Drug-induced cutaneous reactions Małgorzata Sokołowska-Wojdyło, MD, MSc, PhD Elżbieta Grubska-Suchanek MD, PhD Department of Dermatology, Venereology and Allergology, Medical University of Gdansk

Drug hypersensitivity Not expected consequences of medicaments ordered in therapeutic doses in right indication. in 2-6% of hospitalized patients in 8% of other patients

Drug-induced reactions medicaments can be applied topically or systemic different skin lesions; morphology depends from causal factors and mechnism of action in 3-4% of hospitalized patients in 5% of other patients

Reasons of appearance the drug-induced reactions Personal characters: Age and sex Genetical predisposition Some disorders The medicaments’ charcteristics: Chemical structure Additives Long-lasting treatment, especially big doses Long-lasting topical treatment

Dermatoses caused only by medicaments Dug induced reactions Dermatoses caused only by medicaments Toxic epidermal necrolysis (TEN), Lyell syndrome) Erythema perstans Acute generalised exanthematous pustulosis (AGEP) Pseudolymphoma

Drug-induced reactions Dermatoses with different etiology Utricaria Erythema multiforme, nodosum Purpura Autoimmunological disorders: - bullous diseases - systemic lupus erythematosus

Drug-induced reactions Morphology Maculo-papular eruption Hemorrhagic Lichenoidal Acneiforme Vesicular and bullous Pigmentous Morfeiform Necrotic Pruritus Hair and nails lesions

Maculo-papular exanthemas 1st description: 1967 (after ampicillin) - about 5% of ampicillin treated patients Clinical morphology can imitate infectious disorders 1st symptomes: 5 days – 2 weeks after 1st tablet Positive patch test and blastic transformation test in some cases – IV mechanism G-C (?)

Drug-induced reaction Type of reaction Causative drug Maculo-papular eruption Aminopenicylines Sulphonamides NSAiDs Anticonvulsants Psuchotropics Allopurinol ACE inhibitors beta-blockers

Drug-induced reaction Type of reaction Causative drug Urticaria Quincke edema Antibiotics (penicillin) Sulphonamides Aspirin, NSAiDs Heterologous serum Insulin Contrast medium ACE inhibitors Opiate

Drug-induced urticaria - mechanisms Allergic urticaria Cause I mechanism G-C 2. III mechanism G-C Pnc, pirazolons, sulphonamides Sera, pnc, cephalosporins Nonallergic urticaria Cuase Direct release of mediators Idiosyncrasia Inibition of inflammatory mediators inactivation Contrast media (Iod), opiates, curara, polimyksine Aspiryn, NSAiDs ACE inhibitors Angiotensines

Drug – induced reactions Type Causative drug Erythemas Erythema perstans Erythema nodosum Erythema multiforme / Stevens-Johnson syndrome barbituranes, paracetamol, sulphonamides, tetracyclines antibiotics, sulphonamides, NSAiDs, estrogens NSAiDs, barbituranes, anticonvulsants

Lyells’ syndrome (TEN) drugs ! Very rare: infections, vaccines, chemical substances, graft versus host disease Skin, mucosa of respiratory and digestive system Complications: electrolites disturbances, secondary bacterial infections

Drug-induced TEN (most often causative drugs) anticonvulsants (fenytoin, carbamazepine) pirazolones’ derivatives sulphonamides beta-lactams chinolones allopurinol

Drug-induced reactions Type cause Haemorrhagic reaction trombocytopathies trombocytopenies vasculitis ASA cytostatics antibiotics (beta-lactams, tetracyclines, streptomycine) sulphonamides NSAiDs diuretic drugs ACE inhibitors beta-blockers anticonvulsants

Vasculitis Systemic: skin, kidneys, lungs, heart, brain, digestive tract Classifications’ criteria: - etiopathogenesis - clinical picture - vessels anatomy - histopathological picture

Allergic (leucoclastic) vasculitis Hierergic purpur (polymorphous lesions ) III mechanism G-C Causative factors: bakteria, viruses, fungi, protozoa, drugs, food

Drug-induced reactions Type Cause Phototoxic, photoallergic psolarens sulphonamides NSAiDs tetracyclines chinolones thiazydes furosemid antimalarial antidepressive hormones

Photohypersensitivity Typ reakcji Obraz kliniczny Phototoxic Photoallergic Sun burn like lesions (only on sun exposed skin), hiperpigmentations, lichenoid exanthemas, lupus-like, PCT Eczema-like (can be not only on sun exposed skin)

Drug-induced reactions Type Cause Erythrodermia barbiturans carbamazepine nitrofurantoin NSAiDs sulphonamides thiazides

Caution! anticonvulsants sulphonamides pirazolones antibiotics (beta-lactams)