[Delayed-type cutaneous drug reactions. Pathogenesis, clinical features and histology]

BACKGROUND

Cutaneous reactions to drugs can be subdivided in different ways. In addition to the standard classification according to the etiopathogenesis there are also classifications based predominantly on morphological criteria. The majority of drug-related cutaneous adverse reactions are immunological reactions which are collectively classified under the term hypersensitivity. These reactions are based on drug-specific immunoglobulin E (IgE) or cell-mediated mechanisms, not on the mechanism of action of the drug and are unpredictable. Delayed type reactions to drugs are forms of type IV T-cell mediated hypersensitivity. A prerequisite is a stable association of a pharmaceutical substance with a protein so that hapten-protein conjugates can be produced. The most common clinical symptom is maculopapular (morbilliform) drug-related exanthema. This article also examines lichen planus like drug reaction and drug-induced (hematogenic) allergic contact dermatitis in more detail.

DIAGNOSTICS

The diagnostics are never trivial but also include the differentiation from viral exanthema and initial phases of severe cutaneous adverse reactions, such as toxic epidermal necrolysis. In addition to the morphological classification, the final diagnosis encompasses the interpretation of histopathological alterations in the skin biopsy, analysis of patient medication history, laboratory results and inclusion of data from the literature. Patch tests can also have additional diagnostic benefits. In vitro tests which involve the cellular incubation of the drug responsible should be reserved for specialized laboratories. A prerequisite for successful treatment is immediate termination of the drug responsible.

THERAPY AND PROGNOSIS

Therapy is symptomatic with topical and also short-term systemic steroids and antihistamines. The prognosis is very good.

Epidemiology of cutaneous drug-induced reactions

Cutaneous reactions represent in many surveillance systems, the most frequent adverse events attributable to drugs. The spectrum of clinical manifestations is wide and virtually encompasses any known dermatological disease. The introduction of biological agents and so-called targeted therapies has further enlarged the number of reaction patterns especially linked with cytokine release or in balance. The frequency and clinical patterns of cutaneous reactions are influenced by drug use, prevalence of specific conditions (e.g., HIV infection) and pharmacogenetic traits of a population, and they may vary greatly among the different populations around the world. Studies of reaction rates in cohorts of hospitalized patients revealed incidence rates ranging from, 1 out 1000 to 2 out 100 of all hospitalized patients. For drugs such as aminopenicillines and sulfamides the incidence of skin reactions is in the order of 3-5 cases out of 100 exposed people. Although the majority of cutaneous reactions are mild and self-limiting, there are reactions such as Stevens Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) which are associated with significant morbidity and mortality. Surveillance systems routed on sound epidemiologic methodology, are needed to raise signals and to assess risks associated with specific reactions and drug exposures. Identification of risk factors for adverse reactions and appropriate genetic screening of groups at higher risk may improve the outcomes of skin reactions.

[Rosacea: Clinical features and classification]

Rosacea is a frequent chronic dermatological disorder mainly affecting the face. Since it affects the appearance, it can be very distressing for the patient leading to psychosocial disturbances. Rosacea occurs in adults, peaking between 40 and 50 years of age. The course of rosacea is quite variable and the disease may stop at any stage. Generally, three main stages are differentiated: erythemato-teleangiectatic rosacea (rosacea stage I), papulopustular rosacea (rosacea stage II), hyperglandular-hypertrophic rosacea (rosacea stage III). Besides these main manifestations numerous special forms exist, which often lead to difficulties in the differential diagnoses and require specific therapeutic strategies. These include rosacea conglobata, rosacea fulminans, granulomatous rosacea, persisting edema, (Morbihan disease), gram negative rosacea, ocular rosacea, and steroid rosacea. Recently increasing numbers of patients have been observed, whose rosacea was were induced by inhibitors of epidermal growth factors (cetuximab, geftinib) used as chemotherapy in patients with different malignancies. These side effects have been described as acneiform eruptions but at least some of the described patients have a rosacea-like appearance; therefore, this form can be classified as a subset of drug induced rosacea.

[The spectrum of drug eruptions]

Drug eruptions are frequently encountered and they represent "diseases of medical progress". They are expected in about 2% of treated patients. Their putative diagnosis is based on a set of imputability factors. Several distinct drug-induced skin disorders are identified. They are initially recognized from personal experience, but the implication to a specific drug derives from the collective experience of published evidence. Their histopathological aspect is often evocative or demonstrative for the nature of the dermatosis. Some drug eruptions follow an indolent course, while others are life-threatening.

Physiopathology of adverse cutaneous drug reactions--applied perceptions: part I

Adverse cutaneous drug reactions are common, but their physiopathology is largely elusive. The authors assess various reactions to facilitate their diagnosis and treatment. Some of the common reaction patterns are included with the prime objective of highlighting their physiopathology.

