Terbinafine-induced subacute cutaneous lupus erythematosus

Cutaneous lupus erythematosus: diagnosis and management

Cutaneous lupus erythematosus (CLE) includes a variety of lupus erythematosus (LE)-specific skin lesions that are subdivided into three categories - chronic CLE (CCLE), subacute CLE (SCLE) and acute CLE (ACLE) - based on clinical morphology, average duration of skin lesions and routine histopathologic examination. This paper describes our personal experience in the management of CLE over the last 30 years, with details on preferential therapeutic options related to clinical, histologic and immunopathologic aspects of each clinical subset of the disease. Effective sunscreening and sun protection are considered the first rule in the management of CLE because of the high degree of photosensitivity of the disease. Antimalarial agents are crucial in the treatment of CLE and are the first-line systemic agents, particularly in discoid LE (DLE) and SCLE. Dapsone is the drug of choice for bullous systemic LE (BSLE) as well as for LE in small dermal vessels (e.g. leukocytoclastic vasculitis). Retinoids, known as second-line drugs for systemic therapy, are sometimes used to treat chronic forms of CLE and are particularly successful in treating hypertrophic LE. Systemic immunosuppressive agents are required to manage the underlying systemic LE disease activity in patients with ACLE. These drugs, especially azathioprine, methotrexate, cyclophosphamide and cyclosporine, together with corticosteroids, constitute third-line systemic therapy of CLE. In our experience, oral prednisone or parenteral 'pulsed' methylprednisolone are useful in exacerbations of disease activity. Thalidomide provides one of the most useful therapeutic alternatives for chronic refractory DLE, although its distribution is limited to a few countries because of the risk of teratogenicity and polyneuropathy. However, medical treatment with local corticosteroids remains the mainstay of CLE treatment, especially for DLE. Patient education regarding the disease is also important in the management of CLE, because it helps relieve undue anxiety and to recruit the patient as an active participant in the treatment regimen.

Progress in the understanding of the pathology and pathogenesis of cutaneous drug eruptions : implications for management

Cutaneous drug eruptions are among the most common adverse reactions to drug therapy. The etiology may reflect immunologic or nonimmunologic mechanisms, the former encompassing all of the classic Gell and Combs immune mechanisms. Cumulative and synergistic effects of drugs include those interactions of pharmacokinetic and pharmacodynamic factors reflecting the alteration by one drug of the effective serum concentration of another and the functions of drugs and their metabolites that interact to evoke cutaneous and systemic adverse reactions. Recent observations include the role of concurrent infection with lymphotropic viruses and drug effects that, through the enhancement of lymphoid blast transformation and/or lymphocyte survival and the contribution of intercurrent systemic connective tissue disease syndromes, promote enhanced lymphocyte longevity and the acquisition of progressively broadening autoantibody specificities. The latter are particularly opposite to drug-induced lupus erythematosus and to drug reactions in the setting of HIV infection. Specific common types of cutaneous drug eruptions will be discussed in this review. Successful management of cutaneous drug eruptions relies upon the prompt discontinuation of the causative medication; most drug eruptions have a good prognosis after this is accomplished. Oral or topical corticosteroids can be administered to aid in the resolution of some types of eruptions. Antihistamines or anti-inflammatory agents may also be administered for some eruptions.

Drug-induced rheumatic syndromes

Rheumatic syndromes related to drug therapies have been described for decades. The introduction of many new therapeutic agents in recent years has been accompanied by an increase in such reported associations. By definition, drug-induced syndromes are temporally related to starting a drug, and the symptoms and signs generally regress with its discontinuation. The classic and still most common cases resemble systemic lupus erythematosus or scleroderma. Some newer agents appear related to myositis or vasculitis. The origins of most of these syndromes remain obscure.

Itraconazole versus terbinafine in the management of onychomycosis: an overview

Ever since the introduction of itraconazole and terbinafine in the management of onychomycosis, there has been a revival of interest in the latter. In order to comprehend the intricate emerging scenario, an endeavor has been made to form a distinct outline in the shape of an overview on several of their facets. The review, therefore, envisages forming and facilitating instant decision-making.

Drug-induced, Ro/SSA-positive cutaneous lupus erythematosus

OBJECTIVE

To study the clinical and immunopathologic findings of drug-induced, Ro/SSA-positive cutaneous lupus erythematosus (CLE).

DESIGN

Retrospective medical and laboratory record review.

SETTING

Immunodermatology Division of Johns Hopkins Hospital (Baltimore, Md).

PATIENTS

Of 120 patients found to have anti-Ro/SSA antibodies by hemagglutination and/or double immunodiffusion, 70 had clinical and immunopathologic confirmation of CLE. Fifteen of these 70 patients had a history of new drug exposure, defined as less than 6 months, associated with disease development.

RESULTS

The disease-associated drugs included hydrochlorothiazide (5 patients), angiotensin-converting enzyme inhibitors (3 patients), calcium channel blockers (3 patients), interferons (2 patients), and statins (2 patients). The most common presentations were photodistributed diffuse erythema and subacute CLE-type lesions without evidence of significant systemic disease. All specimens revealed interface dermatitis and fine granular IgG deposition along the basement membrane zone and throughout the epidermis. Most patients experienced improvement or resolution of clinical lesions within 8 weeks and decrease of Ro/SSA titers within 8 months after discontinuation of drug treatment.

CONCLUSIONS

Antihypertensive drugs are the most commonly associated with Ro-positive CLE. Clinical and immunopathologic features of this drug-induced variant do not seem to differ from the idiopathic disease. In most cases, the disease improves or resolves on discontinuation of the offending drug treatment. It is not known if these drugs precipitate disease in patients who have subclinical disease. Drug-induced Ro/SSA-positive CLE should be included on the differential diagnosis in patients presenting with photosensitive or subacute CLE-type eruptions.

Skin manifestations of drug reactions

Dermatologic manifestations of adverse drug reactions are commonly encountered in both hospital-based and ambulatory medical practice. Diagnosis is confounded by the myriad clinical presentations associated with cutaneous drug eruptions. Some presentations are highly characteristic, while others are not as straightforward, and may simulate other primary dermatoses. In many cases, patients are utilizing several medications and an obvious temporal relationship to a specific drug is not always apparent or expressed by the patient during disclosure of his or her medical history. A thorough medication history and a high index of suspicion are very important components in the diagnosis of drug eruptions.

Management of skin disease in patients with lupus erythematosus

Skin disease in patients with lupus erythematosus may be subdivided into two broad categories - those represented by a 'specific' histopathology, the interface dermatitis, and those with changes that are not specific to lupus erythematosus, for example, vasculitis, mucin infiltration, etc. The specific skin lesions that are most common are discoid lupus erythematosus (DLE) and subacute cutaneous lupus erythematosus (SCLE). Evaluation will allow the treating physician to assign a prognosis. Cutaneous lesions can generally be managed with standard therapies. Patients with discoid LE and subacute cutaneous LE are generally photosensitive, and therefore sunscreens, protective clothing and behavioural alteration should be discussed with all patients. Topical corticosteroids are a standard form of therapy, but 'newer' agents such as retinoids, calcipotriene and tacrolimus might be effective. Antimalarial agents are generally effective. Attempts to reduce or stop smoking may aid in the control of cutaneous LE. The choice of alternative therapy is personal, and discussions of the risks and benefits should be carefully documented.