Terbinafine-Induced Subacute Cutaneous Lupus Erythematosus

Analysis of clinical characteristics of terbinafine-induced subacute cutaneous lupus erythematosus

INTRODUCTION

Terbinafine may cause subacute cutaneous lupus erythematosus (SCLE), and we aimed to analyze its clinical characteristics.

METHODS

We collected literature on terbinafine-induced SCLE from 1997 to 2023 for retrospective analysis. Thirty-seven patients (33 females and 4 males) were included.

RESULTS

The patients have a median age of 49.5 years (range 18-79) and onset time of 5 weeks (range 1-12). SCLE is mainly manifested as annular erythematous (83.3%), scaly erythematous (44.4%), and maculopapular erythematous (13.9%). Mainly, histopathological manifestations are lymphocytic infiltrate (55.6%), hyperkeratosis (38.9%) and keratinocyte necrosis (38.9%). Positive immunological parameters mainly include antinuclear antibody (100.0%), anti-Ro/SSA antibody (94.1%), and anti-La/SSB antibody (72.2%). Past medical history usually includes photosensitivity (33.3%), inflammatory disease (33.33%), and lupus erythematosus (12.1%). Symptoms are completely resolved within a median time of 35 days (range 7-84) after discontinuation of terbinafine and treatment with topical corticosteroids, systemic corticosteroids, hydroxychloroquine, and immunosuppressant. No recurrence was observed within 12 months (range 1.5-48) of follow-up.

CONCLUSION

These results suggest that terbinafine-induced SCLE should be comprehensively diagnosed based on clinical symptoms, histopathological manifestations, immunological parameters, and past medical history. Terbinafine should be immediately discontinued when SCLE occurs, while systemic and topical corticosteroids combined with hydroxychloroquine may be an effective treatment.

Cutaneous lupus erythematosus induced by drugs - novel insights

Introduction: There is a growing list of drugs implicated in inducing both subacute and chronic forms of cutaneous lupus erythematosus. It is important to recognize these drugs in order to quickly treat patients with drug induced disease.Areas covered: This paper reviews the current literature describing drugs implicated in causing cutaneous lupus erythematosus. A Pubmed search was used to compile a list of medications implicated up to August 2019. It reviews new classes of drugs identified as causing cutaneous lupus erythematosus, the pathophysiology of the disease process, and current recommendations for treatment of the disease.Expert opinion: Many drugs have been identified as inducing lupus, and many more continue to be described in new reports. Further research is needed to understand this phenomenon, which will aid in the diagnosis and treatment of affected patients.

Drug-induced cutaneous lupus erythematosus after immunoglobulin treatment in chronic inflammatory demyelinating polyneuropathy: a case series

We describe six patients with cutaneous lupus erythematosus (cLE) during immunoglobulin G (IgG) treatment. Five patients were diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP) and one patient with possible CIDP. Five patients received intravenous immunoglobulin (IVIg) and one patient received subcutaneous immunoglobulin (SCIg). Skin lesions were systematically assessed by a dermatologist including skin biopsies. Patients showed disseminated erythematous plaques on several parts of the body with pre-dominance of the chest and face. Skin biopsies showed perivascular and perifollicular vacuolar inflammation, consistent with the diagnosis of cLE. There were no signs of systemic lupus erythematosus. Anti-SSA (Ro60) antibodies were found in two patients and anti-Ro52 antibodies were detectable in one patient. Symptoms improved in three patients after switching to another brand of IVIg and after use of topical corticosteroids. However, these measures did not lead to a complete resolution of the skin lesions. To achieve complete remission, IgG treatment was ceased in four patients. This led to remission of the skin lesions in two patients and to marked improvement in the other two patients. IVIg had to be restarted in two patients because of a relapse of CIDP which led to worsening of the skin lesions. In one patient with clear IVIg dependency, treatment was continued with addition of topical steroids. In the patient using SCIg, cLE was photosensitive and showed spontaneous remission. The relation of cLE with IgG treatment suggests an immunoglobulin-induced cLE. Only one report previously described the occurrence of IVIg induced cLE in a patient with common variable immunodeficiency.

[Terbinafine : Drug-induced lupus erythematodes and triggering of psoriatic skin lesions]

Based on the technical information that oral terbinafine must be used with caution in patients with pre-existing psoriasis or lupus erythematosus, the literature was summarized. Terbinafine belongs to the drugs able to induce subcutaneous lupus erythematosus (SCLE)-with a relatively high risk. The clinical picture of terbinafine-induced SCLE may be highly variable and can also include erythema exsudativum multiforme-like or bullous lesions. Thus, differentiation of terbinafine-induced Stevens-Johnson syndrome or toxic epidermal necrolysis may be difficult. Therefore, terbinafine should be prescribed with caution in patients who show light sensitivity, arthralgias, positive antinuclear antibodies or have a history of SLE or SCLE. Case reports include wide-spread, but mostly nonlife-threatening courses, which did not require systemic therapy with steroids or antimalarials in every case. Terbinafine is also able to induce or to aggravate psoriasis. The latency period seems to be rather short (<4 weeks). Terbinafine therefore is not first choice if a systemic therapy with antimycotics is indicated in a patient with psoriasis or psoriatic diathesis. Azole derivatives according to the guidelines may be used as an alternative.

