CUTANEOUS DRUG

ERUPTIONS

DR. PUBALAN MUNIANDY MRCP[UK]

INCIDENCE
 DIFFICULT TO ASSESS BUT COMMON PROBLEM
 INCIDENCE DATA ARE MAINLY RETROSPECTIVE
AND DATA REPORTING IS NOT MANDATORY
 GROSS UNDER-REPORTING
 VARIES FROM 6-30% OF PRESCRIPTIONS IN THE
US
 ADVERSE DRUG REACTIONS DURING
HOSPITALIZATION VARIES MARKEDLY – 10-20%
 ABOUT 3-8% OF HOSPITAL ADMISSIONS ARE DUE
TO ADRs
DIFFERENTIAL RISK

 INCREASED RISK OF ADRs

 WOMEN ARE MORE LIKELY THAN MEN
 INCIDENCE OF ADR INCREASES WITH
AGE
 PATIENTS WITH HIV AND AIDS
 SJOGRENS SYNDROME
 HLA TYPES AND SUSCEPTIBILITY
– PENICILLAMINE TOXICITY
– ALLOPURINOL TOXICITY HLA Aw33 AND
B17
CLASSIFICATION

 NON IMMUNOLOGICAL
– PREDICTABLE
 SIDE EFFECTS
 OVERDOSAGE
 DRUG INTERACTIONS
 METABOLIC CHANGES
 EXACERBATION OF DISEASE

– UNPREDICTABLE
 INTOLERANCE
 IDIOSYNCRASY
IMMUNOLOGICAL[UNPREDICTABLE]

 IgE DEPENDENT
– URTICARIA AND ANAPHYLAXIS

 ANTIBODY MEDIATED TYPE 2

 IMMUNE COMPLEX DEPENDENT

– URTICARIA AND ANAPHYLAXIS
– SERUM SICKNESS
– VASCULITIS
– ARTHUS PHENOMENON

 CELL MEDIATED TYPE 4

PATTERNS OF CUTANEOUS DRUG
ERUPTIONS

 EXANTHEMATOUS REACTIONS
 PURPURA
 PSORIASIFORM ERUPTIONS
 LICHENOID ERUPTIONS
 PHOTOSENSITIVITY
 FIXED DRUG ERUPTIONS
 DRUG INDUCED LUPUS
 DRUG INDUCED PEMPHIGUS
 PITYRIASIS ROSEA LIKE ERUPTIONS
 ERYTHEMA NODOSUM
 EXFOLIATIVE ERYTHRODERMA
 URTICARIA/ANGIOEDEMA/ANAPHYLAXIS
 ERYTHEMA MULTIFORME SJS AND TEN
EXANTHEMATOUS ERUPTIONS
SERUM SICKNESS

 DRUG ANTIGEN PERSISTS IN

CIRCULATION TO FORM AG-AB
COMPLEXES
 DEVELOP 1-2 WEEKS AFTER
ADMINISTRATION
 MANIFESTS AS FEVER, ARTHRITIS,
NEPHRITIS, NEURITIS AND OEDEMA
AND AN URTICARIAL OR PAPULAR
RASH
DRESS

 DRUG RASH EOSINOPHILIA WITH SYMTEMIC

SYMPTOMS
 SPECIFIC SEVERE IDIOSYNCRATIC RXN
 ERYTHEMATOUS WIDESPREAD RASH
EXFOLIATIVE DERMATITIS, FEVER,
LYMPHADENOPATHY AND VISCERAL INVOLVEMENT,
EOSINOPHILIA
 PONTENTIALLY LIFE THREATENING WITH 10%
MORTALITY
 ANTICONVULSANTS, ALLOPURINOL, DAPSONE,
SULPHONAMIDES
 RASH AND SYSTEMIC SYMPTOMS MAY PERSIST FOR
WEEKS
EM/SJS/TEN

 WELL RECOGNIZED CUTANEOUS ADR

 EM CHARACTERISED BY TARGET
LESIONS ON THE DISTAL
EXTREMITIES ESP DORSA OF HANDS
AND EXTENSOR FOREARMS
 LESIONS MAY INVOLVE PALM AND
TRUNK AS WELL AS ORAL AND
GENITAL MUCOSA
 MAY FOLLOW VACCINATION
SJS AND TEN

 SPECTRUM OF THE SAME DISEASE

 EXTENSIVE EM LESIONS ON THE TRUNK <
10% BODY SURFACE AREA
 FEVER, MALAISE, MYALGIA,ARTHRALGIA
 TEN – SHEET LIKE EROSIONS > 10% BSA
WITH SEVERE MUCOSAL INVOLVEMENT –
CONJUNCTIVA, CORNEAL, IRIDEAL, BUCCAL,
LABIAL AND GENITAL MM
 BOTH ASSOCIATED WITH SIGNIFICANT
MORBIDITY AND MORTALITY
TREATMENT OF SJS/TEN

 PROMPT DIAGNOSIS AND MANAGEMENT

 WITHDRAWAL OF SPECIFIC DRUG
 INTRAVENOUS ACCESS AND FLUID,
ELECTROLYTE AND PROTEIN
REPLACEMENT
 MANAGED IN AN INTENSIVE CARE OR
BURNS CENTER
 TEMPERATURE CONTROL
 PREVENTION OF STRESS ULCERS
 CAREFUL SKIN NURSING
CONTINUED –SPECIFIC THERAPY

 EYE MANAGEMENT MUST BE AGGRESSIVE

 CORTICOSTEROIDS
 INTRAVENOUS IMMUNOGLOBULINS-
INHIBITION OF Fas-Fas LIGAND MEDIATED
APOPTOSIS – 0.2 -0.75G/KG PER DAY FOR
4 DAYS
 CYCLOSPORIN
 THALIDOMIDE
DRUGS OF SPECIAL INTEREST

 PENICILLIN AND ANTIBIOTICS

 NON-STEROIDAL
ANTIINFLAMMATORY DRUGS
 ALLOPURINOL
 ANTI CONVULSANTS
 ANTI PSYCHOTICS
 THIAZIDE DIURETICS
ALLOPURINOL

 DERMATOLOGICAL COMPLICATIONS OCCUR

IN 10% OF CASES
 MORBILLIFORM ERUPTIONS, DRUG
HYPERSENSITIVITY[DRESS], SJS AND TEN
 MAY POTENTIATE THE EFFECT OF
AMPICILLIN
 COMMONER IN PATIENTS WITH IMPAIRED
RENAL FUNCTION AND THOSE ON
THIAZIDES
THIAZIDE DIURETICS

 PHOTOSENSITIVITY IS WELL KNOWN

 SUBACUTE LE
 LICHENOID ERUPTIONS
 XEROSTOMIA
 VASCULITIS
SULPHONAMIDES

 REACTIONS OCCUR IN 1-5%

 SLOW ACETYLATORS AT RISK
 MORBILLIFORM RASH
 EM/SJS/TEN
 ERYTHEMA NODOSUM
 EXFOLIATIVE DERMATITIS
 FDE
 LUPUS LIKE SYNDROME
PREVENTION

 MUST BE THE AIM

 DETAILED DRUG HISTORY
 NEVER REPEAT THE SAME MISTAKE
 WARN PATIENTS OF POSSIBILITIES
AND ACTION TO BE TAKEN
 MEDIC ALERT BRACELET OR DRUG
ALLERGY CARDS
 KNOW THE DRUGS YOU PRESCRIBE
WELL