Skin manifestations of drug allergy

An Allergic Reaction in Contrast-enhanced Ultrasound Lymphography for Lymphovenous Bypass Surgery

Lymphedema following oncologic intervention can cause significant lifelong morbidity for patients in whom conservative management fails. The associated swelling, discomfort, pain, and recurrent cellulitis greatly diminish quality of life. Surgical procedures, including suction-assisted lipectomy, lymphovenous anastomosis (LVA), and vascularized lymph node transfers, show effectiveness in both volume reduction in affected extremities and symptom relief. However, the success of procedures like LVA is dependent on effective preoperative lymphatic mapping to identify suitable vessels for anastomosis. Traditional superficial lymphatic mapping uses near infrared fluorescence indocyanine green (ICG) imaging. Moreover, recent advances in contrast-enhanced ultrasound (CEUS) lymphography increased lymphovenous bypass target identification for LVA in the extremities.7 CEUS lymphography uses microbubbles as a contrast-enhancing agent injected intradermally into the affected extremity with subsequent identification of superficial collecting lymphatic vessels using ultrasound. Although a recent report noted an uptick in severe and critical adverse drug reactions to an ultrasound contrast agent injected intravenously in stress echocardiography, adverse drug reactions associated with ultrasound contrast-enhancing agents in body ultrasound are rare. The safety profile and potential complications from CEUS lymphography in the lymphedema population have yet to be fully characterized. In this case report, the authors present the first cutaneous adverse drug event following a secondary exposure to the contrast used for CEUS imaging. Mechanisms and justifications for an immune-mediated process are explored, and a review of similar manifestations in other related contrast applications is discussed.

The role of the environment in allergic skin disease

PURPOSE OF REVIEW

This paper explores how environmental factors influence allergic skin diseases, including atopic dermatitis (AD), contact dermatitis (CD), urticaria, angioedema, and reactions to drugs and insect bites.

RECENT FINDINGS

Research indicates a significant impact of environmental elements on allergic skin diseases. High air pollution levels exacerbate symptoms, while climate change contributes to increased skin barrier dysfunction, particularly affecting AD. Allergen prevalence is influenced by climate and pollution. Irritants, like those in detergents and cosmetics, play a major role in CD. Plants also contribute, causing various skin reactions. Understanding the interplay between environmental factors and allergic skin diseases is crucial for effective management. Physicians must address these factors to support patient well-being and promote skin health amidst environmental changes.

[Antibiotic allergies: targeted approach in suspected β‑lactam allergy]

Allergic reactions to antibiotics belong to hypersensitivity drug reactions and can trigger both immunoglobulin E-mediated symptoms and T cell-mediated symptoms. Skin manifestations are the most common symptoms. Although reporting a penicillin allergy results in considerable restrictions in the treatment of acute infections, which may be associated with poor treatment outcomes, in most cases the label 'penicillin allergy' is not called into question or critically reviewed. However, in 85-90% of patients, 'penicillin allergy' constitutes a mislabeling of a non-specific intolerance reaction that does not pose a risk to the patient when re-exposed to penicillins. Careful history taking, an evaluation of manifestations in the past, and easy-to-perform initial diagnostic steps are crucial in differentiating non-specific intolerance reactions from penicillin allergy sensu stricto. Thus, a penicillin de-labeling strategy allows for optimized antibiotic therapy in the event of a future infection. Although allergic cross-reactivity between different β‑lactam antibiotics can occur, the risk for a severe cross-reactivity is dependent on chemical properties of the specific β‑lactam. Published cross-reactivity tables can help in risk stratification and choice of alternative β‑lactam agents.

[Antibiotic allergies: targeted approach in suspected β‑lactam allergy]

Allergic reactions to antibiotics belong to hypersensitivity drug reactions and can trigger both immunoglobulin E-mediated symptoms and T cell-mediated symptoms. Skin manifestations are the most common symptoms. Although reporting a penicillin allergy results in considerable restrictions in the treatment of acute infections, which may be associated with poor treatment outcomes, in most cases the label 'penicillin allergy' is not called into question or critically reviewed. However, in 85-90% of patients, 'penicillin allergy' constitutes a mislabeling of a non-specific intolerance reaction that does not pose a risk to the patient when re-exposed to penicillins. Careful history taking, an evaluation of manifestations in the past, and easy-to-perform initial diagnostic steps are crucial in differentiating non-specific intolerance reactions from penicillin allergy sensu stricto. Thus, a penicillin de-labeling strategy allows for optimized antibiotic therapy in the event of a future infection. Although allergic cross-reactivity between different β‑lactam antibiotics can occur, the risk for a severe cross-reactivity is dependent on chemical properties of the specific β‑lactam. Published cross-reactivity tables can help in risk stratification and choice of alternative β‑lactam agents.

