Clinical pattern of cutaneous drug eruption among children and adolescents in north India

Case report: Generalized bullous fixed drug eruption mimicking epidermal necrolysis

Generalized bullous fixed drug eruption (GBFDE) is the most severe form of fixed drug eruption and can be misdiagnosed as epidermal necrolysis (EN). We report the case of a 42-year-old male patient presenting with more than 50% skin detachment without defined areas of exanthema or erythema and a history of one prior event of EN caused by acetaminophen (paracetamol), allopurinol, or amoxicillin 1.5 years ago. The initial diagnosis was GBFDE or EN. The histology of a skin biopsy was unable to distinguish between the two diseases. The course of the disease, the later clinical presentation, and the medical and medication history, however, were in favor of a diagnosis of GBFDE with two potentially culprit drugs: metamizole and ibuprofen. Moxifloxacin, enoxaparin sodium, hydromorphone, and insulin human were administered concomitantly, which makes them suspicious as well. Unfortunately, the patient received an additional dose of metamizole, one of the possible causative drugs, and he developed another bullous reaction within 1 month. This led to the diagnosis of GBFDE due to metamizole. This report highlights the challenges of distinguishing two rare diseases and elucidates the importance of distinct clinical presentation and detailed medication history.

Fixed Drug Eruptions With Flavoured Liquid Formulations of Over-the-Counter Analgesics: A Case Report

Type 4 hypersensitivity reactions convey a number of conditions that include fixed drug eruptions (FDEs). They share similar pathophysiologic backgrounds and sometimes presentation but can have very variable prognostications. Drugs are amongst the possible causes with acetaminophen and other NSAIDs being reported very frequently. We present a case of a patient reacting to flavoured oral ibuprofen and acetaminophen formulations, exhibiting FDEs with bullae formation. We describe our successful challenge to non-flavoured acetaminophen and ibuprofen. We briefly discuss FDEs in regard to their incidence, pathophysiology, and management.

The association between air pollution, meteorological factors, and daily outpatient visits for urticaria in Shijiazhuang, Hebei Province, China: a time series analysis

The associations of air pollution and meteorological factors with the outpatient visits of urticaria remain poorly studied. This study aimed to assess the association between air pollution, meteorological factors, and daily outpatient visits for urticaria in Shijiazhuang, China, during 2014-2019. Daily recordings of air pollutant concentrations, meteorological data, and outpatient visits data for urticaria were collected during the 6 years. Descriptive research methods were used to describe the distribution characteristics and demographic features of urticaria. A combination of the generalized linear regression model (GLM) and distribution lag nonlinear model (DLNM) was used to evaluate the lag association between environmental factors and daily outpatient visits for urticaria. Stratified analyses by gender (male; female) and age (< 18 years; 18-39 years; > 39 years) were further conducted. The dose-response relationship between daily urticaria visits and CO, NO₂, O₃, temperature, and relative humidity was nonlinear. High concentrations of CO, NO₂, O₃, and high temperatures increased the risk of urticaria outpatient visits. The maximum cumulative association of high concentrations of CO, NO₂, and O₃ was lag 0-14 days (CO: RR = 1.10, 95%CI: 1.06, 1.31; NO₂: RR = 1.09, 95%CI: 1.01, 1.08; O₃: RR = 1.16, 95%CI: 1.08, 1.25), and high temperatures was lag 0-7 days (RR = 1.27, 95%CI: 1.14, 1.41). Low concentrations of NO₂, O₃, and high humidity, on the other hand, act as protective factors for urticaria outpatient. The maximum cumulative association of low concentrations of NO₂ was the 0-day lag (RR = 0.97, 95%CI: 0.95, 0.99), O₃ was lag 0-5 days (RR = 0.94, 95%CI: 0.88, 0.99), and high humidity was lag 0-10 days (RR = 0.93, 95%CI: 0.89, 0.98). Stratified analyses showed that the risk of urticaria outpatient visits was higher for the males and in the < 18 years age group. In conclusion, we found that the development of urticaria in Shijiazhuang has a distinct seasonal and cyclical nature. Air pollutants and meteorological factors had varying degrees of influence on the risk of urticaria outpatient visits. This study provides indirect evidence for a link between air pollution, meteorological factors, and urticaria outpatient visits.

