drug induced exfoliative dermatitis

Systemic and potentially life-threatening complications include fluid and electrolyte imbalance, thermoregulatory disturbance, fever, tachycardia, high-output failure, hypoalbuminemia, and septicemia. Systemic derangements may occur with exfoliative. Drugs that have been implicated in the causation of LPP include captopril, cinnarizine, ramipril, simvastatin, PUVA, and antituberculous medications. 2010;125(3):70310. Early enteral nutrition has also a protective effect on the intestinal mucosa and decreases bacterial colonization. 2016;2:14. Although the etiology is often unknown, exfoliative dermatitis may be the result of a drug reaction or an underlying malignancy. The type of rash that happens depends on the medicine causing it and your response. N Engl J Med. Anti-Allergic Agents Immunoglobulin E Allergens Cetirizine Histamine H1 Antagonists, Non-Sedating Histamine H1 Antagonists Loratadine Emollients Nasal Decongestants Dermatologic Agents Leukotriene Antagonists Antigens, Dermatophagoides Ointments Histamine Antagonists Eosinophil Cationic Protein Adrenal Cortex Hormones Terfenadine Antipruritics Antigens, Plant . A catabolic state thus ensues, which is often responsible for significant weight loss. Erythema multiforme (EM), Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. J Am Acad Dermatol. Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid and linear IgA dermatosis have to be considered. The fluid of blisters from TEN patients was found to be rich in TNF-, produced by monocytes/macrophages present in the epidermis [42], especially the subpopulation expressing CD16, known to produce higher levels of inflammatory cytokines [43]. Drugs such as paracetamol, other non-oxicam NSAIDs and furosemide, bringing a relatively low risk of SJS/TEN a priori, are also highly prevalent as putative culprit agents in large SJS/TEN registries, due to their widespread use in the general population [63, 64] (Table1). Furosemide or ethacrynic acid may be required to maintain an adequate urinary output [90]. Kano Y, et al. 2003;21(1):195205. Rare dermatological side effects such as alopecia, exfoliative dermatitis, xeroderma, pruritus have been reported. A marked increase in serum soluble Fas ligand in drug-induced hypersensitivity syndrome. Next vol/issue 1990;126(1):3742. Mild to severe alopecia and transient or permanent nail dystrophy also may be encountered. Google Scholar. . Exfoliative Dermatitis: Definition, Causes, Treatments and More Int J Mol Sci. Rzany B, et al. 2013;168(3):55562. Int J Dermatol. Blood gas analysis, glucose and creatinine levels together with electrolytes should be evaluated and therapy should be modified accordingly. Most common used drugs are: morphine, fentanyl, propofol and midazolam. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. TNF- has a dual role: interacts with TNF-R1 activating Fas pathway and activates NF-B leading to cell survival. Gen Dent. 5% silver nitrate compresses have antiseptic properties. Would you like email updates of new search results? Toxic epidermal necrolysis (Lyell syndrome). Recent advances in the genetics and immunology of StevensJohnson syndrome and toxic epidermal necrosis. Acute processes usually favor large scales, whereas chronic processes produce smaller ones. 2008;159(4):9814. Wolkenstein P, et al. Curr Opin Allergy Clin Immunol. Unauthorized use of these marks is strictly prohibited. Archivio Istituzionale della Ricerca Unimi, Nayak S, Acharjya B. This has been called the nose sign.18, Once the erythema is well established, scaling inevitably follows (Figure 1). 2002;118(4):72833. Qilu Pharmaceutical Co., Ltd. GEFITINIB- gefitinib tablet, coated A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus. Incidence of toxic epidermal necrolysis and StevensJohnson Syndrome in an HIV cohort: an observational, retrospective case series study. Vasoactive amines may be necessary in case of shock. A drug eruption may start as a rash but eventually progress to more generalized exfoliative dermatitis. 