Mixed T Helper1/T Helper2/T Cytotoxic Profile in Subjects with Chronic Chagas Disease with Hypersensitivity Reactions to Benznidazole

Dermatitis is the most common adverse event during treatment with benznidazole in chronic Chagas disease and is probably mediated by T cells. A set of molecules representative of the different type IV hypersensitivity reactions was evaluated in the circulation and skin biopsies of Trypanosoma cruzi-infected subjects presenting dermatitis during benznidazole administration. Through cytometric bead assays and enzyme-linked immunosorbent assay capture techniques, the serum levels of cytokines, chemokines, proapoptotic molecules, and mediators of the activation and migration of eosinophils and T cells were measured in subjects infected with Trypanosoma cruzi who exhibited skin adverse events (n = 22) and compared with those without adverse events (n = 37) during benznidazole therapy. Serum levels of interleukin- 5 (IL-5), soluble Fas cell surface death receptor ligand (FAS-L), and interferon γ-induced protein (IP-10) significantly increased at 7 to 30 days posttreatment with benznidazole and decreased thereafter in subjects with dermatitis but not in those without dermatitis. Circulating eotaxin levels were lower in subjects with dermatitis than in those without. Two patterns emerged in the skin biopsies: a T helper 1/T cytotoxic profile and a T helper 2/T cytotoxic profile with the presence of CD4⁺ and CD8⁺ T cells. Increased low-density lipoprotein (LDL), glutamic-oxaloacetic transaminase (GOT), uremia, and T cell activation emerged as risk factors for the development of dermatitis during benznidazole administration. These results support a delayed-type hypersensitivity reaction to benznidazole, involving CD4⁺ and CD8⁺ T cells and eosinophils, and a mixed cytokine profile. This study provides new insights for better management of adverse drug reactions to benznidazole. IMPORTANCE This study identified the risk factors for the development of adverse reactions to benznidazole and identified a set molecule to monitor the appearance of these reactions. This knowledge might improve the safety of benznidazole administration.

Pregabalin Induced Maculopapular Eruption in an Elderly Male

Pregabalin is used in the treatment of neuropathic pain of various etiologies and as adjuvant in epilepsy. Blockade of the α2δ subunit of L and N type Ca-channels is its main mechanism of neurotropic action. Compared to other antiepileptics like phenytoin, valproate and lamotrigine, and other neuropathic pain medications such as amitriptyline and duloxetine, pregabalin has a relatively favorable safety profile and hence is a drug of choice for many geriatricians. Here we describe a case of maculopapular rash induced by pregabalin in an elderly man which resolved with withdrawal of the offending drug and conservative management. We have also conducted a literature review of similar cases and highlight the clinical patterns and management strategies for pregabalin induced skin rashes.

Association between the HLA-B*1502 gene and mild maculopapular exanthema induced by antiepileptic drugs in Northwest China

BACKGROUND

The relationship between the HLA-B*1502 gene and maculopapular exanthema (MPE) induced by antiepileptic drugs (AEDs) has not yet been elucidated. In this study, we investigated the association between AED-induced MPE (AED-MPE) and the HLA-B*1502 gene in patients in Northwest China.

METHODS

We enrolled 165 subjects including nine patients with AED-MPE and 156 AED-tolerant patients as controls. HLA-B*1502 gene polymorphism was detected using digital fluorescence molecular hybridization (DFMH). The results of HLA genotyping were expressed as positive or negative for the HLA-B*1502 allele. An analysis of AED-MPE risk factors was performed using binary logistic regression, and differences in genotype frequencies between groups were assessed with the continuity correction chi-square test.

RESULTS

We found that the HLA-B*1502 gene was a risk factor for AED-MPE (P = 0.028). The incidence of MPE induced by the two types of AEDs was different, and the incidence of aromatic AEDs use was higher that of non-aromatic AEDs use (P = 0.025). The comparison of the gene frequencies of the HLA-B*1502 allele between the two groups taking aromatic AEDs was also statistically significant (P = 0.045). However, there were no significant differences in terms of age, gender, ethnicity, or region in patients with MPE induced by AEDs. In addition, no association between the HLA-B1502 allele and CBZ- or OXC-induced MPE was found.

CONCLUSIONS

In northwestern China, the HLA-B*1502 allele was associated with aromatic AED-MPE. Since MPE can develop into Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN), the HLA-B*1502 gene should be evaluated before administering AEDs.

Drug Allergy and Cutaneous Adverse Reactions

Allergy or hypersensitivity to drugs often affects the skin and sometimes also mucosa. While immediate type reactions show a rather homogeneous pattern, delayed type reactions reveal a high variability. In both cases it may not always be easy to differentiate drug reactions from non-drug-induced skin conditions. Furthermore, the different types of cutaneous adverse reactions may be difficult to distinguish in the beginning. This accounts predominately for delayed hypersensitivity reactions that can occur after a variety of medications and present with manifold lesions. Most of these cutaneous adverse reactions are mild, but some are severe with high morbidity and mortality. In the clinical setting, it is important to recognize the signs that point to a more severe condition early on in order to initiate appropriate management. In addition, it is crucial to identify the potentially culprit medication on the basis of a detailed medication history and by evaluating the relevant exposure times of certain drugs that differ substantially between the various reaction types. After the acute stage of the adverse reaction is managed successfully, further allergologic testing may be undertaken to confirm the offending drug.