Severe Generalized Bullous Fixed Drug Eruption Treated with Cyclosporine: A Case Report and Literature Review

Generalized bullous fixed drug eruptions (GBFDEs) are rare in the paediatric population. We present the case of a 7-year-old girl with GBFDE believed to be secondary to oral ibuprofen, who experienced rapid resolution of lesions and cessation of blistering with a 3-week course of oral cyclosporine. To the best of our knowledge, this is the first report of a paediatric case of GBFDE treated with cyclosporine. In our report, we review published cases of GBFDE in children, and all adult cases managed with cyclosporine.

Pediatric drug eruptions

Drug eruptions in children are common but in general less studied than their adult counterparts. Aside from having significant impact on the child's health and quality of life, these reactions can limit what medications the patient can receive in the future. Familiarity with pediatric drug eruptions is important for accurate diagnosis and to prevent future recurrence or ineffective therapy. Our current understanding of how drug reactions differ mechanistically between children and adults is poor. There are multiple factors that could be contributing to the differing incidence, presentation, and treatment modalities offered to pediatric versus adult patients. For many of these cutaneous drug reactions, the treatment regime is not standardized, being based primarily on case reports. Although not comprehensive, this review highlights common pediatric drug eruption patterns and discuss diagnostic mimickers. Five cutaneous adverse drug reactions in the pediatric population are presented: morbilliform (exanthematous) eruptions, urticarial eruptions, serum sickness-like reactions, fixed drug eruptions, and DRESS syndrome. Clinical features, diagnostic workup, and management are discussed with an emphasis on the pediatric population.

Fixed Drug Eruptions: An Update, Emphasizing the Potentially Lethal Generalized Bullous Fixed Drug Eruption

A fixed drug eruption (FDE) is a relatively common reaction associated with more than 100 medications. It is defined as a same-site recurrence with exposure to a particular medication. The primary approach and treatment for all types of FDEs are to identify and remove the causative agent, often accomplished by a thorough history of medication and other chemical exposures, and possibly prior episodes. The most common category of FDE, localized FDE, whether bullous or non-bullous, is self-limited. Although one can confirm the causative agent using oral challenge testing, it is not recommended due to the risk of severe exacerbation or possible generalization; patch testing is now preferred. Bullous FDE may resemble erythema multiforme. Treatment of localized FDE includes medication removal, patient counseling, and symptomatic relief. Failure to remove the causative agent in localized FDE can lead to recurrence, which is associated with increased inflammation, hyperpigmentation, and risk of a potentially lethal generalized bullous FDE (GBFDE), which may resemble Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Distinguishing GBFDE from SJS and TEN is salient and will be stressed: GBFDE has more rapid onset in 1-24 h rather than in weeks, less or no mucosal involvement, less or no systemic involvement, and a tendency for a more favorable prognosis; however, recent experience suggests it may be just as life-threatening. This review will provide a comprehensive update and approach to diagnosis and management.

Fever as a predictor of positive lymphocyte transformation test

BACKGROUND

Few studies have characterized the clinical manifestations of delayed antibiotic hypersensitivity (AH) diagnosed using objective methods. The lymphocyte transformation test (LTT) is a reproducible method to diagnose type IV hypersensitivity. The purpose of the study was to evaluate the characteristics of delayed AH diagnosed on LTT in children.

METHODS

We performed a retrospective analysis of patients who were evaluated for AH using LTT at National Center for Child Health and Development, Tokyo, from 2002 to 2014. We extracted patient demographics, type and duration of antibiotics, and clinical characteristics from the medical records. Clinical manifestations were compared between LTT-positive and LTT-negative cases.

RESULTS

Seventy-five cases for which 101 drugs were tested were included in this study. LTT was positive against 34 drugs in 26 cases. Median age was 5 years (IQR, 1-9 years), and 49% of patients had underlying disease. LTT was performed at a median of 18 days (IQR, 4-59 days) after the suspected episode. The median number of days from the initiation of therapy to the onset of symptoms was 4. Rash was the most common manifestation (89%). Fever (>38°C) was observed in 20 cases (27%). Onset of fever preceded the rash in nine cases (45%), appeared simultaneously in five (25%), appeared afterwards in four (20%), and was unknown in two (10%). Fever was an independent factor associated with AH when comparing LTT-positive and LTT-negative cases (OR, 3.61; 95%CI: 1.03-12.64).

