In Situ Patch Test and Repeated Open Application Test for Fixed Drug Eruption: A Multicenter Study

BACKGROUND

Few studies have evaluated allergy workup in fixed drug eruption (FDE) in a large population.

OBJECTIVE

To evaluate the sensitivity of a standardized allergy workup for diagnosing the cause of FDE, with a focus on in situ repeated open application tests (ROATs).

METHODS

In a retrospective multicenter study, we analyzed the practice of conducting a complete allergy workup for the etiological diagnosis of FDE. It consisted of 3 steps: in situ patch tests (PTs) for all cases except pure mucosal involvement, followed by in situ ROAT if in situ PT results were negative, and finally a drug challenge (DC). The in situ ROAT involved daily application of the suspected drug on a previously affected FDE site for 7 days.

RESULTS

Of 98 suspected FDE cases, 61 patients (median age 61 y; male-to-female ratio 1.8) with a complete allergy workup were included. In 4 cases, even the DC yielded negative results. Among the remaining 57 patients with a positive workup, implicated drugs included paracetamol (12 cases), β-lactams (11 cases), imidazoles (9 cases, including 5 with metronidazole), nonsteroidal anti-inflammatory drugs (8 cases), iodinated contrast media (4 cases), cotrimoxazole (3 cases), and various other drugs in 10 patients. The diagnosis was confirmed by in situ PT in 17 of 54 cases (31.5%), in situ ROAT in 14 of 40 cases (35%) (with 4 cases showing remote reactivation of FDE sites), and DC in 26 cases.

CONCLUSIONS

The sequential allergy workup involving successively in situ PT, in situ ROAT, and DC is a reliable and safe method for diagnosing the cause of FDE. In situ tests exhibited a sensitivity of over 50%.

Recurrent Fluconazole-Induced Fixed Drug Eruption of the Digit with Nail Matrix Involvement: A Case Report and Review of the Literature

Introduction

Fixed drug eruptions (FDEs) are cutaneous hypersensitivity reactions due to an offending drug and are rarely associated with nail involvement. Moreover, FDEs associated with fluconazole use are sparsely reported in literature.

Case Presentation

We report a case of a recurrent FDE with involvement of one finger and corresponding Beau's lines due to fluconazole use. The diagnosis of FDE secondary to fluconazole use was confirmed histopathologically, with improvement after the application of twice daily 0.05% clobetasol propionate ointment.

Conclusion

FDEs are hypersensitivity reactions that occur after exposure to an offending drug. FDEs uncommonly affect the nail matrix and are often not caused by fluconazole. It is important for dermatologists to assess for changes in the nail plate when evaluating a patient with FDE and evaluate all medications a patient is taking.

Photobiomodulation Therapy for Multiple Painful Fixed Drug Eruptions: The First Case Report

Introduction: Fixed drug eruption (FDE), a very specific adverse drug reaction and one of the most common types of drug eruption, generally resolves spontaneously within 7-10 days upon withdrawal of the causative agent; however, extensive and severe cases may also require systemic drug therapy. The present study aimed to report a case in which a broad spectrum of severe, painful lesions of FDE was managed with photobiomodulation therapy (PBMT). Case Report: A 31-year-old Caucasian woman presented with many extremely painful mucocutaneous lesions of FDE which had arisen 8 days before, following a long period of hospitalization. The lesions were not responsive to either corticosteroids or analgesics within 5 days, and then seven daily sessions of PBMT were proposed. Pain alleviation was achieved on the 1^st day of PBMT, and the lesions showed an advanced course of healing on the 3^rd day. Within 7 days of PBMT, the lesions were almost completely repaired. In a 3-month follow-up period, no relapse of any FDE lesion was reported. Conclusion: PBMT may be a promising strategy for the management of painful lesions of FDE refractory to conventional medication therapy. However, further studies are needed to confirm this hypothesis.

Oral fixed drug eruption: Analyses of reported cases in the literature

BACKGROUND

This analytic study aimed to summarize the data regarding OFDEs manifestations and characteristics available up to date.

