Systemic Medications of Dermatological Importance in COVID-19

Early December 2019 witnessed an international outbreak of a novel coronavirus (COVID 19) designated severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). Since then, a number of therapeutic molecules have been explored to have potential efficacy against the SARS-Cov-2 per se or its sequelae. There are no Food and Drug Administration specific therapies approved so far; however, numerous drugs based on varying levels of evidence, in vitro studies and compassionate drug trials are being established as therapeutic agents, especially drugs approved for previous emergence of the severe acute respiratory syndrome (SARS-CoV-1) and Middle east respiratory syndrome coronavirus (MERS-Cov). Numerous active clinical trials for COVID-19 with more than 150 drugs and products are under study. Needless to say, many dermatological drugs are being employed to mitigate this pandemic threat. We aim to review drugs with potential against SARS-Cov-2 widely used in dermatology practice. Additionally, rampant and overzealous use of these drugs as well as introduction of new molecules might lead to emergence of adverse effects associated with these agents. Dermatologists must be on lookout for any cutaneous adverse effects of these drugs. J Drugs Dermatol. 2020;19(9):889-892. doi:10.36849/JDD.2020.5323.

Systemic Medications of Dermatological Importance in COVID-19

Early December 2019 witnessed an international outbreak of a novel coronavirus (COVID 19) designated severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). Since then, a number of therapeutic molecules have been explored to have potential efficacy against the SARS-Cov-2 per se or its sequelae. There are no Food and Drug Administration specific therapies approved so far; however, numerous drugs based on varying levels of evidence, in vitro studies and compassionate drug trials are being established as therapeutic agents, especially drugs approved for previous emergence of the severe acute respiratory syndrome (SARS-CoV-1) and Middle east respiratory syndrome coronavirus (MERS-Cov). Numerous active clinical trials for COVID-19 with more than 150 drugs and products are under study. Needless to say, many dermatological drugs are being employed to mitigate this pandemic threat. We aim to review drugs with potential against SARS-Cov-2 widely used in dermatology practice. Additionally, rampant and overzealous use of these drugs as well as introduction of new molecules might lead to emergence of adverse effects associated with these agents. Dermatologists must be on lookout for any cutaneous adverse effects of these drugs. J Drugs Dermatol. 2020;19(9):889-892. doi:10.36849/JDD.2020.5323.

The use of drug calendars for the diagnosis of cutaneous drug eruptions in the age of electronic medical records

A morbilliform drug eruption is the most common condition leading to a dermatology consultation for a patient in the hospital. Timing is an important diagnostic tool since the onset of a skin rash usually takes place within days-to-weeks of the start of the implicated drug. A comprehensive, thorough, and reliable drug history by the clinician is essential. Therefore, to assist in the task of determining the causative medication of a new skin rash in a hospitalized patient, the creation of a drug calendar is recommended. The development of an electronic version of the drug calendar offers several benefits over the manual version. As the use of electronic medical records continues to become the standard in medicine, the electronic drug calendar will serve as an invaluable tool for the diagnosis of drug hypersensitivity.

The thymus and activation-regulated chemokine (TARC) level in serum at an early stage of a drug eruption is a prognostic biomarker of severity of systemic inflammation

BACKGROUND

In severe drug eruptions, precise evaluation of disease severity at an early stage is needed to start appropriate treatment. It is not always easy to diagnose these conditions at their early stage. In addition, there are no reported prognostic biomarkers of disease severity in drug eruptions. The aim of this study was to test whether the thymus and activation-regulated chemokine (TARC) level in serum at an early stage of a drug eruption can serve as a prognostic biomarker of systemic inflammation.

METHODS

Study participants included 76 patients who received a diagnosis of a drug eruption, one of the following: drug rash with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome, maculopapular exanthema, and erythema multiforme. Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) was eliminated in this study because scoring system for evaluating the severity was established. Correlation coefficients between serum TARC levels and indicators of systemic inflammation, including the neutrophil-to-lymphocyte ratio, Glasgow prognostic score, modified systemic inflammatory response syndrome (mSIRS) score, and C-reactive protein in serum were evaluated.