CONCLUSIONS

Fever was a common presenting symptom of delayed AH in children aged ≤18 years.

Rashes and other hypersensitivity reactions associated with antiepileptic drugs: A review of current literature

This article provides an overview of the pathogenesis and risk factors associated with antiepileptic drug (AED) hypersensitivity reactions, provides prescribing guidelines that may minimize the risk of antiepileptic induced rashes, and discusses treatment options for rashes. Articles indexed in PubMed, Science Citation, and Google Scholar (January 1946-March 2019) were systematic searched using the following key terms: hypersensitivity, rash, antiepileptic, epilepsy, cross-sensitivity, desensitization, patch testing and supplemented with our clinical experiences. Additional references were identified from a review of literature citations. AEDs are associated with cutaneous adverse reactions. Aromatic AEDs and higher titration rates are associated with increased risk of hypersensitivity reaction. Patient characteristics, underlying health conditions, and genetic variations may increase the likelihood of a hypersensitivity reaction. Once a hypersensitivity reaction occurs, the likelihood of cross sensitivity to another AED increases, especially among other aromatic AEDs. Withdrawal of the causal agent and initiation of a lower risk agent usually leads to resolution of symptoms. Desensitization protocols may be an option for patients whose seizures only respond to the AED causing the rash.

Fixed-drug Eruptions: What can we Learn from a Case Series?

BACKGROUND

A fixed-drug eruption (FDE) is a unique cutaneous adverse drug effect in the form of recurrent lesions at the same site after re-exposure to the offending agent.

AIM

The aim of the study was to identify changes in trends in fixed drug eruptions with regard to causative drug or patient risk factors.

METHODS

Cases of FDEs encountered between March 2014 to May 2017 during routine pharmacovigilance activities were analyzed.

RESULTS

FDEs made up 8.4% of total adverse drug reactions and 11.1% of cutaneous reactions. Majority of the patients were adults between 18 and 45 years old. The average lag period between drug intake and appearance of FDE was 2.04 days. Commonly affected sites were extremities, lips, head and neck, and genitalia. Number of FDE lesions varied from 1 to > 6, with nearly half the patients (46%) presenting with a single lesion. Antimicrobials (80.6%) and nonsteroidal anti-inflammatory drugs (20.8%) were most frequent drugs implicated. Route of administration was oral for all causative drugs. History of an FDE was positive in 26 (50.2%) of the cases. Majority of the patients (21 out of 25 or 84%) whose lesions appeared within minutes to hours of suspected drug intake had a history of FDE. Furthermore, 66.7% of patients with multiple lesions had a history of FDE while only 34.8% of patients with a single lesion had such a history.

CONCLUSION

FDEs are common cutaneous reactions with antimicrobials and anti-inflammatory agents, with increased likelihood of extensive and multiple lesions in patients with a history of FDE.

Dapsone-associated fixed drug eruption

INTRODUCTION

Dapsone is a sulfone drug used to treat infectious conditions and also numerous dermatologic diseases. Fixed drug eruption is a distinctive adverse cutaneous reaction associated with the initial administration and subsequent delivery of a specific agent. Areas covered: The authors preformed a literature search using the following keywords: dapsone, fixed drug eruption, and adverse cutaneous drug reaction. Bibliographies were also reviewed for pertinent articles. The results were combed for relevant papers and reviewed. Articles pertaining to dapsone-associated fixed drug eruption were included. Expert commentary: The majority of cases of dapsone-associated fixed drug eruption in the literature come from Africa or India where there is a high prevalence of patients treated for leprosy. Characteristics of these cases are similar to fixed drug eruption described in the western literature, with differences in frequency of multiple versus solitary lesions. Dapsone-associated fixed drug eruption should be considered when reviewing the drug history of a patient with fixed drug eruption. In the case of darker pigmented individuals, multiple fixed drug eruption lesions may be more common. Multiple lesions may mimic Kaposi's sarcoma in human immunodeficiency virus positive patients. Dapsone-associated fixed drug eruption should be considered in the differential diagnosis of multiple hyperpigmented lesions.

