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Cutaneous Drug Reactions (3) Flashcards

1
Q

Which drug classes are more commonly known for inducing skin reactions?

A

NSAIDs
Antibiotics
Antiepileptics

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2
Q

Drug related skin reaction severity background

A

Most drug related skin eruptions are NOT serious
But they can be severe or life threatening

Serious reactions include:
angioedema, erythroderma, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)

In most cases drug eruptions are reversible - resolve after causative drug is withdrawn

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3
Q

What can cause a cutaneous drug reaction?

A

Any medicine the patient is currently taking or has recently been exposed to including…
-prescribed and over-the-counter medicines
-herbal or homoeopathic preparations
-vaccines
-contrast media

Note - non drug components (inactive ingredients) may cause hypersensitivity reactions in patients as well

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4
Q

2 Mechanisms of cutaneous drug reactions, which one is more common?

A

Can be immunological or non-immunological
Non-immunologic causes are more common

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5
Q

Immunological cutaneous drug reaction mechanism

A

Immunological - hypersensitivity reactions (Type I-IV)

-drugs or their metabolites act as haptens and bind to peptides, modifying them to become immunogenic
-this induces a cell mediated or humoral immune response

-subsequent exposures can results in more severe reactions (because the immune system develops memory, so it reacts faster and stronger the second time)

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6
Q

Nonimmunological cutaneous drug reaction mechanism

A

-could be due to hereditary enzyme deficiencies or idiopathic

-could be dose dependent (cumulation)

-could be due to photosensitivity - formation of toxic products due to the effect of UV radiation

-could be direct physical/chemical toxicity (due to irritant)

-pseudo immunologic: causes direct release of cytokines (Mast cell degranulation, alternate complement system, cycloxyginase inhibitors)

-could be due to drug interactions

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7
Q

How does the route of administration have an effect on potential to induce cutaneous reaction?

A

In general topical application has the greatest potential to induce allergy, followed by parenteral, and then oral administration

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8
Q

Certain patient groups appear to be predisposed to cutaneous drug reactions… (2)

A

Patients with altered immune status
-like those with viral infections - Epstein Barr or HIV

Patients with altered drug metabolism
-could be due to organ impairment or genetic components

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9
Q

Timing and diagnosis

A

Timing of skin reactions is a useful diagnostic tool
-in general the onset is within a few weeks of starting the causative drug

But can vary…

Hypersensitivity reactions to penicillin can occur several weeks after stopping drug

Skin eruption seen with beta blocker generally occurs after many months of treatment

Gold can also lead to very late reactions

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10
Q

Guidelines for assessing/diagnosing cutaneous drug reactions

A

Exclude other causes (especially infections)

Examine interval between drug introduction and induction

Determine if similar reactions occurred previously with same/similar compounds

Note any improvement after withdrawal of drug and any reaction after readministration

Biopsy is helpful in defining the type of reaction pattern but not in identifying the offending drug

CBC - elevated eosinophil count, lymphocytosis with atypical lymphocytes

Skin test helpful in IgE mediated reaction (penicillin)

Skin prick or blood tests - not usually helpful in skin manifestations of allergy
-skin prick tests are risky - due to possibility of a late phase reaction

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11
Q

Skin test/RAST for penicillin allergy consideration

A

This can only detect a IgE mediated allergy (type 1)
Penicillin allergy can be type 1-4
(so it may not detect the other type of allergy)

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12
Q

General treatments of cutaneous drug reactions

A

For pruritus
-calamine lotion or systemic antihistamines

For inflammation and itch
-topical corticosteroids

For more serious reactions
-systemic corticosteroids

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13
Q

Exanthematous drug eruptions

A

Aka morbilliform or maculopapular drug rashes

Often pruritic
Typically appear 4-21 days after starting offending medication

Symmetrically distributed pink/red macules and papules that spread rapidly and may coalesce

Patients with HIV or bone marrow transplant are at increased risk of developing this

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14
Q

Management of exanthematous drug reaction

A

Identify and discontinue causative agent - most important!