RESULTS

Serum TARC levels positively correlated with the neutrophil-to-lymphocyte ratio, Glasgow prognostic score, mSIRS score, C-reactive protein, albumin, white blood cell count, body temperature, and pulse rate. TARC levels negatively correlated with systolic blood pressure. Among these parameters, the mSIRS score showed strong correlation (correlation coefficient: 0.68).

CONCLUSIONS

Serum TARC levels correlate well with indicators of systemic inflammation and of disease severity among patients with a drug eruption except SJS/TEN. Serum TARC may be a prognostic biomarker of severity of inflammation in drug eruptions.

Common Skin Conditions in Children: Noninfectious Rashes

Cutaneous adverse drug reactions are among the most common noninfectious rashes of childhood. Cutaneous adverse drug reactions are classified as morbilliform, urticarial, bullous, pustular, or psoriasiform. Atopic dermatitis is one of the most common inflammatory cutaneous eruptions, and is characterized by pruritus and flexural distribution. Emollients and topical corticosteroids are first-line therapies. Topical calcineurin inhibitors are second-line, steroid-sparing drugs for certain conditions, such as face and eyelid eczema. Systemic and immunologic conditions have mucocutaneous features, such as malar rash, discoid lupus, and photosensitivity in systemic lupus erythematosus; lip, oral, and extremity changes as well as polymorphous rash in Kawasaki disease; erythematous, scaly plaques in psoriasis; and xerosis and face, hand, and leg skin changes in type 1 diabetes. Genetic conditions that manifest as changes in skin pigmentation are important to recognize because of the thorough diagnostic evaluation they warrant, the often challenging interventions they necessitate, and the permanent disability that frequently accompanies them. These conditions include neurofibromatosis, LEOPARD syndrome, incontinentia pigmenti, congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome, hypomelanosis of Ito, and acanthosis nigricans. Childhood dermatologic emergencies often are associated with infection and drugs and require early recognition and intervention.

Erlotinib-Induced Transverse Fissure-Like Skin Lesions of Fingers

Erlotinib is an epidermal growth factor receptor tyrosine kinase (EGFR-TK) antagonist used in the therapy of non-small cell lung cancer. This agent has been associated with several dermatologic side effects, the most common being acneiform rash involving the face, neck, chest, and back. The occurrence of skin side effects has been correlated with both therapeutic efficacy and increased overall survival in these patients. We report herein unusual erlotinib-induced skin lesions affecting fingers, with a transverse fissure-like appearance and beefy-red laceration-like center. A unique feature is their location on adductor surfaces and more proximal aspects of the phalanges. This erlotinib side effect has not been previously reported in the medical literature.

Low incidence of anti-drug antibodies in patients with type 2 diabetes treated with once-weekly glucagon-like peptide-1 receptor agonist dulaglutide

Therapeutic administration of peptides may result in anti-drug antibody (ADA) formation, hypersensitivity adverse events (AEs) and reduced efficacy. As a large peptide, the immunogenicity of once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist dulaglutide is of considerable interest. The present study assessed the incidence of treatment-emergent dulaglutide ADAs, hypersensitivity AEs, injection site reactions (ISRs), and glycaemic control in ADA-positive patients in nine phase II and phase III trials (dulaglutide, N = 4006; exenatide, N = 276; non-GLP-1 comparators, N = 1141). Treatment-emergent dulaglutide ADAs were detected using a solid-phase extraction acid dissociation binding assay. Neutralizing ADAs were detected using a cell-based assay derived from human endothelial kidney cells (HEK293). A total of 64 dulaglutide-treated patients (1.6% of the population) tested ADA-positive versus eight (0.7%) from the non-GLP-1 comparator group. Of these 64 patients, 34 (0.9%) had dulaglutide-neutralizing ADAs, 36 (0.9%) had native-sequence GLP-1 (nsGLP-1) cross-reactive ADAs and four (0.1%) had nsGLP-1 neutralization ADAs. The incidence of hypersensitivity AEs and ISRs was similar in the dulaglutide versus placebo groups. No dulaglutide ADA-positive patient reported hypersensitivity AEs. Because of the low incidence of ADAs, it was not possible to establish their effect on glycaemic control.

