drug induced exfoliative dermatitis drug induced exfoliative dermatitis

All authors read and approved the final manuscript. Google Scholar. A useful sign for differential diagnosis is the absence of mucosal involvement, except for conjunctiva. Comprehensive survival analysis of a cohort of patients with StevensJohnson syndrome and toxic epidermal necrolysis. 2002;118(4):72833. Here we provide a systematic review of frequency, risk factors, molecular and cellular mechanisms of reactions, clinical features, diagnostic work-up and therapy approaches to drug induced ED. 2013;133(5):1197204. (See paras 3 - 42 and 3- 43.) A catabolic state thus ensues, which is often responsible for significant weight loss. The management of toxic epidermal necrolysis. Anticoagulation therapy. During the acute reaction, diagnosis of ED is mainly based on clinical parameters. loss of taste Derm: stevens-johnson syndrome, toxic epidermal necrolysis, rash, exfoliative dermatitis, hair . Posadas SJ, et al. Granulysin: Granulysin is a pro-apoptotic protein that binds to the cell membrane by means of charge interaction without the need of a specific receptor, producing a cell membrane disruption, and leading to possible cell death. 2007;56(5 Suppl):S1189. Interstitial nephritis is common in DRESS syndrome, occurring roughly in 40% of cases, whereas pre-renal azotemia may occur in SJS and TEN. It is not completely clear whether EM and SJS are separate clinical entities or if they represent two different expressions of a single disease process. Toxic epidermal necrolysis: Part II Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. Before 1. HHS Vulnerability Disclosure, Help Arch Dermatol. Int J Mol Sci. Morel E, et al. 2013;69(2):1734. A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus. The site is secure. In HIV patients, the risk of SJS and TEN have been reported to be thousand-fold higher, roughly 1 per 1000 per year [19]. Mediterr J Hematol Infect Dis. eCollection 2018. Synthetic bilaminar membranes with silver nitrate have also a role in skin repairing and avoid protein loss through the damaged skin [100, 101]. Soak for 5 to 10 minutes and rinse off before patting dry. (sometimes fatal), erythema multiforme, Stevens-Johnson syndrome, exfoliative dermatitis, bullous dermatitis, drug rash with eosinophilia and systemic symptoms (DRESS . CAS 00 Comments Please sign inor registerto post comments. Plasmapheresis may have a role in the treatment of ED because it removes Fas-L [96], other cytokines known to be implied in the pathogenesis (IL-6, IL-8, TNF-) [97, 98]. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Provided by the Springer Nature SharedIt content-sharing initiative. In patients with SJS/TEN increased serum levels of retinoid acid have been found. . Acute processes usually favor large scales, whereas chronic processes produce smaller ones. Pharmacogenet Genom. Painkiller therapy. The applications of topical cyclosporine and autologous serum have also been showed to be useful in refractory cases [103]. Google Scholar. It might be. Previous vol/issue. A recently published meta-analysis by Huang [110] and coworkers on IVIG in SJS/SJS-TEN/TEN reviewed 17 studies with 221 patients and compared the results obtained with high-dosage IVIG (>2g/kg) compared to lower-dosage IVIG (<2g/kg). Bastuji-Garin S, et al. If necessary, it can be repeated every 68h. NSAIDs should be avoided as they can induce ED as well. Beneficial effect of plasma exchange in the treatment of toxic epidermal necrolysis: a series of four cases. Antipyretic therapy. Am J Clin Dermatol. Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. . Case Rep Dermatol Med. Exfoliative Dermatitis is a serious skin cell disorder that requires early diagnosis and treatment. Tumor necrosis factor : TNF- seems also to play an important role in TEN [41]. Indian J Dermatol. Please enable it to take advantage of the complete set of features! Copyright 1999 by the American Academy of Family Physicians. Google Scholar. Br J Dermatol. It often precedes or is associated with exfoliation (skin peeling off in scales or layers), when it may also be known as exfoliative dermatitis (ED). J Invest Dermatol. Fluid balance is a main focus. Cutaneous graft-versus-host diseaseclinical considerations and management. Plasmapheresis. Rabelink NM, Brakman M, Maartense E, Bril H, Bakker-Wensveen CA, Bavinck JN. Even though there is a strong need for randomized trials, anti-TNF- drugs, in particular a single dose of infliximab 5mg/kg ev or 50mg etanercept sc should be considered in the treatment of SJS and TEN, especially the most severe cases when IVIG and intravenous corticosteroids dont achieve a rapid improvement. A review of DRESS-associated myocarditis. 