Severe Rowell syndrome associated with oral terbinafine

A Rare Case of a Patient with Systemic Lupus Erythematosus who Presented with Rowell Syndrome Responding to Treatment with Hydroxychloroquine and Prednisone with One Year of Relapse Free Survival on Belimumab

Rowell Syndrome, first described in 1963 by Rowell et al., is an infrequently reported and unique syndrome occurring in patients with Systemic Lupus Erythematosus (SLE). This syndrome characteristically presents with erythema multiforme-like lesions as well as other specific immunologic and histopathologic manifestations. Since Rowell's original description, diagnostic criteria have been proposed and modified to better describe the syndrome. We describe a 32-year-old African American female patient with a previous history of SLE who presented with dermatologic, immunologic, and histopathologic manifestations that fit the modified diagnostic criteria for Rowell Syndrome.

A Case of Rhupus with Rowell Syndrome

We report a case of 30-year-old female who presented initially with hair loss, photosensitive malar rash, morning stiffness and synovitis. She was diagnosed with Rhupus syndrome based on clinical and laboratory findings. Few months after starting hydroxychloroquine, esomeprazole and azathioprine, and failing methotrexate (because of erosive pill-induced esophagitis), she presented with generalized maculopapular dusky reddish rash in her body, back and extremities. Her anti-double stranded-DNA, anti-nuclear antibody, anti-Ro/SSA and anti-La/SSB were positive. Anti-cyclic citrullinated peptide antibody was moderately positive. She had low complements: C3 and C4. Herpes simplex IgM and mycoplasma tested negative. Skin biopsy from right arm showed evidence of erythema multiform. She met the criteria for the diagnosis of Rowell syndrome. We managed her with hydroxychloroquine, prednisolone, mycophenolate mofetil and topical agents and discontinued esomeprazole. We also review the management of Rowell syndrome in the literature.

[Terbinafine : Drug-induced lupus erythematodes and triggering of psoriatic skin lesions]

Based on the technical information that oral terbinafine must be used with caution in patients with pre-existing psoriasis or lupus erythematosus, the literature was summarized. Terbinafine belongs to the drugs able to induce subcutaneous lupus erythematosus (SCLE)-with a relatively high risk. The clinical picture of terbinafine-induced SCLE may be highly variable and can also include erythema exsudativum multiforme-like or bullous lesions. Thus, differentiation of terbinafine-induced Stevens-Johnson syndrome or toxic epidermal necrolysis may be difficult. Therefore, terbinafine should be prescribed with caution in patients who show light sensitivity, arthralgias, positive antinuclear antibodies or have a history of SLE or SCLE. Case reports include wide-spread, but mostly nonlife-threatening courses, which did not require systemic therapy with steroids or antimalarials in every case. Terbinafine is also able to induce or to aggravate psoriasis. The latency period seems to be rather short (<4 weeks). Terbinafine therefore is not first choice if a systemic therapy with antimycotics is indicated in a patient with psoriasis or psoriatic diathesis. Azole derivatives according to the guidelines may be used as an alternative.

Terbinafine-induced lichenoid drug eruption

Drug-induced lichen planus has been induced by antibiotics, anticonvulsants, antidiabetics, antimalarials, antitubercular drugs, antihypertensives, psychiatric drugs, chemotherapeutic agents, diuretic, heavy metals, NSAIDs, etc. Terbinafine, an antifungal agent, is widely used for dermatophyte infections and onychomycosis. Cutaneous adverse effects of terbinafine are rarely reported. Here, we report a case of terbinafine-induced lichenoid drug eruption in a 22-year-old who presented with generalized lichenoid eruption 2 weeks after terbinafine initiation of. The body and lip cleared completely after 8 weeks of drug withdrawal; nail change cleared after 12 weeks.

Rowell's syndrome induced by terbinafine

Terbinafine, a systemic antifungal commonly prescribed for onychomycosis (fungal infection involving the nails) has been reported to cause various cutaneous adverse effects. We describe an overlap syndrome between cutaneous lupus and erythaema multiforme induced by this medication with a review of other reported cases.

[What's new in clinical dermatology?]

L’année 2013 a été l’année des études génétiques de type GWAS (Genome wide association studies) au service de maladies fréquentes (psoriasis et dermatite atopique) visant à identifier des gènes candidats et celles des grandes cohortes de population tirées de registres publics ou privés. Ainsi des corrélations épidémiologiques sont déclinées : psoriasis et surrisque vasculaire, psoriasis et pathologies ORL, rosacée et migraines, acné et habitudes alimentaires, eczéma et carcinome basocellulaire, vitiligo et moindre risque de cancers cutanés, lupus cutané Ro/SS-A et cancer, eczéma chronique et inhibiteurs calciques, pemphigoïde et diurétiques de l’anse. Les liens entre isotrétinoïne et MICI ne sont pas confirmés. Ceux liant azathioprine et cancers cutanés le sont. Des toxidermies nouvelles voient le jour (pigmentations à l’interféron, hypodermites et sarcoïdose aux inhibiteurs de BRAF muté, toxidermies au vandétanib, etc.) et des toxidermies anciennes sont « revisitées » (patch-tests dans les toxidermies sévères, pigmentation à l’hydroxychloroquine, dermatoses neutrophiliques à l’azathioprine). Diane35^® a fait une fausse sortie en janvier 2013 mais le tétrazépam, lui, a fait une vraie sortie en juillet 2013. Des aspects originaux de différentes infections cutanées sont abordés et des données nouvelles sur les MST (méningococcémies et homosexuels masculins, PVH, herpès, syphilis congénitale). Enfin, quelques articles concernant la dermatoscopie, la microscopie confocale et la dermatologie esthétique seront discutés.