Trigger factors of cutaneous lupus erythematosus: a review of current literature

It is currently believed that autoimmune conditions are triggered and aggravated by a variety of environmental factors such as cigarette smoking, infections, ultraviolet light or chemicals, as well as certain medications and vaccines in genetically susceptible individuals. Recent scientific data have suggested a relevant role of these factors not only in systemic lupus erythematosus, but also in cutaneous lupus erythematosus (CLE). A variety of environmental factors have been proposed as initiators and exacerbators of this disease. In this review we focused on those with the most convincing evidence, emphasizing the role of drugs in CLE. Using a combined search strategy of the MEDLINE and CINAHL databases the following trigger factors and/or exacerbators of CLE have been identified and described: drugs, smoking, neoplasms, ultraviolet radiation and radiotherapy. In order to give a practical insight we emphasized the role of drugs from various groups and classes in CLE. We also aimed to present a short clinical profile of patients with lesions induced by various drug classes.

A systematic review of drug-induced subacute cutaneous lupus erythematosus

The initial appearance of subacute cutaneous lupus erythematosus (SCLE) skin lesions in conjunction with Ro/SS-A autoantibodies occurring as an adverse reaction to hydrochlorothiazide [i.e. drug-induced SCLE (DI-SCLE)] was first reported in 1985. Over the past decade an increasing number of drugs in different classes has been implicated as triggers for DI-SCLE. The management of DI-SCLE can be especially challenging in patients taking multiple medications capable of triggering DI-SCLE. Our objectives were to review the published English language literature on DI-SCLE and use the resulting summary data pool to address questions surrounding drug-induced SCLE and to develop guidelines that might be of value to clinicians in the diagnosis and management of DI-SCLE. A systematic review of the Medline/PubMed-cited literature on DI-SCLE up to August 2009 was performed. Our data collection and analysis strategies were prospectively designed to answer a series of questions related to the clinical, prognostic and pathogenetic significance of DI-SCLE. One hundred and seventeen cases of DI-SCLE were identified and reviewed. White women made up the large majority of cases, and the mean overall age was 58·0 years. Triggering drugs fell into a number of different classes, highlighted by antihypertensives and antifungals. Time intervals ('incubation period') between drug exposure and appearance of DI-SCLE varied greatly and were drug class dependent. Most cases of DI-SCLE spontaneously resolved within weeks of drug withdrawal. Ro/SS-A autoantibodies were present in 80% of the cases in which such data were reported and most remained positive after resolution of SCLE skin disease activity. No significant differences in the clinical, histopathological or immunopathological features between DI-SCLE and idiopathic SCLE were detected. There is now adequate published experience to suggest that DI-SCLE does not differ clinically, histopathologically or immunologically from idiopathic SCLE. It should be recognized as a distinct clinical constellation differing clinically and immunologically from the classical form of drug-induced systemic lupus erythematosus.

Drug-induced subacute cutaneous lupus erythematosus

Subacute cutaneous lupus erythematosus (SCLE) is a subset of cutaneous lupus erythematosus with unique immunologic and clinical features. The first description dates back to 1985 when a series of five patients were found to have hydrochlorothiazide-induced SCLE. Since that time, at least 40 other drugs have been implicated in the induction of SCLE.

Subacute cutaneous lupus erythematosus induced by terbinafine: case report and review of literature

SUMMARY

Systemic lupus erythematosus and subacute cutaneous lupus erythematosus (SCLE) occasionally evolve as adverse reactions to a large variety of chemically different drugs. We here report on a 76-year-old woman who developed SCLE within 10 days after initiation of oral terbinafine. Analysis of the 27 cases of terbinafine-induced SCLE in the literature revealed that this disorder has been reported 6 times more often in females than in males. Skin lesions evolved on average around 7 weeks after starting the drug. In 79% of the cases ANA could be detected while antibodies against Ro/SS-A and La/SS-B were found in 86% and 39%, respectively. Remarkably, anti-histone antibodies were present in only 29%. In all cases terbinafine-induced SCLE resolved after discontinuation of the triggering agent. Systemic treatment with anti-malarials and/or corticosteroids does not appear to be mandatory.

Drug-induced lupus

Drug-induced lupus (DIL) is a rare adverse reaction to a large variety of drugs with features resembling those of idiopathic systemic lupus erythematosus (SLE). It usually develops only after months and, quite commonly, years of treatment with the offending agent, although latencies of days or weeks have been described in some instances. There are some indications that the risk of DIL can increase with higher daily and cumulative doses and with longer duration of therapy. There are no definitive and commonly accepted diagnostic criteria for DIL, but the following guidelines have been proposed: (a) sufficient and continuing exposure to a specific drug, (b) at least one symptom compatible with SLE, (c) no history suggestive of SLE before starting the drug, and (d) resolution of symptoms within weeks (sometimes months) after discontinuation of the putative offending agent. In addition, it is frequently suggested that the presence of ANA is required for the diagnosis of DIL. However, negative ANA test results should not automatically preclude such a diagnosis, particularly if a patient has other autoantibodies associated with SLE/DIL.

