To confirm ATT induced erythroderma and narrow down the offending agents, sequential rechallenge with ATT was done and again these patients had similar lesions erupt all over the body only with isoniazid and pyrazinamide. Ann Intern Med. In order to rule out autoimmune blistering diseases, direct immune fluorescence staining should be additionally performed to exclude the presence of immunoglobulin and/or complement deposition in the epidermis and/or the epidermal-dermal zone, absent in ED. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Ophthalmologic consultations must be repeated at fixed intervals to avoid the appearance of conjunctival irreversible complications such as chronic conjunctivitis with squamous metaplasia, trichiasis, symblepharon, punctate keratitis and sicca syndrome. [49] confirmed these results and even suggested that higher dosage regimen with 2.74g/kg seem to be more effective in survival outcome. J Allergy Clin Immunol. Patients should be educated to avoid any causative drugs. It is recommended to use 1.5mg/kg hydrocortisone. Incidence and drug etiology in France, 1981-1985. The taper of steroid therapy should be gradual [93]. Next vol/issue This has been called the nose sign.18, Once the erythema is well established, scaling inevitably follows (Figure 1). 1998;282(5388):4903. Clinical Considerations for Treatment and Prophylaxis of Mpox Infection 2011;71(5):67283. Infliximab was used in cases refractory to high-dosage steroid therapy and/or IVIG. Drug eruptions that initially present as morbilliform, lichenoid or urticarial rashes may progress to generalized exfoliative dermatitis. McCormack M, et al. Theoretically, any drug can trigger a reaction, but the medications most associated with this disorder are: Allopurinol; Antiepileptic medications; Barbiturates Exfoliative Dermatitis - StatPearls - NCBI Bookshelf Patients present an acute high-grade of skin and mucosal insufficiency that obviously leads to great impairment in the defenses against bacteria that normally live on the skin, increasing the high risk of systemic infections. Beneficial effect of plasma exchange in the treatment of toxic epidermal necrolysis: a series of four cases. Download. Dermatitis - Diagnosis and treatment - Mayo Clinic Sassolas B, et al. Tumor necrosis factor : TNF- seems also to play an important role in TEN [41]. Article Exfoliative Dermatitis: Symptoms, Causes, and Treatment - WebMD Yamada H, Takamori K. Status of plasmapheresis for the treatment of toxic epidermal necrolysis in Japan. Ann Allergy Asthma Immunol. Nature. Drug-Induced Kidney Injury & Exfoliative Dermatitis Symptom Checker: Possible causes include Gold Salt. The authors wish to thank Dr. Gary White for the picture of EM showed in Fig. N.Z. Australas J Dermatol. Wolkenstein P, et al. A population-based study with particular reference to reactions caused by drugs among outpatients. Jang E, Park M, Jeong JE, Lee JY, Kim MG. Sci Rep. 2022 May 12;12(1):7839. doi: 10.1038/s41598-022-11505-0. Exfoliative dermatitis is characterized by generalized erythema with scaling or desquamation affecting at least 90% of the body surface area. 2011;50(2):2214. 2012;27(4):21520. PubMed Barbaud A. Considered variables in SCORTEN are shown in Table2. A marked increase in serum soluble Fas ligand in drug-induced hypersensitivity syndrome. The serum levels of granulysin were also found to be increased in the early stage of SJS/TEN, but not in other cutaneous DHR [40]. 1996;135(2):3056. The velocity of infusion should be regulated according to patients arterial pressure with the aim of 30mL/h urinary output (1mL/kg/h in case of a child). Exfoliative Dermatitis to Anti Tubercular Drugs - Academia.edu Initial symptoms could be aspecific, as fever, stinging eyes and discomfort upon swallowing, occurring few days before the onset of mucocutaneous involvement. Kirchhof MG et al. Blood gas analysis, glucose and creatinine levels together with electrolytes should be evaluated and therapy should be modified accordingly. Hematologic: anemia, including aplastic and hemolytic. In: Eisen AZ, Wolff K, editors. journal.pds.org.ph In more severe cases corneal protective lens can be used. Here we provide a systematic review of frequency, risk factors, molecular and cellular mechanisms of reactions, clinical features, diagnostic work-up and therapy approaches to drug induced ED. New York: McGraw-Hill; 2003. pp. Other clinical findings include lymphadenopathy, hepatomegaly, splenomegaly, edema of the foot or ankle4,6 and gynecomastia.19, The scaling that occurs in exfoliative dermatitis can have severe metabolic consequences, depending on the intensity and the duration of the scaling. 