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Woodruff CM, Botto N. The Role of Patch Testing in Evaluating Delayed Hypersensitivity Reactions to Medications. Clin Rev Allergy Immunol 2022; 62:548-561. [PMID: 35113364 PMCID: PMC9156465 DOI: 10.1007/s12016-022-08924-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/19/2022]
Abstract
Confirming drug imputability is an important step in the management of cutaneous adverse drug reactions (CADR). Re-challenge is inconvenient and in many cases life threatening. We review the literature on ideal patch testing technique for specific CADRs. Testing should be performed approximately 3 months after the resolution of the eruption using standard patch testing techniques. Commercially available patch test preparations are available for a minority of drugs, so in most cases, testing should be performed with the drug at various recommended concentrations and in different vehicles. Testing to all known excipients, such as dyes, vehicles and preservatives is also important. Immunosuppressive medications should be discontinued or down titrated to the lowest tolerable dose to decrease the risk of false negative reactions. We provide an overview of expert recommendations and extant evidence on the utility of patch testing for identifying the culprit drug in common CADRs and for specific drug or drug classes. Overall, there appears to be significant variability in the patch test positivity of different drugs, which is likely the result of factors intrinsic to the drug such as dermal absorption (as a function of lipophilicity and molecular size) and whether the drug itself or a downstream metabolite is implicated in the immune reaction. Drugs with high patch test positivity rates include beta-lactam antibiotics, aromatic anticonvulsants, phenytoin, and corticosteroids, among others. Patch testing positivity varies both as a function of the drug and type of CADR. The sum of the evidence suggests that patch testing in the setting of morbilliform eruptions, fixed drug eruption, acute generalized exanthematous pustulosis, and possibly also drug-induced hypersensitivity syndrome, photoallergic and eczematous reactions may be worthwhile, although utility of testing may vary on the specific drug in question for the eruption. It appears to be of limited utility and is not recommended in the setting of other complex CADR, such as SJS/TEN and leukocytoclastic vasculitis.
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Affiliation(s)
| | - Nina Botto
- University of California San Francisco, San Francisco, CA, USA
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2
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Patch Testing in Adverse Drug Reactions. Contact Dermatitis 2021. [DOI: 10.1007/978-3-030-36335-2_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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3
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Perks A, Bates TJ, Velangi S, Brown RM, Poveda-Gallego A. Probable etoricoxib-induced fixed drug eruption involving the oral mucosa: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 131:e100-e107. [PMID: 33468439 DOI: 10.1016/j.oooo.2020.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 11/15/2022]
Abstract
Fixed drug eruption (FDE) is a cutaneous adverse drug reaction characterized by recurrence of lesions at the same sites each time a specific drug is taken. Oral mucosal involvement is rare. Nonsteroidal anti-inflammatory drugs are one of the most common offending drug groups in FDE; however, selective cyclooxygenase-2 inhibitors, such as etoricoxib, are rarely implicated. We present a case of oral mucosal and cutaneous FDE induced by etoricoxib that, to the best of our knowledge, is the first reported case of this nature. We describe the diagnostic challenges and review the pertinent literature. The value of drug provocation testing and patch testing in FDE is also discussed.
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Affiliation(s)
- Alexandra Perks
- Oral Medicine, Birmingham Dental Hospital and School of Dentistry, Birmingham, UK.