Skin eruptions in children: Drug hypersensitivity vs viral exanthema

Childhood rashes or exanthemas are common and are usually relatively benign. There are many causes of rash in children, including mainly viruses, and less often bacterial toxins, drugs, allergens and other diseases. Viral exanthema often appears while children are taking a medication in the course of a viral infection; it can mimic drug exanthema and is perceived as a drug allergy in 10% of cases. In the vast majority of cases, the distinction between virus-induced and drug-induced skin eruption during the acute phase is not possible. The drugs most commonly implicated are beta-lactams (BL) and non-steroidal anti-inflammatory drugs (NSAIDs). Viruses, commonly Epstein-Barr virus (EBV), human herpesvirus 6 (HHV6) and cytomegalovirus (CMV), and the bacterium, Mycoplasma pneumoniae, may cause exanthema either from the infection itself (active or latent) or because of interaction with drugs that are taken simultaneously. Determination of the exact diagnosis requires a careful clinical history and thorough physical examination. Haematological and biochemical investigations and histology are not always helpful in differentiating between the two types of exanthema. Serological and polymerase chain reaction (PCR) assays can be helpful, although a concomitant acute infection does not exclude drug hypersensitivity. A drug provocation test (DPT) is although considered the gold standard for the diagnosis and is not preferred by the patients. Skin tests are not well tolerated, and in vitro tests, such as the basophil activation test and lymphocyte transformation, are of low sensitivity and specificity and their relevance is debatable. Based on current evidence, we propose a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous eruption while receiving a drug.

Drug Induced Cutaneous Manifestations due to Treatment of Gastrointestinal Disorders

Cutaneous manifestations due to drugs used in the treatment of gastrointestinal disorders are multiple and common. Adequate diagnosis is of great importance, bearing in mind that the therapeutic regimen depends on its diagnosis. In this review, we provided an overview of the most common drug-induced skin lesions with a detailed explanation of the disease course, presentation and treatment, having in mind that in recent years, novel therapeutic modalities have been introduced in the treatment of various gastrointestinal disorders, and that incidence of cutaneous adverse reactions has been on the rise.

Efficacy and Safety of Traditional Chinese Herbal Medicine for Antipsychotic-Related Constipation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Constipation is a common but often ignored side effect of antipsychotic treatment, although it is associated with adverse outcomes. The results of the efficacy and safety of traditional Chinese herbal medicine (TCM) in treating constipation are mixed across studies. This is a systematic review and meta-analysis of randomized controlled trials (RCTs) of the efficacy and safety of TCM compared to Western medicine (WM) in treating antipsychotic-related constipation. Methods: Major international electronic (PubMed, EMBASE, Cochrane Library, and Web of Science) and Chinese (Wanfang, WeiPu VIP, SinoMed, and CNKI) databases were searched from their inception to November 29, 2020. Meta-analysis was performed using the random-effects model. Results: Thirty RCTs with 52 arms covering 2,570 patients in the TCM group and 2,511 patients in the WM group were included. Compared with WM, TCM alone was superior regarding the moderate response rate [risk ratio (RR) = 1.165; 95% confidence interval (CI): 1.096-1.238; P < 0.001], marked response rate (RR = 1.437; 95% CI: 1.267-1.692; P < 0.001), and remission rate (RR = 1.376; 95% CI: 1.180-1.606; P < 0.001) for constipation, while it was significantly associated with lower risk of rash (RR = 0.081; 95% CI: 0.019-0.342; P = 0.001). For the moderate response rate, meta-regression analyses revealed that publication year (β = -0.007, P = 0.0007) and Jadad score (β = 0.067, P < 0.001) significantly moderated the results. For the remission rate, subgroup and meta-regression analyses revealed that the geographical region (P = 0.003), inpatient status (P = 0.035), and trial duration (β = 0.009, P = 0.013) significantly moderated the results. Conclusions: The efficacy of TCM for antipsychotic-related constipation appeared to be greater compared to WM, while certain side effects of TCM, such as rash, were less frequent.