A phase I open-label trial evaluating the cardiovascular safety of regorafenib in patients with advanced cancer

PURPOSE

To characterize the cardiovascular safety profile of regorafenib in patients with advanced cancer.

METHODS

Patients received regorafenib 160 mg/day for 21 days followed by a 7-day break. The primary endpoint was the change from baseline in QTcF at the regorafenib t(max) (Day 21, Cycle 1 or 2) and changes in left ventricular ejection fraction (LVEF) from baseline on Cycle 2, Day 21. Secondary objectives were pharmacokinetics, safety, anti-tumor activity and effects on electrocardiogram intervals. QT intervals were corrected using the methods of Fridericia (QTcF) and Bazett (QTcB). LVEF was assessed by multigated acquisition scanning.

RESULTS

Fifty-three patients were enrolled, and all received at least one dose of regorafenib 160 mg. Twenty-five patients received regorafenib for 21 days without dose reduction. The mean change from baseline in QTcF at t(max) was (-)2 ms (90 % CI -8, 3). No patient experienced a change from baseline in QTcF > 60 ms, and two had QTcF changes between 30 and 60 ms. No patient had a QTcF or QTcB > 480 ms. In 27 patients who received at least 80 mg of regorafenib, the mean change from baseline in LVEF% ± SD was 1.7 ± 7.8. In 14 patients without a dose reduction, the mean change from baseline in LVEF% was (-)0.1 ± 8.6 at Cycle 2, Day 21. Four patients experienced a LVEF decrease between 10 and 20 %.

CONCLUSION

The effects of regorafenib on the QT/QTc interval and LVEF were modest and unlikely to be of clinical significance in the setting of advanced cancer therapy.

A Case of Acute Generalized Exanthematous Pustulosis (AGEP) Possibly Induced by Iohexol

Acute generalized exanthematous pustulosis (AGEP) is an uncommon disease manifested as an erythematous pustular eruption. It is usually caused by systemic medication. We describe a patient with acute generalized pustular eruption induced by iohexol. A 52-year-old woman developed fever and a generalized pustular eruption on the neck, trunk and extremities three days after taking iohexol. The culture from pustules was sterile. Other systemic and laboratory examinations were normal. A skin biopsy from a lesion on the trunk showed the features of a drug-induced pustular eruption as a subcorneal blister including neutrophils and eosinophils, mild spongiosis, and a sparse infiltrate at neutrophils and eosinophils in the papillary dermis. The patient had no history of psoriasis. The lesions resolved with systemic corticosteroid therapy within one week and did not relapse. According to our investigation, iohexol-induced AGEP has not been previously reported. We present an interesting case.

[Impact of wet work on epidermal barrier (tewl and stratum corneum hydration) and skin viscoelasticity in nurses]

BACKGROUND

Nurses are prone to develop hand eczema due to occupational exposure to irritants, including wet work. The aim of the study was to evaluate the impact of wet work on selected skin properties, reflecting epidermal barrier function--transepidermal water loss (TEWL) and stratum corneum hydration--and additionally skin viscoelasticity, in nurses.

MATERIAL AND METHODS

Study subjects included 90 nurses employed in hospital wards. Measurements were carried out within the dorsal aspect of the dominant hand, using a Cutometer MPA 580 equipped with Tewameter TM 300 and Corneometer CM 825 (Courage & Khazaka, Germany) probes. Examina- tions took place on hospital premises. Similar measurements were performed in the control group of females non-exposed to irritants.

RESULTS

In the examined group of nurses, mean TEWL was 15.5 g/h/m2 and was higher than in the control group (12.99 g/h/m2). After rejecting the extreme results, the difference between the groups proved to be statistically significant (p < 0.05). The mean value of stratum corneum hydration was lower in the examined group (37.915) compared with the control group (40.05), but the difference was not sta tistically significant. Also results of viscoelasticity assessment showed no significant differences between studied groups.

CONCLUSIONS

The results of the assessment of skin biophysical properties show that wet work exerts a moderately adverse impact on skin condition. A higher TEWL value and a lower stratum corneum hydration in workers exposed to irritants reflect an adverse impact of these factors on the epidermal barrier function.