| | - Timothy John Bates
- Oral Pathology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Shireen Velangi
- Dermatology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Rachel M Brown
- Oral Pathology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ana Poveda-Gallego
- Oral Medicine, Birmingham Dental Hospital and School of Dentistry, Birmingham, UK
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Pérez-Sánchez N, Doña I, Bogas G, Salas M, Testera A, Cornejo-García JA, Torres MJ. Evaluation of Subjects Experiencing Allergic Reactions to Non-Steroidal Anti-Inflammatory Drugs: Clinical Characteristics and Drugs Involved. Front Pharmacol 2020; 11:503. [PMID: 32425774 PMCID: PMC7212440 DOI: 10.3389/fphar.2020.00503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs), the most commonly prescribed and consumed medicines worldwide, are the main triggers of drug hypersensitivity reactions (DHRs). The underlying mechanisms of NSAID-DHRs may be related to COX-1 inhibition (cross-hypersensitivity reactions, CRs) or to immunological recognition (selective reactions, SRs), being the latter remarkably less studied. SRs include those usually appearing within the first hour after drug intake (single-NSAID-induced urticaria/angioedema or anaphylaxis, SNIUAA), and those usually occurring more than 24 h after (single-NSAID-induced delayed reactions, SNIDR). We have evaluated the largest series of patients with SRs, analyzing the number of episodes and drugs involved, the latency for reaction onset, the clinical entities, among other variables, as well as the value of available diagnostic methods. Globally, pyrazolones and arylpropionics were the most frequent culprits (39.3% and 37.3%, respectively). Pyrazolones were the most frequent triggers in SNIUAA and arylpropionics in SNIDR. Urticaria was the most common clinical entity in SNIUAA (42.4%) followed by anaphylaxis (33.3%); whereas SNIDR induced mostly fixed drug eruption (41.1%) and maculopapular exanthema (32.6%). The percentage of patients diagnosed by clinical history was higher in SNIUAA compared with SNIDR (62.7% versus 35.3%, p = 0.00015), whereas the percentage of those diagnosed by skin tests was higher in SNIDR than in SNIUAA (47.1% versus 22.8%, p = 0.00015). Drug provocation test with the culprit was performed in 67 SNIUAA (14.5%) and in 9 SNIDR (17.6%) patients. Our results may be of interest not only for allergologists but also for other clinicians dealing with these drugs, and can be useful for the correct identification of subjects experiencing DHRs to NSAIDs, and for avoiding mislabeling. Moreover, as NSAIDs are highly consumed worldwide, our results may be of interest for evaluating other populations exposed to these drugs.
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Affiliation(s)
- Natalia Pérez-Sánchez
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain.,Departamento de Medicina, Universidad de Málaga, Malaga, Spain
| | - Inmaculada Doña
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - Gador Bogas
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - María Salas
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - Almudena Testera
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - José A Cornejo-García
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Malaga, Spain
| | - María J Torres
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain.,Departamento de Medicina, Universidad de Málaga, Malaga, Spain.,Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Malaga, Spain.,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Malaga, Spain
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Ammar H, Ben Fredj N, Ben Fadhel N, Chadli Z, Ben Romdhane H, Boughattas NA, Chaabane A, Aouam K. Celecoxib-induced bullous fixed drug eruption: An unusual presentation. Br J Clin Pharmacol 2019; 85:2638-2639. [PMID: 31376180 DOI: 10.1111/bcp.14072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/01/2019] [Accepted: 07/12/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Helmi Ammar
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Nadia Ben Fredj
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Najeh Ben Fadhel
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Haifa Ben Romdhane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Naceur A Boughattas
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Amel Chaabane
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Karim Aouam
- Department of Pharmacology, EPS Fattouma Bourguiba, Faculty of Medicine, University of Monastir, Monastir, Tunisia
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Usefulness of Cutaneous Provocation Tests to Study Drugs Responsible for Cutaneous Adverse Drug Reactions. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-0198-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Sousa ASD, Cardoso JC, Gouveia MP, Gameiro AR, Teixeira VB, Gonçalo M. Fixed drug eruption by etoricoxib confirmed by patch test. An Bras Dermatol 2017; 91:652-654. [PMID: 27828643 PMCID: PMC5087228 DOI: 10.1590/abd1806-4841.20164301] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 01/26/2015] [Indexed: 11/22/2022] Open
Abstract
Non-steroidal, anti-inflammatory drugs, followed by antibiotics, are the main
causes of fixed drug eruption. They provoke one or several round erythematous or
bullous lesions that recur in the same place after taking the causative
medication. A positive patch test on residual, lesional skin can replace
satisfactorily oral reintroduction. We describe the case of a 74-year-old woman
with numerous, rounded, erythematous lesions on the trunk and recurrent
blistering on the fifth right-hand finger, which developed a few hours after
taking etoricoxib. Lesional patch testing with etoricoxib was positive and
reproduced the typical pattern of a fixed drug eruption upon histopathology. We
emphasize the specific reactivity of the etoricoxib patch test, and the capacity
to reproduce the histologic pattern of the reaction.
