eMedicine Specialties > Dermatology > Allergy & Immunology

Drug Eruptions: Treatment & Medication

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

Treatment

Medical Care

  • The ultimate goal is always to discontinue the offending medication if possible. Individuals with drug eruptions are often the most ill patients taking the most medications, many of which are essential for their survival. However, all nonessential medications should be limited. Once the offending drug has been identified, it should be promptly discontinued. Knowledge of the common eruption inducing–medications may help in identifying the offending drug.
  • Patients can possibly continue to be treated through morbilliform eruptions (ie, continue medication even in patients with a rash). The eruption often resolves, especially if the individual is being treated with antihistamines. Most authorities believe that exanthematous drug eruptions are not a precursor to severe reactions, such as TEN. Nevertheless, all patients with severe morbilliform eruptions should be monitored for mucous membrane lesions, blistering, and skin sloughing.
  • Treatment of a drug eruption depends on the specific type of reaction. Therapy for exanthematous drug eruptions is supportive in nature. First-generation antihistamines are used 24 h/d. Mild topical steroids (eg, hydrocortisone, desonide) and moisturizing lotions are also used, especially during the late desquamative phase.
  • Severe reactions, such as SJS, TEN, and hypersensitivity reactions, warrant hospital admission. TEN is best managed in a burn unit with special attention given to electrolyte balance and signs of secondary infection. Because adhesions can develop and result in blindness, evaluation by an ophthalmologist is mandatory. In addition, mounting evidence indicates that intravenous immunoglobulin (IVIG) may improve outcomes for TEN patients.21,22,23
  • Hypersensitivity syndrome, a systemic reaction characterized by fever, sore throat, rash, and internal organ involvement, is potentially life threatening. Timely recognition of the syndrome and immediate discontinuation of the anticonvulsant or other offending drug are crucial. Patients may require liver transplantation if the drug is not stopped in time. Treatment with systemic corticosteroids has been advocated.

Medication

Therapy for most drug eruptions is mainly supportive in nature. Morbilliform eruptions are treated with oral antihistamines and topical steroids. IVIG is currently the most common agent used to treat TEN. Cyclosporine may also have a role in the treatment of TEN. Prednisone may be used in the treatment of hypersensitivity syndrome with heart and lung involvement, severe serum sickness–like reaction, and Sweet syndrome.

First-generation antihistamines

These agents antagonize H1 receptors and block release of histamine. They provide symptomatic relief of pruritus and help improve eruptions.


Hydroxyzine HCl (Anxanil, Atarax, Atozine, Durrax, Vistaril)

Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical CNS. Available as 10-, 25-, 50-, or 100-mg tab.

Adult

25 mg PO q6h

Pediatric

10 mg/5 mL syr, 0.5-1 mg/kg/d PO qid

CNS depression may increase with alcohol or other CNS depressants (eg, meperidine, barbiturates)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Clinical exacerbations of porphyria (may not be safe in porphyria); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness; not recommended in early pregnancy or breastfeeding


Diphenhydramine HCl (Benadryl, Benylin, Diphen, AllerMax)

For symptomatic relief of allergic symptoms caused by release of histamine in immune reactions.

Adult

25-50 mg tab PO q4-6h

Pediatric

12.5 mg/5 mL syr, 5 mg/kg/d PO divided q4-6h

Potentiates effect of CNS depressants; because of alcohol content, do not administer syr form to patient taking medications that can cause disulfiramlike reactions

Documented hypersensitivity; MAOIs

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction

Second-generation antihistamines, nonsedating

These agents cause less, if any, drowsiness than first-generation agents.


Loratadine (Claritin)

Selectively inhibits peripheral histamine H1 receptors.

Adult

10-20 mg PO qd

Pediatric

<2 years: Not established
2-6 years: 5 mg PO qd
>6 years: Administer as in adults

Ketoconazole, erythromycin, procarbazine, and alcohol may increase levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Start at low dose in renal and liver impairment; caution in breastfeeding

Corticosteroids

Topical agents provide symptomatic relief of pruritus. Systemic steroids are used in persons with hypersensitivity syndrome, severe serum sickness–like reactions, and Sweet syndrome.


Desonide 0.05% cream, ointment, lotion

For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability.

