Cutaneous adverse drug reaction profile in a tertiary care out patient setting in eastern India

A Cross-Sectional Study of Epidemiological and Clinical Aspects of Pityriasis Rosea along with Dermoscopic Analysis and Histopathology Correlation

Background

Pityriasis Rosea (PR) is a common, yet enigmatic, dermatological condition characterized by a distinctive clinical presentation. Despite its prevalence, the aetiology and pathogenesis of PR remain elusive.

Aims

To study the epidemiological and clinical aspects of patients with PR. To study dermoscopic findings and carry out histopathological correlation.

Methods

A cross-sectional study of 50 patients was conducted. A detailed clinical history was taken and an examination was done followed by a dermoscopy. Quantitative data like age and duration of disease are presented with the help of standard deviation. Qualitative risk factors, like gender, age groups, symptomatology, site of lesion, findings or cutaneous examination, dermoscopy findings, and histopathology findings, are presented with the help of frequency and percentages.

Results

PR shows male preponderance and mean age of occurrence being 30.8 ± 15.7 years. Forty per cent of patients had an atypical clinical presentation. The most frequently seen dermoscopy findings were diffuse red background (58%), peripheral collarette scale (62%), and peripheral dotted vessels (50%). On histopathology, the most common findings were spongiosis (44%), parakeratosis (38%), irregular acanthosis (34%), perivascular lymphocytic infiltrate (56%), and red blood cell extravasation (36%).

Limitations

Sample size was less due to COVID. As this was a corss-sectional study follow up of patients could not be done.

Conclusion

While the diagnosis of PR is clinical, it is difficult in atypical cases where dermoscopy comes to the aid. It also helps identify the age of lesions, thus helping decide the treatment strategy for patients. Biopsy remains the gold standard in ruling out other differentials of PR.

Evaluation of severe adverse cutaneous drug reactions in patients admitted to tertiary care center: A cross-sectional study

Background and Aims

Adverse cutaneous drug reactions (ACDRs) are common and potentially life-threatening, while also hindering patient compliance to medications. Given the regional differences in patterns and prevalence of ACDRs, it is important to study the epidemiology, as well as the clinical and outcome patterns of patients with ACDRs in Iran.

Methods

This cross-sectional study on ACDRs was conducted among hospitalized patients in a referral university hospital in the city of Isfahan, Iran. The patients' demographics, clinical information, and outcomes, including age, gender, past medical history, medication history, drug reaction with eosinophilia and systemic symptoms (DRESS) diagnosis, Steven-Johnson Syndrome (SJS) diagnosis, toxic epidermal necrosis (TEN) diagnosis, treatment regimen (steroids or intravenous immunoglobulin [IVIG]) and outcome information, including intensive care requirements, severe medical complications, or death, were obtained from medical records.

Results

A total of 195 patients with a mean age of 40 years and consisting of 61% females were included. Carbamazepine, lamotrigine, sodium valproate, and phenytoin are the most commonly reported medications. Rate of complications was 45% with DRESS, SJS, and TEN diagnosed in 26%, 47%, and 19%, respectively. Treatment was carried out with steroids and IVIG in 81% and 19%, respectively. Among patients, 15% required intensive care and 5% died. Diagnosis of TEN, older age, and baseline heart disease were predictors of mortality. Patients with SJS were younger and more likely to be males, and they were more likely to have eye complications. On the other hand, patients with the diagnosis of TEN were more likely to receive IVIG and intensive care, and had a higher mortality rate.

Conclusion

Our study provides insight into the demographics and clinical patterns of Iranian patients with ACDRs. This will help in predicting rates of complications, treatments, and outcomes in patients and therefore make proper management decisions.

A Study of Cutaneous Adverse Drug Reactions at a Tertiary Care Center in Andhra Pradesh, India

INTRODUCTION

Practically all physicians encounter a diverse range of suspected cutaneous adverse drug reactions (CADRs) in their daily clinical practice. The skin and mucosa are the most often encountered areas for the early presentation of numerous adverse drug reactions. Cutaneous adverse drug reactions are classified as benign or severe. The clinical manifestations of drug eruptions can range from mild maculopapular exanthema to severe cutaneous adverse drug reactions (SCARs).

OBJECTIVE

To determine the varied clinical and morphological presentations of CADRs and to identify the culprit drug and common drugs causing CADRs.

