eMedicine Specialties > Dermatology > Allergy & Immunology

Drug Eruptions: Differential Diagnoses & Workup

Author: Jonathan E Blume, MD, Instructor in Clinical Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Westwood Dermatology and Dermatologic Surgery Group PA
Coauthor(s): Thomas N Helm, MD, Clinical Associate Professor, Departments of Dermatology and Pathology, State University of New York at Buffalo; Director, Buffalo Medical Group Dermatopathology Laboratory; Michelle Ehrlich, MD, Fellow for the American Academy of Cosmetic Surgery, Staff Physician, Department of Dermatology, La Jolla SpaMD; Charles Camisa, MD, Head of Clinical Dermatology, Vice-Chair, Department of Dermatology, Cleveland Clinic Foundation
Contributor Information and Disclosures

Updated: Jan 5, 2009

Differential Diagnoses

Acute Febrile Neutrophilic Dermatosis
Measles, Rubeola
Contact Dermatitis, Allergic
Pityriasis Rosea
Contact Dermatitis, Irritant
Porphyria Cutanea Tarda
Erythema Multiforme
Psoriasis, Pustular
Erythema Nodosum
Rubella
Erythroderma (Generalized Exfoliative Dermatitis)
Syphilis
Gianotti-Crosti Syndrome (Papular Acrodermatitis of Childhood)
Urticaria, Acute
Graft Versus Host Disease
Urticaria, Chronic
Hypersensitivity Vasculitis (Leukocytoclastic Vasculitis)
Lichen Planus

Other Problems to Be Considered

Autoimmune blistering disease
Exacerbation of preexisting cutaneous disease
Infection (viral [most common], bacterial, fungal)

Workup

Laboratory Studies

  • History and physical examination are often sufficient for diagnosing mild asymptomatic eruptions.
  • Severe or persistent eruptions may require further diagnostic testing.
    • Biopsy can be helpful in confirming the diagnosis of a drug eruption (eg, by showing eosinophils in morbilliform eruptions or numerous neutrophils without vasculitis in persons with Sweet syndrome).
    • CBC count with differential may show leukopenia, thrombocytopenia, and eosinophilia in patients with serious drug eruptions.
    • Serum chemistry studies may be useful. Liver involvement leading to death can occur in persons with hypersensitivity syndromes. Special attention should be paid to the electrolyte balance and renal and/or hepatic function indices in patients with severe reactions such as SJS, TEN, or vasculitis.
    • Antibody and/or immunoserology tests may be ordered. Antihistone antibodies are noted in persons with drug-induced SLE, whereas anti-Ro/SS-A antibodies are most common in persons with drug-induced SCLE.
    • Direct cultures may be needed to investigate a primary infectious etiology or secondary infection.
    • Urinalysis, stool guaiac tests, and chest radiography are important for patients with vasculitis.

Imaging Studies

  • Chest radiography, along with urinalysis and stool guaiac tests, is important for patients with vasculitis.

Other Tests

  • Rechallenge tests by means of skin prick or patch testing to confirm the causative agent is of limited value.
  • Skin tests may be hazardous to patients who have had severe reactions.
  • With the possible exception of AGEP, patch tests have a low sensitivity and specificity and are not useful.20

Histologic Findings

In some cases, biopsy may be helpful in establishing a diagnosis of a drug reaction.

Histopathology of an exanthematous drug eruption may show both superficial and deep perivascular inflammatory cell infiltrates. Eosinophils in the infiltrate suggest such a drug eruption (see Media file 21).

In patients with Sweet syndrome, biopsy reveals edema of the superficial dermis and a dense infiltrate of neutrophils. Leukocytoclasia may be present, but vasculitis is absent.

Histopathology of TEN shows subepidermal split, full-thickness epidermal necrosis and a sparse perivascular lymphocytic infiltrate (see Media file 20).

More on Drug Eruptions

Overview: Drug Eruptions
Differential Diagnoses & Workup: Drug Eruptions
Treatment & Medication: Drug Eruptions
Follow-up: Drug Eruptions
Multimedia: Drug Eruptions
References
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Further Reading

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Keywords

adverse cutaneous drug reactions, cutaneous reaction to drugs, drug-induced cutaneous reactions, mucocutaneous drug reactions, dermatoses, dermatosis, cutaneous eruptions, cutaneous drug reactions, adverse drug reactions, drug allergy, fixed drug reactions, medication adverse effects, medication side effects, adverse effects, side effects, medication allergy

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Contributor Information and Disclosures

Author

Jonathan E Blume, MD, Instructor in Clinical Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Westwood Dermatology and Dermatologic Surgery Group PA
Jonathan E Blume, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, American Medical Association, American Society for Dermatologic Surgery, International Society of Dermatology, and National Psoriasis Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Thomas N Helm, MD, Clinical Associate Professor, Departments of Dermatology and Pathology, State University of New York at Buffalo; Director, Buffalo Medical Group Dermatopathology Laboratory
Thomas N Helm, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, and American Society of Dermatopathology
Disclosure: Nothing to disclose.

Michelle Ehrlich, MD, Fellow for the American Academy of Cosmetic Surgery, Staff Physician, Department of Dermatology, La Jolla SpaMD
Disclosure: Nothing to disclose.

Charles Camisa, MD, Head of Clinical Dermatology, Vice-Chair, Department of Dermatology, Cleveland Clinic Foundation
Charles Camisa, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Neil Shear, MD, Professor and Chief of Dermatology, Professor of Medicine, Pediatrics and Pharmacology, University of Toronto Faculty of Medicine; Head of Dermatology, Sunnybrook Women's College Health Sciences Center and Women's College Hospital, Canada
Neil Shear, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Clinical Pharmacology and Therapeutics, Canadian Dermatology Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Genetech Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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