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Source: Law RM, Law DTS. Dermatologic Drug Reactions and Common Skin Conditions. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://www.accesspharmacy.com/content.aspx?aid=7998475. Accessed June 3, 2012.

  • Drug-induced skin reactions caused by irritants or allergens.

  • Exanthematous reactions: maculopapular rashes and drug hypersensitivity syndrome
  • Urticarial reactions: urticaria, angioedema, and serum sickness-like reactions
  • Blistering reactions: fixed drug eruptions, Stevens–Johnson syndrome, and toxic epidermal necrolysis
  • Pustular eruptions: acneiform drug reactions and acute generalized exanthematous pustulosis (AGEP)
  • Drug-induced hyperpigmentation: due to increased melanin (e.g., hydantoins), direct deposition (e.g., silver, mercury, tetracyclines, and antimalarials), or other mechanisms (e.g., fluorouracil)
  • Drug-induced photosensitivity reactions
    • Phototoxic (nonimmunologic): amiodarone, tetracyclines, sulfonamides, psoralens, coal tar
    • Photoallergic (immunologic): sulfonamides, sulfonylureas, thiazides, nonsteroidal antiinflammatory drugs (NSAIDs), chloroquine, carbamazepine

Signs and Symptoms

  • Maculopapular (penicillins, cephalosporins, sulfonamides, anticonvulsants):
    • Afebrile, with pruritic erythematous macules and papules
    • Usually begins within 7–10 days after starting medication
    • Resolves within 7–4 days after drug discontinuation
    • Lesions may spread and become confluent
  • Drug hypersensitivity syndrome (allopurinol, sulfonamides, barbiturates, phenytoin, carbamazepine, lamotrigine, dapsone):
    • Exanthematous eruption with fever, lymphadenopathy, and multiorgan involvement (kidneys, liver, lung, bone marrow, heart, and brain).
    • Begins 1–4 weeks after starting drug; may be fatal if not treated promptly.
  • Urticaria and angioedema (penicillins, aspirin, sulfonamides, radiograph contrast media, opioids):
    • Urticaria may be first sign of emerging anaphylactic reaction characterized by:
      • Hives
      • Pruritic red raised wheals
      • Angioedema
      • Mucous membrane swelling that typically occurs within minutes to hours
  • Serum sickness-like reactions: urticarial eruptions with fever, rash (usually urticarial), and arthralgias usually within 1–3 weeks after starting drug.
  • Fixed drug eruptions (tetracyclines, barbiturates, sulfonamides, codeine, NSAIDs):
    • Pruritic, red, raised lesions that may blister; may include burning or stinging.
    • Lesions may evolve into plaques; recur in same area each time drug is given.
    • Lesions appear and disappear within minutes to days, leaving hyperpigmented skin for months.
  • Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) (sulfonamides, penicillins, hydantoins, carbamazepine, barbiturates, lamotrigine, NSAIDs, allopurinol):
    • Blistering eruptions that may be severe and life threatening.
    • Onset within 7–14 days after drug exposure.
    • Generalized tender/painful bullous formation with fever, headache, and respiratory symptoms leading to rapid clinical deterioration.
    • Lesions show rapid confluence and spread, resulting in extensive epidermal detachment and sloughing.
    • May result in:
      • Fluid loss
      • Hypotension
      • Electrolyte imbalances
      • Secondary infections
  • Acneiform reactions (corticosteroids, androgens, anticonvulsants, isoniazid, lithium): pustular eruptions with onset within 1–3 weeks.
  • Acute generalized exanthematous pustulosis (AGEP) (β-lactam antibiotics, macrolides, calcium channel blockers):
    • Acute onset (within days), fever, diffuse erythema, and pustules.
    • Generalized desquamation occurs 2 weeks later.
  • Sun-induced reactions: erythema, papules, edema, and sometimes vesicles in areas exposed to sunlight (e.g., ears, nose, cheeks, forearms, and hands).

  • Perform medical history to determine:
    • Signs and symptoms
      • Onset
      • Progression
      • Timeframe
      • Lesion location and description
    • Urgency
      • Severity, area, and extent of skin involvement
      • Signs of systemic/generalized reaction or disease condition)
    • Medication history
  • Assess lesions to identify
  • Inspect skin for:
    • Color
    • Texture
    • Size
    • Temperature

  • Relieve symptoms and decrease skin lesions.
  • Remove precipitating factors.
  • Prevent recurrences.
  • Avoid adverse treatment effects.
  • Improve quality of life.

  • Discontinue suspected drug as quickly as possible and avoid use ...

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