MATERIALS AND METHODS

Patients with clinical features suspected of CADRs presenting to the outpatient department (OPD) of dermatology, venereology, and leprosy (DVL) between December 2021 to November 2022 at Great Eastern Medical School and Hospital (GEMS), Srikakulam, Andhra Pradesh, India, were considered for the study. This was a cross-sectional, observational study. The patient's clinical history was taken in detail. This included chief complaints (symptoms, site of onset, duration, drug history, latency time between drug administration and the appearance of cutaneous lesions), family history, associated diseases, the morphology of lesions, and mucosal examination. Upon drug discontinuation, improvement in cutaneous lesions and systemic features were noted. A complete general examination, systemic examination, dermatological tests, and mucosal examination were performed.

RESULTS

A total of 102 patients were involved in the study, of whom 55 were males and 47 were females. The male-to-female ratio was 1.17:1, with a slight male majority. The most common age group was 31 to 40 years for both males and females. Itching was the predominant complaint in 56 patients (54.9%). The mean latency period was shortest in urticaria (2.13+/- 0.99 hours) and longest in lichenoid drug eruption (4.33+/- 3.93 months). Most patients developed symptoms after a week of taking the drug (53.92%). A history of similar complaints was present in 38.23% of patients. Analgesics and antipyretics (39.2%) were the most common culprit drugs followed by antimicrobials (29.4%). Among analgesics and antipyretics, aceclofenac (24.5%) was the commonest culprit drug. Benign CADRs were observed in 89 patients (87.25%), and severe cutaneous adverse reactions (SCARs) were observed in 13 patients (12.74%). The common CADRs presented were drug-induced exanthem (27.4%). Imatinib-induced psoriasis vulgaris and lithium-induced scalp psoriasis were observed in one patient each. Severe cutaneous adverse reactions were observed in 13 patients (12.74%). Anticonvulsants, nonsteroidal anti-inflammatory drugs (NSAIDs), and antimicrobials were the culprit drugs for SCARs. Eosinophilia was present in three patients, deranged liver enzymes was present in nine patients, a deranged renal profile was present in seven patients, and death occurred in one patient with toxic epidermal necrolysis (TEN) of SCARs.

CONCLUSION

Before prescribing any drug to a patient, a detailed drug history and family history of drug reactions need to be obtained. Patients should be advised to avoid over-the-counter usage of medications and self-administration of drugs. If adverse drug reactions occur, it is advised to avoid readministration of the culprit drug. Drug cards must be prepared and given to the patient, mentioning the culprit drug as well as the cross-reacting drugs.

Drug-Induced Severe Cutaneous Adverse Reactions: Insights Into Clinical Presentation, Immunopathogenesis, Diagnostic Methods, Treatment, and Pharmacogenomics

SCARs are rare and life-threatening hypersensitivity reactions. In general, the increased duration of hospital stays and the associated cost burden are common issues, and in the worst-case scenario, they can result in mortality. SCARs are delayed T cell-mediated hypersensitivity reactions. Recovery can take from 2 weeks to many months after dechallenging the culprit drugs. Genetic polymorphism of the HLA genes may change the selection and presentation of antigens, allowing toxic drug metabolites to initiate immunological reactions. However, each SCARs has a different onset latency period, clinical features, or morphological pattern. This explains that, other than HLA mutations, other immuno-pathogenesis may be involved in drug-induced severe cutaneous reactions. This review will discuss the clinical morphology of various SCARs, various immune pathogenesis models, diagnostic criteria, treatments, the association of various drug-induced reactions and susceptible alleles in different populations, and the successful implementation of pharmacogenomics in Thailand for the prevention of SCARs.

Cutaneous Adverse Drug Reactions in a Tertiary Teaching Hospital: A Prospective, Observational Study

OBJECTIVE

To describe clinical patterns, identify associated drugs, and perform causality assessment of cutaneous adverse drug reactions.

MATERIALS AND METHODS

In this prospective, observational study, patients with signs of cutaneous drug reaction from the department of dermatology of a tertiary teaching hospital were included. Patients with viral exanthemas were excluded. The patterns of cutaneous drug reactions, and associated drugs were noted. Naranjo scale was used for causality assessment of adverse drug reactions.

RESULTS

Sixty-five patients (mean age 38.1 years) were included. Skin lesions were seen after 2 days of drug consumption in 25 (38.5%) patients. Pigmentation, fixed drug eruption, and maculo-papular rashes were seen in 13 (20%), 22 (33.8%), and 12 (18.5%) patients, respectively. Thirty-five (53.85%) patients had other associated symptoms. Fever was seen in 22 (33.8%) patients. Thirty-two (49.2%) cases had exposure to antibacterial agents. Most commonly associated drugs with reactions were nonsteroidal anti-inflammatory agents 14 (21.5%) followed by beta-lactam antibiotics 12 (18.5%), and fluroquinolones 7 (10.8%). Fifty-seven (87.7%) adverse drugs reactions had "probable" association with the drug."