A practical, clinical approach to the assessment and management of suspected insulin allergy

BACKGROUND

Although allergic reactions to insulin are uncommon, they can be difficult to diagnose and management may be very difficult in subjects with Type 1 diabetes with severe allergy. Access to allergists and specialist diagnostic tests is limited and few diabetes specialists are familiar with desensitization as a means of treating allergy. People with diabetes may develop symptoms which mimic insulin allergy but are attributable to other conditions.

CASE REPORTS

Here we describe three cases of insulin allergy. One patient presented with severe, albeit localized, urticarial reactions at injection sites. The most severe case was a woman with recent-onset Type 1 diabetes who presented with grade 2 anaphylaxis. The third patient presented with generalized urticaria and angioedema. Insulin allergy was confirmed in all three cases.

METHODS

Assessment involved measurement of immunoglobulin and anti-insulin antibody levels. Skin testing was performed in two cases. Treatments included desensitization in one case, alternative insulin preparations, antihistamines and continuous subcutaneous insulin infusion. In all three cases of insulin allergy there has been successful resolution of symptoms.

CONCLUSIONS

The clinical assessment and investigation in cases of suspected insulin allergy is described, along with detailed algorithms for skin testing and desensitization. This case series demonstrates an approach to challenging cases of suspected insulin allergy which will be helpful for diabetes specialists.

Pathophysiology of adverse cutaneous drug reactions--applied perceptions: Part II

Adverse cutaneous drug reactions are a group with common morphology. Much research has been performed on such reactions, but their pathophysiology is largely unknown. The authors provide a critical appraisal of the various aspects of their diagnosis and treatment. Some of the common reaction patterns are included with the prime objective of highlighting their pathophysiology.

Physiopathology of adverse cutaneous drug reactions--applied perceptions: part I

Adverse cutaneous drug reactions are common, but their physiopathology is largely elusive. The authors assess various reactions to facilitate their diagnosis and treatment. Some of the common reaction patterns are included with the prime objective of highlighting their physiopathology.

Risk of rash in cancer patients treated with vandetanib: systematic review and meta-analysis

BACKGROUND

Vandetanib is an oral inhibitor of vascular endothelial growth factor receptor, epidermal growth factor receptor, and rearranged during transfection tyrosine kinases. It is approved for the treatment of unresectable or metastatic medullary thyroid cancer. Its use may be hindered due to adverse events, including rash. The reported incidence and risk of rash to vandetanib varies widely and has not been more closely investigated. Therefore, we conducted a systematic review and meta-analysis of the literature to determine the incidence and risk of developing a rash.

DATA SOURCES

Databases from PubMed from 1996 through July 2011 and abstracts presented at the American Society of Clinical Oncology annual meetings from 2004 through July 2011 were searched for relevant studies.

STUDY SELECTION

Eligible studies were prospective trials that described side effects of all-grade or high-grade rash for patients who received vandetanib 300 mg as a single agent. The incidence of all-grade and high-grade rash and relative risk were calculated using random-effects or fixed-effects models.

RESULTS

Of 63 studies initially identified, nine met the selection criteria and were included for the study. A total of 2961 patients were included for analysis. The summary incidences of all-grade and high-grade rash were 46.1% [95% confidence interval (CI), 40.6-51.8%] and 3.5% (95% CI, 2.5-4.7%), respectively. From randomized controlled trials, patients who received vandetanib 300 mg had a significantly increased risk of developing all-grade rash in comparison with controls, with a relative risk of 2.43 (95% CI, 1.37-4.29; P = 0.002).

CONCLUSION

There is a significant risk of developing rash in cancer patients receiving vandetanib. Awareness and treatment of this adverse event is critical to ensure adherence and maximize dosing, guaranteeing the best possible clinical benefit.

A new proposal for a clinical-oriented subclassification of baboon syndrome and a review of baboon syndrome

OBJECTIVE

To review baboon syndrome (BS).

DATA SOURCES

Date sources were obtained from PubMed and Google Scholar: Photographs of baboon syndrome were obtained from our patient.