MATERIALS AND METHODS

We searched online databases for relevant articles and summarized their data regarding age, gender, Main drug classification and name, additional drugs, dosages, primary disorders, OFDE presentation and location, extra-oral presentation and location, follow-up, and treatment.

RESULTS

The mean age of OFDE-affected patients was 38.9. Most of the reported cases were between 30 and 60 years of age. The female/male ratio was 1.12/1. Three drug classifications, which were mainly associated with OFDEs, were analgesics (27.8%), antibiotics (22.2%), and antifungals (11.1%). The most common additional drugs were oral contraceptives and corticosteroids. The three most prevalent disorders or conditions were infectious disease (23.7%), pain (13.2%) and auto-immune disease (10.5%). Erythematous lesions without blister (38.9%), lichenoid drug eruptions (16.7%), blisters/vesicles (13.9%) and ulcers (13.9%) were the most common manifestations of OFDEs. The rarest manifestation of OFDE was pigmentation. Lips, tongue, buccal mucosa, palate and gingiva were the sites in which OFDEs occurred in the included studies. Similar to OFDEs, erythematous lesions without blisters and lichenoid drug eruptions were the most prevalent extra-oral manifestations. The most common time for OFDE manifestations was one to three days after taking the drug.

CONCLUSIONS

Due to the similarities between the reported cases of OFDEs, clinicians should familiarize themselves with OFDE cases in order to screen suspected patients effectively.

Fixed drug eruption and anaphylaxis induced concurrently by erdosteine: a case report

BACKGROUND

Erdosteine is used as a mucolytic agent and has a low incidence of adverse drug reactions, most of which are gastrointestinal and mild. Moreover, drug antigens rarely induce multiple simultaneous immunologic reactions. Only one previous case report has demonstrated hypersensitivity reaction induced by erdosteine. Here, we report a case of fixed drug eruption and anaphylaxis, which were concurrently induced by erdosteine. The association between the symptoms and erdosteine was proven by a drug provocation test.

CASE PRESENTATION

A 35-year-old woman presented with recurrent angioedema and pruritic rash on the hands, which developed within 2 h following the administration of drugs, including erdosteine, for acute upper respiratory infection. Her rash was characterized by well-defined erythematous plaques, which recurred at the same site following the administration of the medications. She also experienced angioedema of the lips. Fixed drug eruption was considered after excluding other possible causes for the presented skin lesions. A drug provocation test confirmed that fixed drug eruption on both hands had occurred after administration of erdosteine, suggesting that erdosteine was the cause of the allergic reaction. However, she also experienced angioedema, isolated wheal, and laryngeal edema; thus, IgE-mediated type I hypersensitivity could also be concurrently occurring with the fixed drug eruption.

CONCLUSIONS

We report about a patient who was diagnosed with two different hypersensitivity reactions concurrently induced by erdosteine. We also demonstrate that patients may exhibit multiple simultaneous symptoms that usually arise from overlapping of different hypersensitivity mechanisms. Physicians should be aware of the possibility that some patients who are allergic to certain drugs could exhibit several symptoms caused by different mechanisms of hypersensitivity reactions simultaneously.

Lichenoid dermatoses involving the vulva: A clinical-pathologic correlation✰

The lichenoid tissue reaction pattern generally signifies cytotoxic damage to the epithelium. When such reaction pattern occurs on vulvar skin or mucosa, the effects can result in considerable morbidity. None of the entities discussed in this review are entirely unique to the vulva, however, some entities may classically occur at this site, while others tend to be widespread diseases that may incidentally affect vulvar skin and mucosa. Given the complex anatomy of the vulva and the bridging of a site showing both keratinizing squamous epithelium and non-keratinizing squamous mucosa, histopathologic features may display variation in presentation. Although identification of a "lichenoid reaction pattern" alone may provide insight into the disease process, understanding of clinical presentation and specific sites of involvement, along with recognition of the nuanced features of the disease entities can help establish a specific diagnosis. Accurate histopathologic diagnoses by pathologists can improve the ability for treating clinicians to implement timely and effective treatment.