CONCLUSION

Fixed drug eruption is the commonest presentation of cutaneous adverse drug reactions and antimicrobial agents are most commonly associated with it. According to the Naranjo scale, the majority of the cutaneous drug reactions have a "probable" association with the offending drugs.

Comparison of Sensitivities of Skin Prick and Intradermal Tests with Oral Rechallenge Test: A Prospective Interventional Hospital-Based Study

Background:

Identification of culprit drug causing adverse cutaneous drug reactions may not be possible clinically due to the intake of more than one drug.

Aim:

To compare the sensitivity of skin tests with gold standard oral rechallenge test to detect adverse cutaneous drug reactions.

Materials and Methods:

This is a prospective interventional hospital-based study of patients with adverse cutaneous drug reactions attending the outpatient department of dermatology and venereology at a tertiary care center over a 12-month period. Skin prick tests, intradermal tests, and oral rechallenge tests were performed in these patients and their sensitivities were compared. The data of quantitative nature is presented in mean and standard deviation, and categorical variables are presented in number and percentage. The sensitivity of skin tests is compared with the gold standard oral rechallenge test.

Results:

A total of 49 patients with adverse cutaneous drug reactions were evaluated. Clinical spectrum of adverse cutaneous drug reactions ranged from mild to severe, with fixed drug eruption being the commonest (55.1%) followed by maculopapular exanthem (32.7%). The highest incidence was with fluoroquinolones (43.8%) followed by nonsteroidal anti-inflammatory drugs. Fluoroquinolones were the major cause of fixed drug eruption followed by nonsteroidal anti-inflammatory drugs. The sensitivity of skin prick test and intradermal tests were 49% and 73%, respectively and the difference was highly significant (P < 0.001). The difference in sensitivity in skin prick test versus oral rechallenge test and intradermal test versus oral rechallenge test was also highly significant (P < 0.001).

Limitations:

Small sample size was a major limitation. Histopathological examinations and human leukocyte antigen associations could not be done.

Conclusion:

Predominant causative drugs were fluoroquinolones followed by nonsteroidal anti-inflammatory drugs. Sensitivities of skin prick test and intradermal test were quite good and these skin tests should be performed before oral rechallenge test in cases of adverse cutaneous drug reactions.

Severe cutaneous adverse drug reactions: Incidence, clinical patterns, causative drugs and modalities of treatment in Assiut University Hospital, Upper Egypt

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and overlap SJS/TEN are life-threatening diseases that are most frequently caused by drugs. Much debate remains about the role of systemic corticosteroids (SCs) in their treatment. Our aim to determine the incidence, causative drugs, the role and side effects of SCs in severe cutaneous adverse reactions (SCARs), in Assiut University Hospital (AUH). Patients This study was conducted in Department of Dermatology at AUH, from 2012 to 2017. All patients with SJS, overlap SJS/TEN and TEN admitted during this period were included in the study. Eighty-three patients with SCARs were included in this study. The most common type was SJS (67.5%). The incidence ranged from 1.7% in 2012 to 7.7% in 2017. Carbamazepine, valproic acid, lamotrigine, diclofenac sodium, and flucloxacillin-amoxicillin were the most common causative drugs. The most common side effects of SCs were peptic ulcer (55.5%) and hypertension (51.8%). The mortality rate in patients treated with SCs was 100% in TEN, 33.3% in overlap SJS/TEN and 16.3% in SJS. The patients of SCARs must be aware of the causative drugs and must never be re-administered. SCs in treatment of SCARs may increase the complications and the mortality rate.

Impact of Climatic Variations on Drug-induced Skin Reactions in Two Different Regions of India

BACKGROUND

Around 2-3% of hospitalizations have been reported due to dermatological adverse drug reactions. Recent studies suggest that climatic variations affect the skin barrier function and extreme conditions aggravate skin disorders.

OBJECTIVE

The present study was designed to compare the impact of climatic variations on drug-induced skin reactions in the Northern and Eastern regions of India.

METHODS

We performed a one-year retrospective study to evaluate the impact of climatic variations (temperature and humidity) on drug-induced skin reactions in the Eastern (Kalyani, West Bengal) and Northern (Karnal, Haryana) regions. Drug-induced skin reactions were reported month-- wise in both the Eastern and Northern regions. Temperature and humidity levels were also noted month-wise in both regions. The direct correlation between climatic variations and the number of drug reactions were assessed using Pearson's correlation and quadratic regression analysis.

