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THE DIAGNOSIS AND TREATMENT

OF FIXED DRUG ERUPTION

By:
Indah Zulhijma Wattiheluw (2009-83-024)
Triani Farah D. Alyanto (2009-83-025)
Sari Ristiyanti Tetlageni (C11109389)

Advisor
Dr. Andi Manggabarani

Supervisor
dr. A.M. Adam Sp.KK (K), FiSDV 1
A fixed drug eruption (FDE):
an adverse cutaneous reaction to an ingested drug,
characterized by the formation of a solitary (but at times
multiple) erythematous patch or plaque.

If the patient is rechallenged with the offending drug, the


FDE occurs repeatedly at the identical skin site within
hours of ingestion.
Johnson RA, Wolff K. Fixed drug eruption in : Color atlas and synopsis of clinical dermatology. Sixth edition.
New York : McGraw-Hill. P;2009. p.566-568
US :
2-5% for inpatients
1% for outpatients
16-21% of all cutaneous
drug eruptions International :
fixed drug eruptions to
be the second or third
most common skin
manifestation of adverse
drug events
Mortality/Morbidity
Localized Race
hyperpigmentation is FDE have no known
a common racial predilection. A
complication, but pain, genetic susceptibility:
infection, and, rarely, HLA-B22 is possible
hypopigmentation,
also may occur.
A male to female ratio = 1:1
Sex

FDE have been reported in patients as


young as 1.5 years and as old as 87
years.
Age The mean age30.4 years in males and
31.3 years in females
Intraepidermal CD8 T cells with an effector
memory phenotype resident major contributing
role.

Activation CD8 T triggering the lesion

Additional recruitment of CD4 and CD8 T cells


to a specific tissue site would also contribute to the
late stage of lesion development

The influx of regulatory T cells into the epidermis


observed in fully evolved lesions would serve to
limit harmful immune reactions.
1. In Resting Stage Intraepidermal
CD8 T cells remain quiscent,
2. Upon Drug Intake activated to
Release IFN gamma and cytotoxic
granule into microenvironment,
3. Mast Cell epidermis activation
of intraepidermal CD8 induction
of cell adhesion,
4. In fully elvolved lesion,
keratinocytes killed,
5. End of immune response, Treg cells
are recruited into the lession and
serve to inhibit severe immune
responses mediated by
intraepidermal CD8 T Cells.

Figure The cascade of events triggered


by drug intake

Shiohara T. Fixed drug eruption: pathogenesis and diagnostic tests. Curr Opin Allergy Clin Immunol. Wolters
Kluwer Health- Lippincott Williams & Willkins. 9:316321
Clinical history and manifestation

Patients frequently give a history of identical lesion


occurring at the identical location

Skin symptoms: Usually asymptomatic. Maybe pruritic,


painful, or burning. Painful when eroded

Time to onset of lesion: Occur from 30 min to 8 h after


ingestion of drug in previously sensitized individual

Duration of lesion: Lesions persist if drug is continued.


Resolve days to few weeks after drug is discontinued
Most commonly, lesions are solitary and can spread to become
Initially erythema, then dusky red to violaceous
quite large, but they may be multiple
The characteristic early lesion is a sharply demarcated macule,
round or oval in shape. Occurring within hours after ingestion of
the offending drug
Lesions become edematous, thus forming a
plaque, which may evolve to become a bulla
and then an erosion

Genital skin is frequently


involved site, but any site
may be involved;
perioral, periorbital.
Occur in conjunctivae,
oropharynx
Blood routine : not useful to help diagnose FDE, even
eosinophilia can be increast

Patch test : Suspected drug can be placed as a patch test at


a previously involved site; an inflammatory response occurs in
only 30% of cases.
Biopsi

Acute interface dermatitis with prominent vacuolar change and individual


necrotic keratinocytes within the epidermis
(hematoxylin-eosin, 100)
Steven- Toxic Cellulitis
Johnson Epidermal
Syndrome Necrolysis
Stop the use of
drugs suspected
as the cause

Systemic
Topical Therapy
Treatment
Corticosteroids Antihistamines
Prednison : 3x10 mg/day (At Sedative
urticaria, erythema, dermatitis antihistamine may
medicamentosa, purpura, also, if there is
erythema nodosum, exanthema itching
fikstum, and PEGA drug allergy)
Prednison : 3-4 x 10 mg/day (At
eritrodermia)
Topical treatment
Depend on the circumstances, whether the lesion is dry or wet

Dry lesion Wet lesion

Use powder with antipruritic Compress (ex: salicylic


for erythema and urticaria acid solution 1% )
(ex: salicylic 2% with
menthol - 1%)
Corticosteroid creams for At
exanthema fikstum (ex:
hidrokortison 1% or 2 %)