Clinical Pharmacokinetics and Pharmacodynamics of Rifampicin in Human Tuberculosis

The introduction of rifampicin (rifampin) into tuberculosis (TB) treatment five decades ago was critical for shortening the treatment duration for patients with pulmonary TB to 6 months when combined with pyrazinamide in the first 2 months. Resistance or hypersensitivity to rifampicin effectively condemns a patient to prolonged, less effective, more toxic, and expensive regimens. Because of cost and fears of toxicity, rifampicin was introduced at an oral daily dose of 600 mg (8-12 mg/kg body weight). At this dose, clinical trials in 1970s found cure rates of ≥ 95% and relapse rates of < 5%. However, recent papers report lower cure rates that might be the consequence of increased emergence of resistance. Several lines of evidence suggest that higher rifampicin doses, if tolerated and safe, could shorten treatment duration even further. We conducted a narrative review of rifampicin pharmacokinetics and pharmacodynamics in adults across a range of doses and highlight variables that influence its pharmacokinetics/pharmacodynamics. Rifampicin exposure has considerable inter- and intra-individual variability that could be reduced by administration during fasting. Several factors including malnutrition, HIV infection, diabetes mellitus, dose size, pharmacogenetic polymorphisms, hepatic cirrhosis, and substandard medicinal products alter rifampicin exposure and/or efficacy. Renal impairment has no influence on rifampicin pharmacokinetics when dosed at 600 mg. Rifampicin maximum (peak) concentration (C_max) > 8.2 μg/mL is an independent predictor of sterilizing activity and therapeutic drug monitoring at 2, 4, and 6 h post-dose may aid in optimizing dosing to achieve the recommended rifampicin concentration of ≥ 8 µg/mL. A higher rifampicin C_max is required for severe forms TB such as TB meningitis, with C_max ≥ 22 μg/mL and area under the concentration-time curve (AUC) from time zero to 6 h (AUC₆) ≥ 70 μg·h/mL associated with reduced mortality. More studies are needed to confirm whether doses achieving exposures higher than the current standard dosage could translate into faster sputum conversion, higher cure rates, lower relapse rates, and less mortality. It is encouraging that daily rifampicin doses up to 35 mg/kg were found to be safe and well-tolerated over a period of 12 weeks. High-dose rifampicin should thus be considered in future studies when constructing potentially shorter regimens. The studies should be adequately powered to determine treatment outcomes and should include surrogate markers of efficacy such as C_max/MIC (minimum inhibitory concentration) and AUC/MIC.

Hematologic Features of Children and Adolescent Patients with Acute Hypersensitivity Reactions on Drugs and Food

Hematological parameters and blood biochemical markers were measured in 131 children and adolescent patients (70 boys) aged 2 to 17 years with acute hypersensitivity reactions induced by food (59 patients) and medicines (72 patients) in order to establish differences in clinical manifestations and hematological parameters in children with food and drug hypersensitivity and to elaborate the hematological criteria for differentiating the possible pathophysiological mechanisms of various types of hypersensitivity. Both groups of patients had comparable clinical symptoms with a predominance of skin lesions. The significant differences between the groups with drug- and food-induced hypersensitivity reactions were found in their red blood characteristics. In patients with hypersensitive reactions to drugs, significantly lower levels of erythrocytes and hemoglobin were found, while the median values of these parameters did not exceed the limits of reference values. These differences persisted also in the analysis of hemoglobin values, analyzed with accounting for the age and sex of patients. The reduction of hemoglobin was not accompanied by an increase in bilirubin in these patients. Thus, this fact does not support the assumption about the drug-induced hemolysis as a main effect influencing the hematological parameters. Hemogram evaluation performed during 7–10 days after admission demonstrated a higher level of hemoglobin in both groups. The biochemical markers were not significantly distinguished except bilirubin and alkaline phosphatase which were higher in patients with food-induced hypersensitivity.

A humanized mouse model to study mast cells mediated cutaneous adverse drug reactions

Recently a G‐protein‐coupled receptor, MAS Related GPR Family Member X2 (MRGPRX2), was identified as a specific receptor on human mast cells responsible for IgE independent adverse drug reactions (ADR). Although a murine homologue, Mrgprb2, has been identified for this receptor, its affinity for many ADR‐causing drugs is poor making it difficult to undertake in vivo studies to examine mechanisms of ADR and to develop therapeutic strategies. Here, we have created humanized mice capable of generating MRGPRX2‐expressing human MCs allowing for the study of MRGPRX2 MCs‐mediated ADR in vitro as well as in vivo. Humanized mice were generated by hydrodynamic‐injection of plasmids expressing human GM‐CSF and IL‐3 into NOD‐scid IL2R‐γ^−/− strain of mice that had been transplanted with human hematopoietic stem cells. These GM/IL‐3 humice expressed high numbers of tissue human MCs but the MRGPRX2 receptor expressed in MCs were limited to few body sites including the skin. Importantly, large numbers of MRGPRX2‐expressing human MCs could be cultured from the bone marrow of GM/IL‐3 humice revealing these mice to be an important source of human MCs for in vitro studies of MRGPRX2‐related MCs activities. When GM/IL‐3 humice were exposed to known ADR causing contrast agents (meglumine and gadobutrol), the humice were found to experience anaphylaxis analogous to the clinical situation. Thus, GM/IL‐3 humice represent a valuable model for investigating in vivo interactions of ADR‐causing drugs and human MCs and their sequelae, and these mice are also a source of human MRGPRX2‐expressing MCs for in vitro studies.