Symptomatic treatment
-antipruritic agents
-topical steroids

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15
Q

Signs with exanthematous drug reaction that should alert clinician of possibility of a severe reaction… (5)

A

-mucous membrane involvement
-temperature greater than 38.5 C
-blisters
-facial edema and erythema
-lymphadenopathy (swollen lymph nodes)

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16
Q

2 types of ampicillin rashes (and the difference regarding future use)

A

Urticarial reaction - mediated by skin sensitizing antibody

Exanthematous maculopapular reaction - no allergic basis established, much more common

Ampicillin and other penicillins should not be given to patients who have had previous urticarial reactions while taking ampicillin.

Ampicillin may safely be given to patients who have previously had a maculopapular ampicillin rash.

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17
Q

Urticaria

A

Hives
-red, itchy welts

Drug-induced urticaria is the second most common form of cutaneous drug reaction after exanthematous reactions

Hives typically fade in less than 24 hours and recur in another area

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18
Q

Angioedema

A

Urticarial swelling of deep dermal and subcutaneous tissues and mucous membranes
-this can be a life threatening reaction

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19
Q

Mechanisms of drug induced urticaria (3)

A
  1. Anaphylactic and accelerated reactions (immunological histamine release)
    -IgE dependent immediate reaction (minutes to hours) and accelerated reaction (late phase reaction) - type 1 hypersensitivity
    -penicillin is most common cause
  2. Nonimmunological histamine release
    -reaction can occur within minutes
    -drug exerts direct action on mast cell or other pathways (causing histamine release)
  3. Serum sickness
    -circulating immune complexes cause serum sickness (type III hypersensitivity)
    -urticaria occurs 4-21 days after drug ingestion
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20
Q

Serum sickness presentation

A

Type III hypersensitivity

Presents with: fever, malaise, and lymphadenopathy (most common); arthralgias, urticaria, and morbilliform skin eruption also possible
-the skin eruptions (urticaria) is usually preceded with a prodromal phase (consisting of these flu like symptoms)

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21
Q

aspirin/NSAID induced urticaria

A

Anaphylactoid
Mechanism is thought to be due to cyclooxygenase inhibition which results in augmented production of leukotrienes
-arachidonic acid is converted by cox enzymes but also by lipoxygenase (LOX) to generate leukotrienes
-so when cox enzymes are inhibited, more of the arachidonic acid goes down the LOX pathway, producing more leukotrienes which result in the anaphylactoid reaction

Antihistamines are therefore less effective for treating these reactions

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22
Q

ACE inhibitor induced angioedema

A

ACE inhibitors are one of the most common causes of angioedema
-higher occurrence in African Americans

Mechanism is believed to be due to increased levels of bradykinin

So- this is NOT immunologic induced and therefore NOT a true allergy (it should however definitely still be recorded in the patients chart)

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23
Q

Opiates

A

Nonimmunologic histamine releasers
-induce mast cells on skin to generate by a direct effect on the cell and release histamines

(other non immunologic histamine releasers are polymyxin B, lobster, and strawberries)

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24
Q

What are the 4 SCAR (severe cutaneous adverse drug reactions)