STUDY SELECTIONS

PubMed and Google Scholar were searched up to June 30, 2010. The search terms were "baboon syndrome", "SDRIFE" and "thimerosal allergy". Reverse references from relevant articles and Google Scholar were also used. As BS is a classical disease and cases of offending agents were relatively old, some references were more than five years old. In order to gather as many cases of offending agents as possible, more than 50 references were collected.

RESULTS AND CONCLUSION

We divided BS into as 4 groups; classical baboon syndrome, topical drug-induced baboon syndrome, systemic drug-induced baboon syndrome and symmetrical drug-related intertriginous and flexural exanthema (SDRIFE). The pathomechanism of BS is still unknown. A delayed type of hypersensitivity reaction, a recall phenomenon, pharmacologic interaction with immune-receptors and anatomical factors may be involved in the causation of BS.

Drug induced psoriasis

Psoriasis is a chronic inflammatory skin disorder clinically characterized by erythematous, sharply demarcated papules and rounded plaques covered by silvery micaceous scale. While the exact causes of psoriasis have yet to be discovered, the immune system and genetics are known to play major roles in its development. Many external factors including infections, stress and medications may exacerbate psoriasis. Some of the most common medications know to trigger or worsen existing psoriasis include lithium, gold salts, beta blockers and antimalarials. Exacerbation of psoriasis due to the following medications has also been observed: adrenergic antagonists, interferon, gemfibrozil, iodine, digoxin and chlonidine. Having reviewed a variety of cases, we observed a relationship between certain medications and documented their involvement in exacerbating or inducing psoriasis.

Recognition of immune reconstitution syndrome necessary for better management of patients with severe drug eruptions and those under immunosuppressive therapy

The immune reconstitution syndrome (IRS) is an increasingly recognized disease concept and is observed with a broad-spectrum of immunosuppressive therapy-related opportunistic infectious diseases and severe drug eruptions complicated by viral reactivations. Clinical illness consistent with IRS includes tuberculosis, herpes zoster, herpes simples, cytomegalovirus infections and sarcoidosis: thus, the manifestations of this syndrome and diverse and depend on the tissue burden of the preexisting infectious agents during the immunosuppressive state, the nature of the immune system being restored, and underlying diseases of the hosts. Although IRS has originally been reported to occur in the setting of HIV infection, it has become clear that the development of IRS can also be in HIV-negative hosts receiving immunosuppressive agents, such as prednisolone and tumor necrosis factor α inhibitors, upon their reduction and withdrawal. Drug-induced hypersensitivity syndrome, a life-threatening multiorgan system reaction, is another manifestation of the newly observed IRS. Clinical recognition of the IRS is especially important in improving the outcome for diseases with an otherwise life-threatening progenosis. Clinicians should be aware of the implications of IRS and recognize that relieving the symptoms and signs of immune recovery by anti-inflammatory therapies needs to be balanced with anti-microbial therapies aiming at reducing the amplitude and duration of tissue burden of preexisting microbes.

Cutaneous toxicities of antiretroviral therapy for HIV: part I. Lipodystrophy syndrome, nucleoside reverse transcriptase inhibitors, and protease inhibitors

Antiretroviral medications for the treatment of HIV are common drugs with diverse and frequent skin manifestations. Multiple new cutaneous effects have been recognized in the past decade. Dermatologists play an important role in accurately diagnosing and managing the cutaneous toxicities of these medications, thereby ensuring that a patient has as many therapeutic options as possible for life-long viral suppression. Part I of this two-part series on the cutaneous adverse effects of antiretroviral medications will discuss HIV-associated lipodystrophy syndrome, which can be seen as a result of many antiretroviral medications for HIV, and the specific cutaneous effects of the nucleoside reverse transcriptase inhibitors and protease inhibitors.

