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Common causes of exanthematous drug rashes include: penicillins sulfa drugs cephalosporins anti-seizure drugs allopurinol
There are many types of drug eruption, which range from a clinically mild and unnoticed rash to a severe cutaneous adverse reaction (SCAR) that may be life-threatening. The most common drug eruptions are: Morbilliform or exanthematous drug eruption. Urticaria and/or angioedema (which rarely leads to anaphylaxis ).
Drug rashes are the body's reaction to a certain medicine. The type of rash that happens depends on the medicine causing it and your response. Medicines have been linked to every type of rash, ranging from mild to life-threatening. The timing of the rash can also vary.Type of rashSymptomsCauseAcnePimples and red areas that appear most often on the face, shoulders, and chestAnabolic steroids, corticosteroids, bromides, iodides, and phenytoinExfoliative dermatitisRed, scaly skin that may thicken and peel and involve the entire bodyAntibiotics that contain sulfa, barbiturates, isoniazid, penicillins, and phenytoinFixed drug eruptionA dark red or purple rash that reacts at the same siteAntibiotics and phenolphthalein (found in certain laxatives)HivesRaised red bumpsAspirin, certain medicine dyes, penicillins, and many other medicines
In medicine, a drug eruption is an adverse drug reaction of the skin. Most drug-induced cutaneous reactions are mild and disappear when the offending drug is withdrawn. These are called "simple" drug eruptions. However, more serious drug eruptions may be associated with organ injury such as liver or kidney damage and are categorized as "complex". Drugs can also cause hair and nail changes, affect the mucous membranes, or cause itching without outward skin changes. The use of synthetic pharmaceut
Morbilliform drug eruption is the most common form of drug eruption. Many drugs can trigger this allergic reaction, but antibiotics are the most common group. The eruption may resemble exanthems caused by viral and bacterial infections. A morbilliform skin rash in an adult is usually due to a drug.
- Life-Threatening Features
- Exanthematous Drug Reactions
- Drug Hypersensitivity Syndrome
- Drug-Induced Urticaria
- Fixed Drug Eruption
- Drug-Induced Photosensitivity
- Drug-Induced Pigmentation
Drug eruptions are common – think carefully before you prescribe an unnecessary medicine! In hospital patients, rashes are commonly attributed to and often caused by medications. Clinical manifestations are very variable. About 3% of patients admitted to hospital have rashes due to adverse drug reactions but in others the cutaneous signs are due to the underlying or intercurrent illness (e.g. viral or bacterial exanthemas or internal disease), non-specific reactions to treatment (e.g. sweat-rashdue to prolonged bed rest with plastic sheeting) or independent skin disease that has not been recognised by hospital staff. True drug reactions may mimic other skin diseases. In general, the rash improves when the drug is withdrawn. This may occur quickly but in some cases takes weeks or longer.
Adverse drug eruptions can be dangerous, especially toxic epidermal necrolysis (TEN) and drug hypersensitivity syndrome. Features indicating a potentially serious reaction include: 1. Facial and/or mucousmembrane involvement 2. Widespread confluent erythema or erythroderma 3. Skin pain 4. Blistering, purpura or necrosis 5. Urticariathat includes tongue or throat swelling 6. High fever 7. Lymphadenopathy, arthralgias or arthritis 8. Abnormal blood count, hepatic or renal dysfunction 9. Shortness of breath, wheezing, hypotension
The patient may need to be coaxed to report their drug history. Although adverse reactionsare less likely to arise from drugs that the patient has been on for a long period of time, this is not always the case. Suggest these are brought to the clinic for inspection. Ask about all medications taken in the last three months: 1. Prescribed and unprescribed 2. Oral, injected, patches, creams, ointments 3. Household remedies: laxatives, hypnotics, analgesics 4. Herbals, vitamins, homeopathic remedies It is not possible to memorise all possible causes of all possible drug eruptions. Standard reference handbooks such as the MIMS and manufacturers' data sheets include rash in the list of potential adverse effects for nearly every drug.
These are often also described as toxic erythema. Features include: 1. Abrupt onset 5-10 days after new drug prescribed (or 1-3 days after its reintroduction); 2. May be associated with fever and malaise; 3. Most often morbilliform i.e. symmetrical erythematous macules and papules, but the rash may be scarlatiniform (tiny red spots) or confluent lesions presenting as large erythematous patches or urticated plaques; 4. More likely in patients with infectious mononucleosis, leukaemia or human immunodeficiency virus infectionand in those also taking allopurinol (especially to ampicillin and derivatives); 5. Can progress to erythroderma, drug hypersensitivity syndrome or toxic epidermal necrolysis. The suspected drug or drugs should be discontinued, and the rash usually subsides within a week. Unfortunately there are no useful in vitro or in vivo tests to confirm hypersensitivity reactions and re-challenge is not recommended (although it sometimes occurs inadvertently at a later date)....
A morbilliform eruptionin association with internal organ involvement and fever indicates possible drug hypersensitivity syndrome (DHS). This has a mortality rate of about 10%.
Drug-induced urticaria may occur with or without angioedema. It arises up to three weeks after first exposure (or minutes on re-challenge). It may be due to type 1 hypersensitivity (e.g. penicillin), sometimes in association with anaphylaxis and constitutional symptoms (respiratory distress, vascularcollapse and shock). It may also be due to direct release of inflammatory mediators from mast cells on first exposure to the drug (e.g. opiates, aspirin, NSAID, muscle relaxants). ACE inhibitors such as captopril and enalapril may cause recurrentangioedema without urticaria, rarely commencing months or years after the drug was first prescribed. Serum sickness is combination of urticaria, fever and arthralgia (sometimes lymphadenopathy, nephritis, endocarditis) and may be due to antibiotics especially cefaclor.