Drug Hypersensitivity Reactions

Drug hypersensitivity reactions (DHRs) may be classified based on timing (immediate vs delayed), mechanisms, and pattern of clinical manifestations. Management may include selection of alternative, non-cross reactive agents, drug allergy testing, graded challenge and/or desensitization. Immediate skin testing only identifies risk for immediate-type allergic DHR and has a negative predictive value for only a limited number of drugs (eg, penicillin). Desensitization induces a temporary state of tolerance that is maintained only so long as the drug is continued. This article discusses special considerations about antibiotics, angiotensin-converting enzyme inhibitors, anesthetic agents, aspirin and nonsteroidal antiinflammatory drugs, radiocontrast media, and chemotherapeutic agents.

The role of the dermatologist in the immune-mediated/allergic diseases - position statement of the EADV task force on contact dermatitis, EADV task force on occupational skin diseases, UEMS-EBDV subcommission allergology and European Dermatology Forum

BACKGROUND

The members of the Task Force on Contact Dermatitis and the Task Force on Occupational Dermatoses of the European Academy of Dermatology and Venereology (EADV), of the European Dermatology Forum (EDF), and the members of the UEMS Section of Dermatology-Venereology (UEMS-EBDV) we want to vindicate the fundamental role that the specialist in Dermatology has in the diagnosis and management of Immuno-mediated /allergic Diseases.

OBJECTIVE

In disagreement with the blueprint paper of the UEMS section of Allergology (2013), in which dermatologists are excluded from one of their core activities it was decided to write this consensus paper.

DISCUSSION

The skin occupies a crucial place in the broad spectrum of allergic diseases; there is no other organ with such a multitude of different clinical conditions mediated by so many pathogenetic immune mechanisms. Subsequently, dermatologists play a fundamental role in the management of immune-mediated diseases including among others contact dermatitis, atopic dermatitis, urticaria and angioedema or cutaneous adverse drug, food and arthropod reactions. The essential role of dermatology in the diagnostic, therapeutic and preventive management of immune mediated /allergic diseases which is crucial for patient management is justified from both the academic and professional point of view.

CONCLUSION

Based on the best care of the patient with cutaneous immune allergic disease a multidisciplinary approach is desirable and the dermatologist has a pivotal role in patient management. Be so good and no one will not ignore you, dermatologist. Ideally Dermatology should be governed according the following Henry Ford statement: "Arriving together is the beginning; keeping together is progress; working together is success."

Mild cutaneous reactions to drugs

Adverse reactions to drugs are not frequent in childhood. Cutaneous reactions are the most frequent in this age group. Mild cutaneous reactions are immediate or delayed adverse reactions that do not seriously compromise the clinical condition of children. The patients usually early improve and recover the state of health. Although it is difficult to define the prevalence accurately, we could affirm that the rate adverse reaction to drugs are often over estimated by both the families and the physicians. Therefore, children may be prone to loss of school days and inappropriate or sub-optimal treatments. However, the identification of a true adverse reaction to drugs allows adequate treatment and alert to further exposure to harmful drugs.

EAACI position paper on how to classify cutaneous manifestations of drug hypersensitivity

Drug hypersensitivity reactions (DHRs) are common, and the skin is by far the most frequently involved organ with a broad spectrum of reaction types. The diagnosis of cutaneous DHRs (CDHR) may be difficult because of multiple differential diagnoses. A correct classification is important for the correct diagnosis and management. With these guidelines, we aim to give precise definitions and provide the background needed for doctors to correctly classify CDHR.

Pancrelipase-Induced Hypersensitivity Reaction: Case Report and Review of Literature

INTRODUCTION

Drug-induced exanthems are commonly associated with NSAIDs, antibiotics, and anti-epileptics. Pancrelipase is frequently used for conditions resulting in pancreatic exocrine insufficiency. Published case reports of pancrelipase hypersensitivity focus on the respiratory manifestations.

CASE REPORT

Here we report a case of skin hypersensitivity resulting from pancrelipase use. To further assess this association, we used a Naranjo nomogram, which determines the likelihood that an adverse drug reaction is the result of the drug itself. Our patient had a score of seven, suggesting our patient had a probably adverse drug reaction.

DISCUSSION

As pancrelipase is a commonly prescribed drug, clinicians should be aware of the potential hypersensitivity skin reactions associated with pancrelipase.