Danger signs in drug hypersensitivity

ADRs are frequently considered iatrogenic complications and, therefore, pose a specific challenge for the physician-patient relationship. Early recognition of a potential ADR is possible, especially on the skin, in addition to characteristic clinical danger signs. Cutaneous manifestations are variable, depending on the causative pathomechanism. It is impossible to conclude the causative agent from the morphology of the cutaneous lesions. The intake of several drugs in the time before the elicitation of the drug reaction usually poses a diagnostic challenge. It is crucial for the precision of any further allergological work-up to document the type of rash precisely as well as the time course of drug intake and appearance of the first symptoms. involvement of internal organs or circulating blood cells. Timely recognition of such cutaneous lesions and the correct differential diagnosis with prompt withdrawal of the putative culprit drug are essential to reducing morbidity and preventing mortality. This article discusses risk factors, early symptoms, and danger signs indicating a possibly severe course of an ADR and advises on early actions.

Hand-foot syndrome and seborrheic dermatitis-like eruption induced by erlotinib

Erlotinib is an epidermal growth factor receptor tyrosine kinase inhibitor that is responsible for several cutaneous side effects. We report a case of hand-foot syndrome associated with a papulo-pustular and seborrheic dermatitis-like eruption of the face in a 61-year-old patient treated with erlotinib for lung cancer.

Drug-induced pruritus: a review

Pruritus is an unpleasant sensation that leads to scratching. In addition to several diseases, the administration of drugs may induce pruritus. It is estimated that pruritus accounts for approximately 5% of all skin adverse reactions after drug intake. However, to date there has been no systematic review of the natural course and possible underlying mechanisms of drug-induced pruritus. For example, no clear distinction has been made between acute or chronic (lasting more than 6 weeks) forms of pruritus. This review presents a systematic categorization of the different forms of drug-induced pruritus, with special emphasis on a therapeutic approach to this side-effect.

Multiple drug allergy in patients with cutaneous adverse drug reactions diagnosed by in vitro drug-induced interferon-gamma release

BACKGROUND

Multiple drug allergy syndrome is a rarely reported clinical condition characterized by an adverse reaction to more than one different class of pharmacologically and structurally unrelated drugs. The pathogenesis may involve immediate-type or delayed-type hypersensitivity.

OBJECTIVES

To further characterize patients with MDA in terms of the type of CADR, drug intake and clinical drug suspicion.

METHODS

The study group comprised 12 patients (6 males, 6 females) with CADRs showing in vitro drug-induced IFNgamma release for multiple drugs, suggesting the presence of MDA. The diagnostic role of in vitro IFNgamma release in identifying the culprit drugs was evaluated in terms of clinical data and the results of in vivo tests (withdrawal and/or challenge tests) with the offending drugs.

RESULTS

Clinical relevance was attributed to in vitro drug-induced IFNgamma release towards multiple drugs in this series of 12 patients with a variety of CADRs, implying MDA. The results of in vivo tests for the offending drugs confirmed the diagnosis. The main causative agents responsible were antibiotics and non-steroidal anti-inflammatory drugs.

CONCLUSIONS

The study further supports the role of a T cell-mediated mechanism in the pathogenesis of MDA. The in vitro drug-induced IFNgamma release test may serve as a laboratory tool to identify the culprit drugs associated with this allergy.

[How I explore...A patient with palmar erythema]

Palmar erythema occurs in a series of physiological and pathological conditions. The first group encompasses hereditary and idiopathic conditions, as well as the time of pregnancy and ageing. The pathological states include some dermatoses as well as hepatic, autoimmune, infectious and paraneoplastic conditions. Medications may also be responsible for palmar erythema, in particular some chemotherapy agents.

Clinical presentation and pathophysiology of EGFRI dermatologic toxicities

This review summarizes the pathophysiology and clinical presentation of the cutaneous toxicities associated with EGFR inhibition. Such effects include papulopustular reactions, xerosis, pruritus, fissures, nail changes, hair changes, telangiectasias, hyperpigmentation, and mucositis. Most management strategies for these toxicities have been based on anecdotal experience; clinical trials are needed to provide uniform characterization to allow for evidence-based treatment strategies.