Tissue-resident memory T cells in the skin

PURPOSE

Tissue-resident memory T (T_RM) cells are a newly described subset of memory T cells. The best characterized T_RM cells are CD8+ and express CD103 and CD69. These cells are non-recirculating and persist long term in tissues, providing immediate protection against invading pathogens. However, their inappropriate activation might contribute to the pathogenesis of autoimmune and inflammatory disorders. In the skin, these cells have been described in psoriasis, vitiligo, and melanoma among other diseases.

METHODS

Literature review was done to highlight what is currently known on the phenotype and function of T_RM cells and summarizes the available data describing their role in various cutaneous conditions.

RESULTS

Resolved psoriatic skin and disease-naïve non-lesional skin contain a population of IL-17-producing T_RM cells with shared receptor sequences that recognize common antigens and likely contribute to disease recurrence after cessation of therapy. In vitiligo, T_RM cells produce perforin, granzyme B, and interferon-γ following stimulation by interleukin-15 and collaborate with recirculating memory T cells to maintain disease. In melanoma, increased accumulation of T_RM cells was recently shown to correlate with improved survival in patients undergoing therapy with immune checkpoint inhibitors.

Cefotaxime induced generalized bullous fixed drug eruption - A case report

•

Based on the characteristics of the antimicrobial spectrum of Cefotaxime, low incidence of allergy, and lack of adverse effects, Cefotaxime has been used successfully for prophylaxis of a number of infectious diseases.

•

Drug reactions like FDE are very frequently seen by dermatologists in the day to day practice. FDE to Cefotaxime is not usual.

•

Healthcare professionals should have a high index of suspicion should aware of the possibility of reactions to Cephalosporin.

Fixed drug eruption (FDE) is the most common cutaneous adverse drug reaction. Cefotaxime, a broad-spectrum third-generation cephalosporin, appeared to be a safe and effective therapy in greater than 90% of infections including cellulitis, abscesses and necrotizing ulcers of the skin and subcutaneous tissues but here we report a rare case of 36 years old female patient developed generalized bullous FDE after intravenous administration of Cefotaxime.

Ivermectin-induced fixed drug eruption in an elderly Cameroonian: a case report

Background

Cutaneous adverse reactions to medications are extremely common and display characteristic clinical morphology. A fixed drug eruption is a cutaneous adverse drug reaction due to type IV or delayed cell-mediated hypersensitivity. Ivermectin, a broad-spectrum anti-parasitic compound, has been an essential component of public health campaigns targeting the control of two devastating neglected tropical diseases: onchocerciasis (river blindness) and lymphatic filariasis.

Case presentation

We report the case of a 75-year-old Cameroonian man of the Bamileke ancestry who developed multiple fixed drug eruptions a few hours following ivermectin intake that worsened with repeated drug consumption. Discontinuation of the drug, counselling, systemic steroids, and orally administered antihistamines were the treatment modalities employed. Marked regression of the lesions ensued with residual hyperpigmentation and dyschromia.

Conclusion

Keen observation on the part of physicians is mandatory during the administration of ivermectin for quick recognition and prevention of this adverse drug reaction.

[Histopathology of cutaneous drug reactions]

There are many different types of cutaneous adverse reactions. The most classical reactions are driven by T lymphocytes that specifically react towards a drug, with an individual genetic susceptibility linked to certain type I major histocompatibility complex alleles. These reactions are characterized by a wide variety of clinical and histopathological presentations, and a wide range of severity. The most frequent entity is the maculopapular rash, while the most aggressive forms are the Steven-Johnson syndrome and toxic epidermal necrolysis (SJS-TEN). The histopathological alterations associated to each of these syndromes have been better described in the literature during the past 10 years, encompassing non-specific lesions, as in most drug induced maculopapular rashes, to more specific inflammatory patterns. The finding of confluent apoptotic keratinocytes with epidermal detachment is the prototypical aspect of SJS-TEN. There are however numerous pitfalls, and a similar aspect to those observed in each cutaneous drug reactions entities can be found in other diseases. DRESS syndrome can indeed present with dense and epidermotropic T-cell infiltrate, sometimes with nuclear atypias, and thus can be difficult to distinguish from a primary or secondary cutaneous T-cell lymphoma. The diagnosis of cutaneous adverse reactions relies on a clinical-pathological confrontation and requires an accurate evaluation of drug imputability.