RESULTS AND DISCUSSION

Overall, 99 and 81 dermatological adverse drug reactions were reported in tertiary care hospitals in the Northern and Eastern regions, respectively. During the summer season, the humidity level was found to be low in the Northern region as compared to the Eastern region. During this period, drug-induced skin reactions were reported significantly (p<0.05) more in the Northern region as compared to the Eastern region. Furthermore, quadratic regression analysis revealed that climatic variations contributed to drug reaction variability in the Northern region (68.5%) and Eastern region (23.5%).

CONCLUSION

Therefore, the difference in the prevalence of drug-induced skin reactions may be related to the different climatic conditions among these two regions. Further studies in controlled climatic conditions should be performed for definitive correlations and to look into possible solutions.

Drug hypersensitivity reactions in Asia: regional issues and challenges

There are geographical, regional, and ethnic differences in the phenotypes and endotypes of patients with drug hypersensitivity reactions (DHRs) in different parts of the world. In Asia, aspects of drug hypersensitivity of regional importance include IgE-mediated allergies and T-cell-mediated reactions, including severe cutaneous adverse reactions (SCARs), to beta-lactam antibiotics, antituberculous drugs, nonsteroidal anti-inflammatory drugs (NSAIDs) and radiocontrast agents. Delabeling of low-risk penicillin allergy using direct oral provocation tests without skin tests have been found to be useful where the drug plausibility of the index reaction is low. Genetic risk associations of relevance to Asia include human leucocyte antigen (HLA)-B*1502 with carbamazepine SCAR, and HLA-B*5801 with allopurinol SCAR in some Asian ethnic groups. There remains a lack of safe and accurate diagnostic tests for antituberculous drug allergy, other than relatively high-risk desensitization regimes to first-line antituberculous therapy. NSAID hypersensitivity is common among both adults and children in Asia, with regional differences in phenotype especially among adults. Low dose aspirin desensitization is an important therapeutic modality in individuals with cross-reactive NSAID hypersensitivity and coronary artery disease following percutaneous coronary intervention. Skin testing allows patients with radiocontrast media hypersensitivity to confirm the suspected agent and test for alternatives, especially when contrasted scans are needed for future monitoring of disease relapse or progression, especially cancers.

Aetiopathogenesis of severe cutaneous adverse reactions (SCARs) in children: A 9-year experience in a tertiary care paediatric hospital setting

BACKGROUND

Severe cutaneous adverse reactions (SCARs) are delayed-type hypersensitivity reactions to drugs including as follows: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), Stevens-Johnson syndrome (SJS), Toxic Epidermal Necrolysis (TEN) and Acute Generalized Exanthematous Pustulosis (AGEP). Incidence, triggers and management of SCARs have not been investigated in large-scale epidemiological studies on children.

OBJECTIVE

The aim of our study was to collect epidemiological, clinical and aetiological data from children with SCARs referred to our tertiary care paediatric hospital of Florence.

METHODS

From 2010 to 2018 charts of children with diagnosis of SCAR were reviewed, and data collected during the acute phase and/or the subsequent allergy evaluation. Patients underwent patch tests, intradermal tests and lymphocyte transformation tests. All children were investigated for infectious diseases.

RESULTS

Incidence of SCARs in hospitalized children was 0.32% over a 9-year period. Fifty-four children were enrolled (31 M; 23 F; median age 6.5 years): 17 cases of DRESS, 30 SJS, 3 TEN, 2 AGEP, 1 linear immunoglobulin A bullous disease (LABD) and 1 pemphigus. Twenty-eight out of 54 patients underwent drug allergy investigations, and 50% of them resulted positive. Combining clinical history and results of allergy work-up, 74% SCARs seem to be caused by drugs, 18.6% by both drugs and infections, 3.7% by infections, and 3.7% remained idiopathic. No deaths occurred.

CONCLUSIONS

In this study, SCARs incidence is in line with literature data. Drugs were most commonly the leading cause. Management of SCARs requires cooperation among professional figures for an early diagnosis and a prompt treatment. Mortality rate seems to be lower in children.

Analysis of Cutaneous Adverse Drug Reactions Reported at the Regional ADR Monitoring Center

Introduction:

Skin is one of the major target organ for adverse drug reactions (ADRs). The incidence of dermatological ADRs among indoor patients in developed countries ranges from 1–3%, whereas in developing countries such as India, it is 2–5%.

Aims:

To analyze the clinical spectrum, seriousness, outcome, causality, severity, and preventability of the cutaneous ADRs.

Material and Methods:

All cutaneous ADRs reported at the Regional Adverse Drug Reaction Monitoring Center between January 2013 to May 2016 were identified and evaluated. A retrospective analysis was carried out for clinical presentation, causality (as per the WHO–UMC scale and the Naranjo’a reactions (ADRs) Severity (Hartwig and Seigel scale), and preventability (Schumock and Thornton criteria) of a said drug.