2023 BioMed Central Ltd unless otherwise stated. HHS Vulnerability Disclosure, Help Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. An increased metabolism is typical of patients with extended disepithelizated areas. Contact Dermatitis. Correction of hyperthermia or hypothermia Antibiotic administration when underlying infection is suspected or identified as cause of exfoliative dermatitis or when a secondary skin and soft. A slow acetylator genotype is a risk factor for sulphonamide-induced toxic epidermal necrolysis and StevensJohnson syndrome. Case Presentation: We report the development of forearm panniculitis in two women during the treatment with Panitumumab (6 mg/Kg intravenous every 2 weeks) + FOLFOX-6 (leucovorin, 5- fluorouracil, and oxaliplatin at higher dosage) for the . The EuroSCAR-study. Allergic rhinitis and atopic dermatitis. Medical search. Web J Dermatol. Skin conditions. Cookies policy. Four cases are described, two of which were due to phenindione sensitivity. Harr T, French LE. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. d. Cysts and tumors. J Am Acad Dermatol. In conclusion we suggest that therapy with cyclosporine is valuable option with a dosage of 35mg/kg oral or iv for 7days. Death ligand TRAIL, secreted by CD1a+and CD14+cells in blister fluids, is involved in killing keratinocytes in toxic epidermal necrolysis. J Allergy Clin Immunol. Etanercept: monoclonal antibody against the TNF- receptor. Granulysin is a key mediator for disseminated keratinocyte death in StevensJohnson syndrome and toxic epidermal necrolysis. It is advised against the use of silver sulfadiazine because sulphonamide can be culprit agents. PubMed A central role in the pathogenesis of ED is played by CD8+ lymphocytes and NK cells. J Immunol. . Toxic epidermal necrolysis: effector cells are drug-specific cytotoxic T cells. The more common forms of erythroderma, such as eczema or psoriasis, may persists for months or years and tend to relapse. A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus. J Am Acad Dermatol. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Allergol Immunopathol (Madr). Contact dermatitis from topical antihistamine . Paquet P, et al. The enhanced activation of CD8 T cells seems also to be influenced by the impaired function of CD4+CD25+FoxP3+Treg cells found in the peripheral blood of TEN patients in the acute phase [46]. Fluid balance is a main focus. Corticosteroids could also reduce the amount of keratinocytes apoptosis and the activation of caspases [105]. Exfoliative Dermatitis Treatment & Management: Medical Care - Medscape 1996;135(1):611. For SJS/TEN, corticosteroids are the cornerstone of treatment albeit efficacy remains unclear. Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid and linear IgA dermatosis have to be considered. DailyMed - DICLOFENAC SODIUM- diclofenac sodium solution 7 DRUG INTERACTIONS 7.1 PDE-5-Inhibitors and sGC-Stimulators 7.2 Ergotamine 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Lactation 8.4 Pediatric Use 8.5 Geriatric Use 10 OVERDOSAGE 10.1 Signs and Symptoms, Methemoglobinemia 10.2 Treatment of Overdosage 11 DESCRIPTION 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action 12.2 Pharmacodynamics 12. . Exfoliative dermatitis is a disease process in which most, and sometimes all, of the skin is involved in erythematous inflammation resulting in massive scaling.1 A variety of diseases and other exogenous factors may cause exfoliative dermatitis. If necessary, it can be repeated every 68h. NSAIDs should be avoided as they can induce ED as well. Unlike EMM, SJS and TEN are mainly related to medication use. CD94/NKG2C is a killer effector molecule in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. 2008;53(1):28. Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. Exanthematous drug eruptions. 2002;118(4):72833. A population-based study of StevensJohnson syndrome. Other patients may warrant PUVA (psoralen plus ultraviolet A) phototherapy, systemic steroids (if psoriasis has been ruled out), retinoids (for exfoliative dermatitis secondary to psoriasis and pityriasis rubra pilaris), or immunosuppressive agents such as methotrexate (Rheumatrex) and azathioprine (Imuran).2527, When used as adjunctive therapy, behavior modification designed to eliminate persistent scratching has been successful in reducing the rate of excoriation and increasing the rate of healing.28. 2009;145(2):15762. The syndrome has been described previously in association with phenindione administration, leptospirosis and heavy metal poisoning. Staphylococcal Scalded Skin Syndrome: criteria for Differential Diagnosis from Lyells Syndrome. Ibuprofene Zen * 20cps Mol 400mg Histopathological and epidemiological characteristics of patients with erythema exudativum multiforme major, StevensJohnson syndrome and toxic epidermal necrolysis. HLA-A* 3101 and carbamazepine-induced hypersensitivity reactions in Europeans. Fas-FasL interaction: Fas is a membrane-bound protein that after interaction with Fas-ligand (FasL) induces a programmed cell death, through the activation of intracellular caspases. AQUACEL Ag in the treatment of toxic epidermal necrolysis (TEN). . Antiviral therapy. The drug level peaks after 1- 4 h in plasma after ingestion with 95% protein binding. Tang