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Objective. Review drug rashes from minor to life-threateningTypical Benign Drug ExanthemHives/AngioedemaDRESS (Hypersensitivity reaction)SJS/TEN. Some drugs are worse than others rate of skin eruptions associated with?. AntibioticsAminopenicillins 5-7%Antibacterial sulfonamides 3-4%Antiepile
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1. Drug Eruptions for the Teledermatologist Jay Vary, MD PhD
Acting Instructor, Dermatology
VAPSHCS and UW
jvary@uw.edu
2. Objective Review drug rashes from minor to life-threatening
Typical Benign Drug Exanthem
Hives/Angioedema
DRESS (Hypersensitivity reaction)
SJS/TEN
3. Some drugs are worse than othersrate of skin eruptions associated with… Antibiotics
Aminopenicillins 5-7%
Antibacterial sulfonamides 3-4%
Antiepileptics 5-10%
Allopurinol Rate of skin eruptions associated with drugsRate of skin eruptions associated with drugs
6. Typical Benign Drug Exanthem Aka maculopapular or “morbilliform”
~90% of cutaneous drug reactions.
Type IV (T-cell mediated) hypersensitivity reaction.
Starts 7-14d after start of drug
Stops up to 7d after stopping drug Morbilliform: ; erythematous macules or papules, symmetric, starts on trunk/upper limbs and become confluent; mucous membranes sparedMorbilliform: ; erythematous macules or papules, symmetric, starts on trunk/upper limbs and become confluent; mucous membranes spared
7. Erythematous, macules with some areas of confluenceErythematous, macules with some areas of confluence
8. Later in course can become more dusky red/brownishLater in course can become more dusky red/brownish
10. Benign Drug ExanthemTreatment STOP the offending agent
Oral antihistamines (benadryl, hydroxyzine)
Topical steroids help a little
12. Urticaria (hives) Type I immune response, IgE mediated
Rapid onset within minutes of exposure, lasts hours
Intensely pruritic
Opiates (mast cell activation),
Antibiotics-penicillins, sulfa, vanco
radiocontrast, transfusion, latex
13. This could look like ANYTHING - bullous pemphigoid, Sweet’s syndrome, fungal infection…identifying characteristic is chronicity - fast on, fast offThis could look like ANYTHING - bullous pemphigoid, Sweet’s syndrome, fungal infection…identifying characteristic is chronicity - fast on, fast off
16. STOP the offending agent
Oral antihistamines (benadryl, hydroxyzine)
17. Day 1 fever, n/v, rash, ear pain, dysuria, tender cervical lymphadenopathy
Doxycycline 4 weeks earlierfever, n/v, rash, ear pain, dysuria, tender cervical lymphadenopathy
Doxycycline 4 weeks earlier
18. Day 3
19. DRESS Drug reaction with eosinophilia and systemic symptoms—aka “drug/dilantin hypersensitivity syndrome”
Type IV delayed hypersensitivity reaction
Onset 2-8 weeks after first exposure
Can be fatal (10%) if untreated
21. DRESSTreatment STOP the offending agent
PO or IV steroids
22. Day of Admit 2 weeks earlier, started lamictal at 4 times the intended dose. Presented c/o “flu”. Fever2 weeks earlier, started lamictal at 4 times the intended dose. Presented c/o “flu”. Fever
23. Day 2
24. Day 4
25. What is it, and is their skin going to fall off? EM minor=targetoid lesions, +/- blisters, acral distribution. herpes/mycoplasma. recurrent, no mortality. More blisters and more mucosal involvement = EM major. Classification is contraversial but has major implications for mortality, ranging from ZERO to 60%.EM minor=targetoid lesions, +/- blisters, acral distribution. herpes/mycoplasma. recurrent, no mortality. More blisters and more mucosal involvement = EM major. Classification is contraversial but has major implications for mortality, ranging from ZERO to 60%.
26. Stevens-Johnson Syndrome (SJS)& Toxic Epidermal Necrolysis (TEN) Rare; 1-2 cases per million person years
Occurs 1-3 weeks after starting drug; sooner if rechallenged
URI-prodrome 1-2 weeks before rash
fever (universal), conjunctivitis, pharyngitis, pruritis and PAINFUL SKIN!!
1922, named after two guys, described in two boys aged 7,8 originally thought to have hemorrhagic measles1922, named after two guys, described in two boys aged 7,8 originally thought to have hemorrhagic measles
27. SJS
28. TEN
30. SJS/TENTreatment STOP the offending agent
Admit-Refer to burn ICU if TEN
Ophtho & Gyn consultation to prevent irreversible scarring
Consider PO or IV steroids or IVIG, but benefits are unclear.
31. Acute Exanthematous Generalized Pustulosis (AGEP)
32. Phototoxic reaction
33. Drug induced Lupus
34. Drug induced vasculitis
35. Fixed Drug Eruption
36. Drug induced pigmentation
39. Thank you