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Affiliation(s)
| | | | | | | | | | - Maria Gonçalo
- Hospital Universitário de Coimbra - Coimbra, Portugal
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Antunes J, Prates S, Leiria-Pinto P. Fixed drug eruption due to etoricoxibe - a case report. Allergol Immunopathol (Madr) 2014; 42:623-4. [PMID: 23972405 DOI: 10.1016/j.aller.2013.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/05/2013] [Accepted: 06/19/2013] [Indexed: 11/26/2022]
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Exantema fijo medicamentoso por etoricoxib con tolerancia a celecoxib. Utilidad de las pruebas epicutáneas. ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.ad.2013.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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12
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Fixed Drug Eruption Due to Etoricoxib in a Patient With Tolerance to Celecoxib: The Value of Patch Testing. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:314-5. [DOI: 10.1016/j.adengl.2013.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 04/20/2013] [Indexed: 11/18/2022] Open
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Wurpts G, Merk HF. Unverträglichkeitsreaktionen auf Etoricoxib. ALLERGO JOURNAL 2012. [DOI: 10.1007/s15007-012-0320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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15
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Ponce V, Muñoz-Bellido F, Moreno E, Laffond E, González A, Dávila I. Fixed drug eruption caused by etoricoxib with tolerance to celecoxib and parecoxib. Contact Dermatitis 2012; 66:107-8. [DOI: 10.1111/j.1600-0536.2011.01982.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Andrade P, Brinca A, Gonçalo M. Patch testing in fixed drug eruptions--a 20-year review. Contact Dermatitis 2011; 65:195-201. [PMID: 21702758 DOI: 10.1111/j.1600-0536.2011.01946.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The fixed drug eruption is a common adverse drug reaction. Clear identification of the culprit drug is not always possible in the clinical setting, and oral rechallenge may induce new lesions or severe reactions. OBJECTIVES The main purpose of this study was to evaluate the diagnostic value of patch testing in establishing an aetiological diagnosis in fixed drug eruptions. METHOD A retrospective analysis was conducted evaluating 52 patients (17M/35F, mean age 53±17 years) with clinical diagnoses of fixed drug eruptions submitted to patch tests in a 20-year period in a Dermatology Department. Nonsteroidal anti-inflammatory drugs (NSAID) were clinically suspected in 90.4% of the cases, followed by antibiotics (28.9%) and paracetamol (15.4%). RESULTS Patch tests on pigmented lesions were reactive in 21 patients (40.4%), 20 of those to NSAID (nimesulide, piroxicam and etoricoxib) and 1 to an antihistamine (cetirizine). All patch tests using other drugs were negative, even under conditions of high clinical suspicion. Oral rechallenge allowed confirmation of drug imputability in 5 of 31 test-negative cases. Cross reactivity was frequently observed between piroxicam and other oxicams, and between different antihistamines. CONCLUSIONS Patch testing was shown to be a simple and safe method to confirm drug imputabililty in fixed drug eruption, mainly when NSAID or multiple drugs are suspected. Persistent lack of reactivity to drug classes such as antibiotics and allopurinol represent an important limitation.
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Affiliation(s)
- Pedro Andrade
- Department of Dermatology and Venereology, Coimbra University Hospital, 3000-075 Coimbra, Portugal.
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