YH, et al. A switch to oral therapy can be performed once the mucosal conditions improve. Diagnosis in a routine setting is based on patch test (PT) while skin test (prick and intradermal tests) with a delayed reading are contraindicated in these patients [72]. Cancer Diagnosis & Prognosis Clinical Presentations of Severe Cutaneous Drug Reactions in HIV Clinical features; Delayed type hypersensitivity; Drug hypersensitivity; Erythema multiforme; Exfoliative dermatitis; Lyells syndrome; Pathogenesis; StevensJohnson syndrome; Therapy; Toxic epidermal necrolysis. Posadas SJ, et al. Article Von Hebra first described erythroderma (exfoliative dermatitis) in 1868. During the acute reaction, diagnosis of ED is mainly based on clinical parameters. Mawson AR, Eriator I, Karre S. StevensJohnson syndrome and toxic epidermal necrolysis (SJS/TEN): could retinoids play a causative role? In: Eisen AZ, Wolff K, editors. 2016;2:14. In this study, 965 patients were reviewed. Aminoglutethimide: Aminoglutethimide may lead to a loss of corticosteroid-induced adrenal suppression. Wetter DA, Camilleri MJ. Science. Toxic epidermal necrolysis: Part I Introduction, history, classification, clinical features, systemic manifestations, etiology, and immunopathogenesis. Wu PA, Cowen EW. Am J Dermatopathol. Rifampin, paracetamol, metronidazole, paclitaxel, erythromycin, and ibuprofen have all been reported to cause bullous FDE. Erythroderma (literally, "red skin"), also sometimes called exfoliative dermatitis, is a severe and potentially life-threatening condition that presents with diffuse erythema and scaling involving all or most of the skin surface area (90 percent, in the most common definition). The Nikolskys sign is not specific for SJS/TEN, in fact it is present also in auto-immune blistering diseases like pemphigus vulgaris. Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. . A promising and complementary in vitro tool has been used by Polak ME et al. The therapeutic approach of EMM, SJS, TEN depends on extension of skin, mucosal involvement and systemic patients conditions. Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. 2008;159(4):9814. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Growth-factors (G-CSF). Orton PW, et al. Clin Exp Dermatol. Drug-induced Exfoliative Dermatitis & Eosinophils Increased Symptom Checker: Possible causes include Exfoliative Dermatitis. J Am Acad Dermatol. of Internal Medicine, University of Bari, Bari, Italy, Andrea Nico,Elisabetta Di Leo,Paola Fantini&Eustachio Nettis, You can also search for this author in Expression of alpha-defensin 1-3 in T cells from severe cutaneous drug-induced hypersensitivity reactions. Chung W-H, et al. Unable to load your collection due to an error, Unable to load your delegates due to an error, Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (, Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. Generalized Exfoliative Dermatitis | Johns Hopkins Medicine The relative risk of leukemia inducing erythroderma is highly variable, ranging from 11 to 50 percent.11, Internal (visceral) malignancies cause about 1 percent of all cases of exfoliative dermatitis.11 Frequently, erythroderma is the presenting sign of the malignancy. Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. c. Amyloidosis. Iv bolus of steroid (dexamethasone 100300mg/day or methylprednisolone 2501000mg/day) for 3 consecutive days with a gradual taper steroid therapy is sometimes advised. The induction dosage in EMM is usually 1mg/kg/day that should be maintained until a complete control of the skin is obtained. PDF Drug induced exfoliative dermatitis: state of the art A review of DRESS-associated myocarditis. However, according to a consensus definition [54], EMM syndrome has been separated from SJS/TEN spectrum. 1995;333(24):16007. Drugs such as paracetamol, other non-oxicam NSAIDs and furosemide, bringing a relatively low risk of SJS/TEN a priori, are also highly prevalent as putative culprit agents in large SJS/TEN registries, due to their widespread use in the general population [63, 64] (Table1). Their occurrence can be prevented by avoiding drug over-prescription and drug associations that interfere with the metabolism of the most frequent triggers [118]. [3] The causes and their frequencies are as follows: Idiopathic - 30% Drug allergy - 28% Seborrheic dermatitis - 2% Contact dermatitis - 3% Atopic dermatitis - 10% Lymphoma and leukemia - 14% Psoriasis - 8% Treatment [ edit] Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. Springer Nature. -. Previous vol/issue. The approach to treatment should include discontinuation of any potentially causative medications and a search for any underlying malignancy. Since the earliest descriptions of exfoliative dermatitis, medications have been known to be important causative agents. In serious cases invasive ventilation can be necessary for ARDS. UpToDate Early sites of skin involvement include trunk, face, palms and soles and rapidly spread to