Cutaneous Manifestation of Drug Allergy and Hypersensitivity

Drug hypersensitivity reactions may manifest with either organ-specific or systemic symptoms, but cutaneous eruptions are the most common manifestations. Different medications may cause identical skin symptoms, whereas hypersensitivity to a single drug may manifest with various patterns of symptoms depending on the pathomechanism of hypersensitivity. Drug reactions should be also taken into account in the differential diagnosis of numerous skin rashes. Analysis of morphology of drug-induced lesions, about potential immunologic or nonimmunological mechanisms, is important for the final diagnosis. Thus, here the authors present a morphologic approach to the diagnosis of cutaneous drug-induced eruptions.

The Role of Oncodermatology in the Care of Patients Receiving Cancer Therapy

OBJECTIVE

To review the emerging sub-specialty of oncodermatology and the role of oncodermatology nurses as facilitators of interprofessional collaboration between the oncology team and the dermatology team.

DATA SOURCES

Journal articles indexed on the National Library of Medicine database.

CONCLUSION

The complexity of cancer care with new cancer therapies and their associated dermatologic adverse events profiles benefit from a collaborative, interprofessional approach between dermatology and oncology in the care of the patient with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Oncodermatology nurses are in roles that can facilitate interprofessional collaboration, optimizing the care of patients with cancer.

Disorders characterized by predominant or exclusive dermal inflammation

Some cutaneous inflammatory disorders are typified by a predominant or exclusive localization in the dermis. They can be further subdivided by the principal cell types into lymphocytic, neutrophilic, and eosinophilic infiltrates, and mixtures of them are also seen in a proportion of cases. This review considers such conditions. Included among the lymphoid lesions are viral exanthems, pigmented purpuras, gyrate erythemas, polymorphous light eruption, lupus tumidus, and cutaneous lymphoid hyperplasia. Neutrophilic infiltrates are represented by infections, Sweet syndrome, pyoderma gangrenosum, and hidradenitis suppurativa, as well as a group of so-called "autoinflammatory" dermatitides comprising polymorphonuclear leukocytes. Eosinophil-dominated lesions include arthropod bite reactions, cutaneous parasitic infestations, the urticarial phase of bullous pemphigoid, Wells syndrome (eosinophilic cellulitis), hypereosinophilic syndrome, and Churg-Strauss disease. In other conditions, eosinophils are admixed with neutrophils in the corium, with or without small-vessel vasculitis. Exemplary disorders with those patterns include drug eruptions, chronic idiopathic urticaria, urticarial vasculitis, granuloma faciale, and Schnitzler syndrome (chronic urticarial with a monoclonal gammopathy).

Risk and association of HLA with oxcarbazepine-induced cutaneous adverse reactions in Asians

OBJECTIVE

To investigate the risk and genetic association of oxcarbazepine-induced cutaneous adverse reactions (OXC-cADRs), including Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), in Asian populations (Chinese and Thai).

METHODS

We prospectively enrolled patients with OXC-cADRs in Taiwan and Thailand from 2006 to 2014, and analyzed the clinical course, latent period, drug dosage, organ involvement, complications, and mortality. We also investigated the carrier rate of HLA-B*15:02 and HLA-A*31:01 of patients with OXC-cADRs and compared to OXC-tolerant controls. The incidence of OXC-SJS/TEN was compared with carbamazepine (CBZ)-induced SJS/TEN according to the nationwide population dataset from the Taiwan National Health Insurance Research Database.

RESULTS

We enrolled 50 patients with OXC-cADRs, including 20 OXC-SJS/TEN and 6  drug reaction with eosinophilia and systemic symptoms, of Chinese patients from Taiwan and Thai patients from Thailand. OXC-cADRs presented with less clinical severity including limited skin detachment (all ≦5%) and no mortality. There was a significant association between HLA-B*15:02 and OXC-SJS (p = 1.87 × 10^-10; odds ratio 27.90; 95% confidence interval [CI] 7.84-99.23) in Chinese and this significant association was also observed in Thai patients. The positive and negative predictive values of HLA-B*15:02 for OXC-SJS/TEN were 0.73% and 99.97%, respectively. HLA-A*31:01 was not associated with OXC-cADRs. The incidence and mortality of OXC-SJS/TEN was lower than CBZ-STS/TEN in new users (p = 0.003; relative risk 0.212; 95% CI 0.077-0.584).

CONCLUSIONS

Our findings suggest that HLA-B*15:02 is significantly associated with OXC-SJS in Asian populations (Chinese and Thai). However, the severity and incidence of OXC-SJS/TEN are less than that of CBZ-SJS/TEN. The need for preemptive HLA-B*15:02 screening should be evaluated further.

Drug induced exfoliative dermatitis: state of the art

Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Erythema multiforme (EM), Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Overall, T cells are the central player of these immune-mediated drug reactions. Here we provide a systematic review on frequency, risk factors, pathogenesis, clinical features and management of patients with drug induced ED.

