Contact Dermatitis/ Drug Eruptions Flashcards
Produces parasthesias of fingertips, cyanosis, gangrene
Oxalic acid
Neutralized by limewater or milk of magnesia
Produces a white eschar
May cause glomerulonephritis or arrythmias
Phenol (carbolic acid)
Neutralized by ethyl or isopropyl alcohol
Hydrofluoric acid
Neutralize periungual burns with IL calcium gluconate
May cause low Ca, low Mg, high K and dysrrythmias
Lime, arsenic, zinc dust
May produce folliculitis
Hyperpigmentation, keratoses, scrotal cancer
InSoluble cutting oils
Acne corne
Follicular keratosis and pigmentation from crude petroleum
Acquired perforating dermatosis in field workers
Calcium chloride
Inhalation causes exfoliative erythroderma, eosinophilia, mucous membrane erosions and hepatitis
Trichloroethylene used as degreasing agent and dry cleaning
Contact urticaria
Cetyl amd stearyl alcohol
Produce a pustular eruption on patch testing of no clinical significance
Nickel, mercury, potassium iodide
Other toxicodendron reactors
Cashew (nutshell), rengas tree, spider flower, silver oak
Rescorcinol allergy
Person is elliptical, wheat bran, marine brown algae
Prevents or diminishes poison ivy
Quaterinium 18 bentonite
Sites of early mango dermatitis
Eyelids and prepuce bc from palms
Ingestion of ginkgo fruit results in
Perianal dermatitis
Most common cause of allergic dermatitis in florists
Peruvian lily
Antigenic site of sesquiterpene
Alpha methylene portion
Causes a severe inflammatory bullous rxn
Prairie crocus
Contact urticaria and anaphylaxis
Onion and celery
Cause erythema multiforme
Tea tree oil, cocobolo, rosewood (exotic woods), Bermuda fire sponge
Seaweed dermatitis
Blue green algae (lyngbya), within minutes, area covered
Sabra dermatitis
Prickly pear and fig
Resembles scabies
Pastry baker hand dermatitis
Cinnamon
Dentist dermatitis
Eugenol, clove oil, eucalyptus oil
Allergic sensitizerbof turpentine
Carlene
Best screening agents for clothing dermatitis
Ethylene urea melamine formaldehyde resin, dimethylol dihydroxyethylene
Shoe dermatitis
Rubber accelerators like mercaptobenzothiazole, carbamates, tetramethylthiuram disulfide, K dichromate
*spares web spaces
Black dermatographism
Under jewelry containing zinc, titanium oxide on gold jewelry
Addition of this to cement decreases chrome dermatitis
Ferrous sulfate
Most common component of thimersol to cause ACD
Ethyl mercuric
*those who react to thiosalicilic acid component have piroxicam allergy
Glove allergy
Thiuram
Dental bonding agents
Bisphenol A and glycidyl methacrylate
Orthopedist allergy
Methyl methacrylate monomer
Most common fragrance allergies
Cinnamic alcohol, oak moss, cinnamic aldehyde, hydroxy citronellal, musk ambrette, isoeugenol, geraniol, coumarin, Lyral, eugenal
What color of hair dyes cross react with PPD
Azo dyes - acid violet 6b, water soluble nigrosine, ammonium carbonate
May produce a localized urticarial and generalized histamine reaction
Ammonium persulfste
Allergin of propolis (lip balm, lipstick)
Caffeates
Highest rate of allergy among transdermal meds
Clonidine
*TD meds may have EM like reaction
Anamnestic reaction (recall if sensitized topically then taken internally flare at previous site of ACD)
Antihistamines
Sulfonamides
PCN
Late patch reaction, 7 d
Neomycin
Topical ab with highest rate of contact urticaria and anaphylaxis
Bacitracin
Highest rates of occupational skin disease
Agriculture, fishing, forestry
MC cause of contact urticaria
Nonimmunologic - no prior sensitization
Causes - nettle, DMSO, sorbic acid, benzoic acid, cinnamic aldehyde, cobalt, trafuril
Immunologic urticaria
Latex, potatoes, phenylmercuric propionate
Groups with highest risk of latex allergy (type 1)
Atopic and spina bifida
Banana, avocado, kiwi, chestnut, passion fruit
Open patch tests best for immediate type hypersensitivity
Rast detects 75% of latex allergy
MC drug allergy
Simple exanthems F MC, except males under 3 Occur within 2 weeks but up to 10 d after stopping drug PCNs and Bactria MC May have UV recall
Type 1 hypersensitivity
Skin testing useful
Cells imp in patho of ADR
Th1
Bullous drug without epidermal necrosis
Th1- induce IFN gamma
Th2
Morbilliform and urticarial
Others
CD8 which secrete perforin, granzyme B and FAS ligand causing keratinocytes apoptosis, most dangerous
T cells via GM-CSF and IL8 for agep
Treg markers
Dermal CD4+CD25+foxp3 regulatory T cells reduced in bullous drug eruptions like ten
*tregs with skin homing molecules inreased in early drug hypersensitivity - immunologically active early to suppress immune function but become functionally deficient ( explains autoimmune sequela later in dress)
Sulfa dress crossreactors
Long acting sulfonamides - sulfamethoxazole, sulfadiazine, sulfasalazine
NOT sulfonylureas, thiazides, furosemide or acetazoleamide
Early and late dress findings
Early - interstitial nephritis
Late - SIADH, graves, DM, SLE
COD in dress
Liver or renal
Directly induces HHV6
Sodium valproate *one study showed all fatal dress cases associated with HHV6 reactivation
MC AED to cause dress
Carbamazepine
*hhv6 and 7 reactivation more commonly seen with carb
MC finding in anticonvulsant hypersensitivity syndrome
Fever (50%) adenpoathy (20%), elevated LFT’s ( btw 2/3 and 3/4 of cases)
Lamotrogine dress
Less eosinophilia, LAD and multi organ involvement
Usually occurs within 4 week, may take up to 6 months
Coadministration of valproate increases risk of lamotrigine dress
Slow introduction decreases the risk
Safe alternative for anticonvulsant hypersensitivity
Valproate
Allopurinol hypersensitivity
Normal occurs in the setting of renal failure
MCC of death - CV (25%)
Pancreatitis and DM may develop
Dialysis does not hasten resolution of the eruption
Sulfonamides hypersensitivity due to?