Fixed Drug Eruption to Supplement Containing Ginkgo Biloba and Vinpocetine: A Case Report and Review of Related Cutaneous Side Effects

BACKGROUND: Fixed drug eruption is a cutaneous reaction to a systemic agent that typically presents as an annular or oval erythematous patch or blister and subsequently resolves with postinflammatory hyperpigmentation at the site. Ginkgo biloba leaf extract and vinpocetine are nutritional supplements used to enhance memory in patients with dementia and age-related memory impairment conditions such as Alzheimer's disease. PURPOSE: To describe a fixed drug eruption in a man who repeatedly developed pruritus and macular erythema on his distal penile shaft after ingesting a natural product containing Ginkgo biloba and vinpocetine. METHODS: The medical literature was retrospectively reviewed using PubMed, searching specifically for the terms cutaneous/skin adverse/side effects, fixed drug eruption, Ginkgo biloba, and vinpocetine. Patient reports and previous reviews of the subject were critically assessed, and the salient features of cutaneous adverse effects in patients receiving either Ginkgo biloba or vinpocetine are presented. RESULTS: Cutaneous adverse effects from Ginkgo biloba and vinpocetine are infrequent. Ginkgo biloba fruit can result in contact dermatitis (following topical exposure) and mucosal symptoms of the mouth and anus (following oral exposure); in addition, an erythematous maculopapular generalized eruption or possibly Steven-Johnson syndrome can occur after oral ingestion of the Ginkgo biloba leaf extract. Facial erythema has been associated with vinpocetine ingestion. Pruritus and an annular erythema localized to the distal penile shaft developed after initial and repeat ingestion of a Ginkgo biloba/vinpocetine product. CONCLUSION:Ginkgo biloba and vinpocetine should be added to the agents that can potentially cause a fixed drug eruption.

A Rare Case of Fixed Drug Eruption due to Ondansetron

Fixed drug eruption (FDE) is a unique type of cutaneous drug reaction that typically recurs in the identical locations on re-exposure to the attributed drug. FDE is characterized by the appearance of a single or multiple sharply demarcated violaceous erythematous plaques which heal with residual hyperpigmentation. A 27-year-old woman presented with multiple dark patches over her eyelids, mouth, lips, and shoulders of 1 week's duration. These lesions followed multiple erythematous plaques over the same areas which appeared within 4 hours of the intake of an ondansetron tablet, 12 days previously. The case was diagnosed as post-inflammatory hyperpigmentation following ondansetron-induced FDE. There was an identical episode 1 year earlier due to the intake of the same drug. The causality assessment pointed toward a probable/likely association as per the Naranjo algorithm and the WHO-UMC scale. There have been only a few cases of FDE due to ondansetron in the reported literature.

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.

Tranexamic Acid-Induced Fixed Drug Eruption

A 33-year-old male showed multiple pigmented patches on his trunk and extremities after he took tranexamic acid for common cold. He stated that similar eruptions appeared when he was treated with tranexamic acid for influenza 10 months before. Patch test showed positive results at 48 h and 72 h by 1% and 10% tranexamic acid at the lesional skin only. To our knowledge, nine cases of fixed drug eruption induced by tranexamic acid have been reported in Japan. Tranexamic acid is a safe drug and frequently used because of its anti-fibrinolytic and anti-inflammatory effects, but caution of inducing fixed drug eruption should be necessary.