A
  1. SJS (Stevens-Johnson Syndrome)
  2. TEN (Toxic epidermal necrolysis)
  3. DRESS (Drug reaction with eosinophilia and systemic symptoms aka drug induced hypersensitivity syndrome)
  4. AGEP (Acute generalized exanthemous pustulosis)
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25
Drug reaction with eosinophilia and systemic symptoms (DRESS) causes
Pathogenesis - hereditary or idiopathic Common causes: -allopurinol -antiepileptics (phenytoin, carbamazepine, phenobarbital) -sulfonamides (antimicrobials, dapsone, sulfasalazine) -vancomycin
26
What type of reaction is DRESS?
Immune mediated - type 4 hypersensitivity -so it is a delayed hypersensitivity - presents ~3-8 weeks after drug initiation
27
DRESS presentation
Diffuse maculopapular rash With lab abnormalities including eosinophilia and increased liver function tests (LFTs) Presents as a triad of... 1. rash 2. eosinophilia 3. internal organ involvement
28
What are 2 severe forms of erythema multiforme?
SJS and TEN -they both have mucus membrane involvement -TEN has over 30% BSA involvement
29
Erythema multiforme and SJS
Can result from several underlying causes -most cases are due to herpes virus infection -but can be drug induced Patients typically have fever and flu like symptoms before developing skin eruption May present with blisters, papular lesions, and redness Characteristic sign - concentric rings (looks like bullseye) Involvement of mucosa is common (mouth, eyes, genitalia) - then this is called SJS
30
SJS presentation
fever, malaise, myalgia, arthralgia, and extensive erythema multiforme of the trunk and face. -frequently drug induced
31
Toxic epidermal necrolysis (TEN)
More severe than SJS Highest mortality (30-35%) Considered a medical emergency Characterized by widespread full thickness epidermal necrosis with involvement of over 30% BSA (if its less than that, its considered SJS) Involvement of mucus membranes as well!
32
What type of reactions are SJS and TEN
Type 4 hypersensitivity (immunologically mediated)
33
Which drugs most commonly cause SJS?
Penicillins, tetracyclines, sulfonamides and NSAIDs
34
Which patient population is more susceptible to SJS?
Patients with HIV when taking cotrimoxazole.
35
Which patients are most susceptible to TEN? (3)
Patients with HIV, lupus, and bone marrow transplant
36
Which antiepileptic causes severe skin reactions including SJS and TEN?
Lamotragine
37
Treatment of TEN
Protection of exposed dermis and eroded mucosal surfaces Managing fluid and electrolyte balance Nutritional support Close monitoring for infection - antibiotic therapy should be given at first signs of sepsis Fluid rehydration is essential use of systemic corticosteroids for TEN is controversial
38
Acute Generalized Exanthematous Pustulosis (AGEP) presentation
Acute onset following drug intake Presentation: -fever -numerous nonfollicular, sterile pustules on an erythematous background predominantly in the folds and/or on the face -elevated levels of blood neutrophils (makes sense since there is lots of puss)
39
AGEP most common causes (4)
Calcium channel blockers NSAIDs Anticonvulsants Antimicrobials (particularly those with beta lactam and macrolide properties)
40
Fixed drug eruption presentation
eruptions that occur at the same site each time the same drug is administered eruption can appear within day to few weeks of ingesting the drug and can occur on any part of skin or mucus membranes - frequently occurs at mucocutaneous junctions (where mucosa transitions to skin) -hands, feet, tongue, penis or perianal areas are most frequently affected consists of reddish, dusky purple, or brown round/oval lesions sometimes features blisters (bullae or vesicles) initially one lesion appears, more may follow
41
Fixed drug eruption mechanism
Caused by activation of cytotoxic T lymphocytes in the basal layer by drugs -so this is immune based -every time the drug is taken the reaction occurs in the same place because of memory that has been established by the t cells in the basal layer in that location
42
What are common causes of fixed drug eruptions?
NSAIDs Tetracyclines Sulfa drugs Phenacetin hypnogenics food additives
43
Which drugs can cause or exacerbate acne?
Corticotropin (ACTH) corticosteroids androgens (in females) oral contraceptives haloperidol isoniazid phenytoin lithium
44
Which agents can cause psoriasis eruptions?
