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Overview

Background

The term fixed drug eruption (FDE) describes the development of one or more annular or oval erythematous patches as a result of systemic exposure to a drug; these reactions normally resolve with hyperpigmentation and may recur at the same site with reexposure to the drug. Repeated exposure to the offending drug may cause new lesions to develop in addition to "lighting up" the older hyperpigmented lesions.

Adverse reactions to medications are common and often manifest as a cutaneous eruption. Drug-induced cutaneous disorders frequently display a characteristic clinical morphology such as morbilliform exanthem, urticaria, hypersensitivity syndrome, pseudolymphoma, photosensitivity, pigmentary changes, acute generalized exanthematous pustulosis, lichenoid dermatitis, vasculitis, Stevens-Johnson syndrome, or fixed drug eruption.

Several variants of fixed drug eruption have been described, based on their clinical features and the distribution of the lesions.^{[1, 2, 3, 4, 5, 6, 7, 8]}These include the following:

Pigmenting fixed drug eruption
Generalized or multiple fixed drug eruption
Linear fixed drug eruption
Wandering fixed drug eruption
Nonpigmenting fixed drug eruption
Bullous fixed drug eruption
Eczematous fixed drug eruption
Urticarial fixed drug eruption
Erythema dyschromicum perstans–like fixed drug eruption
Vulvitis
Oral
Psoriasiform
Cellulitislike eruption^[9]

Also see the following related Medscape articles:

Pathophysiology

Although the exact mechanism is unknown, recent research suggests a cell-mediated process that initiates both the active and quiescent lesions. The process may involve an antibody-dependent, cell-mediated cytotoxic response.^[10]CD8⁺ effector/memory T cells play an important role in reactivation of lesions with re-exposure to the offending drug.^{[11, 12]}

The offending drug is thought to function as a hapten that preferentially binds to basal keratinocytes, leading to an inflammatory response.^[13]Through liberation of cytokines such as tumor necrosis factor-alpha, keratinocytes may locally up-regulate expression of the intercellular adhesion molecule-1 (ICAM1).^[14]The up-regulated ICAM1 has been shown to help T cells (CD4 and CD8) migrate to the site of an insult.^{[15, 16]}

The newly arriving and residential CD8 cells likely perpetuate tissue damage by their production of the inflammatory cytokines interferon-gamma and tumor necrosis factor-alpha. CD8 cells isolated from active lesions have also been shown to express alpha E beta 7, a ligand for E-cadherin, which may further contribute to the lymphocyte’s ability to localize to the epidermis. Other cell surface molecules, such as CLA/alpha4beta1/CD4a, that bind E-selectin/vascular cellular adhesion molecule-2/ICAM1 help to further attract CD8 cells to the area.^[10]

Changes in cell surface markers allow vascular endothelium to select CD4 cells for migration into active lesions. These regulatory CD4 cells likely produce interleukin 10, which has been shown to help suppress immune function, resulting in a resting lesion.^[10]As the inflammatory response dissipates, interleukin 15 expression from keratinocytes is thought to help ensure the survival of CD8 cells, helping them fulfill their effector memory phenotypes. Thus, when reexposure to the drug occurs, a more rapid response develops in the exact location of any prior lesions.^[10]

Etiology

The major categories of causative agents of fixed drug eruption include antibiotics, antiepileptics, nonsteroidal anti-inflammatory agents, sildenafil, and phenothiazines, although numerous other agents and certain foods such as cashews and licorice have also been reported as causative agents. Ingestion of the causative agent may occur via any route, including oral, rectal, or intravenous.^{[17, 18]}

Certain classes of drugs with cross-reactions within a class have been reported to elicit a fixed drug eruption with quinolones^[19]and with nonsteroidal anti-inflammatory agents.^[20]In some patients, the reaction may be to a dye rather than the active ingredient.^[21]Fixed drug eruption may rarely be related to foods, including residual antibiotics in meat products and quinine contained in tonic water.^{[22, 23]}

While fixed drug eruptions are uncommon with general anesthesia, propofol has been implicated in causing a drug eruption on the penis.^[24]

The most common cause is trimethoprim-sulfamethoxazole.^{[3, 25]}Other substances implicated to cause fixed drug eruptions are as follows^{[1, 13, 17, 26, 5, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41]}:

Table. Substances Implicated in Fixed Drug Eruptions (Open Table in a new window)