Fixed Drug Eruption due to Achiote Dye

Fixed drug eruption (FDE) is a localized type IV sensitivity reaction to a systemically introduced allergen. It usually occurs as a result of new medication, making identification and avoidance of the trigger medication straightforward; however, in a rare subset of cases no pharmacological source is identified. In such cases, the causative agent is often a food or food additive. In this report we describe a case of a FDE in a 12-year-old girl recently immigrated to the United States from Ecuador who had no medication exposure over the course of her illness. Through an exhaustive patient history and literature review, we were able to hypothesize that her presentation was caused by a dietary change of the natural achiote dye used in the preparation of yellow rice to a locally available commercial dye mix containing tartrazine, or Yellow 5, which has previously been implicated in both systemic hypersensitivity reactions and specifically in FDE. This report adds to the small body of available literature on non-pharmacological fixed hypersensitivity eruptions and illustrates an effective approach to the management of such a presentation when history is not immediately revealing.

Clinical features of fixed drug eruption at a tertiary hospital in Korea

Purpose

Fixed drug eruption (FDE) is characterized by a well-defined erythematous patch, plaque, or bullous eruption that recurs at the same site as the result of systemic exposure to a causative drug, and resolves with or without hyperpigmentation. This study was carried out to identify the common causative drugs and clinical features of FDE in Korea.

Methods

We reviewed electronic medical records of all patients diagnosed with FDE from January 2000 to December 2010 at a tertiary hospital in Korea.

Results

A total of 134 cases were diagnosed as FDE. The mean age was 35.9 years (range, 0-82 years) and 69 (51.5%) of the patients were male. The mean duration from the first event to attending hospital was 1.9 years (range, 1-20 years). The mean number of recurrences was 2.6 (1-10), and 72.6% of patients sought medical care after experiencing symptoms twice or more. Four patients (3.1%) needed hospitalization. The most common sites were the upper extremities (47.7%), followed by the lower extremities, face, abdomen, chest, buttocks and perineum. Clear documentation on the causative drugs was available for 38 patients (28.4%), and among these, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen accounted for 71.1% of cases, and antibiotics accounted for 15.8%. Eighty patients (59.7%) underwent active treatment for FDE, and topical steroids were most frequently prescribed (43.3%), with systemic steroids used in 11.2% of patients.

Conclusions

NSAIDs and acetaminophen were the main causative agents of FDE, however, the causative agents were not assessed in 25% of patients.

Cutaneous drug reactions in children: an update

Cutaneous drug reactions account for a large proportion of adverse drug reactions. Cutaneous drug reactions can be very challenging to diagnose. They can mimic many other skin diseases; this is especially evident during childhood, when viral exanthems are commonplace. Also, if a patient is taking numerous medications, establishing causality to a specific drug can be multifaceted and difficult. The purpose of this review is to highlight an approach to the diagnosis of a suspected cutaneous drug reaction in a child. We have classified different types of drug eruptions by morphology: exanthematous, urticarial, pustular, and bullous. Within each of these groups we have divided them into simple, benign, or non-febrile and complex or febrile reactions. We also include a miscellaneous group to ensure a methodical review.

Psoriasiform drug eruption associated with sodium valproate

As psoriasis is a common skin disorder, knowledge of the factors that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. Drug intake is a major concern in this respect, as new drugs are constantly being added to the list of factors that may influence the course of the disease. We report a patient with a psoriasiform drug eruption associated with the use of sodium valproate. Physicians should be aware of this type of reaction. Early detection of these cases has practical importance since the identification and elimination of the causative drug are essential for therapy success.

Cutaneous adverse drug reaction profile in a tertiary care out patient setting in eastern India

Background:

Cutaneous adverse drug reactions (CADR) are the most frequent of all manifestations of drug sensitivity and manifest with varied and diverse morphology.

Aims:

To study the prevalence and clinical spectrum of CADR among patients attending outpatient department (OPD) in a tertiary care hospital.

Materials and Methods:

An observational study was undertaken over a 1-year period in dermatology OPD of a tertiary care teaching hospital in Eastern India. Patients presenting with suspected drug-related cutaneous lesions were included if drug identity could be ascertained. Clinical profiling was done. Drug history was recorded in a format specified in Indian National Pharmacovigilance Programme and causality assessment carried out as per World Health Organization-Uppsala Monitoring Centre (WHO-UMC) criteria.

