urticaria/cutaneous drug reactions jerry tan md frcp university of western ontario windsor, ontario
TRANSCRIPT
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Urticaria/Cutaneous Drug Reactions
Jerry Tan MD FRCP University of Western Ontario
Windsor, Ontario
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Objectives
List the morphological types of cutaneous drug eruptions
Differentiate between the hypersensitivity exanthems
List types of urticaria and possible provoking factors
Contrast angioedema from urticaria
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Identifying the offending drug
Potential drug triggers:
New drugs within preceding 6 wks
Drugs used intermittently
Laxatives, analgesics
Over the counter and herbal
products Any drug can cause a
cutaneous reaction.
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Cutaneous drug reactions: Specific morphologies
1. Exanthematous
Simple
Hypersensitivity syndrome
2. Urticarial
Simple urticaria
Angioedema
3. Blistering
Fixed drug eruption
Erythema multiforme and variants
Drugs can induce almost
any cutaneous
morphological pattern
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I. Exanthematous eruptions
(syn. morbilliform, maculopapular)
Most common cutaneous drug reaction morphology
Caused by many drugs
most commonly penicillins, sulfonamides, barbiturates,
anticonvulsants
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Simple Exanthem
Patchy pruritic erythema without fever
Usually develops within 1 wk,
resolves within 7-14 days of d/c offending drug
Tx: topical steroids +/- oral antihistamines to
relieve itch
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Exanthematous drug eruptions
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Exanthems: Hypersensitivity Syndrome
triad of fever, skin eruption, internal organ involvement
associated lymphadenopathy, atypical lymphocytosis
and eosinophilia
cutaneous eruption in 85%:
ranges from mild erythema multiforme to potentially life-
threatening Steven-Johnson syndrome (SJS) or toxic epidermal
necrolysis (TEN)
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Variants of hypersensitivity exanthems
EM minor
Target lesions or raised, edematous papules @ distal
extremities
EM major As above plus with involvement of > 1 mucous membranes;
Epidermal detachment <10% of total body surface area (TBSA).
SJS/TEN
Widespread blisters predominant @ trunk and face
> 1 mucous membrane erosions;
epidermal detachment < 10% TBSA for SJS; > 30% for TEN.
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Causes: Hypersensitivity Syndrome
o Drugs (anticonvulsants, antibiotics, allopurinol, NSAIDs)
o infections,
o neoplasia,
o autoimmune disease,
…the more severe the reaction, the likelier a drug trigger
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Clinical types: Hypersensitivity exanthems
1. Erythema Multiforme: target lesions
2. Stevens Johnson Syndrome (SJS) - target lesions
+ extensive mucosal erosions
3. Toxic epidermal necrolysis (TEN) - extensive
epidermal necrosis and skin detachment
•
•
often associated with hepatitis;
less frequently nephritis, pneumonitis, vasculitis
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EM minor
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Phenotypic variety in EM. A Edematous/urticarial; B urticarial lesions with central crusting; C Erythematous plaques with dusky centers; D classic target lesions on the palms.
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Stevens-Johnson syndrome. Epidermal detachment (A) and involvement of the conjunctivae (B) and oral mucosa (above)
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Toxic epidermal necrolysis (TEN)
A Detachment of large
sheets of necrolytic
epidermis (>30% body
surface area), leading to
extensive areas of
denuded skin.
B Hemorrhagic crusts with
mucosal involvement.
C Epidermal detachment of
palmar skin.
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Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
Stevens Johnson Syndrome (SJS)
= EM + mucosal erosions
o Fever, epidermal detachment < 10% body surface area
Toxic epidermal necrolysis (TEN)
= extensive epidermal necrosis and skin detachment
o
o
Fever, epidermal detachment > 30% body surface area
Associated hepatitis, nephritis, pneumonitis, vasculitis; risk of
sepsis
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Treatment for SJS and TEN
1.
2.
3.
4.
withdraw triggering factor
admit to burn unit (for TEN);
specialist consultations;
supportive therapy +/- steroids, IV
immunoglobulin, or cyclosporine
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II. Urticarial eruptions
1. Urticaria
o Itchy edematous well defined wheals of varying sizes
o involves epidermis and upper dermis
2. Angioedema
o pale, poorly defined induration
o edema also involves deep dermal and subcutaneous tissues
o Potentially life threatening if involves oro-pharynx
o Associations: nausea, vomiting, diarrhea, abdo pain, laryngeal
edema, brochospasm, hypotension (anaphylaxis)
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Urticarial reactions Mast cell activation and degranulation by:
type I immediate hypersensitivity (IgE mediated) or
direct non-immunologic activation of mast cells (IgE independent)
Treatment:
1. withdrawal of trigger factor(s)
2. oral antihistamines
3. for severe cases (angioedema, anaphylaxis): epinephrine
injections, systemic steroids, emergency care
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Widespread urticaria
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Angioedema:
• Swelling is
deeper than
urticaria
• may affect
mucosal sites
• often pale and
poorly defined.
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Types of urticaria
Type Provoking factors Comments
Foods, insect stings, drugs, contact agents,Acute Duration < 6 weeks
infections, systemic diseases, idiopathic
Chronic Idiopathic, otherwise similar to acute Duration > 6 weeks
Cholinergic Heat, exercise, hot showers Tiny red wheals
Typically hands (gloves), feet (footwear), Contact Rubber latex common trigger
mouth (balloons)
aquagenic (water); adrenergic (stress); cold;
Physical heat; physical (pressure, rubbing, vibration); Discrete physical trigger factors
solar;
Tender, not itchy. Lesions last > 24 hrs. Vasculitis Primary and secondary vasculitides
Residual purpura, hyperpigmentation.
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III. Blistering Eruptions
1. Fixed drug eruption
2. Erythema Multiforme (bullous type) / Stevens Johnson
syndrome / Toxic epidermal necrolysis
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Fixed drug eruption
Solitary itchy dusky red macule or edematous plaque
Recurs at same site after offending drug exposure
May progressively increase with continued exposure
Common drug offenders:
phenolphthalein, NSAIDs, sulfonamides, antibiotics, barbiturates
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Fixed drug eruptions
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Summary
List specific morphological types of cutaneous drug eruptions
Differentiate between the hypersensitivity exanthems
List types of urticaria and possible provoking factors
Contrast angioedema from urticaria
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Acknowledgements References:
Shear, Knowles and Shapiro Cutaneous Drug Reactions, Web MD Scientific American, Feb 2001.
Lebwohl, M: Cutaneous Manifestations of Systemic Diseases, WebMD Scientific American Medicine, June 2003 update.
Gawkrodger DJ. Dermatology an illustrated color text. Churchill Livingstone 2001
Illustrations: Dermatology Image Atlas: www.dermatlas.org
www.dermis.net
www.derm101.com
www.dermtext.com