Audit of erythema in patients with psoriasis undergoing phototherapy with narrowband (TL-01) ultraviolet B: impact of the introduction of a comprehensive erythema-reporting protocol

Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome in a Patient Taking Lamotrigine: A Case Report Based Literature Review

A 29-year-old patient presented to the hospital with worsening generalized rash for the last two days from a mental health facility. The patient was commenced on lamotrigine two weeks earlier, and he developed fever and generalized macular rash on his body. His blood tests showed deranged liver function tests (LFTs) and clotting with raised eosinophil count, and he was treated for lamotrigine-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. The patient was commenced on prednisolone 50 mg once daily with a proton pump inhibitor cover, and lamotrigine was suspended on advice from Dermatology. The patient showed improvement after 3-4 days of treatment. His skin biopsy showed prominent suppurative granulomatous folliculitis, mild perivascular chronic inflammation, and red blood cell extravasation, including the rare eosinophil. He was weaned off from prednisolone by 5 mg weekly and had complete resolution of symptoms.

Is it Useful to Calculate Minimal Erythema Dose Before Narrowband UV-B Phototherapy?

INTRODUCTION AND OBJECTIVES

The starting dose for narrowband UV-B phototherapy is determined by a patient's skin phototype or minimal erythema dose (MED). Calculation of MED identifies patients with unsuspected photosensitivity. The aim of this study was to investigate the influence of factors such as concomitant use of photosensitizing agents, diagnosis, and combination with acitretin in patients with psoriasis on the frequency and severity of adverse effects in patients with a low MED to narrowband UV-B phototherapy.

MATERIAL AND METHODS

We undertook a retrospective observational cohort study between February 1, 2009 and March 31, 2015. MED values were classified as normal or low.

RESULTS

In total, 302 patients with different skin conditions started narrowband UV-B phototherapy at a dose determined by their MED. No differences were found between patients with a low MED and those with a normal MED for number of drugs taken (P=.071) or use of photosensitizing agents (P=0.806). Following adjustment for age, sex, and phototype, the multivariate analysis showed that psoriasis exerted a protective effect against a low MED (OR=0.31 [95% CI, 0.16-0.58]). No significant risk of erythema or pruritus was detected in patients with a low MED (OR=1.68; 95% CI, 0.91-3.29 and OR=2.04; 95% CI, 0.99-4.22, respectively).

CONCLUSIONS

Psoriasis protects against a low MED. Although erythema and pruritus were more common in patients with a low MED, the differences were not significant.

Drug reaction with eosinophilia and systemic symptoms syndrome in a patient taking phenytoin and levetiracetam: a case report

INTRODUCTION

Drug reaction with eosinophilia and systemic symptoms syndrome is a potentially life-threatening hypersensitivity reaction with rash, fever, and internal organ involvement, often hepatitis, occurring most commonly two to eight weeks after initiation of a medication. The present case is an example of severe and potentially life-threatening hepatitis as a manifestation of drug reaction with eosinophilia and systemic symptoms syndrome.

CASE PRESENTATION

We report a case of anti-epileptic-induced drug reaction with eosinophilia and systemic symptoms syndrome in an 18-year-old African-American man who presented with a five-day history of rash, periorbital and upper extremity edema, hepatitis and fever. Laboratory findings revealed an atypical lymphocytosis, eosinophilia, and elevated serum transaminases. No drug allergies were reported at the time of presentation, but phenytoin and levetiracetam therapy had been initiated five weeks prior to hospital admission for new-onset seizures. Both medications were discontinued on hospital admission, and after three days of high-dose corticosteroid therapy the patient experienced resolution of both his symptoms and laboratory markers of inflammation.

CONCLUSION

Given the significant mortality attributed to drug reaction with eosinophilia and systemic symptoms syndrome, medical personnel should be aware of the potential for this severe hypersensitivity reaction and should ensure close follow-up and offer anticipatory guidance when beginning any new medication, particularly anti-epileptic therapy. Early recognition of drug reaction with eosinophilia and systemic symptoms syndrome and initiation of appropriate therapy are imperative in limiting morbidity.

Fluindione and drug reaction with eosinophilia and systemic symptoms: an unrecognised adverse effect?

PURPOSE

Fluindione is an oral vitamin K antagonist (indanedione derivative) exclusively marketed in France and Luxembourg, known to have immuno-allergic adverse effects such as hepatitis, fever or interstitial nephritis. A few cases of drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported with fluindione. The aim of the present study was to investigate fluindione-induced DRESS cases reported in France and to describe their characteristics.

METHODS

We searched for potential cases of DRESS with fluindione reported in the French pharmacovigilance database since 2000.

RESULTS

Thirty-six cases of DRESS were included and concerned 17 women and 19 men. The mean age was 65 years (median: 68 years, range: 28-95 years). Kidneys and liver were the most frequent organs involved. Thirty-five cases were serious. In 5 cases, the effect was life-threatening. Most of the patients recovered. Fluindione was the only medicine suspected in 26 cases. Skin patch tests, performed in 10 cases, were positive with fluindione in 9 cases.

CONCLUSIONS

Fluindione is not known to be a frequent cause of DRESS. However, the number of reports found is probably underestimated. The seriousness of DRESS, as all immuno-allergic adverse effects, contraindicates fluindione reintroduction. Coumarinic derivatives are the alternatives in patients who need oral anticoagulant treatment.

[A retrospective efficacy and safety study of UVB-TL01 phototherapy and PUVA therapy in palmoplantar psoriasis]

BACKGROUND

Topical therapy is generally insufficient in palmoplantar psoriasis. UVBTL01 phototherapy is a therapeutic alternative and we conducted a retrospective study of the efficacy and safety of this approach and of PUVA therapy in palmoplantar psoriasis.

PATIENTS AND METHODS

All patients treated with UVBTL01 or PUVA therapy from November 2001 to April 2008 were included in the study. Phototherapy was given three times a week. Evaluation was performed after 20 sessions, again after 30 sessions and then at the end of the treatment. Therapeutic outcome was classed as "failure", "slight improvement" or "improvement or clear skin".

RESULTS

UVBTL01 phototherapy and PUVA therapy were effective, with "improvement or clear skin" in respectively 52% and 61% of cases and "slight improvement" in 16% and 23% of cases at the end of the treatment. With UVBTL01, adverse effects occurred in 20% of cases (erythema 18%, first-degree burns 7%) and treatment was discontinued as a result in only 4% of cases. Adverse effects occurred in 50% in patients on PUVA therapy, mainly due to methoxypsoralen intake.

CONCLUSION

UVBTL01 phototherapy and PUVA therapy are efficacious treatments in palmoplantar psoriasis; UVBTL01 phototherapy involves fewer constraints and has fewer adverse effects.