Results:

Out of 2171 ADRs reported during study period, 538 were cutaneous ADRs (24.78%). The most common clinical presentation was maculopapular rash (58.92%) followed by itching (10.59%), and Stevens–Johnson syndrome (4.83%). The time relationship of cutaneous ADRs to drug therapy revealed that they can develop within 1 week to 1 year of treatment. Most common causal drug groups were antimicrobials (46%), non-steroidal anti-inflammatory drugs (NSAIDs) (18%), and antiepileptics (10%). Polypharmacy was observed in 7% of the cases. Most of the cutaneous ADRs were non-serious (91%), however, 10 were life-threatening and 1 was resulted in death due to the Stevens–Johnson syndrome. Causality category for majority of cutaneous ADRs was possible. Although majority of cutaneous ADRs were moderately severe (81%), however, not preventable (89%).

Conclusion:

The occurrence of cutaneous ADRs is common and they developed within 1 week of therapy. Antimicrobial agents and NSAIDs are the most common implicated drug class. Hence, physicians should closely monitor the patient in the first week while using such therapy for early detection and prevention of cutaneous ADRs.

Pityriasis Rosea: Clinical Profile from Central India

Background:

Pityriasis rosea (PR) is a common, self-limiting dermatologic disorder. The information regarding the clinical profile of the disease in India is limited because of inadequate studies.

Materials and Methods:

A retrospective, record-based study on the clinical presentation of PR was conducted in a tertiary care center based in Central India. Data of all the patients presenting to our outpatient department from October 2014 to March 2015 with a clinical diagnosis of PR were analyzed.

Results:

The age of the patients ranged from 9 to 54 (mean-20.32) years. There was a male preponderance with a male-to-female ratio of 1.3:1. History of prodromal symptoms was present in 11 (27.5%) patients. Pruritus was a common symptom in 30 of 40 (75%) patients. Of 40 patients, 15 (35%) had herald patch. The morphology of skin lesions was typical in most of the patients (77.5%). Two (5%) patients had papular skin lesions, four (10%) patients had erythema multiforme-like skin lesions, and one patient each had papulovesicular, psoriasiform, and eczematous skin lesions.

Conclusion:

The clinical features of most of the cases were mostly in accordance with the classical pattern of PR, with few unusual features.

A Study of Cutaneous Adverse Drug Reactions in a Tertiary Care Center in Punjab

CONTEXT

Cutaneous adverse drug eruptions are the most common adverse reactions attributed to drugs in which any type of skin reaction can be mimicked, induced, or aggravated.

AIMS

To study the pattern of various types of cutaneous adverse drug reactions (CADRs), to find out the causative drug(s) involved and to determine the response to treatment and outcome in patients with CADRs.

PATIENTS AND METHODS

This prospective study was done in the department of dermatology. Patients with suspected drug rash, of either sex and all age groups were included in the study.

STATISTICAL ANALYSIS

Frequencies and proportions were calculated using Chi-square test and t-test as the tests of significance. Data was analyzed using SPSS version 21.

RESULTS

A total of 258 patients were enrolled in the study. The most common CADR observed in the study was exanthematous drug eruption in 42.63% patients followed by drug induced urticaria in 21.32% patients. Antimicrobials were the most common offending drugs in 64.73% of patients, followed by non-steroidal anti-inflammatory drugs (NSAIDs) in 15.50% patients. In the study, 12 patients (4.65%) were found to have severe cutaneous adverse drug reactions (SCADRs). Stevens-Johnson syndrome (SJS) - Toxic epidermal necrolysis (TEN) was the most common SCADR (50%) and antituberculous drugs were the most common causative group of drugs causing SCADRs.

CONCLUSION

The most common CADR observed in the study was exanthematous drug eruption and antimicrobials were the most common causative drugs.

Drug-induced phototoxicity: A systematic review

BACKGROUND

Phototoxicity has been attributed to numerous oral drugs over the past 60 years.

OBJECTIVE

Determine the quality of evidence supporting suspected phototoxicity from oral drugs.

METHODS

The MEDLINE and EMBASE databases were searched for all studies that contain original data for drug-induced phototoxicity and were published between May 1959 and December 2016. Study quality was assessed by using a modified Grading of Recommendations, Assessment, Development and Evaluation scale.

RESULTS

The review included 240 eligible studies with a total of 2466 subjects. There were 1134 cases of suspected phototoxicity associated with 129 drugs. Most associations were supported by either very low-quality or low-quality evidence (89.1% of the studies). Medications supported by stronger evidence were vemurafenib, nonsteroidal anti-inflammatory drugs, and antibiotics, specifically, fluoroquinolones and tetracyclines. The most frequently reported drugs were vemurafenib, voriconazole, doxycycline, hydrochlorothiazide, amiodarone, and chlorpromazine. Photobiologic evaluation was performed in only 56 studies (23.3%), whereas challenge-rechallenge was done in 10% of cases.