Results:

Commonest CADR in our study was morbilliform eruption (30.18%), followed by fixed drug eruption (24.52%), Stevens–Johnson syndrome (SJS)-Toxic epidermal necrolysis (TEN) and overlap of two (24.50%), exfoliative dermatitis (7.54%), urticaria (5.6%), phototoxic drug reaction (3.8%), pityriasis rosea-like eruptions (1.89%), and severe mucositis (1.80%). Drugs implicated were sulfonamides (17%), fixed-dose combinations of fluoroquinolones with nitroimidazoles (11.30%), analgesics (11.30%), antiepileptics (11.30%), beta-lactam antibiotics (9.40%), fluoroquinolones alone (7.50%), allopurinol (7.50%), and azithromycin (5.70%). Reaction latency varied from 1 to 43 days. Causality assessment was certain and probable for 18.9% and 41.5% of the reactions, respectively, and reactions were serious in 33.96% (95% confidence interval 21.21-46.71%).

Conclusions:

Cutaneous adverse drug reaction profile in this study is similar in many ways to studies conducted earlier in India. Incidence of life-threatening reactions like SJS-TEN was higher compared with studies conducted abroad. Reaction time and lesion patterns are helpful in identifying an offending drug in the setting of multiple drug therapy.

Drug-induced severe adverse reaction enhanced by human herpes virus-6 reactivation

Reactivation of certain latent viruses has been linked with a more severe course of drug-induced hypersensitivity reaction (HSR). For example, reactivation of human herpes virus (HHV)-6 is associated with severe organ involvement and a prolonged course of disease. The present study discusses an HSR developed in a previously healthy male exposed to ceftriaxone, doxycycline, vancomycin, and trimethoprim/sulfamethoxazole (co-trimoxazole; TMP/SMX). Initially, the patient presented clinical manifestations of HSR, as well as clinical and laboratory measurements compatible with liver and renal failure. Moreover, the patient presented skin desquamation compatible with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis. During the reaction, it was observed HHV-6 reactivation. The severity of clinical symptoms is correlated with HHV-6 titer, as well as with results of the in vitro lymphocyte toxicity assay (LTA). Serum levels of a large panel of cytokines are compared between the patient, a large population of SJS patients, and a cohort of healthy controls, using data collected by our laboratory over the years. HHV-6 was measured in the cell culture media from lymphocytes incubated with each of the 4 drugs. Moreover, we describe a new assay using cytokines released by patient lymphocytes following in vitro exposure to the incriminated drugs as biomarkers of HSR. Based on LTA results, HHV-6 reactivation and cytokine measurements, we establish that only doxycycline and TMP/SMX were involved in the HSR. As result of this analysis, the patient could continue to use the other 2 antibiotics safely.

Causative Drugs and Clinical Outcome in Stevens Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), and SJS-TEN Overlap in Children

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the most severe adverse drug reactions in children.

OBJECTIVES

The objective was to study the causative drugs and outcome in children with SJS, SJS-TEN overlap, and TEN.

MATERIALS AND METHODS

Retrospective analysis of all the in-patient records of children below 18 years of age with the diagnosis of SJS, SJS-TEN overlap, and TEN was carried out.

RESULTS AND CONCLUSIONS

Twenty children were identified, eight patients each were diagnosed as SJS and TEN and four as SJS-TEN overlap. Multiple drugs were implicated in 15 cases while single drug was responsible in 5 cases. Antibiotics (40.7%) were implicated as the commonest cause followed by NSAIDS (25.9%) and anticonvulsants (7.4%). Seventeen patients recovered completely and three patients died.

Toxic epidermal necrolysis (TEN) Lyell's syndrome

Toxic epidermal necrolysis, a unique rapidly developing mucocutaneous reaction pattern, characterized by sheets of erythema, necrosis and bullous detachment of the epidermis, closely resembling that of scalding of the skin and rapidly fatal, was described by Lyell, and is now recognized as toxic epidermal necrolysis (TEN) Lyell's syndrome. The condition is indistinguishable from staphylococcal scalded skin syndrome (SSSS), and generalized fixed drug eruption. Hence, there has always been controversy as regards terminology. It is well conceived that TEN is equivalent to Stevens-Johnson syndrome (SJS), at its greatest severity. TEN, therefore, is a great challenge and warrants instant attention based on a thorough knowledgeable background covering several related facets including the recent advances in pathogenesis and management strategies. The details contained in the following text should prove very useful in the comprehension of a largely intractable entity.