Interferon treatment (cause it in patients with or without history of psoriasis) Beta blockers (worsen psoriasis) Effect of chloroquine and hydroxychloroquine on psoriasis is variable
45
Vasculitis mechanism
Inflammation of blood vessels Drugs can cause both systemic vasculitis with cutaneous manifestations and cutaneous vasculitis with other organ involvement Exact mechanism is unknown - appears to be a type 3 hypersensitivity - immune complex deposition in postcapillary blood vessels
46
Vasculitis presentation
Purpuric lesions that vary in size and number - most commonly on lower extremities May be limited to skin or involve multiple organs including kidneys, liver, joints, or CNS
47
Which drugs cause vasculitis?
Allopurinol Beta lactam antibiotics Sulfonamides Thiazide diuretics Phenytoin Vancomycin
48
Which drug is associated with a hypersensitivity syndrome that typically manifests as a vasculitis involving one or more organ systems
Propylthiouracil (PTU)
49
Blistering drug eruptions
pemphigus and bullous pemphigoid are autoimmune disorders blistering drug eruptions consist of drug induced pemphigus and pemphigoid Caused by drugs containing thiol or sulfhydryl group in their molecular structure (penicillamine or captopril)
50
Lichenoid drug eruptions
Resemble idiopathic lichen planus Caused by arsenicals used to treat syphilis small, shiny, purplish polygonal papules sometimes with white lines known as Wickham's striae
51
Photosensitivity
Reaction that occurs when a photosensitizing agent in or on the skin reacts to normally harmless doses of UV or visible light. May be due to topical or systemic drugs Drug induced photosensitivity is classified as either phototoxic or photoallergic - photo-allergy is immune mediated, phototoxicity is not (causes direct cell damage) Sunscreens, fragrances, and occasionally soaps may also cause photoallergic reactions Patients taking potent photosensitising agents on a long-term basis should be warned of the problem and counselled on the need to avoid direct sunlight, to wear protective clothing and to use sunblocks
52
Which drugs are associated with photosensitivity?
Several antibiotic classes - sulfonamides, tetracyclines, quinolones Amiodarone Chlorpromazine (at high doses)
53
Photo-allergy
Less common than phototoxicity Occurs when UV energy causes drug to bind as hapten to protein on epidermal cells creating antigen that sensitizes nearby lymphocytes - so this is immune mediated (true allergy) Unlike phototoxic reactions, photo-allergy may spread beyond irradiated areas -since it is immune based, the immune cells can spread to other parts of the body -whereas phototoxicity causes direct cell damage to the parts exposed to light
54
Pigmentary disorders
Changes in skin color May occur after lichenoid eruptions or fixed drug eruptions Drug-induced alteration in skin color may result from increased (or more rarely decreased) melanin synthesis, increased lipofuscin synthesis, or cutaneous deposition of drug-related material
55
Examples of drugs that cause pigmentary disorders
Hyperpigmentation - long term use of minocycline, imipramine, imatinib Brown patchy pigmentation - prolonged use of phenytoin
56
TRUE allergies are ________________ mediated cutaneous skin reactions
immunologically mediated (involves antibody or immune cells)
57
A rabbit hunter in Arkansas is diagnosed with ulceroglandular tularemia (also known as rabbit fever) and treated with streptomycin. Within a week, he returns to the hospital. The tularemic papule, lymphadenopathy, and bacteremia have resolved, but he has now developed a raised, itching skin rash and a fever. The drug was discontinued, and the symptoms subsided. What was the role of streptomycin in this case? Is it an antigen?
No! The streptomycin acts as a hapten Antibodies recognize proteins The streptomycin acts as a hapten, covaletnly binds to proteins and alters them making them immunogenic proteins - this is what the antibody will recognize
58
A 62-year-old man presented at the Accident and Emergency department with unilateral swelling of the face, lips, jaw line and cheek. About 24 hours ago he had noticed some swelling of his cheek, and since then it had gradually progressed and there was now massive swelling of his lips and face. He described having experienced several previous episodes of localised swelling of the face over the last 6-12 months. Medical history included hypertension and depression. Current drug therapy: ● Enalapril 10mg daily ● Bendroflumethiazide 2.5mg daily ● Citalopram 20mg daily He had been taking all of these medicines for at least 5 years and had not taken any others recently. What condition do the symptoms suggest? Which of the patient's medicines is most likely to be responsible? Is this a true allergy?