LIMITATIONS

Only English-language publications were reviewed. Cases of phototoxicity that had been incorrectly categorized as photoallergy would not have been included.

CONCLUSIONS

Most purported associations between oral drugs and phototoxicity are not supported by high-quality evidence. Despite the variable quality of data, clinicians should be aware of the possible consequences of long-term use of culprit drugs.

Under ambient UVA exposure, pefloxacin exhibits both immunomodulatory and genotoxic effects via multiple mechanisms

Pefloxacin (PFLX) is an antibiotic, which shows broad spectrum antimicrobial activities. It is an important derivative of fluoroquinolones (FLQs) group. Ultraviolet radiation (200-400nm) causes major problem for living being which comes at the earth surface naturally through sunlight and increasing regularly due to ozone depletion. PFLX was photodegraded in 5h and forms photoproduct under UVA exposure. At the non photocytotoxic dose PFLX, shows reduced phagocytosis activity, NO (nitric oxide) production, large vacuole formation and down regulated IL-6, TNF-α and IL-1 in BALB/c macrophages at both genes and proteins levels. At higher doses (photocytotoxic doses), PFLX induced a concentration dependent decrease in cell viability of human keratinocyte cell line (HaCaT) and peritoneal macrophages of BALB/c mice. Our molecular docking suggests that PFLX binds only to the cleaved DNA in the DNA-human TOP2A complex. Topoisomerase assay confirmed that PFLX inhibits human topoisomerase by forming an adduct with DNA. Photosensitized PFLX also caused intracellular ROS mediated DNA damage and formation of micronuclei and cyclobutane pyrimidine dimers (CPDs). Increase intracellular ROS leads to apoptosis which was proved through lysosomal destabilization and reduced mitochondrial membrane potential (MMP). Our present study shows that ambient UVA exposure in the presence of PFLX caused immunomodulatory as well as photogenotoxic effects. Therefore, patients under PFLX drug treatment should avoid sunlight exposure, especially during peak hours for their photosafety.

Adverse Medication Reactions

Cutaneous adverse drug reactions (ADRs) are among the most frequent adverse reactions in patients receiving drug therapy. They have a broad spectrum of clinical manifestations, are caused by various drugs, and result from different pathophysiological mechanisms. Hence, their diagnosis and management is challenging.

Severe cutaneous ADRs comprise a group of diseases with major morbidity and mortality, reaching 30 % mortality rate in cases of Toxic Epidermal Necrolysis.

This chapter covers the terminology, epidemiology, pathogenesis and classification of cutaneous ADR, describes the severe cutaneous ADRs and the clinical and laboratory approach to the patient with cutaneous ADR and presents the translation of laboratory-based discoveries on the genetic predisposition and pathogenesis of cutaneous ADRs to clinical management guidelines.

Nevirapine: Most Common Cause of Cutaneous Adverse Drug Reactions in an Outpatient Department of a Tertiary Care Hospital

INTRODUCTION

Skin is the most commonly involved organ in adverse drug reactions. Most of the cutaneous adverse drug reactions (CADRs) being of mild to moderate severity are likely to be diagnosed and treated in an outpatient setting. Consequently, knowledge regarding morphological pattern, severity and drugs implicated in causation of these CADRs has important implications for healthcare personnel.

AIM

To determine the current clinical pattern of CADRs and to assess their causality and severity with the help of standard scales.

STUDY DESIGN AND SETTING

A prospective, observational study was conducted in the outpatient department of skin and venereal disease in a tertiary care hospital.

MATERIALS AND METHODS

Patients with suspected CADR after consumption of systemic drug(s) were enrolled in the study. Data regarding demographics, clinical manifestations of CADR, drug history preceding the reaction, concomitant illness, relevant laboratory investigations etc was obtained. This data was then analysed for morphological pattern, causality and severity. CADRs with causality assessment possible and above on the basis of World Health Organization-Uppsala Monitoring Centre causality assessment system were considered for analysis.

STATISTICS

Descriptive statistics were used to express results of pattern, severity and causality of CADRs.

RESULTS

Ninety patients were enrolled in the study. Male to female ratio for CADRs was 1:2.33. Maculopapular rash was most commonly encountered CADR in 76.67% cases followed by urticaria (8.89%), Stevens-Johnson syndrome (4.4%) and fixed dose eruptions (3.33%). Antiretrovirals were implicated in 75.56% (68/90) of CADRs. Nevirapine was suspected in 52 out of 90 (57.77%) cases of CADRs which included 39 cases of maculopapular rash, five cases of urticaria, four cases of Stevens-Johnson syndrome, and two cases each of pustular rash and angioedema respectively. Antimicrobials, antiepileptics and Non-steroidal Anti-inflammatory Drugs (NSAIDs) were other suspected drugs.

