Intertriginous eruption induced by terbinafine: a review of baboon syndrome

Symmetric drug-related intertriginous and flexural exanthema: Clinicopathologic study of 19 cases and review of literature

BACKGROUND

Symmetric drug-related intertriginous and flexural exanthema (SDRIFE) is a cutaneous drug reaction characterized by gluteal/anogenital erythema and symmetric involvement of other intertriginous location(s) without systemic signs. Clinicopathologic characterization has been limited to case reports and small series. We describe 19 new cases and review the literature to better define the clinical and histopathologic spectrum of SDRIFE.

METHODS

Pathology archives were searched for "SDRIFE" and "baboon syndrome." Cases meeting clinical criteria were included. Clinical and histopathologic features were recorded. Previous reports of SDRIFE with histopathologic descriptions were reviewed.

RESULTS

Nineteen new cases were included, over half triggered by antibiotics. Six new causative medications were identified. Median onset was 7 days. Typical lesions were erythematous plaques or papules with or without scale. The most common histopathologic finding was superficial perivascular lymphocytic infiltrate followed by dermal eosinophils, spongiosis, and orthokeratosis. Basal vacuolization and apoptotic keratinocytes were less common. Interstitial histiocytes were present in almost half of our cases. Other findings included atypical lymphocytes and "flame figure."

CONCLUSIONS

Appreciation of the range of inciting medications and clinicopathologic features in SDRIFE will improve recognition of this condition. Although many histopathologic features overlap with other common dermatitides, biopsy may assist in excluding key clinical mimics.

First report of tamoxifen-induced baboon syndrome

Background

Baboon syndrome is a rare, type IV hypersensitivity reaction causing a maculopapular rash. Tamoxifen is an antineoplastic agent, working as an estrogen receptor antagonist, also called a selective estrogen receptor modulator. A variety of rashes were reported with Tamoxifen use to‐date except baboon syndrome. The Tamoxifen‐induced baboon syndrome seems to be reversible, as discontinuation of the drug improves clinical outcomes.

Aim

Herein, we present the first case of Tamoxifen‐induced baboon syndrome which occurred 8 years after initiation of Tamoxifen use.

Patients

A 44‐year‐old woman presented with papulovesicular eruption on her body and erythema on her face for a duration of 6 months. There was no evidence of ocular or mucosal involvement. She was diagnosed with breast cancer and treated with tamoxifen 10 mg twice daily over the past 8 years. She was not taking other medications or over‐the‐counter supplements at the time of presentation. The patient underwent urgent skin biopsies of two lesions on her buttock and thigh. No organisms were seen on Gram stain. The patient's skin biopsy revealed extensive hyperorthokeratosis, minimal parakeratosis, hypergranulosis, and lichenoid interface dermatitis in the irregularly acanthotic epidermis supporting diagnosis of fixed drug eruption. Following a multidisciplinary discussion, the patient was diagnosed with baboon syndrome or symmetrical drug‐related intertriginous and flexural exanthema (SDRIFE) associated with Tamoxifen.

Results

Hence, Tamoxifen was immediately discontinued and treated with oral steroid along with topical agents. She showed improvement of clinical abnormalities within days after discontinuation of Tamoxifen.

Conclusions

Given the widespread use of Tamoxifen in the management of patients with breast cancer, it is important that healthcare professionals monitor for rare, however clinically significant, and potentially life‐threatening dermatological manifestations of Tamoxifen use, such as baboon syndrome.

Oral Antifungal Therapy: Emerging Culprits of Cutaneous Adverse Drug Reactions

Introduction

Antifungals are one of the most widely used drugs in dermatology practice for dermatophytosis. Oral antifungal therapy against superficial dermatophytosis is generally associated with a low incidence of adverse events in an immunocompetent population. However, lately, cutaneous adverse drugs reactions (CADRs) have been reported with varying incidence rates in the patients on oral antifungal therapy with many uncommon morphological patterns. The present, observational study was conducted over a period of 4 months to report the cases which presented with antifungal therapy-associated CADRs.

Materials and Methods

It was an observational, prospective study carried out at a tertiary care center in Western India over a period of 4 months. All patients diagnosed with superficial dermatophytic infections (clinically and fungal hyphae seen on 10% potassium hydroxide mount) started on oral antifungal therapy, presenting with cutaneous manifestation other than the primary dermatophytosis were included. The incidence of CADRs due to oral antifungal agents and the percentage of each clinical type of the CADR observed was calculated.

Results

The incidence of CADRs due to antifungal drugs was 8.3 per 10,000 patients. In total, 35 cases were reported out of 4,208 cases of dermatophytosis. Terbinafine was the most common causative drug, accounting for nearly 83% of cases, followed by itraconazole for 14% cases, and griseofulvin for 2.8% of cases.

Conclusion

The role of systemic antifungals must not be overlooked in any patient with a CADR and should be reported as a trend indicator.