2004;59(8):80920. Von Hebra first described erythroderma (exfoliative dermatitis) in 1868. Google Scholar. Trautmann A, et al. (sometimes fatal), erythema multiforme, Stevens-Johnson syndrome, exfoliative dermatitis, bullous dermatitis, drug rash with eosinophilia and systemic symptoms (DRESS . Exfoliative dermatitis may happen as a complication of other skin issues. official website and that any information you provide is encrypted Notably, Agr inhibitors have not yet been more rigorous pre-clinical testing using the established analyzed using rigorous testing with systemic applica standards for drug development. Oral manifestations of erythema multiforme. (2.4, 5.6) Embryo-fetal Toxicity: Can cause fetal harm. Diclofenac sodium topical solution, like other NSAIDs, can cause serious systemic skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations . Generalized Exfoliative Dermatitis | Johns Hopkins Medicine However, according to a consensus definition [54], EMM syndrome has been separated from SJS/TEN spectrum. Allergol Immunopathol (Madr). 2018 Jan 28;2018:9095275. doi: 10.1155/2018/9095275. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. journal.pds.org.ph 2014;71(1):1956. Apoptosis-inducing factors and lymphocyte-mediated cytotoxicity have been deeply investigated in ED. Plasmapheresis may have a role in the treatment of ED because it removes Fas-L [96], other cytokines known to be implied in the pathogenesis (IL-6, IL-8, TNF-) [97, 98]. Article The prognosis of cases associated with malignancy typically depends on the outcome of the underlying malignancy. Although the etiology is. Here we provide a systematic review on frequency, risk factors, pathogenesis, clinical features and management of patients with drug induced ED. Ann Intern Med. When less than 10% of the body surface area (BSA) is involved, it is defined SJS, when between 10 and 30% of BSA it is defined overlapping SJS/TEN, when more than 30% of BSA, TEN [2] (Additional file 1: Figure S1, Additional file 2: Figure S2). The SJS histology is characterized by a poor dermal inflammatory cell infiltrate and full thickness necrosis of epidermis [20, 49]. These patches tend to spread until, after a matter of days or weeks, most of the skin surface is covered with an erythematous, pruritic eruption. Science. Arch Dermatol. 2012;42(2):24854. Arch Dermatol. 1998;282(5388):4903. Management of patients with a suspected drug induced exfoliative dermatitis J Immunol. Management of patients with a suspected drug induced exfoliative dermatitis, acute generalized exanthematous pustulosis, algorithm of drug causality for epidermal necrolysis, European registry of severe cutaneous adverse reactions to drugs. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Exfoliative Dermatitis is a serious skin cell disorder that requires early diagnosis and treatment. Samim F, et al. Paradisi et al. Ann Allergy Asthma Immunol. Initial symptoms could be aspecific, as fever, stinging eyes and discomfort upon swallowing, occurring few days before the onset of mucocutaneous involvement. Four cases are described, two of which were due to phenindione sensitivity. Ann Burns Fire. 2012;27(4):21520. J Am Acad Dermatol. In spared areas it is necessary to avoid skin detachment. 2015;13(7):62545. 2004;114(5):120915. In the acute phase, before determination of the etiology, treatment consists of measures to soothe the inflamed skin. The exact role of FasL in the pathogenesis of toxic epidermal necrolysis is still questionable especially because a correlation between serum FasL levels and disease severity has not been established and because its levels have been found to be increased also in drug-induced hypersensitivity syndrome and maculopapular eruption [36]. To confirm ATT induced erythroderma and narrow down the offending agents, sequential rechallenge with ATT was done and again these patients had similar lesions erupt all over the body only with isoniazid and pyrazinamide. Early sites of skin involvement include trunk, face, palms and soles and rapidly spread to cover a variable extension of the body. The most important actions to do are listed in Fig. Antiviral therapy. These highlights do not include all the information needed to use CAS In conclusion we suggest that therapy with cyclosporine is valuable option with a dosage of 35mg/kg oral or iv for 7days. Cookies policy. Albeit the lack of epidemiologic data regarding EM, its reported prevalence is less than 1% [710]. It can lead to pain, appear on large parts of the body and may require hospitalization. However, patchy, diffuse areas of postinflammatory hyperpigmentation and hypopigmentation may occur, especially in patients with darker skin.1,4 One case of posterythrodermic generalized vitiligo beginning six weeks after the onset of exfoliative dermatitis has been reported.29,30 Residual eruptive nevi and keloid formation are rare sequelae. Etoricoxib-induced toxic epidermal necrolysis: successful treatment with infliximab. JDS | Journal of Dermatological Science | Vol 8, Issue 1, Pages 1-90 Bickle K, Roark TR, Hsu S. Autoimmune bullous dermatoses: a review. 