Clinical research of EGFR inhibitors and related dermatologic toxicities

An acneiform-like skin toxicity is commonly observed in patients with solid tumors treated with epidermal growth factor receptor inhibitors (EGFRIs). This symptomatic rash is related to epidermal growth factor receptor (EGFR) inhibition in the skin. A positive relation between the presence and severity of treatment-related rash and survival has been consistently observed with all EGFRIs approved for clinical use. These findings suggest that rash may be a useful surrogate marker of successful EGFR inhibition and clinical benefit and therefore of possible use in identifying patients most likely to benefit from therapy, as well as to guide dose adjustments. Increasing drug dose until skin toxicity appears is being studied. Further studies are needed to thoroughly evaluate the value of skin toxicity as a surrogate marker for clinical benefit. Current treatments of the skin toxicity are empirical and oriented toward mitigating symptoms and not validated by well-controlled clinical trials. Rational treatments based on the biological mechanisms of the skin toxicity must be developed and tested in well-controlled clinical trials.

Patch Testing for Evaluating Drug Reactions Due to Systemic Antibiotics

Several studies have evaluated patch testing for the diagnosis of drug eruptions, but widespread acceptance of this procedure is lacking in North America. The objective of this review is to address patch testing for the evaluation of exanthematous drug eruptions due to systemic antibiotics, using a MEDLINE database search for articles in English on patch testing for systemic drug eruptions caused by antibiotics.

[Drug allergy]

Drug hypersensitivity results from interactions between a pharmacologic agent and the human immune system. However, some reactions involve additional, poorly-understood, non-immunological mechanisms. The clinical picture is usually very similar to that of real allergic reactions and the therapeutic possibilities are also the same. The clinical symptoms (aspecific symptoms, special diseases, fixed drug eruption, and drug-induced internal symptoms), and the therapeutic and diagnostic possibilities are reported.

Involvement of drug-specific T cells in acute drug-induced interstitial nephritis

Drug-induced interstitial nephritis can be caused by a plethora of drugs and is characterized by a sudden impairment of renal function, mild proteinuria, and sterile pyuria. For investigation of the possible pathomechanism of this disease, drug-specific T cells were analyzed, their function was characterized, and these in vitro findings were correlated to histopathologic changes that were observed in kidney biopsy specimens. Peripheral blood mononuclear cells from three patients showed a proliferative response to only one of the administered drugs, namely flucloxacillin, penicillin G, and disulfiram, respectively. The in vitro analysis of the flucloxacillin-reactive cells showed an oligoclonal immune response with an outgrowth of T cells bearing the T cell receptor Vbeta9 and Vbeta21.3. Moreover, flucloxacillin-specific T cell clones could be generated from peripheral blood, they expressed CD4 and the alphabeta-T cell receptor, and showed a heterogeneous cytokine secretion pattern with no clear commitment to either a Th1- or Th2-type response. The immunohistochemistry of kidney biopsies of these patients revealed cell infiltrations that consisted mostly of T cells (CD4+ and/or CD8+). An augmented presence of IL-5, eosinophils, neutrophils, CD68+ cells, and IL-12 was observed. In agreement with negative cytotoxicity assays, no cytotoxicity-related molecules such as Fas and perforin were detected by immunohistochemistry. The data indicate that drug-specific T cells are activated locally and orchestrate a local inflammation via secretion of various cytokines, the type of which depends on the cytokine pattern secreted and which probably is responsible for the renal damage.

Sulphasalazine-induced DRESS

Drug rash with eosinophilia and systemic symptoms (DRESS) is a hypersensitivity syndrome. It presents with severe cutaneous eruption, fever, lymphadenopathy, hepatitis, haematological abnormalities with eosinophilia, atypical lymphocytes and may also involve other organs. The multi-organ involvement differentiates this entity from other common drug eruptions. DRESS has been associated with higher morbidity and mortality compared to other adverse drug reactions. Sulphasalazine hypersensitivity is rarely reported and we wish to highlight a case of sulfasalazine-induced DRESS presenting as leukocytoclastic vasculitis, hepatitis and haematological abnormalities in a 49-year-old Indian woman.