1990;126(1):437. Exfoliative dermatitis, including Stevens-Johnson syndrome, drug rash with eosinophilia and systemic symptoms, and toxic epidermal necrolysis, has occurred with anti-PD-1/PD-L1 treatments. It characteristically demonstrates diffuse erythema and scaling of greater than 90% of the body surface area. 2006;34(2):768. Hepatobiliary: jaundice, hepatitis, including . 2015;49(3):33542. 8600 Rockville Pike 2018 Feb;54(1):147-176. doi: 10.1007/s12016-017-8654-z. Huff JC. TEN is characterized by full-thickness epidermal necrosis with an evident epidermal detachment and sloughing caused by necrosis of keratinocytes following apoptosis [49, 52]. Ibuprofen Zentiva can be prescribed with OTC Recipe - self-medication. Clin Pharmacol Ther. It can lead to pain, appear on large parts of the body and may require hospitalization. 22 Abacavir-induced hypersensitivity syndrome is strongly associated with HLA-B*5701 during treatment . Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. 585600. Clin Exp Dermatol. Etanercept: monoclonal antibody against the TNF- receptor. 2015;13(7):62545. doi: 10.4103/0019-5154.39732. Toxic epidermal necrolysis associated with Mycoplasma pneumoniae infection. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. 2010 Oct;35(7):723-8. doi: 10.1111/j.1365-2230.2009.03718.x. Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (white arrows) together with atypical two-zoned lesions (black arrows). Journal of Pharmaceutical Research and health Care. Nat Med. Aminoglutethimide: Aminoglutethimide may lead to a loss of corticosteroid-induced adrenal suppression. Exfoliative dermatitis (ED) is defined as diffuse erythema and scaling of the skin involving more than 90% of the total body skin surface area. 1998;37(7):5203. Skin testing in delayed reactions to drugs. Perforin/granzyme B pathway: Nassif and colleagues have proposed a role for perforin/grazyme B in keratinocyte death [37]. Toxic epidermal necrolysis (Lyell syndrome). 12 out of 17 studies concluded for a positive role of IVIG in ED. Allergy. For the calculation, available values on vital and laboratory parameters within the first 3days after admission to the first hospital are considered when the reaction started outside the hospital (community patients) or at the date of hospitalization for in-hospital patients. Kamaliah MD, et al. HLA-B* 5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. Erythema multiforme and toxic epidermal necrolysis. Patch testing in severe cutaneous adverse drug reactions, including StevensJohnson syndrome and toxic epidermal necrolysis. Gastrointestinal: pancreatitis, glossitis, dyspepsia. 2000;115(2):14953. Systemic derangements may occur with exfoliative. Wolkenstein P, et al. 2008;14(12):134350. Typical target lesions consist of three components: a dusky central area or blister, a dark red inflammatory zone surrounded by a pale ring of edema, and an erythematous halo on the periphery. 2002;109(1):15561. Gynecologist consultation is required for avoiding the appearance of vaginal phimosis or sinechias. Minerva Stomatol. [Erythema multiforme vs. Stevens-Johnson syndrome and toxic epidermal necrolysis: an important diagnostic distinction]. The scales may be small or large, superficial or deep. Abe J, et al. A severity-of-Illness score for toxic epidermal necrolysis (SCORTEN) has been proposed and validated to predict the risk of death at admission [81]. Given the different histopathological features of the EM, SJS and TEN, we decided to discuss them separately. Oral manifestations of erythema multiforme. Hypothermia can result in ventricular flutter, decreased heart rate and hypotension. Arch Dermatol. Guidelines for the management of drug-induced liver injury[J]. Stevens-Johnson syndrome and toxic epidermal necrolysis due to anticonvulsants share certain clinical and laboratory features with drug-induced hypersensitivity syndrome, despite differences in cutaneous presentations. 