2010;5:39. Overall, T cells are the central player of these immune-mediated drug reactions. 2010;62(1):4553. Continue Reading. Guidelines for the management of drug-induced liver injury[J]. Barbaud A. Wikizero - Basal-cell carcinoma Exfoliative dermatitis is also a risk factor for epidemic spread of methicillin-resistant Staphylococcus aureus.6,20. Cyclosporine A (Cys A): Cys A works through the inhibition of calcineurin, that is fundamental for cytotoxic T lymphocytes activation. Gonzalez-Delgado P, et al. Drug rashes are the body's reaction to a certain medicine. Stern RS. Medication-Induced Erythroderma | SpringerLink Albumin is recommended only is albumin serum level is <2.5mg/dL. Hepatobiliary: jaundice, hepatitis, including . Grosber M, et al. The authors concluded that they couldnt demonstrate corticosteroids efficacy in monotherapy, but the use of steroid alone is not linked to an increased risk of mortality due to infective complications [108, 109]. In more severe cases continuous iv therapy can be necessary. Palynziq PEGVALIASE 20 mg/mL BioMarin Pharmaceutical Inc. Patients who have exfoliative dermatitis of unknown cause tend to have an unpredictable course, usually replete with multiple remissions and exacerbations.4. (adult rickets), anticonvulsant-induced rickets and osteomalacia, osteoporosis, renal osteodystrophy . Important data on ED have been obtained by RegiSCAR (European Registry of Severe Cutaneous Adverse Reactions to Drugs: www.regiscar.org), an ongoing pharmaco-epidemiologic study conducted in patients with SJS and TEN. Exfoliative dermatitis is a dangerous form of CADR which needs immediate withdrawl of all the four drugs. Bourgeois GP, et al. Harr T, French LE. These highlights do not include all the information needed to use McCormack M, et al. The more common forms of erythroderma, such as eczema or psoriasis, may persists for months or years and tend to relapse. 2013;27(3):35664. The balance of fluids and electrolytes should be closely monitored, since dehydration or hypervolemia can be problems. Patients with underlying skin disorders may respond much more slowly to therapy, but clearing almost always occurs eventually. Morel E, et al. It is important to take into consideration the mechanism of action of the different drugs in the pathogenesis of ED [104]. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Toxic epidermal necrolysis treated with cyclosporin and granulocyte colony stimulating factor. It is also recommended to void larger vesicles with a syringe. Ibuprofene Zen * 20cps Mol 400mg Epilepsia. Skin manifestations of drug allergy. The induction dosage in EMM is usually 1mg/kg/day that should be maintained until a complete control of the skin is obtained. Because a certain degree of cross-reactivity between the various aromatic anti-epileptic drugs exists, some HLAs have been found to be related to SJS/TEN with two drugs, as the case of HLA-B*1502 with both phenytoin and oxcarbazepine [32]. Not responsive to therapy. 1 Article Pathogenicity and Virulence of Staphylococcus Aureus | PDF Eosinophils from Physiology to Disease: A Comprehensive Review. Paquet P, et al. J Dermatol Sci. Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. Mayo Clin Proc. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti-PD-1/PD-L1 treatments. Increased level of retinoid acid could be responsible for keratinocytes apoptosis [99]. Affiliated tissues include skin, liver and bone marrow. Napoli B, et al. The EuroSCAR-study. Several authors reported also an increased incidence for aminopenicillins, cephalosporins, and quinolones [61, 62]. Copyright 2023 American Academy of Family Physicians. and transmitted securely. Locharernkul C, et al. The most commonly used steroids were methylprednisolone, prednisolone and dexamethasone. Abstract Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. 3. Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. They found that the inhibition of these molecules could attenuate the cytotoxic effect of lymphocytes toward keratinocytes. Epidemiological studies on EM, SJS and TEN syndromes report different results, probably related to several biases, such as ethnical differences, diagnostic criteria and drug consumption patterns in different socio-economic systems. Topical treatment. As described in Table3, major differential diagnosis of EM and SJS/TEN are (1) staphylococcal scalded skin syndrome (SSSS), (2) autoimmune blistering diseases and disseminated fixed bullous drug eruption, (3) others severe delayed DHR [6, 70, 82] (4) Graft versus host disease. 2006;34(2):768. Clinicians using antivirals for mpox should be alert for drug-drug interactions with any antiretrovirals used to prevent 16, 17 or treat 18 HIV infection as well as with any other medications used to prevent or treat HIV-related opportunistic infections. Fitzpatricks dermatology in general medicine. Consultation with an oncologist who is well-versed in treatment of cutaneous T-cell lymphoma is advisable once the disease progresses to the tumor stage. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involv ing skin and usually occurring from days to several weeks after drug exposure. Tohyama M, Hashimoto K. Immunological mechanisms of epidermal damage in toxic epidermal necrolysis. 2013;168(3):53949. For the prevention of deep venous thrombosis; usually low molecular weight heparin at prophylactic dose are used. 2. Fischer M, et al. Also, physicians should be vigilant about possible secondary infection, whether cutaneous, pulmonary or systemic. FOIA 1995;14(6):5589. . A classic example of an idiosyncratic reaction is drug-induced . The https:// ensures that you are connecting to the Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. The epidermal-dermal junction shows changes, ranging from vacuolar alteration to subepidermal blisters [20]. The exfoliative process also may involve the scalp, with 25 percent of patients developing alopecia.4 Nails can often become dystrophic, particularly in patients with preexisting psoriasis.4,6, The most frequently noted symptoms in patients with exfoliative dermatitis include malaise, pruritis and a chilly sensation. Insidious development of the erythroderma, progressive debilitation of the patient, absence of previous skin disease and resistance to standard therapy are features that may suggest an underlying malignancy.6,11, Erythroderma is also associated with disorders that cannot easily be classified into groups. Kreft B, et al. As written before, Sassolas B. et al. PubMedGoogle Scholar. Tumor necrosis factor : TNF- seems also to play an important role in TEN [41]. PMC Arch Dermatol. The scales may be small or large, superficial or deep. Drug induced exfoliative dermatitis: state of the art, https://doi.org/10.1186/s12948-016-0045-0, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. It characteristically demonstrates diffuse erythema and scaling of greater than 90% of the body surface area. In a hemodialysis patient with active pulmonary tuberculosis, early withdrawl followed by prompt rechallenging to identify the causative agent and then to achieve cure of pulmonary tuberculosis is an interesting therapeutic challenge. ALDEN, an algorithm for assessment of drug causality in StevensJohnson Syndrome and toxic epidermal necrolysis: comparison with case-control analysis. Polak ME, et al. The time interval between the appearance of exfoliative dermatitis and the appearance of cutaneous T-cell lymphoma lesions can vary from months to years or even decades. They usually have fever, are dyspneic and cannot physiologically feed. Springer Nature. Indian J Dermatol. Staphylococcal Scalded Skin Syndrome: criteria for Differential Diagnosis from Lyells Syndrome. The incidence of erythema multiforme, StevensJohnson syndrome, and toxic epidermal necrolysis. Med J Armed Forces India. StevensJohnson syndrome and toxic epidermal necrolysis: a review of the literature. 1990;126(1):437. Generalized. Arch Dermatol. Some anti-seizure medicines have also been known to cause exfoliative dermatitis. Drug induced interstitial nephritis, hepatitis and exfoliative dermatitis Google Scholar. GULIZ KARAKAYLI, M.D., GRANT BECKHAM, M.D., IDA ORENGO, M.D., AND TED ROSEN, M.D. J Am Acad Dermatol. 