Drug Eruptions/Hypersensitivity:

Erythema Nodosum
Morbilliform Drug Eruption
Fixed Drug Eruption

By:
Ayman M. Mahran, M.D.,
Associate Professor of Dermatology, Venereology & Andrology,
Faculty of Medicine, Assiut University
Erythema Nodosum
 Definition

• Acute, multifactorial, self limiting inflammation of subcutaneous fat

(Panniculitis), caused by a delayed hypersensitivity reaction to a
variety of antigens
 Epidemiology
• Age: 18-34 years, however, any age can be affected

• Sex: More common in females

• Prognosis: Excellent, usually resolves without sequlae

 Pathogenesis

• Acute Panniculitis due to delayed Hypersensitivity reaction (Type IV),

which can be induced by a variety of antigens
 Etiology
• Idiopathic: Most common cause
• Infections: Bacterial, Fungal, Mycobacterial
• Autoimmune diseases: Sarcoidosis, Behcet’s disease, IBD
• Drugs: OCPs, Iodides, Sulphonamides
• Malignancy: Lymphoma
• Pregnancy: 2nd trimester
 Clinical Features
(Non-specific)
Typically, precedes the rash

• Fever
• Malaise
• Arthralgia: Any joint, but, mostly knees, ankles & wrists
• Hilar Lymphadenopathy: Uni (Malignancy)/bilateral (Sarcoidosis)
 Clinical Features
(Skin Rash)
• Acute, painful, ill-defined, erythematous nodules

• Site: Any, but mostly, on extensor aspects of both L.L. (pretibial)

1st week: Firm, red & painful

2nd week: Fluctuant (non-suppurative) & bluish
3rd week: Fades progressively with yellowish discoloration
 Diagnostic Investigations
• Skin Biopsy (deep): when clinical diagnosis is uncertain
• Laboratory & Radiologic to determine cause:
-CBC, ESR, VDRL, ASOT
-Urine & stool examinations
-IBD workup
-Imaging: Chest X-ray to exclude sarcoidosis & T.B.
 Prognosis
• Dependent on the etiology

• Usually, self limiting within 2-8 weeks

• Recurrence is possible
 Treatment
• Treatment of the cause

• Symptomatic:
-Bed rest & leg elevation
-Compresses
-NSAIDs e.g. Ibuprofen
-Potassium Iodide

• In severe/resistant cases: Systemic corticosteroids

Morbilliform Drug Eruptions
(Exantematous Drug Eruption)
 Definition
Maculopapular (measles-like), drug induced eruption, representing type
IV hypersensitivity reaction
 Etiology
• The most common form of drug eruptions

• Antibiotics are the most commonly incriminated drugs

• Viral infections e.g. Ampicillin rash in IMN

 Pathogenesis
Type IV (delayed & cell-mediated) hypersensitivity reactions
It involves 2 main steps:

1.T-cell sensitization: After antigen skin penetration, Langerhans cells

takes the Ag to the LN leading to formation of “Sensitized T cells”

2.T cell response: After repeated exposure

-CD4 cells Ag recognition on APCs causing release of inflammatory
mediators & target cells phagocytosis by macrophages
-CD8 cells Ag recognition on somatic cells causing direct cell
destruction
 Diagnosis
• Recently introduced medication

• Typical rash that disappears after stopping the offending drug:

Erythematous macules and papules on the trunk and extremities with
variable severity

• Non-specific associated manifestations: pruritus & fever

Clinical Presentation
 Treatment
• Stop the offending drug

• Monitoring & stabilization of general condition

• Soothing applications

• Antihistamines

• Systemic Steroids in severe cases

Fixed Drug Eruption
 Definition

Unique hypersensitivity cutaneous drug eruption, in the form of

recurrent lesion at the same site after re-exposure of the causative drug
(antibiotics & NSAIDs)
Clinical Presentation
 Management
• Features: Usually single, well-defined, pruritic, erythematous at first then
pigmented. Atypical presentations are not uncommon

• Lag period: variable

• Site: Skin or MM can be affected

• Fate: Disappears spontaneously on drug discontinuation

• Confirmation: Oral Provocation Test

• Treatment: Symptomatic
Increased Awareness of Different Cutaneous Adverse Reactions to Drugs is Mandatory

Thanking You