Paclitaxel-induced cutaneous lupus erythematosus in patients with serum anti-SSA/Ro antibody

Two women (aged 46 and 56 years) developed annular erythema on their sun-exposed skin, including their forearms and faces, after biweekly i.v. administration of paclitaxel for 3-4 months to treat breast cancer. Both cases showed interface changes of basal keratinocytes and high titers of serum anti-SSA/Ro antibody. The diagnoses of paclitaxel-induced cutaneous lupus erythematosus (LE) were made because the skin eruptions cleared rapidly within 3 weeks after the paclitaxel treatment was discontinued. Paclitaxel is proposed to be a causative agent that can provoke cutaneous LE.

Evaluation of persistence of terbinafine in the hair of normal cats after 14 days of daily therapy

This study determined the residual concentration of terbinafine in cat hair after 14 days of oral treatment. Ten clinically normal cats were administered terbinafine orally at a daily dose of 34-45.7 mg kg(-1) for a total of 14 days. Areas of 15 cm(2) were shaved on the lateral thorax at day 0 and weekly for 8 weeks after the last dose of terbinafine. The hair samples were analysed by high-pressure liquid chromatography to determine the persistence of terbinafine over time. The mean terbinafine concentration in hair was 2.30 ng mg(-1) after 14 days of therapy. The half life was 1.84 weeks after the last dose of terbinafine. With a 99% confidence interval, the concentration of terbinafine remained in the cat hair at or above 0.03 ng mg(-1) (minimal inhibitory concentration (MIC)(90) = 0.03 microg mL(-1)) for 5.3 weeks. Slight deviations in the complete blood cell count and serum chemistry values were not attributed to terbinafine. Four cats experienced vomiting during the terbinafine treatment; two of these cats also experienced intense facial pruritus followed by a macular to papular skin reaction 7-14 days after the discontinuation of terbinafine. In summary, terbinafine persists in hair at concentrations above the MIC for several weeks after stopping medication, even after short-term therapy (14 days). These results suggest that pulse therapy of terbinafine should be further researched and potentially considered as a treatment modality for feline dermatophytosis, an approach that would decrease treatment duration while maintaining effectiveness.

Newly Recognized Cutaneous Drug Eruptions

Many new drugs are entering the marketplace and although some cutaneous reactions might be noted in the preclinical evaluation, some of the reactions, particularly those that are rare, will not be noted until the drugs enter widespread use. In addition, distinctive reactions may occur, as is the case with epidermal growth factor-receptor inhibitors. Careful observation and evaluation might result in a better understanding of "naturally" occurring skin disease.

Anti-SSA/Ro Antibody as a Risk Factor for Fluorouracil-Induced Drug Eruptions Showing Acral Erythema and Discoid-Lupus-Erythematosus-Like Lesions

BACKGROUND

It is well known that fluorouracil (FU) agents frequently induce discoid-lupus-erythematosus (DLE)-like eruptions and acral erythema in Japan. However, the etiology of these drug eruptions caused by FU agents has not been clarified yet.

OBJECTIVE

To determine if the existence of anti-SSA/Ro antibody may be a risk factor for FU-agent-induced DLE-like eruptions and acral erythema.

PATIENTS AND METHODS

Six patients with FU-agent-induced drug eruptions showing DLE-like lesions and acral erythema were enrolled in this study. The titers of anti-SSA/Ro antibody in the sera and the histopathology of the skin lesions were examined.

RESULTS

Biopsy specimens from DLE-like eruptions and all 5 examined acral erythema cases showed lichenoid change of the basal keratinocytes. Direct immunofluorescence studies revealed deposition of immunoglobulins along the basement membrane zone in the lesions of both DLE-like eruptions and acral erythema. Further, all 6 cases had high titers of serum anti-SSA/Ro antibody, which did not decline within 6 months after cessation of the causative drug.

CONCLUSION

We propose that anti-SSA/Ro antibody may be a risk factor for FU-agent-induced drug eruptions showing acral erythema and DLE-like eruptions.

Lupus erythematosus: systemic and cutaneous manifestations

Skin and joint involvements are the most commonly occurring manifestations of systemic lupus erythematosus. There are 3 forms of cutaneous lupus: chronic cutaneous (discoid) lupus, subacute cutaneous lupus, and acute cutaneous lupus. Joint manifestations are usually not associated with warmth of the joints and may be only associated with pain and swelling. Painful or swollen joints respond rapidly to small or moderate doses of corticosteroids, whereas cutaneous manifestations usually respond to antimalarial drugs. Anti-Ro is associated closely with a photosensitive rash and with subacute lupus.