1995;333(24):16007. Drugs that have been implicated in the causation of LPP include captopril, cinnarizine, ramipril, simvastatin, PUVA, and antituberculous medications. Theoretically, any drug can trigger a reaction, but the medications most associated with this disorder are: Allopurinol; Antiepileptic medications; Barbiturates Half-life of the drug is approximately 54 h. Modification of nitisinone in liver and renal dysfunction is yet to be studied. Severe Cutaneous Adverse Reactions: The Pharmacogenomics from Research to Clinical Implementation. Am J Infect Dis. 2010;37(10):9046. sharing sensitive information, make sure youre on a federal Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN, as shown in Fig. Curr Allergy Asthma Rep. 2014;14(6):442. ADRJ,2015,17(6):464-465. This content is owned by the AAFP. Chemicals and Drugs 61. Recurrent erythema multiforme: clinical characteristics, etiologic associations, and treatment in a series of 48 patients at Mayo Clinic, 2000 to 2007. The more common forms of erythroderma, such as eczema or psoriasis, may persists for months or years and tend to relapse. Abstract Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. . Roujeau JC, et al. Even though exfoliative dermatitis is a complex disorder involving many factors, the underlying disease is usually the key determinant of the course and prognosis. In ED increased levels of FasL have been detected in patients sera [33]. It is advised against the use of silver sulfadiazine because sulphonamide can be culprit agents. This compressed maturation process results in an overall greater loss of epidermal material, which is manifested clinically as severe scaling and shedding. This hypermetabolic state is also furtherly increased by the inflammation present in affected areas. Therefore, it is important to identify and treat any underlying disease whenever possible and to remove any contributing external factors.2, Most published studies of exfoliative dermatitis have been retrospective and thus do not address the issue of overall incidence. In order to rule out autoimmune blistering diseases, direct immune fluorescence staining should be additionally performed to exclude the presence of immunoglobulin and/or complement deposition in the epidermis and/or the epidermal-dermal zone, absent in ED. Toxic epidermal necrolysis: effector cells are drug-specific cytotoxic T cells. Abe J, et al. Prevalence is low, with mortality of roughly 512.5% for SJS and 50% for TEN [1, 2]. Mardani M, Mardani S, Asadi Kani Z, Hakamifard A. Dermatol Ther. After 24 hours, split formation was evident in hematoxylin and eosin-stained sections of HOSCs treated . The authors declare that they have no competing interests. Proc Natl Acad Sci USA. Medical genetics: a marker for StevensJohnson syndrome. Pregnancy . 2014;70(3):53948. Important data on ED have been obtained by RegiSCAR (European Registry of Severe Cutaneous Adverse Reactions to Drugs: www.regiscar.org), an ongoing pharmaco-epidemiologic study conducted in patients with SJS and TEN. Severe adverse cutaneous reactions to drugs. The induction dosage in EMM is usually 1mg/kg/day that should be maintained until a complete control of the skin is obtained. This has been called the nose sign.18, Once the erythema is well established, scaling inevitably follows (Figure 1). CAS Gen Dent. Dent Clin North Am. Google Scholar. Exfoliative dermatitis may happen as a complication of other skin issues. Exfoliative dermatitis has been reported in association with hepatitis, acquired immunodeficiency syndrome, congenital immunodeficiency syndrome (Omenn's syndrome) and graft-versus-host disease.2,1517, In reviews of erythroderma, a significant percentage of patients (about 25 percent) do not receive a specific etiologic diagnosis. Fritsch PO. The velocity of infusion should be regulated according to patients arterial pressure with the aim of 30mL/h urinary output (1mL/kg/h in case of a child). Schwartz RA et al. Drugs.com