NKp46+ cells express granulysin in multiple cutaneous adverse drug reactions

BACKGROUND

The spectrum of cutaneous adverse drug reactions (cADRs) ranges from benign presentations to severe life-threatening forms such as toxic epidermal necrolysis (TEN). In TEN, granulysin has been shown to be the key cytotoxic molecule. Still, little is known about the expression of granulysin in other cADRs. As an important source of granulysin, natural killer (NK) cells are of major interest in cADRs. Recently, NKp46 has been identified as the most selective NK-cell marker. However, the role of NKp46(+) cells in cADRs and their contribution to granulysin expression remain to be elucidated.

METHODS

Immunohistochemical and immunofluorescence staining of tissue sections from multiple cADRs were quantitatively and qualitatively evaluated. Further, in vivo and in vitro drug-stimulation tests were performed.

RESULTS

Granulysin is expressed at different levels in multiple cADRs both by NKp46(+) cells and by CD8(+) T cells. Even in mild forms of cADRs, granulysin can be induced in vivo and in vitro in a drug-specific manner. NKp46(+) cells were found to infiltrate the dermal/epidermal junction particularly in TEN.

CONCLUSION

The impressive clinical differences of cADRs may not be uniquely explained by the expression of granulysin. Additional factors such as drug-specific activation and recruitment of NKp46(+) cells to the epidermis may play a role in determining the severity of cADRs. Therefore, unraveling the effects of drugs on NK-cell activation and trafficking may help to better understand the cytotoxic mechanisms behind cADRs.

A new proposal for a clinical-oriented subclassification of baboon syndrome and a review of baboon syndrome

OBJECTIVE

To review baboon syndrome (BS).

DATA SOURCES

Date sources were obtained from PubMed and Google Scholar: Photographs of baboon syndrome were obtained from our patient.

STUDY SELECTIONS

PubMed and Google Scholar were searched up to June 30, 2010. The search terms were "baboon syndrome", "SDRIFE" and "thimerosal allergy". Reverse references from relevant articles and Google Scholar were also used. As BS is a classical disease and cases of offending agents were relatively old, some references were more than five years old. In order to gather as many cases of offending agents as possible, more than 50 references were collected.

RESULTS AND CONCLUSION

We divided BS into as 4 groups; classical baboon syndrome, topical drug-induced baboon syndrome, systemic drug-induced baboon syndrome and symmetrical drug-related intertriginous and flexural exanthema (SDRIFE). The pathomechanism of BS is still unknown. A delayed type of hypersensitivity reaction, a recall phenomenon, pharmacologic interaction with immune-receptors and anatomical factors may be involved in the causation of BS.

[Adverse cutaneous reactions to drugs among hospitalized patients: a one year surveillance]

BACKGROUND

Adverse cutaneous reactions to Drugs (CDRs) are of particular interest among all adverse Drug reactions (ADR) due to their frequency, potential severity and because of the importance of an early diagnosis. Antimicrobial agents, anticonvulsants and non-steroidal anti-inflammatory Drugs are the Drugs associated to the highest risk of CDRs.

AIM

To assess CDRs in hospitalized patients and identify the Drugs involved.

MATERIAL AND METHODS

All patients hospitalized in the Hospital de Clínicas in Montevideo, Uruguay, with suspected CDRs, detected during one year, were included in this prospective study. The imputability was established using the Karch and Lasagna algorithm modified by Naranjo. We analyzed age, gender, Drugs involved, causal disease, severity, latency and evolution.

RESULTS

Seventeen patients, aged 17 to 85 years (15 females) with CDRs were identifed. Twelve had morbilliform exanthemas, four had reactions with eosinophilia and systemic symptoms and one had a Stevens Johnson syndrome. The Drugs involved were antimicrobials in nine cases, hypouricemic agents in four cases, anticonvulsants in three cases and aspartic insulin in one. Twelve patients had a life threatening reaction and one required admission to the intensive care unit. No deaths occurred.

CONCLUSIONS

CDRs were more common in women and most of them were caused by antimicrobial agents.

A mechanism-based classification of dermatologic reactions to biologic agents used in the treatment of cutaneous disease: Part 1

Biologic therapies are an efficacious new method of controlling a number of chronic conditions. Data regarding these medications continues to emerge, giving clinicians a greater understanding of their side effects profiles. The biologic agents used in dermatology, particularly the tumor necrosis factor-alpha inhibitors, have a number of varied dermatologic side effects. In this two-part article, we perform a review of literature regarding the cutaneous side effects of infliximab, etanercept, adalimumab, rituximab, efalizumab, and alefacept. In Part 1, we will discuss cutaneous infections, malignancy, rebound phenomenon, eczema, atopic dermatitis, lichenoid reactions, granulomatous disease, pruritus, acne, and progressive multifocal leukoencephalopathy.