2011;128(6):126676. Schwartz RA, McDonough PH, Lee BW. Google Scholar. Here we provide a systematic review of frequency, risk factors, molecular and cellular mechanisms of reactions, clinical features, diagnostic work-up and therapy approaches to drug induced ED. Valeyrie-Allanore L, et al. SCITECH - Orphan Drug Nitisinone in Dermatology - Journal of Even though there is a strong need for randomized trials, anti-TNF- drugs, in particular a single dose of infliximab 5mg/kg ev or 50mg etanercept sc should be considered in the treatment of SJS and TEN, especially the most severe cases when IVIG and intravenous corticosteroids dont achieve a rapid improvement. In SJS, SJS/TEN and TEN the efficacy of corticosteroids is far from being demonstrated. [Stevens-Johnson Syndrom and Toxic Epidermal Necrolysis--based on literature]. Letko E, Papaliodis DN, Papaliodis GN, Daoud YJ, Ahmed AR, Foster CS. Drug induced exfoliative dermatitis: state of the art. Medicines have been linked to every type of rash, ranging from mild to life-threatening. 1997;22(3):1467. Erythema multiforme StevensJohnson syndrome and toxic epidermal necrolysis. Diagnosis in a routine setting is based on patch test (PT) while skin test (prick and intradermal tests) with a delayed reading are contraindicated in these patients [72]. An official website of the United States government. In: Eisen AZ, Wolff K, editors. 2000;115(2):14953. J Invest Dermatol. 2019 Jan 6;59:463-486. doi: 10.1146/annurev-pharmtox-010818-021818. Chung W-H, et al. Energy requirements of pediatric patients with StevensJohnson syndrome and toxic epidermal necrolysis. 2023 BioMed Central Ltd unless otherwise stated. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Narita YM, et al. Perforin/granzyme B pathway: Nassif and colleagues have proposed a role for perforin/grazyme B in keratinocyte death [37]. 2013;69(4):37583. Patients should be educated to avoid any causative drugs. PubMed 2009;145(2):15762. For these reasons, patients should be admitted to intensive burn care units or in semi-intensive care units where they may have access to sterile rooms and to dedicated medical personnel [49, 88]. Temporary tracheostomy may be necessary in case of extended mucosal damage. Viard I, et al. Bullous pemphigoid is characterized by large, tense bullae, but may begin as an urticarial eruption. More recently, carcinomas of the fallopian tube,12 larynx13 and esophagus14 have been reported as causes of exfoliative dermatitis. CAS Immunoregulatory effector cells in drug-induced toxic epidermal necrolysis. EMM is characterizes by target lesions, circular lesions of 1-2cm of diameter, that are defined as typical or atypical that tends to blister. The dermo-epidermal junction and epidermis are infiltrated mostly by CD8+ T lymphocytes whereas dermal infiltrate, mainly made from CD4+ T lymphocytes, is superficial and mostly perivascular [20, 51]. 2010;85(2):131138. Association between HLA-B* 1502 allele and antiepileptic drug-induced cutaneous reactions in Han Chinese. Abe R. Toxic epidermal necrolysis and StevensJohnson syndrome: soluble Fas ligand involvement in the pathomechanisms of these diseases. Talk to our Chatbot to narrow down your search. 2013;52(1):3444. This is due to a reaction to certain medicines, a pre-existing skin condition, and sometimes cancer. -. Atypical target lesions manifest as raised, edematous, palpable lesions with only two zones of color change and/or an extensive exanthema with a poorly defined border darker in the center(Fig. doi: 10.1016/j.jaad.2013.05.003. Download Free PDF. Sekula P, et al. Severe adverse cutaneous reactions to drugs. Granulysin as a marker for early diagnosis of the StevensJohnson syndrome. Toxic epidermal necrolysis and StevensJohnson syndrome. Increased peripheral blood flow can result in high-output cardiac failure. PTs have to be performed at least 6months after the recovery of the reaction, and show a variable sensitivity considering the implied drug, being higher for beta-lactam, glycopeptide antibiotics, carbamazepine, lamotrigine, proton pump inhibitors, tetrazepam, trimethoprimsulfametoxazole, pseudoephedrine and ramipril [7376]. Do this 2 to 3 times a week.