provides accurate and independent information on more than . asiatic) before starting therapies with possible triggers (e.g. Moreover, the time necessary for cells to mature and travel through the epidermis is decreased. Genotyping is recommended in specific high-risk ethnic groups (e.g. J Am Acad Dermatol. Carrozzo M, Togliatto M, Gandolfo S. Erythema multiforme. Efficacy of plasmapheresis for the treatment of severe toxic epidermal necrolysis: is cytokine expression analysis useful in predicting its therapeutic efficacy? In conclusion we suggest that therapy with cyclosporine is valuable option with a dosage of 35mg/kg oral or iv for 7days. 1983;8(6):76375. Contact Dermatitis. 2005;136(3):20516. Abe R. Toxic epidermal necrolysis and StevensJohnson syndrome: soluble Fas ligand involvement in the pathomechanisms of these diseases. Vasoactive amines may be necessary in case of shock. Chang CC, et al. Risk factors for the development of ocular complications of StevensJohnson syndrome and toxic epidermal necrolysis. The relative risk of leukemia inducing erythroderma is highly variable, ranging from 11 to 50 percent.11, Internal (visceral) malignancies cause about 1 percent of all cases of exfoliative dermatitis.11 Frequently, erythroderma is the presenting sign of the malignancy. 2002;65(9):186170. Article Schopf E, et al. Patmanidis K, et al. 2008;53(1):28. Semin Dermatol. volume14, Articlenumber:9 (2016) Nutritional support. De Araujo E, et al. Histopathological and epidemiological characteristics of patients with erythema exudativum multiforme major, StevensJohnson syndrome and toxic epidermal necrolysis. J Dermatol Sci. J Popul Ther Clin Pharmacol. Article Chem Immunol Allergy. Schneck J, et al. Rheumatology (Oxford). 3. In any case all authors concluded that the blockage of FasL prevents keratinocyte apoptosis [35]. Several authors reported also an increased incidence for aminopenicillins, cephalosporins, and quinolones [61, 62]. CAS 1996;44(2):1646. [117] described a cohort of ten patients affected by TEN treated with a single dose of etanercept 50mg sc with a rapid and complete resolution and without adverse events. Int J Dermatol. Read this article to find out all its symptoms, causes and treatments. Paraneoplastic pemphigus is associated with neoplasms, most commonly of lymphoid tissue, but also Waldenstrms macroglobulinemia, sarcomas, thymomas and Castlemans disease. 1996;135(1):611. In this study, 965 patients were reviewed. The therapeutic approach of EMM, SJS, TEN depends on extension of skin, mucosal involvement and systemic patients conditions. Exfoliative dermatitis accounts for about 1 percent of all hospital admissions for dermatologic conditions.3, Although the disease affects both men and women, it is more common in men, with an average male-to-female ratio of 2.3:1. It recommended to used G-CSF in patients with febrile neutropenia [94, 95]. Cyclosporine A (Cys A): Cys A works through the inhibition of calcineurin, that is fundamental for cytotoxic T lymphocytes activation. Immunol Allergy Clin North Am. The most commonly used steroids were methylprednisolone, prednisolone and dexamethasone. Background: Panitumumab is an EGFR inhibitor used for the treatment of metastatic colorectal cancer (mCRC), even if its use is related to skin toxicity. Google Scholar. The prognosis of cases associated with malignancy typically depends on the outcome of the underlying malignancy. Also, physicians should be vigilant about possible secondary infection, whether cutaneous, pulmonary or systemic. The cutaneous T-cell lymphomas are the lymphomas most commonly associated with exfoliative dermatitis. Ophthalmologic consultations must be repeated at fixed intervals to avoid the appearance of conjunctival irreversible complications such as chronic conjunctivitis with squamous metaplasia, trichiasis, symblepharon, punctate keratitis and sicca syndrome. Hematologic: anemia, including aplastic and hemolytic. Frequently reported adverse events of rebamipide compared to other drugs for peptic ulcer and gastroesophageal reflux disease. StevensJohnson syndrome and toxic epidermal necrolysis. N Engl J Med. The most important actions to do are listed in Fig. Ther Apher Dial. Even patients with clear histories of preexisting dermatoses tend to have biopsies that are not diagnostic when they present with erythroderma.2, Laboratory evaluation of patients with erythroderma is generally not very helpful in determining a specific diagnosis. The incidence of cutaneous adverse drug reactions (CADRs) is high in HIV-infected persons; however, there are large gaps in knowledge about several aspects of HIV-associated CADRs in Africa, which carries the biggest burden of the disease. 