In vitro rapid diagnostic tests for severe drug hypersensitivity reactions in children

BACKGROUND

Previous reports have demonstrated the utility of T-cell proliferation and cytokine release assays as in vitro diagnostic tests for drug causation in drug hypersensitivity reactions (DHR). However, data from pediatric populations are scarce compared with data in adults.

OBJECTIVE

To compare the lymphocyte proliferation assay (LPA) with combination cytokine assays in the pediatric population and to identify its potential use in the acute and postrecovery phases.

METHODS

A total of 18 in vitro tests were undertaken ex vivo to compare drug-specific proliferation and cytokine release (interferon-γ [IFN-γ] and interleukin-4 [IL-4]). The study included 16 patients with DHR: 7 children tested in the acute phase, 7 tested after recovery, and 2 tested during both the acute and postrecovery phases.

RESULTS

The sensitivity of the LPA was better during the acute stage of DHR in children. Cytokine assays revealed a higher frequency of positive drug-specific responses compared with LPA in both the acute (LPA, 77.8%; IFN-γ, 88.9%; IL-4, 100%) and postrecovery phases (LPA, 33.3%; IFN-γ, 66.7%; IL-4, 66.7%). Combination cytokine assays (IFN-γ and IL-4) produced higher positive drug-specific responses in identifying culprit drugs compared with LPA in both the acute and postrecovery phases.

CONCLUSION

In vitro drug-induced T-cell proliferation and cytokine release assays are useful for identification of the causative drug in children with DHR. Cytokine assays (IFN-γ and IL-4) were better than LPA, but when combined, they offer even greater utility in the diagnosis of acute and postrecovery DHR. Cytokine detection is rapid and does not involve radioactivity. These novel in vitro assays may offer a significant advancement in our future management of DHR in children.

Role of dermatology in pharmacogenomics: drug-induced skin injury

Different individuals may respond diversely to the same drug, in terms of efficacy and toxicity. Adverse drug reactions cause about 6% of all hospital admissions and account for up to 9% of hospitalization costs. Drug-induced skin injury (DISI) is the most common presentation of adverse drug reactions, ranging from maculopapular eruptions to severe adverse cutaneous drug reactions (SCARs) with mortality of up to 40%. Specific genetic polymorphisms confer susceptibility to different types of DISI. Identifying patients genetically at risk for SCARs is one of the goals of pharmacogenomics. In this article, the aspects of clinical dermatology relevant to the pharmacogenetics of DISI are reviewed. Many SCARs are now preventable, with consequent reduction of morbidity, mortality and healthcare costs.

Adverse drug reactions in dermatology

Adverse drug reactions (ADRs) - that is, unintended and harmful responses to medicines - are important to dermatologists because many present with cutaneous signs and because dermatological treatments can cause serious ADRs. The detection of ADRs to new drugs is often delayed because they have a long latency or are rare or unexpected. This means that ADRs to newer agents emerge only slowly after marketing. ADRs are part of the differential diagnosis of unusual rashes. A good drug history that includes details of drug dose, time-course of the reaction and factors that may make the patient more susceptible, will help. For example, Stevens-Johnson syndrome with abacavir is much commoner in patients with HLA-B*5701, and has a characteristic time course. Newer agents have brought newer reactions; for example, acneiform rashes associated with epidermal growth factor receptor inhibitors such as erlotinib. Older systemic agents used to treat skin disease, including corticosteroids and methotrexate, cause important ADRs. The adverse effects of newer biological agents used in dermatology are becoming clearer; for example, hypersensitivity reactions or loss of efficacy from antibody formation and progressive multifocal leucoencephalopathy due to reactivation of latent JC (John Cunningham) virus infections during efalizumab treatment. Unusual or serious harm from medicines, including ADRs, medication errors and overdose, should be reported. The UK Yellow Card scheme is online, and patients can report their own ADRs.

Rosacea-like facial rash related to metformin administration in a young woman

Background

Since the skin represents a common site of adverse drug reactions, few data are reported at this time regarding the development of skin rash during the treatment with antidiabetic drugs.

Case presentation

We report a 29-year old woman that developed a facial skin rash during the treatment with metformin. Clinical and laboratory findings excluded the presence of systemic diseases, but several diagnosis and many drugs were administered without clinical improvement. The self-dismission of metformin induced an improvement of symptoms, while the re-challenge documented an impairments of skin rash. The Naranjo probability scale suggested a probable association between metformin and skin rash and metformin was definitively dismissed.

Conclusion

We report for the first time a non vasculitis facial skin manifestation related to metformin in a young woman. However, this case may emphasizes the need to consider the ADRs as a differential diagnosis in order to reduce medical errors and the related medical costs.