Fixed drug eruptions with modafinil

Modafinil is a psychostimulant drug, which has been approved by the US Food and Drug Administration for the treatment of narcolepsy associated excessive daytime sleepiness, sleep disorder related to shift work, and obstructive sleep apnea syndrome. However, presently it is being used as a lifestyle medicine; in India, it has been misused as an "over the counter" drug. Modafinil is known to have several cutaneous side effects. Fixed drug eruption (FDE) is a distinctive drug induced reaction pattern characterized by recurrence of eruption at the same site of the skin or mucous membrane with repeated systemic administration. Only two case reports exist in the literature describing modafinil induced FDE until date. Here, we report two similar cases. The increasing use of this class of drug amongst the medical personnel might be posing a threat to the proper use and encouraging subsequent abuse. There might be a considerable population using these drugs unaware of the possible adverse effects. Authorities should be more alert regarding the sale and distribution of such medicines.

Fixed drug eruption to sitagliptin

Fixed drug eruption is a common adverse effect seen with various drugs notably antibiotics, antiepileptics and non-steroidal anti-inflammatory drugs. Herein we report a case of Sitagliptin induced fixed drug eruption in a 46 year old female who developed circumscribed, erythematous macules all over the body within one week of initiation of Sitagliptin. The lesions resolved with residual hyperpigmentation on cessation of the drug. The diagnosis was confirmed by an oral provocation test which led to a reactivation of the lesions. To the best of our knowledge, this is the first case of fixed drug eruption to Sitagliptin reported in the literature.

[Fixed drug eruption after taking ethambutol]

INTRODUCTION

Fixed drug eruption (FDE) is a specific skin reaction and the only exclusively medicinal dermatosis. Among the drugs usually responsible are the antituberculous antibiotics including rifampicin and, less often, isoniazid and pyrazinamide. FDE after taking ethambutol is rarely described.

CASE REPORT

A 32-year old HIV negative patient presented a FDE localized to the internal surface of the lips and the interdigital folds during the 4th month of antituberculous treatment comprising rifampicin, isoniazid and ethambutol. The diagnosis was supported by the characteristic appearances of the lesions of FDE and their early reappearance in the same areas after accidental reintroduction of antituberculous triple therapy including ethambutol. Double-agent therapy with rifamicin and isoniazid was tolerated well.

CONCLUSION

Discovery of FDE requires a rigorous search for the responsible medicine. During antituberculous treatment, the practitioner has to bear in mind the potential role of ethambutol, which is possibly potentiated by rifampicin.

[Drug patch tests in the investigation of a fixed drug eruption subsequent to 2 courses of cyclophosphamide in combination with mesna]

BACKGROUND

When fixed drug eruption occurs following use of cyclophosphamide and mesna, it is difficult to establish which drug is responsible. We report a new case of patch tests that resulted in withdrawal of mesna and enabled continued treatment with cyclophophamide.

PATIENTS AND METHODS

A 57-year-old female patient with multiple sclerosis presented increasingly severe cutaneous lesions after successive courses of cyclophosphamide. Twenty-four hours after her latest treatment, she presented at the ER with a worse eruption than those to date and including facial lesions. The clinical diagnosis was a fixed drug eruption, and patch tests for mesna one month later were positive.

CONCLUSION

Fixed drug eruption always occurs after recurrent treatment and the investigation must be precise. Patch tests may be used to determine which drug could be responsible. The most conclusive test comprises withdrawal of the incriminated drug with no further signs of drug eruption on resumption of the other medication.

Fixed drug eruption due to ornidazole

A 56-year-old male developed an ulcer on his glans penis and mucosae of upper and lower lips 3 days after taking ofloxacin, cephalexin, and ornidazole. Clinically, a provisional diagnosis of fixed drug eruption was made. The causative drug was confirmed by an oral provocation test which triggered a reactivation of all lesions only with ornidazole.

Non pigmenting mucosal fixed drug eruption due to tadalafil: A report of two cases

Various ‘sex-stimulant’ medicines with fancy names and attractive packaging are available over the counter. Most contain phosphodiesterase 5 inhibitors in various strengths, often with herbal additions. These drugs are used erratically by the lay public, driven by folklore that such usage leads to increase in the length, girth or firmness of the penis. Such indiscriminate use by an otherwise healthy population leads to undue side effects.