Fixed drug eruption (FDE) refers to solitary or multiple oval plaques that arise over a few hours and may have central blisters. It frequently affects mucosal surfaces such as the genitals and lips. FDE resolves in a few days leaving purplish hyperpigmentation, then re-erupts in the same site on re-exposure to the causative drug, which is usually a medication taken intermittently such as paracetamol or antibiotics but may also be a food dye.
Drug-related bleeding into the skin includes: 1. Allergic or cytotoxic thrombocytopenia (plateletcount <30x109/l) 2. Capillary fragilitydue to systemic, inhaled or topical corticosteroids 3. Capillaritis (unknown mechanism) 4. Overdose of anticoagulants often because of drug interaction 5. Coumarin necrosis (cutaneous infarctionespecially in patients deficient in protein C) 6. Leukocytoclasticvasculitis (purpura most often affecting lower legs and feet)
Photosensitivity may be due to toxic or immunological mechanisms or both, from systemic or topical exposure to the medication. The rash affects sites of light exposure (UVA), but may spare habitually exposed areas such as the face and hands. Phototoxic reactions will affect everyone if the dose is high enough, and appears like sunburn (e.g. doxycycline, chlorpromazine). Photoallergic eruptions are generally eczematous or lichenoid(e.g. quinine). Onycholysismay be due to drug-induced photosensitivity.
Several drugs may slowly induce hyperpigmentation of the skin and mucosal surfaces, due to the deposition of melanin (e.g. ACTH, oestrogen/progesterone, phenytoin), haemosiderin (minocycline), exogenous pigment(minocycline) or unknown mechanisms, 1. Pigmentary changes occur on exposed sites in 75% of patients on long-term amiodarone. 2. Clofazimine causes a reddish brown pigmentation on light exposed areas and excretions (sweat, urine and faeces). 3. Carotenaemia due to ingestionof large quantities of red or orange coloured vegetables, supplements containing carotene or rarely, anti-epileptic drugs, causes yellow-orange discolouration most obvious on palms and soles. 4. Pigmentation is not uncommon due to antimalarials, bleomycin, cyclophosphamide, busulphan, phenothiazines, silver (argyria), gold (chrysiasis) and iron.
What is a lichenoid drug eruption? Lichenoid eruptions are uncommon skin rashes that can be induced by many environmental agents, medications or industrial by-products such as inhaled particles.
CLASSIC DRUG REACTION PATTERNS. Exanthematous drug eruptions. Lichenoid drug eruption (drug-induced lichen planus) Exfoliative dermatitis/erythroderma. Urticaria/angioedema. Anaphylaxis. Cutaneous small vessel vasculitis. LESS COMMON DRUG ERUPTIONS. Severe cutaneous reactions.
- Signs and Symptoms
The first steps in the history are as follows: 1. Review the patient’s complete medication list, including prescription and over-the-counter drugs 2. Document any history of previous adverse reactions to drugs or foods 3. Consider alternative etiologies (eg, viral exanthems and bacterial infections) 4. Note any concurrent infections, metabolic disorders, or immunocompromise In addition, the following should be noted and detailed: 1. Interval between introduction of a drug and onset of the eruption 2. Route, dose, duration, and frequency of drug administration 3. Use of parenterally administered drugs (more likely to cause anaphylaxis) 4. Use of topically applied drugs (more likely to induce delayed-type hypersensitivity) 5. Use of multiple courses of therapy and prolonged administration (risk of allergic sensitization) 6. Any improvement after drug withdrawal and any reaction with readministration Physical examination should address clinical features that may indicate a severe, pote...
With mild asymptomatic eruptions, the history and physical examination are often sufficient for diagnosis; with severe or persistent eruptions, further diagnostic testing may be required, as follows: 1. Biopsy 2. Complete blood count (CBC) with differential 3. Serum chemistry studies (especially for electrolyte balance and indices of renal or hepatic function in patients with severe reactions) 4. Antibody or immunoserology tests 5. Direct cultures to investigate a primary infectious etiology or secondary infection 6. Urinalysis, stool guaiac tests, and chest radiography for vasculitis 7. Skin prick or patch testing to confirm the causative agent See Workupfor more detail.
Principles of medical care are as follows: 1. The ultimate goal is to identify and discontinue the offending medication if possible 2. Patients can sometimes continue to be treated through morbilliform eruptions; nevertheless, all patients with severe morbilliform eruptions should be monitored for mucous membrane lesions, blistering, and skin sloughing 3. Treatment of a drug eruption depends on the specific type of reaction 4. Therapy for exanthematous drug eruptions is supportive, involving the administration of oral antihistamines, topical steroids, and moisturizing lotions 5. Severe reactions (eg, SJS, TEN, and hypersensitivity reactions) warrant hospital admission 6. TEN is best managed in a burn unit, and intravenous immunoglobulin (IVIG) may improve outcomes[3, 4, 5] 7. Hypersensitivity syndrome may have to be treated with liver transplantation if the offending drug is not stopped in time; treatment with systemic corticosteroids has been advocated in the acute phase; in the ch...
Morbilliform Drug Eruptions (exanthematous drug eruption; maculopapular drug eruption, "drug rash") Optimal Therapeutic Approach for this Disease. The offending agent should be discontinued if possible. In cases where it... Patient Management. An in-depth history and a drug chart may be required to ...
- Susan Burgin
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