Rapidly Developing Toxic Epidermal Necrolysis

Severe cutaneous reactions with potentially fatal outcomes can have many different causes. The Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare. They are characterized by a low incidence but high mortality, and drugs are most commonly implicated. Urgent active therapy is required. Prompt recognition and withdrawal of suspect drug and rapid intervention can result in favourable outcome. No further international guidelines for treatment exist, and much of the treatment relies on old or experimental concepts with no scientific evidence. We report on a 54-year-old man experiencing rapidly developing drug-induced severe TEN and presented multiorgan failure involving the respiratory and circulatory system, coagulopathy, and renal insufficiency. Detachment counted 30% of total body surface area (TBSA). SCORTEN = 5, indicating a mortality rate >90%. The patient was sedated and mechanically ventilated, supported with fluids and inotropes to maintain a stable circulation. Component therapy was guided by thromboelastography (TEG). The patient received plasmapheresis, and shock reversal treatment was initiated. He was transferred to a specialized intensive care burn unit within 24 hours from admittance. The initial care was continued, and hemodialysis was started. Pulmonary, circulatory, and renal sequelae resolved with intensive care, and re-epithelialization progressed slowly. The patient was discharged home on hospital day 19.

Getting under the skin of adverse drug reactions

Cutaneous drug reactions are among the most commonly reported adverse drug reactions. Drugs prescribed by orthopedic surgeons, such as antibiotics, opiates, and nonsteroidal anti-inflammatory drugs, are common offenders. Cutaneous drug reactions can range from those that are common, mild nuisances to those that are rare, severe, and life-threatening. Medications should be considered part of a differential diagnosis for any dermatologic condition. It is important to recognize the different clinical features and common drugs that are related to each type of reaction. This review characterizes the different forms of cutaneous drug reactions and the clinical features, proposed mechanisms, and drugs frequently associated with each.

A pilot study of paclitaxel combined with gemcitabine followed by interleukin-2 and granulocyte macrophage colony-stimulating factor for patients with metastatic melanoma

It has been suggested that paclitaxel and gemcitabine modulate the immune system. This paper reports the safety and efficacy of paclitaxel plus gemcitabine followed by interleukin-2 (IL-2)and granulocyte macrophage colony-stimulating factor (GM-CSF), the PGIG chemobiotherapy, for patients with metastatic melanoma. All patients received 175 mg/m ( 2) paclitaxel on day 1 and 800 mg/m ( 2) gemcitabine on day two. IL-2 and GM-CSF were administered from day 4 to day 8 at a dosage of 2 MIU/m ( 2) and 100 μg, respectively. The PGIG chemobiotherapy was repeated every 21 d. Serum cytokine levels at baseline and at the end of the second cycle were measured via flow cytometry. Twenty-seven patients with metastatic melanoma accepted PGIG chemobiotherapy from August 2009 to March 2011. There were five patients that exhibited a partial response, 14 patients that exhibited a stable response and eight that displayed progressive disease. Therefore, the response rate was 18.5%, and the disease control rate was 70.4%. The median time to progression and median survival were 4 mo and 8 mo, respectively. The one-year and two-year survival rates were 25.9% and 18.5%, respectively. Frequent side effects included chills, fever, arthralgia, rash and pruritus. Among the 13 patients who experienced a rash and pruritus and the 14 patients who did not suffer from this side effect, the response rates and disease control rates were 30.8% vs 7.1% and 77% vs 64.2%, respectively. No relationship between serum IL-6 levels, clinical response, and either skin side effect was observed. The PGIG chemobiotherapy is safe and effective for the treatment of patients with advanced melanoma, but randomized trials are necessary to validate this effect.

Adverse drug reaction reporting by nurses: analysis of Italian pharmacovigilance database

PURPOSE

The aim of this study was to describe the pattern of adverse drug reaction (ADR) reports sent by Italian nurses after the enactment of the law involving them in the pharmacovigilance system. We also compared the quantity and quality of reports by nurses with those of reports by hospital physicians sent in the same period.

METHODS

We analysed the reports sent to the Italian pharmacovigilance database by nurses from January 2004 to December 2010. Only reports with ADRs causality assessment defined as definite, probable or possible were included in the analysis. The nurses' reports were compared with those sent by hospital physicians in the same period. We excluded from this analysis reports associated with vaccines.

RESULTS

A total number of 1403 reports by nurses have been evaluated. The percentage of nurses' reports of ADRs, which were serious, were 22.9% lower than the 44.9% of reports by physicians, whereas the proportion of probable ADR reports were higher among nurses than hospital physicians (76% vs 67%). Nurses put more emphasis than physicians on application site disorders (log OR = 0.91, 95%CI = 0.55-1.27), skin reactions (log OR = 0.81, 95%CI = 0.70-0.92) and nervous system reactions (log OR = 0.28, 95%CI = 0.11-0.44), whereas physicians more frequently report blood, platelet and liver disorders. Six drugs are present in both the top 10 drugs reported by nurses and hospital doctors.

CONCLUSION

This study gives evidence for the potential capacity of nurses to improve the detection of ADRs.