CONCLUSION

Antiretrovirals especially nevirapine was implicated in variety of CADRs ranging from maculopapular rash to life-threatening reactions like Stevens-Johnson syndrome in an outpatient setting. Women were twice as susceptible as men for CADRs.

Clinical and histologic features of azithromycin-induced liver injury

BACKGROUND & AIMS

Rare cases of azithromycin-induced hepatotoxicity have been reported, with variable clinical and histologic features. We characterized clinical features and outcomes of azithromycin-induced liver injury.

METHODS

We identified patients with azithromycin-induced liver injury from the Drug-Induced Liver Injury Network Prospective Study who had causality scores of definite, highly likely, or probable. Demographic, clinical, and laboratory data and 6-month outcomes were examined.

RESULTS

Eighteen patients (72% female; mean age, 37 y) had causality scores of definite (n = 1), highly likely (n = 9), or probable (n = 8). Common presenting symptoms were jaundice, abdominal pain, nausea, and/or pruritus. For 16 patients, abnormal results from liver tests were first detected 14 days after azithromycin cessation (range, 9-20 d). The median duration of azithromycin treatment was 4 days (range, 2-7 d). The pattern of injury was hepatocellular in 10 patients, cholestatic in 6 patients, and mixed in 2 patients. The mean peak level of alanine aminotransferase was 2127 IU/L, of alkaline phosphatase was 481 IU/L, and of total bilirubin was 9.2 mg/dL. Liver histology showed ductopenia and veno-occlusive changes in a few patients. Two individuals had severe hypersensitivity cutaneous reactions. After 6 months, 8 patients had recovered, 4 patients had chronic injury, 1 patient died, and 1 patient underwent liver transplantation (outcomes were unavailable for 4 patients). Two of the patients who died or underwent liver transplantation had underlying chronic liver disease.

CONCLUSIONS

Azithromycin-induced liver injury occurs within 1 to 3 weeks after azithromycin initiation and predominantly is hepatocellular in nature. Although most patients recover fully, severe cutaneous reactions, chronic injury, and serious complications leading to death or liver transplantation can occur (ClinicalTrials.gov identifier, NCT00345930).

Cutaneous adverse drug reactions in Indian population: A systematic review

Background:

Epidemiological data is limited for cutaneous adverse drug reactions (CADRs) in India. Most of the Indian studies have small sample size and are of limited duration.

Aims:

The aim of this study is to analyze CADRs with reference to the causative drugs and their clinical characteristics in Indian population.

Materials and Methods:

As per selection criteria, electronic databases were searched for publications describing CADRs from January-1995 to April-2013 by two independent investigators. Data of the causative drugs and clinical characteristics were extracted and summarized by absolute numbers, percentages, ranges, and means as presented by the authors. The subgroup analysis of causative drugs was performed for causality assessment, severe or nonsevere reactions and occurrence of common CADRs. Studies showing “definite” and “probable” categories of causality analysis were labeled as “definite and probable causality (DPC) studies”. The other included studies were labeled as “non-DPC studies”.

Results:

Of 8337 retrieved references, 18 prospective studies were selected for analysis. The pooled incidence was 9.22/1000 total among outpatient and inpatient cases. Commonly observed reactions were maculopapular rash (32.39%), fixed drug eruptions (FDEs) (20.13%), urticaria (17.49%) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) (6.84%). The major causative drug groups were antimicrobials (45.46%), nonsteroidal anti-inflammatory drugs (NSAIDs) (20.87%) and anti-epileptic drugs (14.57%). Commonly implicated drugs were sulfa (13.32%), β-lactams (8.96%) and carbamazepine (6.65%). High frequency of CADRs is observed with anti-epileptic drugs in DPC studies only. Carbamazepine, phenytoin and fluoroquinolones had higher severe to nonsevere cutaneous reaction ratio than other drugs. Antimicrobials were the main causative drugs for maculopapular rash, FDEs and SJS/TEN, and NSAIDs for the urticaria. The mortality for overall CADRs, SJS/TEN, and exfoliative dermatitis were 1.71%, 16.39%, and 3.57%, respectively. “Definitely preventable”, “probably preventable” and “not preventable” categories CADRs were 15.64%, 63.14%, and 34.64%, respectively.

Conclusion:

Antimicrobials, NSAIDs and antiepileptic are common causative agents of CADRs in India. Antiepileptic agents show high rates of severe cutaneous reactions.

