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Wei BM, Fox LP, Kaffenberger BH, Korman AM, Micheletti RG, Mostaghimi A, Noe MH, Rosenbach M, Shinkai K, Kwah JH, Phillips EJ, Bolognia JL, Damsky W, Nelson CA. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part I. Epidemiology, pathogenesis, clinicopathological features, and prognosis. J Am Acad Dermatol 2024; 90:885-908. [PMID: 37516359 DOI: 10.1016/j.jaad.2023.02.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/11/2023] [Accepted: 02/26/2023] [Indexed: 07/31/2023]
Abstract
Drug-induced hypersensitivity syndrome (DiHS), also known as drug reaction with eosinophilia and systemic symptoms (DRESS), is a severe cutaneous adverse reaction (SCAR) characterized by an exanthem, fever, and hematologic and visceral organ involvement. Anticonvulsants, antibiotics, and allopurinol are the most common triggers. The pathogenesis involves a complex interplay between drugs, viruses, and the immune system primarily mediated by T-cells. DiHS/DRESS typically presents with a morbilliform eruption 2-6 weeks after drug exposure, and is associated with significant morbidity, mortality, and risk of relapse. Long-term sequelae primarily relate to organ dysfunction and autoimmune diseases. Part I of this continuing medical education activity on DiHS/DRESS provides an update on epidemiology, novel insights into pathogenesis, and a description of clinicopathological features and prognosis.
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Affiliation(s)
- Brian M Wei
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Lindy P Fox
- Department of Dermatology, University of California, San Francisco, California
| | | | - Abraham M Korman
- Department of Dermatology, The Ohio State University, Columbus, Ohio
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Megan H Noe
- Department of Dermatology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, California
| | - Jason H Kwah
- Department of Medicine, Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jean L Bolognia
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut; Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Caroline A Nelson
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Zhang J, Lei Z, Xu C, Zhao J, Kang X. Current Perspectives on Severe Drug Eruption. Clin Rev Allergy Immunol 2021; 61:282-298. [PMID: 34273058 PMCID: PMC8286049 DOI: 10.1007/s12016-021-08859-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
Adverse drug reactions involving the skin are commonly known as drug eruptions. Severe drug eruption may cause severe cutaneous adverse drug reactions (SCARs), which are considered to be fatal and life-threatening, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), acute generalized exanthematous pustulosis (AGEP), and drug reaction with eosinophilia and systemic symptoms (DRESS). Although cases are relatively rare, approximately 2% of hospitalized patients are affected by SCARs. There is an incidence of 2 to 7 cases/million per year of SJS/TEN and 1/1000 to 1/10,000 exposures to offending agents result in DRESS. However, the mortality rate of severe drug eruptions can reach up to 50%. SCARs represent a real medical emergency, and early identification and proper management are critical to survival. The common pathogenesis of severe drug eruptions includes genetic linkage with HLA- and non-HLA-genes, drug-specific T cell-mediated cytotoxicity, T cell receptor restriction, and cytotoxicity mechanisms. A multidisciplinary approach is required for acute management. Immediate withdrawal of potentially causative drugs and specific supportive treatment is of great importance. Immunoglobulins, systemic corticosteroids, and cyclosporine A are the most frequently used treatments for SCARs; additionally, new biologics and plasma exchange are reasonable strategies to reduce mortality. Although there are many treatment methods for severe drug eruption, controversies remain regarding the timing and dosage of drug eruption. Types, dosages, and indications of new biological agents, such as tumor necrosis factor antagonists, mepolizumab, and omalizumab, are still under exploration. This review summarizes the clinical characteristics, risk factors, pathogenesis, and treatment strategies of severe drug eruption to guide clinical management.
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Affiliation(s)
- Jingzhan Zhang
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Zixian Lei
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Chen Xu
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Juan Zhao
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China.,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China
| | - Xiaojing Kang
- Department of Dermatology, People's Hospital of Xinjiang Uygur Autonomous Region, Tianshan District, No. 91, Tianchi Road, Urumqi, 830001, Xinjiang, China. .,Xinjiang Key Laboratory of Dermatology Research, Urumqi, Xinjiang, China.
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