What AED cross reacts?
Slow acetylators
Zonisamide (but not with other AEDs)
HLA in allopurinol hypersensitivity
HLA-B-5801 in Han Chinese
Minocycline hypersensitivity
Deficiency of glutathione a transferase common
Typically begins 2-4 weeks later
Fever, rash and LAD in >80%
HA and cough common
Liver inv in 75%
*particularly associated with interstitial pneumonia with eosinophilia
Dapsone hypersensitivity
Usually begins 4 or more weeks later
Icterus and LAD in 85%
Eosinophilia typically NOT present
Elevated bili in 85% (partially from hemolysis)
Liver inv mixture of hepatocellular and cholestatic
Low albumin is characteristic
Han Chinese hla in SJS/TEN
HLA-B-1502
MCC of SJS in kids
Sulfonamides - MC in spring
Not part of scorten but bad prognostic indicator
Respiratory involvement
May precede SJS
Fever and flu like eruption
Level correlates with BSA involvement in SJS
Soluble Fas Ligand
MC sequale of SJS
Ocular scarring and vision loss
*other include cutaneous scarring, eruptivr nevi, nail abnormalities, transient widespread verrucous hyperplasia resembling SK’s
Radiation induced erythema multiforme
Occurs in NSG pts on phenytoin and steroids who get full brain XRT
Spreads caudad a similar syndrome seen with amifostine
Cd4 count in HIV with high rate of ADR
25-200
Hepatitis but not cutaneous reactions MC if cd4 is above 200
Increased risk of SJS
Nevirapine, especially HLA-DRB1*0101
Abacavir hypersensitivity
HLA-B*5701
MC location of fixed drug
1/2 are oral or genital (erosive symmetric vulvitis)
Cause of FDE with predilection for lips
NSAIDS - especially pyrazolinr derivavtives, paracetamol, naproxen, oxicams and mefenamic acid
*cause of majority of genital FDE - sulfonamides
Causes of FDE
NSAIDS, sulfonamides, barbiturates, TCN, phenolphthalein (laxatives), acetaminophen, cetirizine, celecoxib, dextromethorphan, hydroxyzine, quinine, lamotirigine, phenylpropanolamine, erythromycin, herbs
HLA linked to FDE
HLA-B22
What increases the likelihood of positive patch tests in FDE
Tape stripping
2 variants of nonpigmenting FDE
1) pseudocellulitis or Scarlatiniform
2) SDRIFE - giant cell lichenoid derm on path
Cell found in FDE
Intraepi CD8 which secretes IFN gamma
*once the med is stopped tregs clear (found fewer in number in SJS explaining persistence of rxn)
AGEP
Strong F predominance
Mediated by T cells which produce IL8, IFN gamma, IL4, IL5 and GM-CSF
Mercury exposure, viral/back infections, loxoceles bite, radiocontrast
>90% due to drug - amp/Amox, pristinamycin, quinolone, hydroxychloroquine, sulfonamides ab, terbinafine, imatinib, diltiazem
Fever and MM inv common (non erosive), neutrophilia > eosinophilia
Patch testing pos in 50%
Most common drug induced pseudolyphmphoma
Resembles CTCL, TCR may be positive
AEDs, sulfa (including thiazides), dapsone, antidepressants, vaccines, herbs
MCC of nonimmunologic urticaria
Aspirin and NSAIDs
*trilisate and salsate do not cross react
MCC of immunologic urticaria
PCN
Skin testing useful
Meds that cause urticaria
Bupropion (hepatitis and SSLR), cetirizine and hydrosyzine paradoxically
Angioedema
Blacks 5x more likely
Lisinopril/enalapril more likely than cap
1 week to months so may develop
Children with what dz may suffer potentially fatal macrophage activation syndrome with red men from vancomycin
JIA
Red man caused by elevated histamine levels, may see a macular eruption on the neck which spreads
Photosensitivity action spectra
UVA and visible 315-430)
Photo distributed lichenoid rxn
Thiazides, quinidine, NSAIDs, diltiazem (marked hyperpig). clopidogrel
Voriconazole skin manifestations
Photosensitivity (not dose dep like amiodarone), cheilitis, facial erythema, pseudoporphyria with foot erosions also, eruptive nevi and lentigines, SCCs, photodistributed GA
Photo distributed telangectasias
CCB, cefotaxime
*steroids, OCPs, isotretinoin, IFN, lithium, thiothixene, mtx may induce tel but not through photosensitivity