Cutaneous reactions to drugs in children

Cutaneous eruptions are a commonly reported adverse drug reaction. Cutaneous adverse drug reactions in the pediatric population have a significant impact on patients' current and future care options. A patient's recollection of having a "rash" when they took a medication as a child is a frequent reason for not prescribing a particular treatment. The quick detection and treatment of cutaneous adverse drug reactions, plus identification of the causative agent, are essential for preventing the progression of the reaction, preventing additional exposures, and ensuring the appropriate use of medications for both the current condition and others as the patient ages. The purpose of this review is to discuss a reasonable approach to recognition and initial management of cutaneous adverse drug reactions in children.

Life-threatening acute adverse cutaneous drug reactions

Adverse cutaneous reactions to drugs are frequent, affecting 2% to 3% of all hospitalized patients. Fortunately, only about 2% of adverse cutaneous reactions are severe and very few are fatal. Stevens-Johnson syndrome and toxic epidermal necrolysis are severe life-threatening diseases with a mortality rate reaching 30%, and only prompt recognition and diagnosis, withdrawal of the offensive drug, and referral to an intensive care unit or burn care unit might improve the prognosis and save the patient's life. Drug eruption with eosinophilia and systemic symptoms syndrome, formerly termed drug hypersensitivity syndrome, is a rather distinct severe adverse drug reaction (ADR) characterized by eruption, fever, lymph node enlargement, and single or multiple organ involvement, with a high morbidity and a mortality rate of 10%. These severe ADRs, together with serum sickness-like syndrome, are discussed in this review. Other severe reactions, such as anaphylaxis and vasculitis, are discussed elsewhere in this issue. Although most of the readers, particularly those in the outpatient arena, will not be treating these patients, they are the ones who will see them first, diagnose them, realize the potential danger in their condition, and refer them to the appropriate treatment venue. Therefore, dermatologists should be familiar with these conditions and be prepared to handle them adequately.

Drug eruptions in children with ENT infections

OBJECTIVE

A common problem for the clinician in an outpatient clinic is to distinguish a drug eruption from a viral exanthem in a child. The aim of this study was to describe the common drug eruptions seen in children with ENT infections, suggesting an approach to this problem.

METHODS

We studied the cases of ENT patients aged 15-years-old and below, with the clinical diagnosis of cutaneous adverse reactions. Main variables in the assessment of drug etiology in skin eruptions were previous experience with the drug in the general population, alternative explanation for the eruption, timing between the ingestion of the drug and the appearance of the lesions, drug levels or evidence of overdose or long-acting drug, subsequent progression of the eruption and reactions to dechallenge and rechallenge.

RESULTS

A total of 47 children were examined during a period of 11 months. The indications for drug prescribed were tonsillitis, pharyngitis, rhinitis, otitis and sinusitis. The most usually implicated drugs were amoxycillin-clavulanic acid, cephalosporin, clindamycin, erythromycin, clarithromycin and paracetamol. The main clinical patterns of the eruptions seen were urticaria, maculopapular rash, fixed drug eruption and erythema multiforme.

CONCLUSIONS

Careful clinical examination, detailed history, knowledge of the numerous clinical patterns of the eruptions and the drugs specific reaction rates, as well as oral drug rechallenge, RAST and patch tests if indicated, are essential factors in the management of patients with drug eruptions.

Spectrum of anticonvulsant hypersensitivity syndrome: controversy of treatment

An 18-month-old girl presented with a maculopapular rash 10 days after carbamazepine treatment. Initially, she was suspected of having a viral rash owing to associated fever. She deteriorated rapidly and was suspected of having anticonvulsant hypersensitivity syndrome or Stevens-Johnson syndrome. She developed features compatible with toxic epidermal necrolysis rapidly over 24 to 36 hours. Carbamazepine was then stopped. She responded immediately to high-dose intravenous pulse methylprednisone treatment. We discuss the controversy in the management of anticonvulsant hypersensitivity syndrome, toxic epidermal necrolysis, or Stevens-Johnson syndrome with high-dose corticosteroids, intravenous immunoglobulin, and antibiotics.

