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A drug rash, sometimes called a drug eruption, is a reaction your skin can have to certain drugs. Almost any drug can cause a rash. But antibiotics (especially penicillins and sulfa drugs), NSAIDs ...
View an Illustration of Fixed Drug Eruption and learn more about Papules, Scales, Plaques and Eruptions.
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Apr 01, 2020 · Fixed drug eruption (FDE) is a distinctive type of cutaneous drug reaction that characteristically recurs in the same locations upon reexposure to the offending drug. Acute FDE usually presents with a single or a small number of dusky red or violaceous plaques that resolve leaving postinflammatory hyperpigmentation ( picture 1A-C ).
Oct 09, 2020 · Fixed drug eruption due to nabumetone in a patient with previous fixed drug eruptions due to naproxen. J Investig Allergol Clin Immunol. 2011. 21(2):153-4. . Leleu C, Boulitrop C, Bel B, Jeudy G, Vabres P, Collet E. Quinoline Yellow dye-induced fixed food-and-drug eruption. Contact Dermatitis. 2013 Mar. 68(3):187-8. .
A fixed drug eruption is the term for a drug eruption that occurs in the same skin area every time the person is exposed to the drug. Eruptions can occur frequently with a certain drug (for example, with phenytoin  ), or be very rare (for example, Sweet's syndrome following the administration of colony-stimulating factors  ).
- 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 In general, the rash improves when the drug is withdrawn.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.
A drug rash (drug eruption), also known as a drug reaction, is a skin condition caused by a medication. A drug rash can appear in many forms, and any medication can cause a drug rash. Who's at risk? Drug rashes can appear on people of all ages, all races, and of both sexes.
- Associated Drugs and Rashes
- Potentially Fatal Drug Eruptions
- Associated Diseases
Hospital Episode Statistics from 1996 to 2000 logged 62,000 hospital admissions in England each year due to drug allergies and adverse drug reactions. There is also evidence that these reactions are increasing: between 1998 and 2005, serious adverse drug reactions rose 2.6‑fold. Up to 15% of inpatients have their hospital stay prolonged as a result of an adverse drug reaction. Population studies suggest that drug allergies are over-diagnosed. 10% of the general population have self-reported penicillin allergy but this has been confirmed in less than 1%. This has important clinical consequences, because such patients tend to be treated with broad-spectrum antibiotics which may lead to antibiotic resistance and suboptimal therapy. 5-10% of asthmatic patients develop an allergic reaction to non-steroidal anti-inflammatory drugs (NSAIDs). A five-year analysis of confirmed drug-related eruptions, showed that 39.8% were caused by antibiotics, 21.2% by anti-inflammatories, 7.6% by contrast...History and examination are as important here as in any field.When a patient develops a dermatological problem it is often difficult to decide which, if any, drugs are responsible.Take a careful history, avoiding being too ready to accept the patient's diagnosis of what is to blame, especially if they are on multiple medication. Take note of all medication, including prescr...Urticaria may not be due to a drug at all but the ingestion of strawberries or shellfish. There may be a viral infection. Has the patient had that drug before? Were there any problems then?
These are different from acne vulgarisin that they tend to be over the upper body rather than the face and there are no comedones. Typical drugs are corticosteroids, halogens, haloperidol, hormones, isoniazid, lithium, phenytoin and trazodone: 1. The halogens are usually bromide or iodide. 2. The hormones may be anabolic steroids taken illicitly by bodybuilders or some athletes. Progestogens can also be a problem. This tends to be in low-oestrogen, high-progestogen oral contraceptive pills ra...
Acute generalised exanthematous pustulosis
1. This produces an acute onset of fever and generalised scarlatiniform erythema with many small, sterile, non-follicular pustules. It appears like pustular psoriasis. 2. Most cases are caused by antibiotics, often in the first few days of administration. 3. Some may be viral infections, mercury exposure, or UV radiation. They resolve spontaneously and rapidly, with fever and pustules lasting 7-10 days before desquamation over a few days. 4. Typical drugs include beta-lactam antibiotics, macr...
Alopeciamay occur with angiotensin-converting enzyme (ACE) inhibitors, allopurinol, anticoagulants, azathioprine, bromocriptine, beta-blockers, cyclophosphamide, hormones (especially those with androgenic effects), indinavir, NSAIDs, phenytoin, methotrexate, retinoids and valproate. It is usual with cyclophosphamide therapy but is quite rare with the other medications.
Most drug eruptions are unpleasant rather than potentially life-threatening. There are two that are worthy of special mention.Usually no specific investigation is undertaken in primary care other than removing the suspected drug or even several drugs and monitoring for improvement.Severe reactions require immediate investigation in secondary care (see 'Referral guidelines', below).FBC may show leukopenia, thrombocytopenia and eosinophilia in patients with serious drug eruptions.In the severe forms of reactions, LFTs and renal function should be monitored. In vasculitis, CXR and urinalysis are required.
Although compromise of the immune system dampens the immune response, it may increase the risk of adverse reactions. One study of HIV-positive patients reported a serious adverse drug reaction incidence to antiretroviral therapy of 10%.Stevens-Johnson syndrome or toxic epidermolysis occurs in less than 0.5% of patients.
In uncomplicated cases, remove the offending drug and, if the condition resolves as expected, make notes to the effect that the patient has an adverse reaction to that drug. It may not be possible to be conclusive about which drug, if any, was responsible and, whilst caution is prudent, it is inappropriate to be too eager to label patients as allergic to any specific drug. Many people have probably been wrongly labelled as allergic to penicillin over the years and denied this very safe and effective treatment. However, failure to note allergy can be fatal. Provided that they are not thought to be part of the problem, antihistamines may give some symptomatic relief.
Most cases resolve without complications but it may take 10-14 days for the rash to disappear. Patients with exanthematous eruptions will have mild desquamation as the rash resolves. The Stevens Johnson syndrome has a mortality of around 10% whilst toxic epidermal necrolysis carries a mortality of 50%.
This is a vast but very important area: 1. Drug reactions are iatrogenic and hence contravene the principle of primum non nocere- 'first do no harm'. 2. Patients are often too eager to attribute adverse reactions to prescribed medication but they may be correct. The doctor must keep an open and self-critical mind. 3. History and examination are very important and ask about OTC, 'alternative' and illicit medication. 4. Most drug reactions are minor and self-limiting but certain red flags must be noted: 4.1. If the patient is systemically unwell, this is serious. 4.2. If the rash is extensive, it could progress to a serious exfoliative dermatitis. 4.3. Detachment of the skin is serious. 4.4. Involvement of mucous membranes including eyes and genitalia may suggest Stevens-Johnson syndrome. 5. The doctor must appreciate the protean nature of many adverse reactions and have a low threshold for stopping the drug, although if it is an essential drug this will require more circumspection. 6...
- Dr Laurence Knott
Oct 09, 2020 · Fixed drug eruptions may account for as much as 16-21% of all cutaneous drug eruptions. The actual frequency may be higher than current estimates, owing to the availability of a variety of over-the-counter medications and nutritional supplements that are known to elicit fixed drug eruptions.
- related to: food allergy vs fixed drug eruption pictures
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