MCC of psudoporphyria
Naproxen
- other nsaids but not pyroxicam, TCN, lasix, isotretinoin/acitretin, 5fu, bumetanide, dapson, OCP, rofecoxib, celecoxib, CSA, voriconazole, pyridoxine dialysis (n acytelcycteine may help)
- positive DIF like PCT
Embolia cutis medicamentosa/ livedoid dermatitis/ Nicolau syndrome
Injection site reaction from periarterial injection
Blanching –> macule that evolves into a violations patch with dendrites –> hemorrhagic and ulcerates
Muscle and liver enz may be high
Neurological sequela in 1/3
NSAIDs, steroids, depo, IFN (unrelated agents)
SSLR
Minocycline, bupropion, rituximab
Drug induced ulceration of the lower lip
Type of lichenoid rxn
Usually to diuretics
Radiation recall
Months to yrs following xrt treatment recall rxn with administration of certain chemo drugs, IFN alpha and simvastatin
Similar reactivation of sunburn with mtx can occur
Palifermin associated papular eruption
Resembles flat warts
EGFR cutaneous SE
Papulopustular eruption MC - TCN may treat
TNF alpha and IL1 mediate cutaneous rxn
Curly hair and trichomegaly can be seen
Pso exacerbation, a real psoriasiform hyperkeratosis, PR-like eruption, periorbital edema (PDGFR inhibition)
Imatinib
Lobular panniculitis
Dasatinib
KP like eruption and KAs
Facial/scalp erythema and dysethesia
Sorafenib
GCSF
Injection site reactions Sweets (1 week after initiation) LCV Necrotizing panniculitis Granulomatous skin rxns
Granulomatous skin reactions
GCSF
Anakinra
EPO
IL2
Diffuse erythema followed by desquamation
Mucositis
Pruritus
Flushing
*administration of iodinated contrast material within 2 weeks of IL2 therapy will cause hypersensitivity in 30% of cases
TNF inhibitors
Recall injection site reaction - CD8 mediated
PP PSO in 40%
Mechanism of PSO is through TH1 and increases IFN alpha production
Sarcoid
11% of RA pts treated with etanercept develop positive ANAs, 15% dsDNA
Drug induced lupus avg after 41 weeks - compared to other DIL the tnf inh cause more malar rash, discoid lesions, photosensitivity
Vasculitis - vasculitis (p anca and cryoglob may be positive
Lichenoid drug
Sl increased Risk of NMSC’s, especially if on mtx
Acrodynia/calomel disease
Mercury poisoning in infancy
Painful swelling of the hands/feet with cold/clammy/dusky changes
May see hemorrhagic puncta with blotchy erythema on the trunk
Stomatitis with fever
Albuminuria and hematuria
Dx - Mc in urine
*Mc inhalation may also cause a morbilliform eruption with groin/thigh accentuation like baboon syndrome
Bromoderma
Coalescent pustules on a raised border at the periphery of a lesion
Excessive soft drink ingestion or meds (dextromethorphan hydrobromide)
Iododerma
Acneiform eruption
Dermal bullous lesions
Drug induced SLE
Procainamide, hydralazine, quinidine, captopril, minocycline, INH, carbamazepine, propothiouracil, sulfasalazine, statins
DIL rarely has skin lesions, M=F, mild sx like fever, arthritis, serositis
ANA is positive but not dsDNA, normal C’
TNF alpha inhibitor induced lupus
Especially etanercept Prominent skin lesions F>M Nephropathy with CNS involvement may occur Anti-dsDNA +, hypocomplementemic
Drug induced SCLE
Days to yrs can occur
Terbinafine, hydrochlorothiazide, diltiazem MC
ACE inh, PPI’s, statins, NSAIDs, plaqinel, leflunomide may also cause
May be ANA + and have antihistone ab but have + SSA
Photosensitive lesions but not photodistributed or annular
Etanercept may also cause SCLE
Leukotriene receptor antagonist Churg Strauss syndrome
2 d to 10 mo after
Fluticasone inh may also cause
Eosinophilia, pulmonary > neuropathy sinusitis, cardiac
Usually purpuric lesions of the lower legs
LCV with eos
P ANCA maybe positive
May be caused by unopposed B4 activity
Injected steroids
May migrate along lymphatics and cause linear atrophic hypopigmented hairless streaks
Use TAC acetonide, not hexacetonide