First Indian study evaluating role of biochemical investigations and diagnostic tools in detection of adverse drug reactions

AIM OF STUDY

To evaluate the role of biochemical investigations (BI) and diagnostic tools (DT) in ADR detection.

MATERIALS AND METHODS

An observational prospective cross-sectional study was done using suspected ADR data collection form.

RESULTS

A total of 2381 ADR related events were recorded in two years. Total number/percentage of biochemical abnormalities (BA) related ADR detection rate was 14.57% and of DT was 1.091% in contrast to 84.33% recorded with clinical presentation. Maximum cases were inward patients (87.13%), 67.02% were recorded by active surveillance. ADR detection rate at one point & detection on follow up was 56.31% Vs 46.38%. ADR detection rate of ECG, endoscopy, X-ray were 0.57%, 0.22%, 0.22% and of CT scan, MRI, DEXA scan, USG and biopsy was 0.04% each. Maximum ADRs were severe/serious, latent and Type-A in nature. Anemia (4.6%), followed by liver dysfunction (2.8%), renal dysfunction, electrolyte imbalance, hyperglycemia (1.1% each), abnormal coagulation profile (1%), decrease platelet count (0.8%), hypoglycemia (0.7%) were the most common BAs. Anti retroviral drugs (ART), tirofiban and methotrexate accounted for anemia, ART and anti tubercular drugs for liver & renal dysfunction, insulin for hypoglycemia, tirofiban, paclitaxel, capecipabine and ifosfamide for thrombocytopenia, hematuria by enoxaparin & dyslipidemia with ART were common ADRs.

CONCLUSION

BI and DT can play very important role in ADR detection.

Adverse cutaneous drug reactions: Eight year assessment in hospitalized patients

BACKGROUND

Adverse cutaneous drug reactions (ACDRs) are the most commonly reported adverse drug events. The causative drugs and clinical patterns of ACDRs are different in various populations. This study was conducted to identify the clinical patterns, causative drugs and reasons for drug administration in patients hospitalized due to ACDR.

MATERIALS AND METHODS

This retrospective study was carried out in a referral university hospital, Isfahan, Iran. The medical records of all patients who were hospitalized in the Dermatology Department due to ACDRs were reviewed covering an 8-year period between December 2006 and August 2013.

RESULTS

A total number of 282 patients with the mean age of 29.48 ± 21.18 years were hospitalized in this time period, of which 61% were females. The most common clinical patterns regarding the final diagnosis were Stevens-Johnson syndrome (SJS) (32%), exanthematous drug eruptions (24.5%) and toxic epidermal necrolysis (TEN) (11%). Anticonvulsants were the most frequently implicated drug group (51.8%) followed by antibiotics (33.7%) and analgesics and non-steroidal anti-inflammatory drugs (5.7%). The most common cause of drug administration was seizure (30%) and then upper respiratory tract infections (12%). The frequency distribution of clinical types of reactions was different between age groups (P < 0.001). The severe types (SJS, TEN, drug rash with eosinophilia and systemic symptoms and overlap syndrome) were more frequent in the patients aged ≤50 years old (55.2%) compare to those aged ≤50 years (28%) (P = 0.001).

CONCLUSION

The main causative drugs of ACDRs were anticonvulsants and antibiotics. However, the sever types of reactions were more prevalent.

Cutaneous adverse drug reactions notified by pharmacovigilance in a tertiary care hospital in north India

CONTEXT

Medication-related adverse events, apart from causing significant morbidity and mortality, increase the healthcare cost burden and lead to early treatment discontinuations.

OBJECTIVES

Knowing the fact that cutaneous adverse drug reactions (cADRs) are most frequent, this study was conducted with an aim to describe their clinical profiles and preventive strategies.

METHODS

All adverse drug reaction (ADR) forms filled from January 2012 to January 2013 were scrutinised and forms with cADRs analysed and assessed for causality, preventability and severity.

RESULTS

Of 400 ADR forms, 109 included cADRs. Sixty-eight percent patients were males and mean ± SD age was 35 ± 18 years. Rash, Steven-Johnson syndrome and toxic epidermal necrolysis were the most common presentations. Most frequent culprit drugs included antibiotics and anti-inflammatory agents. Causality was probable or possible in majority. Ninety percent cases were "not preventable". Majority of the patients had mild to moderate reactions and recovered completely after medical management.

CONCLUSIONS

Pharmacovigilance, with special attention to monitoring and reporting of cADRs must be encouraged. As major bulk of cADRs result from physician prescribed drugs, awareness on part of the physician can help in their timely detection and management, thereby restricting the associated damage.