Adult

Apply sparingly 2-4 times/d

Pediatric

Apply as in adults

Documented hypersensitivity; fungal, viral, and bacterial skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use, application over large surface areas, application of potent steroids, and occlusive dressings may increase systemic absorption and may result in Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria


Prednisone (Deltasone, Orasone, Sterapred)

Immunosuppressant for treatment of immune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity; available in 2.5-, 5-, 10-, 20-, or 50-mg tab.

Adult

1-2 mg/kg PO qd initially, taper over 4-6 wk

Pediatric

1-2 mg/kg PO qd or divided bid/qid; taper over 2 wk as symptoms resolve

Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Absolute: Systemic fungal infection, herpes simplex keratitis, hypersensitivity (usually with corticotropin but occasionally noted with IV preparations)
Relative: hypertension, active tuberculosis, congestive heart failure, prior psychosis, positive intradermal positive protein derivative text, glaucoma, severe depression, diabetes mellitus, active peptic ulcer disease, cataracts, osteoporosis, recent bowel anastomosis, pregnancy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur

Immunoglobulins

These agents are used to treat TEN.


Intravenous immunoglobulin (Gammagard, Gamimune)

Blood product prepared from pooled plasma of healthy donors. Following features are possibly relevant to efficacy: neutralization of circulating myelin antibodies through anti-idiotypic antibodies; down-regulation of proinflammatory cytokines, including IFN-gamma; blockade of Fc receptors on macrophages; suppression of inducer T and B cells and augmentation of T-suppressor cells; blockade of complement cascade; promotion of remyelination; and 10% increase in CSF IgG.

Adult

1 g/kg IV qd for 3 consecutive days

Pediatric

Administer as in adults

Documented hypersensitivity; IgA deficiency; anti-IgE/IgG antibodies

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Consider checking serum IgA level before therapy and using IgA-depleted IVIG (G-Gard-SD) if indicated; may increase serum viscosity and thromboembolic events; migraine headache reported; 10% increased risk of aseptic meningitis; increased risk of urticaria, pruritus, or petechiae 2-5 d after infusion, which may last <1 mo; increased risk of renal tubular necrosis in elderly persons, diabetes, volume depletion, or preexisting kidney disease; can alter laboratory values (eg, elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk); apparent hyponatremia

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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References

  1. Iannini P, Mandell L, Felmingham J, Patou G, Tillotson GS. Adverse cutaneous reactions and drugs: a focus on antimicrobials. J Chemother. Apr 2006;18(2):127-39. [Medline].

  2. Green JJ, Manders SM. Pseudoporphyria. J Am Acad Dermatol. Jan 2001;44(1):100-8. [Medline].

  3. Coopman SA, Johnson RA, Platt R, Stern RS. Cutaneous disease and drug reactions in HIV infection. N Engl J Med. Jun 10 1993;328(23):1670-4. [Medline].

  4. Dacey MJ, Callen JP. Hydroxyurea-induced dermatomyositis-like eruption. J Am Acad Dermatol. Mar 2003;48(3):439-41. [Medline].

  5. Ellgehausen P, Elsner P, Burg G. Drug-induced lichen planus. Clin Dermatol. May-Jun 1998;16(3):325-32. [Medline].

  6. Camilleri M, Pace JL. Drug-induced linear immunoglobulin-A bullous dermatosis. Clin Dermatol. May-Jun 1998;16(3):389-91. [Medline].

  7. Antonov D, Kazandjieva J, Etugov D, Gospodinov D, Tsankov N. Drug-induced lupus erythematosus. Clin Dermatol. Mar-Apr 2004;22(2):157-66. [Medline].

  8. Brenner S, Bialy-Golan A, Ruocco V. Drug-induced pemphigus. Clin Dermatol. May-Jun 1998;16(3):393-7. [Medline].

  9. Brauchli YB, Jick SS, Curtin F, Meier CR. Association between beta-blockers, other antihypertensive drugs and psoriasis: population-based case-control study. Br J Dermatol. Jun 2008;158(6):1299-307. [Medline].

  10. Dika E, Varotti C, Bardazzi F, Maibach HI. Drug-induced psoriasis: an evidence-based overview and the introduction of psoriatic drug eruption probability score. Cutan Ocul Toxicol. 2006;25(1):1-11. [Medline].

