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Chapter 31: Cutaneous Drug Reactions

Sylvia A. Martinez-Cabriales; Neil H. Shear

CUTANEOUS DRUG REACTIONS

Therapeutic Approach

Cutaneous reactions to drugs or cutaneous adverse drug reactions (CADR) range from simple drug exanthems limited solely to the skin to rare, life-threatening reactions due to systemic involvement, such as acute generalized exanthematous pustulosis (AGEP), drug reaction eosinophilia and systemic symptoms (DReSS), or toxic epidermal necrolysis (TEN). Immediate withdrawal of the offending drug (careful attention should be paid to all medications taken in the 8 weeks prior to the event) and supportive care is the most crucial management aspect. Medications that may decrease the elimination of the culprit drug should be discontinued as well. Treatment setting and adjuvant medications should be decided on a case-by-case basis.

The authors typically treat mild CADR with topical corticosteroids (high to super-high potency), antihistamines, and supportive care while systemic corticosteroids are added based on the patient’s clinical response and evolution. For DReSS cases, hospitalization is recommended to closely monitor visceral involvement and systemic corticosteroids are typically added regardless its severity.

Patients who have developed a severe CADR should not be rechallenged with the offending drug. See Table 31-1.

Table 31-1Cutaneous Adverse Drug Reactions Treatment Table
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Table 31-1 Cutaneous Adverse Drug Reactions Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE
Topical Therapy
Corticosteroids

Acneiform eruption AGEPb

DReSS

Drug-induced photosensitivity

Exanthematous maculopapular drug eruption (EMPDE)***

Fixed drug eruption (FDE) reactions***

 Modulate genetic transcription, leading to immunosuppressive and anti-inflammatory effects

Medium (eg, betamethasone dipropionate 0.025%; betamethasone valerate 0.1% cr and lotion; hydrocortisone valerate 0.2% cr, oint; mometasone furoate 0.1% cr and lotion; prednicarbate cr and ung 1%) to high (eg, amcinonide 0.1% ung; betamethasone dipropionate 0.05% cr, ung, lotion; desoximetasone 0.25% cr, oint; fluocinonide 0.05% cr, ung; triamcinolone 0.1% ung or 0.05% cr) potency bid for 1 wk

Super-high potency (eg, betamethasone dipropionate 0.05% ung; clobetasol propionate 0.05% cr and ung; desoximetasone 0.25% spray, fluocinonide 0.1% cr; halobetasol propionate 0%-0.5% cr and ung) QD-BID if severe CADR

Most common: skin atrophy

Other: Endocrine: growth retardation in infants and children, iatrogenic cushingoid changes, and suppression of hypothalamic–pituitary–adrenal axis

Skin: hypertrichosis, skin infection (bacterial, fungal, and viral infections, eg, tinea incognito), steroid-induced acne, and steroid-induced rosacea

Side effects

Pregnancy category C

III (DReSS; AGEP; NEH)1-6,7

IV (acneiform eruption)8-10
Systemic Therapy
Antiviral therapy

DReSS

If confirmation of viral reactivation or viral-induced organ damage

 Inhibition of viral DNA synthesis by inhibiting a DNA polymerase

Valacyclovir (Val): Adults: Initial: 900 mg po bid for 21 d; Mt: 900 mg po QD until clinically improvement of viral-related symptoms or eradication of viremia

>2 y: 20 mg/kg TID (max dose 1 g tid)

Ganciclovir (Gan): Adults: Initial: 5 mg/kg IV q12h for 14-21 d; Mt: 5 mg/kg IV QD

G is not FDA- and Health Canada-approved in children (safety is not ...

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