ADVERSE REACTIONS OF NITROFURANTOIN, TRIMETHOPRIM AND SULFAMETHOXAZOLE IN CHILDREN

PURPOSE

Many children with urological disease require long-term treatment with antibiotics. In many cases the choice of medical instead of surgical management hinges on the implied safety of certain drugs. Recently some groups have advocated subureteral injection procedures to avoid long-term antibiotics for low grade reflux. We present a concise and relevant review on the use and adverse reactions of nitrofurantoin, trimethoprim and sulfamethoxazole in children.

MATERIALS AND METHODS

We reviewed the literature regarding the safety and toxicity of these drugs. Information regarding absorption, excretion and dosing was also gathered to explain better the mechanisms of toxicity.

RESULTS

Adverse reactions in children reported in the literature related to nitrofurantoin are gastrointestinal disturbance (4.4/100 person-years at risk), cutaneous reactions (2% to 3%), pulmonary toxicity (9 patients), hepatoxicity (12 patients and 3 deaths), hematological toxicity (12 patients), neurotoxicity and an increased rate of sister chromatid exchanges. Adverse reactions in children related to trimethoprim/sulfamethoxazole are almost exclusively due to the sulfamethoxazole component, including cutaneous reactions (1.4 to 7.4 events per 100 person-years at risk), hematological toxicity (0% to 72% of patients) and hepatotoxicity (5 patients). The majority of adverse reactions were found in children on full dose therapy and not prophylaxis.

CONCLUSIONS

The use of nitrofurantoin, trimethoprim and sulfamethoxazole is safe in children for long-term prophylactic therapy. The antibiotic safety issue should not be misconstrued as an argument for surgical therapy, whether minimally invasive or not. Adverse reactions exist to these medicines but they are less common than seen in adults, presumably because of the lower dose used for therapy, and the lack of significant comorbidities and drug interactions in children. Serious side effects are extremely rare and most are reversible by discontinuing therapy. The extremely low potential for significant adverse reactions should be discussed with parents.

Fixed drug eruption in the genital area in 15 boys

Fixed drug eruption (FDE) is manifested as localized, circumscribed, round or oval plaques that characteristically recur in the same site with each use of the offending drug. The drugs most commonly implicated are phenolphthalein, barbiturates, antibiotics, salicylates, contraceptives, and anticonvulsants. FDE can appear on different parts of the body. The sites of predilection are the lips, genitalia, and sacral area. There are no reports of large series of pediatric patients with FDE involving the genitalia. We describe 15 boys with genital FDE associated with several drugs. Their average age at diagnosis was 3.2+/-2.2 years (range 6 months-8 years). The clinical presentation usually consisted of swelling and erythema of the penis and/or scrotum associated with pruritus, restlessness, urinary retention, and painful micturation. The diagnosis was supported by clinical history. The causative drugs were identified and confirmed by a provocation test, resolution after the drug was stopped, and a positive migration inhibiting factor (MIF) test. Genital FDE in children is uncommon, but the drugs associated with this entity are in such widespread use in pediatric practice that its recognition may be important, especially considering its easy treatability.

Management of cutaneous drug reactions

Drugs are potent chemicals that often have effects in the body beyond the desired action. These effects may range from mild and expected side effects to dramatic and life-threatening anaphylaxis. Adverse drug reactions account for between 2% and 6% of hospital admissions and may prevent administration of otherwise effective therapeutic agents. Cutaneous and mucocutaneous eruptions are the most common adverse reactions to oral or parenteral drug therapy, and the spectrum ranges from transitory exanthematous rash to the potentially fatal toxic epidermal necrolysis. Different mechanisms, including both immunologic and nonimmunologic, are responsible for cutaneous adverse drug reaction. The treatment of cutaneous drug eruptions essentially rests on accurate history, a thorough physical examination, discontinuation of the offending drug, and supportive care. The management of a cutaneous drug eruption is very much individualized, based on the clinical setting. This review aims to provide a general approach to the patient with a presumed cutaneous drug reaction.