Drug-Induced Psoriasis: An Evidence-Based Overview and the Introduction of Psoriatic Drug Eruption Probability Score

Psoriasis is a common skin disorder that needs a long-term management, not only because, of its prevalence but also because of the profound impact it can have on patients quality of life. Drugs may result in exacerbation of a preexisting psoriasis, in induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or in precipitation of the disease in persons without family history of psoriasis or in predisposed individuals. The knowledge of the drugs that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. By reviewing the literature, there are many reports on drug-induced psoriasis, but the data are not univocal. We propose, when possible, the use of a probability score from the authors to obtain a better classification and further understanding of drug-induced psoriasis.

[Retrospective analysis of adverse cutaneous drug reactions in patients hospitalized in Department of Dermatology and Venereology of Pomeranian Medical University in 1996-2006]

INTRODUCTION

Every adverse and undesirable event observed after administration of the therapeutic dose of the drug is defined as adverse drug reaction. The aim of the study was to evaluate the incidence frequency of cutaneous adverse drug reactions, to define the drugs inducing such reactions and to define the type of the most frequently found lesions in patients admitted to Department of Dermatology and Venereology of Pomeranian Medical University in Szczecin (PAM) in 1996-2006.

MATERIAL AND METHODS

A retrospective analysis of medical files of the patients, who were hospitalized in the Department of Dermatology and Venereology of PAM in Szczecin in 1996-2006, was carried out. Due to cutaneous adverse drug reactions, 386 patients were hospitalized. They made 4.25% of all admitted to our Department.

RESULTS

These reactions were found more frequently in females (65.5%) than in males (34.5%). Non-steroidal anti-inflammatory drugs induced adverse events most frequently (37.6%), followed by aminopenicillin antibiotics, particularly amoxycillin-containing agents, responsible for 25.8% of these reactions. Other antibiotics were responsible for undesirable events less frequently--9.6%. Macular and maculopapular rashes were the most frequently observed adverse cutaneous drug reactions (42.0% of the cases), followed by acute urticaria and Quincke's oedema (39.1% of all reactions), whereas contact dermatitis after topical drugs was found in 8.0% of the cases.

CONCLUSIONS

Cutaneous adverse drug reactions were mainly induced by non-steroidal anti-inflammatory drugs and aminopenicillin antibiotics. The most frequent forms of cutaneous adverse drug reactions were maculopapular rashes, acute urticaria and Quincke's oedema.

Cutaneous reactions to drugs in children

Cutaneous eruptions are a commonly reported adverse drug reaction. Cutaneous adverse drug reactions in the pediatric population have a significant impact on patients' current and future care options. A patient's recollection of having a "rash" when they took a medication as a child is a frequent reason for not prescribing a particular treatment. The quick detection and treatment of cutaneous adverse drug reactions, plus identification of the causative agent, are essential for preventing the progression of the reaction, preventing additional exposures, and ensuring the appropriate use of medications for both the current condition and others as the patient ages. The purpose of this review is to discuss a reasonable approach to recognition and initial management of cutaneous adverse drug reactions in children.

Classification and management of skin, hair, nail and mucosal side-effects of epidermal growth factor receptor (EGFR) inhibitors

Inhibitors of epidermal growth factor receptor (EGFR) are commonly used as therapeutic agents in oncology. In contrast to currently used oncological treatments, these inhibitors almost always cause skin- and skin adnex toxicity. About 85% of treated patients develop to a more or lesser extent an acneiform eruption. Xerosis cutis and painful nail disorders occur in, respectively, 35% and 10-15% of all treated patients. Also hair and mucosal changes have been reported, although to a lesser extent. These skin- and skin adnex toxicities are reversible after withdrawal of treatment, but are seldom a reason to stop or interrupt therapy. This review outlines the classification, the pathogenesis and therapy of these skin, hair, nail and mucosal changes due to EGFR inhibition. Informing the patient and management of these side-effects is very important to reduce discomfort and as such to increase compliance to therapy.