The condition is angioedema The agent causing it is likely enalapril (ACE inhibitor) This is NOT a true allergy (it is caused by an increase in bradykinin by the ACE inhibitor, it is NOT immune mediated) - however it can still be life threatening and should be noted in the patient's chart
59
Ms. B, a 34-year-old woman, presented to her doctor with a painful pruritic rash on her arms, legs and neck. The rash had begun within a day or so of sun exposure and was not completely confined to sun-exposed areas. The affected skin was erythematous, with some blistering vesicles. Ms. B had no recent use of any new skincare products or cosmetics. There was no significant medical history. Her only prescribed medication was the combined oral contraceptive pill, which she had been taking for the past 10 years. Ms. B also reported taking ibuprofen when required for painful periods; she had been taking it over the last 48 hours. 1.What type of drug eruption do the symptoms suggest? 2.How should the patient be managed?
1. Photo allergy - immune mediated (since it was not confined to sun exposed areas, this can happen with photo allergy but not phototoxicity) 2. The drug responsible for this is the NSAID (ibuprofen) - stop this and switch to acetaminophen instead
60
Co-administration of lamotragine and _______________ can increase the risk of an allergic reaction
Valproate
61
Immediate vs non immediate drug allergies
Immediate -type 1 - IgE mediated -initially reaction may happen in 5-7 days, but upon first re-exposure can occur within an hour Delayed/nonimmediate -typically mediated by t cells -occur weeks-months after initial exposure
62
Which cutaneous drug eruptions is type 1 mediated allergy?
Urticaria (hives)
63
WM is a 58 year old female with a history of seizures. She began therapy with phenytoin ~4 weeks ago. Today she presents to the hospital with a diffuse maculopapular rash, eosinophilia (1,700 cells/mm3) and increased LFTs. All other labs are within normal limits. Temp 100.2F What kind of reaction is WM experiencing?
DRESS
64
Which anticonvulsants have cross reactivity? (7)
Aromatic anticonvulsants: -Carbamazepine -Oxcarbazepine -Lamotragine -Phenytoin -Phenobarbital -Felbamate -Zonisamide
65
BV is a 18 year old who began taking minocycline ~ 2 weeks ago for treatment of acne. Today she presents to the hospital with an urticarial rash. For the past 48 hours she reports subjective fever and arthralgias. Lab results are pending. What kind of reaction is BV experiencing?
Serum sickness -this is a type 3 hypersensitivity immune reaction -occurs 7-14 days after drug exposure -presents with fever, malaise, and lymphadenopathy (most common); arthralgias, urticaria, and morbilliform skin eruption also possible
66
AZ is a 45 year old male with bipolar 1 disorder. He began carbamazepine ~ 1 week ago. Today he presents to the hospital with fever (temp 102.4 F) and a blistering rash that covers ~15% of his body including his mucus membranes.
SJS -mucus membranes are involved but it is only 15% (if it were over 30% then it would be TEN) (technically <10% is SJS, > 30% is TEN, 10-30% is SJS-TEN overlap)
67
Long term consequences of SJS/TEN
permanent visual impairment, temporary nail loss, cutaneous scarring, and irregular pigmentation TEN: systemic organ involvement, including acute kidney failure, neutropenia, respiratory failure, and death
68
HF is a 61 year old male who started therapy with diltiazem 3 days ago for heart rate control in atrial fibrillation. Today he presents with fever and a pustular rash. Laboratory abnormalities include high neutrophils. What type of reaction is HF experiencing?
AGEP -puss and high neutrophils
69
PJ is a 78 year old female presenting today with purpuric lesions on the lower extremities. She started sulfamethoxazole/trimethoprim ~5 days ago for treatment of a complicated urinary tract infection. Lab values show an increase in Scr from 0.9 to 1.2 mg/dL What type of reaction is PJ experiencing?
Vasculitis -purpuric lesions on lower extremities and kidney complications

Imm/Musculoskel/Skin (16 decks)

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