Fixed drug eruptions. Incidence, recognition, and avoidance

Drug eruptions often have nonspecific clinical findings, and the evaluation of the probability of an eruption being a drug-induced event is difficult. A few types of drug eruption do not present such problems, and the fixed drug eruption is one of those whose clinical findings are specific enough to allow a diagnosis. The fixed drug eruption is a commonly reported type of drug eruption. The incidence of fixed drug eruptions has tended to increase, although the overall number of drug eruption cases has decreased. This is one of the reasons why fixed drug eruptions are familiar to dermatologists. The most characteristic findings of a fixed drug eruption are recurrence of similar lesions at the same sites and healing with residual hyperpigmentation. The residual hyperpigmentation serves as an indicator of site recognition. Diagnosis is not always easy; for example, as is the case for nonpigmenting fixed drug eruptions, which do not have any residual hyperpigmentation. The development of molecular biology may help to clarify the pathogenesis of fixed drug eruptions, but the reason for their recurrence on the same sites is still unknown. Identification of the causative drug or drugs is essential for the management of fixed drug eruptions, as it is for other drug eruptions. The causative drug or drugs and cross-reactants should be avoided to prevent recurrence. To date, rechallenge is the most reliable method of identifying causative drugs, but increasingly the use of skin tests has gained the attention of investigators. The validity and the problems of skin tests are discussed, and an approach to the clinical management of fixed drug eruptions is presented.

An unusual form of Stevens-Johnson syndrome with subcorneal pustules associated with Mycoplasma pneumoniae infection

We report a 10-year-old girl in whom Stevens-Johnson syndrome (SJS) (with acute gingivostomatitis and conjunctivitis) was associated with a pustular eruption clinically and histologically similar to Sneddon-Wilkinson subcorneal pustulosis. This is a very rare form of SJS, the true incidence of which is probably underestimated.

Recognising antibacterial hypersensitivity in children

Adverse reactions to antibacterial agents are not uncommon in children. They are classified as 'immediate' or 'nonimmediate' according to the time interval between drug administration and onset. Immediate reactions occur within 1 hour and are manifested by urticaria and/or angioedema, bronchospasm and anaphylactic shock; immunological reactions are mediated by IgE antibodies. The main nonimmediate reactions (occuring after more than 1 hour) are maculopapular rash, urticaria and serum sickness; T lymphocytes may participate in maculopapular rash. Clinical assessment of such reactions is complex. The patient's history is fundamental; the allergological examination includes in vivo and in vitro tests selected on the basis of the clinical features and the phase of reaction. In the late phase, prick and intradermal tests are sensitive in evaluating beta-lactam allergy. Together with delayed-reading intradermal testing, patch testing seems to be useful in diagnosing maculopapular reactions to systemically administered aminopenicillins. Determination of specific IgE levels is the most common in vitro method for diagnosing immediate reactions. In the acute phase, serum tryptase and urinary N-methylhistamine assays are reliable in diagnosing type I pathogenic mechanisms in immediate reactions. Unfortunately, there are few in vitro tests for evaluating other reactions, and most are not fully validated. In selected cases, provocation tests should be performed.

Fixed drug eruptions in children

To determine the anatomic location and offending drug in fixed drug eruptions (FDE) in children, we performed a 5-year retrospective analysis. Thirty-five children with FDE were evaluated. The most common cause of FDE was the combination drug trimethoprim-sulfamethoxazole.

Drug eruptions in Bangkok: a 1-year study at Ramathibodi Hospital

BACKGROUND

As new drugs are introduced onto the market, it is important to determine those that can cause cutaneous reactions and with what frequency. In addition, drugs that have been used for a long period of time may cause new types of eruption that have not been observed previously. The purpose of this study was to evaluate the types of drug eruption and the causative agents in a hospital-based population for a period of 1 year.

METHODS

All in- and outpatients consulting for drug eruptions at the Dermatology Clinic, Ramathibodi Hospital from June 1995 to May 1996 were included in the study. The history and physical examination were performed by one of the authors. In suspected cases, a skin biopsy was carried out to confirm the diagnosis. Rechallenge tests with suspected drugs were performed with informed consent.

RESULTS

One hundred and thirty-two patients were enrolled in the study. The most common types of drug eruption were maculopapular eruption, fixed drug eruption, and urticaria. Antimicrobial agents were found to be the most common causative drugs, followed by antipyretic/anti-inflammatory agents and drugs acting on the central nervous system.

CONCLUSIONS

Although the most common type of drug eruption and the most common causative agents were not different from those found in previous studies, the new generation of antibiotics and antifungal agents were found to be a frequent cause of drug eruptions. New types of drug eruption, such as generalized exanthematous pustulosis and acral erythema, were observed in this study.