Management of Rash and Other Toxicities in Patients Treated with Epidermal Growth Factor Receptor—Targeted Agents

Inhibition of the epidermal growth factor receptor (EGFR) represents one of the most important avenues for research and development in the field of cancer therapy. The EGFR is a member of the ErbB receptor tyrosine kinase (TK) family, which also includes ErbB-2 (HER2/neu), ErbB-3 (HER3), and ErbB-4 (HER4). Current EGFR therapies available for use include monoclonal antibodies, such as cetuximab, and small-molecule EGFR TK inhibition by agents such as erlotinib. Side effects of these agents include dermatologic manifestations without the bone marrow suppressive properties of chemotherapy. Understanding of rash and how it relates to EGFR inhibitor toxicity and, perhaps more importantly, EGFR inhibitor response must be more clearly defined with clinical trials. The optimum management of rash in patients receiving anti-EGFR therapy remains somewhat controversial; this is secondary to imprecise classification of rash as well as the lack of clinical trials to determine the most appropriate treatment algorithm for these patients. We propose a treatment strategy to help aggressively treat dermatologic side effects allowing patients to continue receiving therapy without dose interruption or drug discontinuation.

Drug rash with eosinophilia and systemic symptoms vs toxic epidermal necrolysis: the dilemma of classification

According to contemporary vernacular, when the cutaneous manifestations of drug rash with eosinophilia and systemic signs (DRESS) syndrome are those of Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN), the condition is defined as "DRESS syndrome with severe cutaneous reactions". In this article, we have presented arguments for and against including patients with skin lesions of the SJS/TEN syndromes who also have fever (practically all of the patients) and internal organ involvement (most of the patients) under the definition of DRESS syndrome. After weighing the arguments for and against this alteration of definition, we conclude that it makes more sense for patients with SJS/TEN to be classified as such and not be lumped together under the misleading label of DRESS syndrome.

EGFR-targeted therapy for patients with colorectal cancer: patient management and future directions

The epidermal growth factor receptor (EGFR) signaling pathway is of particular relevance for patients with colorectal cancer (CRC); preclinical data indicate a role for EGFR in tumor cell growth, invasion, metastasis, and tumor angiogenesis. The goal of this program is to provide an overview of the EGFR signaling pathway as well as current and future treatment options for EGFR-targeted therapy in patients with CRC.

Drug eruptions: approaching the diagnosis of drug-induced skin diseases

Adverse drug reactions are a major problem in drug therapy, and cutaneous drug reactions account for a large proportion of all adverse drug reactions. Cutaneous drug reactions are also a challenging diagnostic problem since they can mimic a large variety of skin diseases, including viral exanthema, collagen vascular disease, neoplasia, bacterial infection, psoriasis, and autoimmune blistering disease, among others. Furthermore, determining that a particular medication caused an eruption is often difficult when the patient is taking multiple drugs. In this review, we will describe and illustrate a thoughtful, comprehensive, and clinical approach to the diagnosis and management of adverse cutaneous drug reactions. A morphologic approach to drug eruption includes those that are classified as maculopapular, urticarial, blistering or pustular with or without systemic manifestations. Exanthematous drug eruptions, drug hypersensitivity syndrome, urticaria and angioedema, serum sickness-like reactions, fixed drug eruptions, drug-induced autoimmune blistering diseases, Stevens-Johnson syndrome, toxic epidermal necrolysis, drug-induced acne, acute generalized exanthematous pustulosis, lichenoid drug eruptions and photosensitivity eruptions will be discussed.

[Tissue toxicity of antiseptics]

AIM

Local antiseptics are used for desinfection of skin and for lavage of wounds. The aim of this study was to determine the tissue toxicity of different antiseptics and to measure the irritation score (IS) and the irritation threshold (IT) for each substance.

METHOD

The tissue compatibilities of Dibromol, Kodan, Jodobac, Octenisept, Lavasept 0.2 %, hydrogen peroxide, chlorhexidindigluconate 0.5 % and 2-propanol 60 % were evaluated in the in vivo hens eggs chorion-allantoic membrane test (HET-CAM).

RESULTS

We found the most severe tissue toxicity for chlorhexidin digluconate 0.5 % (IS 20) and Kodan (IS 18). Irritating values were found for Dibromol (IS 14), Octenisept (IS 14) and 2-propanol 60 % (IS 13). Moderate vascular injuries were caused by Jodobac (IS 2). In the HET-CAM test Lavasept 0.2 % (IS 0) and hydrogen peroxide (IS 0) showed no tissue toxicity.

CONCLUSION

Our results show that some of the tested antiseptics might cause severe vascular injuries as a sign of tissue toxicity. The tissue compatibility of Lavasept 0.2 % and hydrogen peroxide is much better than the compatibility of the other tested substances. With focus on the literature and our results, Lavasept 0.2 % can be recommended as the local antiseptic of choice.

[Drug eruptions]

In the following paper, there have been discussed the mechanisms of reactions which may result from adverse drug effects. In particular, the paper shows a clinical picture of skin lesions and various dermatological entities in which drugs are triggering factors.