  11. Tsankov N, Angelova I, Kazandjieva J. Drug-induced psoriasis. Recognition and management. Am J Clin Dermatol. May-Jun 2000;1(3):159-65. [Medline].

  12. Clark BM, Kotti GH, Shah AD, Conger NG. Severe serum sickness reaction to oral and intramuscular penicillin. Pharmacotherapy. May 2006;26(5):705-8. [Medline].

  13. Hazin R, Ibrahimi OA, Hazin MI, Kimyai-Asadi A. Stevens-Johnson syndrome: pathogenesis, diagnosis, and management. Ann Med. 2008;40(2):129-38. [Medline].

  14. Lee HY, Pang SM, Thamotharampillai T. Allopurinol-induced Stevens-Johnson syndrome and toxic epidermal necrolysis. J Am Acad Dermatol. Aug 2008;59(2):352-3. [Medline].

  15. Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. Dec 14 1995;333(24):1600-7. [Medline].

  16. MacMorran WS, Krahn LE. Adverse cutaneous reactions to psychotropic drugs. Psychosomatics. Sep-Oct 1997;38(5):413-22. [Medline].

  17. Roe E, Garcia Muret MP, Marcuello E, Capdevila J, Pallares C, Alomar A. Description and management of cutaneous side effects during cetuximab or erlotinib treatments: a prospective study of 30 patients. J Am Acad Dermatol. Sep 2006;55(3):429-37. [Medline].

  18. Shipley D, Ormerod AD. Drug-induced urticaria. Recognition and treatment. Am J Clin Dermatol. 2001;2(3):151-8. [Medline].

  19. Asnis LA, Gaspari AA. Cutaneous reactions to recombinant cytokine therapy. J Am Acad Dermatol. Sep 1995;33(3):393-410; quiz 410-2. [Medline].

  20. Barbaud A. Drug patch testing in systemic cutaneous drug allergy. Toxicology. Apr 15 2005;209(2):209-16. [Medline].

  21. French LE, Trent JT, Kerdel FA. Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome: our current understanding. Int Immunopharmacol. Apr 2006;6(4):543-9. [Medline].

  22. Mukasa Y, Craven N. Management of toxic epidermal necrolysis and related syndromes. Postgrad Med J. Feb 2008;84(988):60-5. [Medline].

  23. Paquet P, Piérard GE, Quatresooz P. Novel treatments for drug-induced toxic epidermal necrolysis (Lyell's syndrome). Int Arch Allergy Immunol. Mar 2005;136(3):205-16. [Medline].

  24. Bork K. Adverse drug reactions. In: Demis DJ, ed. Clinical Dermatology. Vol 3. Philadelphia, Pa: Lippincott-Raven; 1998.

  25. Breathnach SM, Hintner H. Adverse Drug Reactions and the Skin. London, England: Blackwell Scientific; 1992.

  26. Campos-Fernandez Mdel M, Ponce-De-Leon-Rosales S, Archer-Dubon C, Orozco-Topete R. Incidence and risk factors for cutaneous adverse drug reactions in an intensive care unit. Rev Invest Clin. Nov-Dec 2005;57(6):770-4. [Medline].

  27. Coombs RRA, Gell PGH. Classification of allergic reactions responsible for clinical hypersensitivity and disease. Clin Aspects Immunol. 1968;575-96.

  28. Daoud MS, Schanbacher CF, Dicken CH. Recognizing cutaneous drug eruptions. Reaction patterns provide clues to causes. Postgrad Med. Jul 1998;104(1):101-4, 107-8, 114-5. [Medline].

  29. Fitzpatrick JE. New histopathologic findings in drug eruptions. Dermatol Clin. Jan 1992;10(1):19-36. [Medline].

  30. Greenberger PA. 8. Drug allergy. J Allergy Clin Immunol. Feb 2006;117(2 Suppl Mini-Primer):S464-70. [Medline].

  31. Heidary N, Naik H, Burgin S. Chemotherapeutic agents and the skin: An update. J Am Acad Dermatol. Apr 2008;58(4):545-70. [Medline].