Drug-induced hypersensitivity syndrome (DIHS): a reaction induced by a complex interplay among herpesviruses and antiviral and antidrug immune responses

A relationship between viral infections and the simultaneous or subsequent development of allergic inflammation has often been observed in various clinical situations. Recent studies suggest an intimate relationship between reactivations of herpesviruses including human herpesvirus 6 (HHV-6) and the development of a severe systemic hypersensitivity reaction referred to as drug-induced hypersensitivity syndrome (DIHS). This syndrome has several important clinical features that cannot be solely explained by drug antigen-driven oligoclonal expansion of T cells: they include paradoxical worsening of clinical symptoms after discontinuation of the causative drug. In view of the similarity to GVHD or immune reconstitution syndrome (IRS) in clinical manifestations and emergence of viral infections, the clinical symptoms observed during the course of DIHS and GVHD are likely to be mediated by antiviral T cells that can cross-react with the drug and alloantigens, respectively. In considering common intrinsic properties of the causative drugs to potentially induce immunosuppression, reconstitution of a valid immune response to these viruses, which is typically observed in IRS, may be the most crucial process that takes place after withdrawal of the causative drug in patients with DIHS. Thus, this syndrome should be regarded as a reaction induced by a complex interplay among several herpesviruses (EB virus, HHV-6, HHV-7, and cytomegalovirus), antiviral immune responses, and drug-specific immune responses. This review includes discussion of the pathomechanism, the clinical symptoms, laboratory findings, pathological findings and therapy.

Effect of Olopatadine and Other Histamine H1 Receptor Antagonists on the Skin Inflammation Induced by Repeated Topical Application of Oxazolone in Mice

Histamine H1 receptor antagonists have long been prescribed for atopic dermatitis as an adjuvant therapy with topical therapy by local applied steroids. Olopatadine is one of the second-generation histamine H1 receptor antagonists that are treated for allergic disorders. We investigated that the effect of olopatadine on oxazolone-induced chronic contact hypersensitivity response in BALB/c mice compared with other histamine H1 receptor antagonists loratadine, cetirizine and fexofenadine. The chronic contact hypersensitivity induced by repeated application of oxazolone was treated with olopatadine and other histamine H1 receptor antagonists at the effective doses on histamine-induced paw edema in mice. The effects of these drugs in the oxazolone-induced model were quantified by measurements of ear swelling, and levels of cytokines in the lesioned ear. Olopatadine significantly inhibited the ear swelling and the increased production of IL-4, IL-1beta, IL-6, GM-CSF and NGF in the lesioned ear. On the other hand, the other histamine H1 receptor antagonists did not significantly suppress the increase in ear thickness. Moreover, they did not affect the production of cytokines in the lesioned ear. These results indicate that olopatadine appears to exert additional biological effects besides its blockade of the histamine H1 receptor.

Reticulated multifocal fixed drug eruption due to mefenamic acid - a new morphological pattern

Fixed drug eruption is a heterogeneous pattern of cutaneous reaction to certain drugs. Different morphological patterns of fixed drug eruption can occur. We describe a new morphology of fixed drug eruption showing a reticulated pattern as a result of ingestion of mefenamic acid and discuss the possible mechanism underlying such an appearance.

Risk of skin reactions when using ibuprofen-based medicines

Adverse reactions to drugs are a frequent cause of morbidity and medical consultation; it is no surprise that nonsteroidal anti-inflammatory drugs (NSAIDs) run second, after antibiotics, mainly of the beta-lactam group (penicillins and cephalosporins). Numerous clinical pictures involving the skin--various morbilliform rashes, urticaria and angioedema as the most common--due to hypersensitivity to a particular NSAID (i.e., ibuprofen) have been described; other clinically defined skin diseases such as vasculitis, Steven-Johnson's syndrome, photosensitivity, fixed drug eruptions, livedo-like dermatitis, linear drug eruption, lichenoid drug eruption, exanthematous pustulosis, eczematous eruption, contact dermatitis and pemphigoid have received the attention of physicians. Extensive use around the world makes it interesting to investigate adverse cutaneous reactions to ibuprofen and other members of the propionic acid derivative group, to ascertain their prevalence, clinical presentation and prevention. This paper presents a review of published literature concerning cutaneous hypersensitivity reactions to ibuprofen and related arylpropionic acids.

Pustular skin lesions in patients treated with infliximab: report of two cases

Two cases are presented in which repeated use of the TNF-alpha blocker infliximab may have led to development of pustular skin lesions. These findings might result in an improved understanding regarding the safety of infliximab with long-term usage.