cover a variable extension of the body. This compressed maturation process results in an overall greater loss of epidermal material, which is manifested clinically as severe scaling and shedding. Incidence of hypersensitivity skin reactions. Medical search. Frequent 2011;20(5):103441. (5.7, 8.1, 8.3) ADVERSE REACTIONS The most commonly reported adverse drug reactions (ADRs), reported in more than 20% of the patients and greater than placebo were skin reactions and diarrhea . Curr Allergy Asthma Rep. 2014;14(6):442. Med Sci Monit. J Burn Care Res. Therefore, it is important to identify and treat any underlying disease whenever possible and to remove any contributing external factors.2, Most published studies of exfoliative dermatitis have been retrospective and thus do not address the issue of overall incidence. 2000;115(2):14953. EM is a self-limited skin condition mainly associated with infections and drugs [53, 54]. Detection of a herpes simplex viral antigen in skin lesions of erythema multiforme. Trigger is an exotoxin released by Staphylococcus aureus [83]. Hypervolemia can also occur in patients with exfoliative dermatitis, contributing to the likelihood of cardiac failure.2124, In most patients with erythroderma, skin biopsies show nonspecific histopathologic features, such as hyperkeratosis, parakeratosis, acanthosis and a chronic perivascular inflammatory infiltrate, with or without eosinophils. 2013;69(2):173174. Indian J Dermatol. Dr. Ramesh Bhandari - Deputy Co-ordinator & Secretary, AMC - LinkedIn Hum Mol Genet. Exfoliative Dermatitis: Symptoms, Diagnosis & Treatments - Healthline Mayo Clin Proc. CAS Rheumatology (Oxford). [81]. Rare dermatological side effects such as alopecia, exfoliative dermatitis, xeroderma, pruritus have been reported. Comprehensive survival analysis of a cohort of patients with StevensJohnson syndrome and toxic epidermal necrolysis. J Popul Ther Clin Pharmacol. ALDEN, an algorithm for assessment of drug causality in StevensJohnson Syndrome and toxic epidermal necrolysis: comparison with case-control analysis. The https:// ensures that you are connecting to the Paquet P, Pierard GE. Medication-Induced Erythroderma | SpringerLink 2005;102(11):41349. 583-587. Ann Intern Med. Ann Burns Fire. Interferon alfa (Roferon-A, Intron A, Alferon N), Isoniazid (Laniazid, Nydrazid; also in Rifamate, Rimactane), Isosorbide dinitrate (Isordil, Sorbitrate), Para-amino salicylic acid (Sodium P.A.S. All non-indispensable drugs have to be stopped because they could alter the metabolism of the culprit agent. Hospitalization and dermatologic consultation are indicated in most cases to ensure that all of the necessary cutaneous, laboratory and radiologic investigations and monitoring are performed. For carbamazpine, several studies have found a common link between specific HLAs and different kinds of cutaneous adverse reactions, as for HLA-A*3101 in Japanese [30] and Europeans [31]. The diagnosis of GVDH requires histological confirmation [87]. (See paras 3 - 42 and 3- 43.) As written before, Sassolas B. et al. Exfoliative dermatitis is also a risk factor for epidemic spread of methicillin-resistant Staphylococcus aureus.6,20. Int J Dermatol. StevensJohnson syndrome and toxic epidermal necrolysis: the Food and Drug Administration adverse event reporting system, 2004-2013. Grosber M, et al. Harr T, French LE. A catabolic state thus ensues, which is often responsible for significant weight loss. Mockenhaupt M, et al. Exfoliative Dermatitis disease: Malacards - Research Articles, Drugs Retrospective review of StevensJohnson syndrome/toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. AR 40-501 Standard of Medical Fitness 14 Jun 2017 Insidious development of the erythroderma, progressive debilitation of the patient, absence of previous skin disease and resistance to standard therapy are features that may suggest an underlying malignancy.6,11, Erythroderma is also associated with disorders that cannot easily be classified into groups. 2015;64(3):2779. Fitzpatricks dermatology in general medicine. CAS DRUG- Induced- Dermatologic-RXNS lam University St. John's University Course Drug induced disease (CPP 6102) Academic year2023/2024 Helpful? Increased peripheral blood flow can result in high-output cardiac failure. A severity-of-Illness score for toxic epidermal necrolysis (SCORTEN) has been proposed and validated to predict the risk of death at admission [81]. See this image and copyright information in PMC. 2003 Oct 25;147(43):2089-94. Theoretically, any drug may cause exfoliative dermatitis. Br J Dermatol. 2012;51(8):889902. Department of Allergy and Clinical Immunology, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy, Mona-Rita Yacoub,Maria Grazia Sabbadini&Giselda Colombo, Vita-Salute San Raffaele University, Milan, Italy, Mona-Rita Yacoub,Alvise Berti,Corrado Campochiaro,Enrico Tombetti,Giuseppe Alvise Ramirez,Maria Grazia Sabbadini&Giselda Colombo, Section of Allergy and Clinical Immunology, Dept.