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.

Causality, severity and preventability assessment of adverse cutaneous drug reaction: a prospective observational study in a tertiary care hospital

INTRODUCTION

The number of subjects involved in a clinical trial are limited, whose findings cannot be extrapolated to the entire population.Due to the emergence of newer molecules the pattern of Adverse Cutaneous Drug Reaction(ACDR) also changes frequently. The need for this study is for early diagnosis, to reduce the morbidity and mortality due to ACDR and to ensure safety of the patients.

MATERIAL AND METHODS

Forty one subjects with the diagnosis of ACDR were included in the study for a period of 12 months(Jan 2009- Dec 2009). The informations such as patient demographic details, drug history, associated comorbid conditions and pattern of the skin reaction were noted. Assessment was done for causality, severity and preventability using separate valid scales.

RESULTS

The most common ACDR was fixed drug eruption (43.9%) and the most common causative drug for the same was surprisingly found to be paracetamol. Antimicrobials were the most common causative drug group and two significant associated risk factors were multiple drug intake and history of allergy. Among the total reactions 78% were of probable category and 59% were of moderate level severity reaction. Out of which 12% of the cases were definitely preventable.

A case of levocetirizine-induced fixed drug eruption and cross-reaction with piperazine derivatives

Fixed drug eruption is an uncommon adverse drug reaction caused by delayed cell-mediated hypersensitivity. Levocetirizine is an active (R)-enatiomer of cetirizine and there have been a few reports of fixed drug eruption related to these antihistamines. We experienced a case of levocetirizine-induced fixed drug eruption and cross-reaction with other piperazine derivatives confirmed by patch test. A 73-year-old female patient presented with recurrent generalized itching, cutaneous bullae formation, rash and multiple pigmentation at fixed sites after taking drugs for common cold. She took bepotastine besilate (Talion®) and levocetirizine (Xyzal®) as antihistamine. She took acetaminophen, pseudoephedrine 60 mg / triprolidine 2.5 mg (Actifed®), dihydrocodeinebitartrate 5 mg / di-methylephedrine hydrochloride 17.5 mg / chlorpheniramine maleate 1.5 mg / guaifenesin 50 mg (Codening®) and aluminium hydroxide 200 mg / magnesium carbonate 120 mg (Antad®) at the same time. Patch test was done with suspected drugs and the result was positive with levocetirizine. We additionally performed patch test for other antihistamines such as cetirizine, hydroxyzine, fexofenadine and loratadine. Piperazine derivatives (cetirizine and hydroxyzine) were positive, but piperidine derivatives (fexofenadine and loratadine) were negative to patch test. There was no adverse drug reaction when she was challenged with fexofenadine. We report a case of levocetirizine-induced fixed drug eruption confirmed by patch test. Cross-reactions were only observed in the piperazine derivatives and piperidine antihistamine was tolerant to the patient.

Fixed drug eruption to fluconazole: a case report and review of literature

Fixed drug eruption (FDE) is mainly characterized by skin lesions that recur at the same anatomic sites upon repeated exposures to an offending agent. It represents the most common cutaneous adverse drug reaction pattern in Indian patients. Here, we report an FDE to fluconazole.

Flurbiprofen-induced generalized bullous fixed drug eruption

Fixed drug eruption (FDE) is an unusual drug-related side effect that results in recurrent lesions whenever the causative drugs are used. FDEs usually occur as a single, sharply demarcated, round erythematous patch or plaque, occasionally with localized bullae. The most common offending agents include antimicrobials, nonsteroidal anti-inflammatory drugs, and antiepileptics. There are some reports where contact dermatitis and cutaneous vasculitis have been associated with the use of flurbiprofen. We present the case of a 50-year-old man with flurbiprofen-induced generalized bullous FDE. To the best of our knowledge, the most serious form of FDE, the generalized bullous FDE, to be caused by flurbiprofen has not been reported previously.

