually asymptomatic.
May be pruritic, painful, or burning.
Painful when eroded.

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 Time to onset of lesion(s) :

Occur from 30 min to 8 h after ingestion of
drug in previously sensitized individual.
Duration of lesion(s):
Lesions persist if drug is continued.
Resolve days to few weeks after drug is
discontinued.

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5 Nov 2015

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 Skin Lesions
The characteristic early lesion is a sharply

demarcated macule, round or oval in

shape, occurring within hours after
ingestion of the offending drug.
Initially erythema, then dusky red to
violaceous.
Most commonly, lesions are solitary and
can spread to become quite large (Fig. 229A), but they may be multiple (Fig. 22-9B)
with random distribution;
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5 Nov 2015

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 Lesions become edematous, thus forming a

plaque, which may evolve to become a bulla

(Fig. 22-8B) and then an erosion.
Eroded lesions, especially on genitals or oral
mucosa, are quite painful.
After healing, dark brown with violet hue
postinflammatory hyperpigmentation.
Genital skin (Fig. 35-19) is frequently involved
site, but any site may be involved; perioral,
periorbital (Fig. 22-8A).
Occur in conjunctivae, oropharynx.
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FB: Eko Kepik - HP: 08122914685

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 LABORATORY EXAMINATIONS
Dermatopathology
Similar to findings in erythema multiforme
and/or TEN.
Patch Test
Suspected drug can be placed as a patch
test at a previously involved site

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 MANAGEMENT
Identify and withhold the offending drug.
Non-eroded lesions can be treated with a

potent topical glucocorticoid ointment.

Eroded cutaneous lesions can be treated
with an antimicrobial ointment and a
dressing until the site is reepithelialized.
For widespread, generalized, and highly
painful mucosal lesions, oral prednisone 1
mg/kg body weight tapered over a course
of 2 weeks.
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5 Nov 2015

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TH AN K YO U

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