  32. Hunziker T, Kunzi UP, Braunschweig S, Zehnder D, Hoigne R. Comprehensive hospital drug monitoring (CHDM): adverse skin reactions, a 20-year survey. Allergy. Apr 1997;52(4):388-93. [Medline].

  33. Keet I, Meyaard L, Boucher E, et al. Allergic reactions to cotrimoxazole correlate with decreased T-cell reactivity compatible with a Th1 to Th2 shift [abstr PO-A19-0404]. Int Conf AIDS. 1993;9 (1):202.

  34. Kramer MS, Leventhal JM, Hutchinson TA, Feinstein AR. An algorithm for the operational assessment of adverse drug reactions. I. Background, description, and instructions for use. JAMA. Aug 17 1979;242(7):623-32. [Medline].

  35. Lerch M, Pichler WJ. The immunological and clinical spectrum of delayed drug-induced exanthems. Curr Opin Allergy Clin Immunol. Oct 2004;4(5):411-9. [Medline].

  36. Litt JZ. Drug Eruption Reference Manual 2002. New York, NY: Parthenon; 2002.

  37. Mayorga C, Pena RR, Blanca-Lopez N, Lopez S, Martin E, Torres MJ. Monitoring the acute phase response in non-immediate allergic drug reactions. Curr Opin Allergy Clin Immunol. Aug 2006;6(4):249-57. [Medline].

  38. McKenna JK, Leiferman KM. Dermatologic drug reactions. Immunol Allergy Clin North Am. Aug 2004;24(3):399-423, vi. [Medline].

  39. Mockenhaupt M, Schopf E. Epidemiology of drug-induced severe skin reactions. Semin Cutan Med Surg. Dec 1996;15(4):236-43. [Medline].

  40. Nigen S, Knowles SR, Shear NH. Drug eruptions: approaching the diagnosis of drug-induced skin diseases. J Drugs Dermatol. Jun 2003;2(3):278-99. [Medline].

  41. Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol. Feb 2007;56(2):181-200. [Medline].

  42. Revuz J, Valeyrie-Allanore L. Drug reactions. In: Dermatology. Vol 1. Philadelphia, Pa: Mosby; 2003:333-53.

  43. Roujeau JC, Bioulac-Sage P, Bourseau C, Guillaume JC, Bernard P, Lok C, et al. Acute generalized exanthematous pustulosis. Analysis of 63 cases. Arch Dermatol. Sep 1991;127(9):1333-8. [Medline].

  44. Sahin S, Comert A, Akin O, Ayalp S, Karsidag S. Cutaneous drug eruptions by current antiepileptics: case reports and alternative treatment options. Clin Neuropharmacol. Mar-Apr 2008;31(2):93-6. [Medline].

  45. Shapiro LE, Shear NH. Mechanisms of drug reactions: the metabolic track. Semin Cutan Med Surg. Dec 1996;15(4):217-27. [Medline].

  46. Stern RS, Steinberg LA. Epidemiology of adverse cutaneous reactions to drugs. Dermatol Clin. Jul 1995;13(3):681-8. [Medline].

  47. Susser WS, Whitaker-Worth DL, Grant-Kels JM. Mucocutaneous reactions to chemotherapy. J Am Acad Dermatol. Mar 1999;40(3):367-98; quiz 399-400. [Medline].

  48. Ward HA, Russo GG, Shrum J. Cutaneous manifestations of antiretroviral therapy. J Am Acad Dermatol. Feb 2002;46(2):284-93. [Medline].

  49. Warnock JK, Morris DW. Adverse cutaneous reactions to antidepressants. Am J Clin Dermatol. 2002;3(5):329-39. [Medline].

  50. Warnock JK, Morris DW. Adverse cutaneous reactions to mood stabilizers. Am J Clin Dermatol. 2003;4(1):21-30. [Medline].

  51. Wolf R, Orion E, Marcos B, Matz H. Life-threatening acute adverse cutaneous drug reactions. Clin Dermatol. Mar-Apr 2005;23(2):171-81. [Medline].

  52. Wolverton SE. Update on cutaneous drug reactions. Adv Dermatol. 1997;13:65-84. [Medline].

  53. Wyatt AJ, Leonard GD, Sachs DL. Cutaneous reactions to chemotherapy and their management. Am J Clin Dermatol. 2006;7(1):45-63. [Medline].

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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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