A case of fixed drug eruption due to doxycycline and erythromycin present in food

A fixed drug eruption (FDE) is not difficult to diagnose, given its clinical characteristics. However, the causative agent can be difficult to identify, particularly when the patient denies ingestion of any drugs. To the best of our knowledge, we present herein the first reported case of an FDE caused by antibiotics taken in food; doxycycline and erythromycin contained in pork and fish. A 57-year-old female experienced repeated episodes of well-demarcated erythematous patches covering her entire body. She denied taking any medications, but she thought that the lesions appeared after consuming pork and/or fish. An oral provocation test showed positive results for doxycycline and erythromycin, commonly used antibiotics in live-stock farming and in the fishing industry. Because of the antibiotics' thermostability, cooking does not guarantee the elimination of residual drugs. From the patient's history, we concluded that doxycycline and erythromycin contained in the pork and fish that she ate were the cause of the FDE.

Maximal Points of Head's Zone in Fixed Drug Eruption

The principles determining the primary localization of lesions in fixed drug eruption (FDE) are still unknown. Studies investigating the predilection areas in FDE have indicated drug-related, trauma-related, or inflammation-related specific site involvement, as well as visceracutaneous reflex-related specific site involvement. The importance of viscerocutaneous reflexes for the location of dermatoses was first recognized in the 1960s. Head's zones are viscerocutaneous reflex projection fields on the skin that extend over certain dermatomes and possess a reflex-associated maximal point. Recently, in a Turkish collective of patients, three women with the primary location of FDE lesions on the maximal points of Head's zones were presented. We also experienced 3 cases with FDE where the lesions were located at specific sites (buttocks), the so-called maximal points of Head's zones, which are known to be the most active dermatomal areas of an underlying visceral pathology. An underlying internal disturbance (ureter stone, pyelonephritis and chronic pelvic inflammatory disease) was found in all 3 patients, corresponding to the organ-related maximal point of Head's zones in each case. In conclusion, the primary location of FDE lesions on the maximal points of Head's zones revealed relevant organ disorders with corresponding projection fields.

Fixed drug eruption due to allopurinol: positive oral provocation

A fixed drug eruption (FDE) is characterized by the presence of a solitary or multiple, pruritic, well-circumscribed, erythematous plaques. These lesions have tendency to recur at same sites and heal with residual hyperpigmenation. With repeated attacks, the size and/or number of the lesions may increase. So far, more than 100 drugs have been implicated in causing FDEs, including ibuprofen, sulfonamide, naproxen, and tetracylines. FDE caused by allopurinol has been rarely reported in the literature, but there has been no confirmed case based on oral provocation test. Herein, we report a case of FDE in which the lesions recurred whenever allopurinol was administered for the treatment of gout. A 64-year-old male experienced repeated episodes of well-demarcated dusky erythematous patches on the whole body for 2 months. He took allopurinol intermittently for amelioration of his gout symptom, but denied other medication history. Pruritic erythematous edema developed on the previous lesions 12 hours after oral provocation of 200 mg of allopurinol.

Fixed Drug Eruption due to Iopromide (Ultravist®)

A 69-year-old male presented with several painful erythematous patches on both palms and trunk several days after receiving iopromide (Ultravist®, Shering, Berlin, Germany). A fixed drug eruption (FDE) due to iopromide was suspected clinically. However, at that time, the patch test with iopromide at the lesion site gave negative results. Three years later, the patient was mistakenly administered iopromide again and patches with vesicles recurred on the same sites as well as on the genitalia. This episode was repeated once again after 1 year. In all episodes, the skin lesion resolved after application of topical steroids. Although a patch test with iopromide was negative in our case, we made a diagnosis of FDE due to iopromide because the skin lesions occurred again at the previously involved area after re-exposure to iopromide. To date, only three cases of FDE caused by non-ionic monomers have been documented in the English literature. Herein, we report on an interesting case of FDE caused by iopromide.