2012;366(26):2492501. . In: Eisen AZ, Wolff K, editors. Erythroderma is a rare but severe Adverse Drug Reaction (ADR) of phenytoin. Genome-scale investigation of drug-induced termination codon-readthrough in a model system of epidermolysis bullosa . Fischer M, et al. Despite improved knowledge of the immunopathogenesis of these conditions, immune-modulatory therapies currently used have not been definitively proved to be efficacious [49, 107], and new strategies are urgently needed. Apoptosis as a mechanism of keratinocyte death in toxic epidermal necrolysis. Br J Dermatol. J Burn Care Res. Pichler WJ, Tilch J. Moreover Mawson A and colleagues hypothesized that the efficacy of plasmapheresis is able to reduce serum level of vitamin A. Granulysin is a key mediator for disseminated keratinocyte death in StevensJohnson syndrome and toxic epidermal necrolysis. A serious cutaneous adverse drug reaction namely exfoliative dermatitis (erythroderma) is associated with isoniazid use . J Dermatol. The former is usually a recurring, localized eruption of the skin characterized by pathognomonic target or iris lesions, with minimal or no mucosal involvement (Fig. Patients who have exfoliative dermatitis of unknown cause tend to have an unpredictable course, usually replete with multiple remissions and exacerbations.4. Google Scholar. MRY, MGS, EN and GC designed the study, selected scientifically relevant information, wrote and revised the manuscript. Nayak S, Acharjya B. Drugs such as paracetamol, other non-oxicam NSAIDs and furosemide, bringing a relatively low risk of SJS/TEN a priori, are also highly prevalent as putative culprit agents in large SJS/TEN registries, due to their widespread use in the general population [63, 64] (Table1). In spared areas it is necessary to avoid skin detachment. Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. tion in models of the types of systemic disease for S. aureus pathogenesis research is also expected to receive which anti-virulence drugs would be most desirable. Pathophysiology DIP. 2005;102(11):41349. The authors wish to thank Dr. Gary White for the picture of EM showed in Fig. Atypical target lesions manifest as raised, edematous, palpable lesions with only two zones of color change and/or an extensive exanthema with a poorly defined border darker in the center(Fig. In addition to all these mechanisms, alarmins, endogenous molecules released after cell damage, were found to be transiently increased in SJS/TEN patients, perhaps amplifying the immune response, including -defensin, S100A and HMGB1 [47]. 2012;51(8):889902. It could also be useful to use artificial tears and lubricating antiseptic gels. However, according to a consensus definition [54], EMM syndrome has been separated from SJS/TEN spectrum. Mucosal involvement could achieve almost 65% of patients [17]. The syndrome has been described previously in association with phenindione administration, leptospirosis and heavy metal poisoning. Schwartz RA, McDonough PH, Lee BW. For carbamazpine, several studies have found a common link between specific HLAs and different kinds of cutaneous adverse reactions, as for HLA-A*3101 in Japanese [30] and Europeans [31]. Privacy Liver injury and exfoliative dermatitis caused by nifuratel[J]. 2012;13(1):4954. Diagnosis in a routine setting is based on patch test (PT) while skin test (prick and intradermal tests) with a delayed reading are contraindicated in these patients [72]. J Allergy Clin Immunol. 2008;34(1):636. Federal government websites often end in .gov or .mil. Chung W-H, et al. d. Cysts and tumors. N Engl J Med. EMM is a clinically severe, potentially life-threatening, extensive sloughing of epidermis, generally involving mucosal tissue.