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Drug Eruptions for the Teledermatologist

Objective. Review drug rashes from minor to life-threateningTypical Benign Drug ExanthemHives/AngioedemaDRESS (Hypersensitivity reaction)SJS/TEN. Some drugs are worse than others rate of skin eruptions associated with?. AntibioticsAminopenicillins 5-7%Antibacterial sulfonamides 3-4%Antiepile

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Drug Eruptions for the Teledermatologist

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    1. Drug Eruptions for the Teledermatologist Jay Vary, MD PhD Acting Instructor, Dermatology VAPSHCS and UW jvary@uw.edu

    2. Objective Review drug rashes from minor to life-threatening Typical Benign Drug Exanthem Hives/Angioedema DRESS (Hypersensitivity reaction) SJS/TEN

    3. Some drugs are worse than others rate of skin eruptions associated with… Antibiotics Aminopenicillins 5-7% Antibacterial sulfonamides 3-4% Antiepileptics 5-10% Allopurinol Rate of skin eruptions associated with drugsRate of skin eruptions associated with drugs

    6. Typical Benign Drug Exanthem Aka maculopapular or “morbilliform” ~90% of cutaneous drug reactions. Type IV (T-cell mediated) hypersensitivity reaction. Starts 7-14d after start of drug Stops up to 7d after stopping drug Morbilliform: ; erythematous macules or papules, symmetric, starts on trunk/upper limbs and become confluent; mucous membranes sparedMorbilliform: ; erythematous macules or papules, symmetric, starts on trunk/upper limbs and become confluent; mucous membranes spared

    7. Erythematous, macules with some areas of confluenceErythematous, macules with some areas of confluence

    8. Later in course can become more dusky red/brownishLater in course can become more dusky red/brownish

    10. Benign Drug Exanthem Treatment STOP the offending agent Oral antihistamines (benadryl, hydroxyzine) Topical steroids help a little

    12. Urticaria (hives) Type I immune response, IgE mediated Rapid onset within minutes of exposure, lasts hours Intensely pruritic Opiates (mast cell activation), Antibiotics-penicillins, sulfa, vanco radiocontrast, transfusion, latex

    13. This could look like ANYTHING - bullous pemphigoid, Sweet’s syndrome, fungal infection…identifying characteristic is chronicity - fast on, fast offThis could look like ANYTHING - bullous pemphigoid, Sweet’s syndrome, fungal infection…identifying characteristic is chronicity - fast on, fast off

    16. STOP the offending agent Oral antihistamines (benadryl, hydroxyzine)

    17. Day 1 fever, n/v, rash, ear pain, dysuria, tender cervical lymphadenopathy Doxycycline 4 weeks earlierfever, n/v, rash, ear pain, dysuria, tender cervical lymphadenopathy Doxycycline 4 weeks earlier

    18. Day 3

    19. DRESS Drug reaction with eosinophilia and systemic symptoms—aka “drug/dilantin hypersensitivity syndrome” Type IV delayed hypersensitivity reaction Onset 2-8 weeks after first exposure Can be fatal (10%) if untreated

    21. DRESS Treatment STOP the offending agent PO or IV steroids

    22. Day of Admit 2 weeks earlier, started lamictal at 4 times the intended dose. Presented c/o “flu”. Fever2 weeks earlier, started lamictal at 4 times the intended dose. Presented c/o “flu”. Fever

    23. Day 2

    24. Day 4

    25. What is it, and is their skin going to fall off? EM minor=targetoid lesions, +/- blisters, acral distribution. herpes/mycoplasma. recurrent, no mortality. More blisters and more mucosal involvement = EM major. Classification is contraversial but has major implications for mortality, ranging from ZERO to 60%.EM minor=targetoid lesions, +/- blisters, acral distribution. herpes/mycoplasma. recurrent, no mortality. More blisters and more mucosal involvement = EM major. Classification is contraversial but has major implications for mortality, ranging from ZERO to 60%.

    26. Stevens-Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN) Rare; 1-2 cases per million person years Occurs 1-3 weeks after starting drug; sooner if rechallenged URI-prodrome 1-2 weeks before rash fever (universal), conjunctivitis, pharyngitis, pruritis and PAINFUL SKIN!! 1922, named after two guys, described in two boys aged 7,8 originally thought to have hemorrhagic measles1922, named after two guys, described in two boys aged 7,8 originally thought to have hemorrhagic measles

    27. SJS

    28. TEN

    30. SJS/TEN Treatment STOP the offending agent Admit-Refer to burn ICU if TEN Ophtho & Gyn consultation to prevent irreversible scarring Consider PO or IV steroids or IVIG, but benefits are unclear.

    31. Acute Exanthematous Generalized Pustulosis (AGEP)

    32. Phototoxic reaction

    33. Drug induced Lupus

    34. Drug induced vasculitis

    35. Fixed Drug Eruption

    36. Drug induced pigmentation

    39. Thank you

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