Acetaminophen	Acyclovir	Allopurinol	Allylisopropyl-acetylurea	Amide local anesthetics
Amlexanox	Amoxicillin	Anticonvulsants	Articaine	Aspirin
Atenolol	Barbiturates	Botulinum toxin	Carbamazepine	Cashew nut
Ceftriaxone	Celecoxib	Cetirizine	Chloral hydrate	Chlordiazepoxide
Chlorhexidine	Chlormezanone	Chlorphenesin carbonate	Citicoline	Clarithromycin
Clioquinol	Clopidogrel	Codeine	Colchicines	Cyclizine
Cyproterone acetate	Dextromethorphan	Dimenhydrinate	Diphenhydramine	Dipyrone
Docetaxel	Eperisone hydrochloride	Erythromycin	Ethenzamide	Feprazone
Finasteride	Flecainide	Fluconazole	Fluoroquinolones	Foscarnet
Gabapentin	Griseofulvin	Hydroxyzine	Ibuprofen	Interferon
Iodinated radiography contrast media	Iomeprol	Kakkon	Ketoconazole	Lactose
Lamotrigine	Lentils	Liquorice Lomeprol	Lopamidoln	Loratadine
Lormetazepam	Magnesium trisilicate	Mefenamic acid	Melatonin	Methaqualone
Metramizole	Metronidazole	Metaform	Minocycline	Multivitamins
Naproxen	Nimesulide	Omeprazole	Ondansetron	Opium alkaloids
Oxyphenbutazone	Paclitaxel	Pamabrom	Papaverine	Para-aminosalicylic acid
Penicillins	Phenazone	Phenolphthalein	Phenylbutazone	Phenylephrine
Phenylpropanolamine	Phenytoin	Pipemidic acid	Piroxicam	Procarbazine
Prochlorperazine	Pseudoephedrine	Quinine	Rifampin	Scopolia
Sodium benzoate	Strawberries	Sulfamethoxazole	Tartrazine	Terbinafine
Tetracyclines	Theophylline	Thiacetazone	Ticlopidine	Tinidazole
Tolfenamic acid	Tosufloxacin	Tranexamic acid	Trimethoprim	Tropisetron

Frequency

United States

The prevalence of drug eruptions has been reported to range from 2-5% for inpatients and greater than 1% for outpatients.^[42]Fixed drug eruptions may account for as much as 16-21% of all cutaneous drug eruptions. The actual frequency may be higher than current estimates, owing to the availability of a variety of over-the-counter medications and nutritional supplements that are known to elicit fixed drug eruptions.

International

The international prevalence is variable but is likely similar to that in the United States. Most studies report fixed drug eruptions to be the second or third most common skin manifestation of adverse drug events.^[43]

Race

Fixed drug eruptions have no known racial predilection. A genetic susceptibility to developing a fixed drug eruption with an increased incidence of HLA-B22 is possible.^{[44, 45]}

Sex

One large study of 450 patients revealed a male-to-female ratio of 1:1.1 for fixed drug eruptions.^[1]

Age

Fixed drug eruptions have been reported in patients as young as 1.5 years and as old as 87 years. The mean age at presentation is 30.4 years in males and 31.3 years in females.^[1]

Prognosis

The prognosis is very good, and an uneventful recovery should be expected. No deaths due to fixed drug eruption have been reported. Residual hyperpigmentation is very common, but this is less likely with the nonpigmenting variant.

Widespread lesions may initially mimic toxic epidermal necrolysis, but they have a benign clinical course.^[46]Again, localized hyperpigmentation is a common complication, but pain, infection, and, rarely, hypopigmentation, also may occur.^[1]

Patient Education

Patients should be counseled on medication avoidance and possible cross-reactions of similar medications. Patients should notify their physicians of all drug allergies they have experienced.

Clinical Presentation

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Media Gallery

Targetoid fixed drug eruption on the abdomen of a child.
Hyperpigmented fixed drug eruption on the hip of an adult.
Vesicular fixed drug eruption on the glans penis.
Multiple hyperpigmented fixed drug eruptions on the trunk.
Hyperpigmented fixed drug eruption on the right side of the upper lip.
Acute interface dermatitis with prominent vacuolar change and individual necrotic keratinocytes within the epidermis (X10).
Interface dermatitis, vacuolar change, necrotic keratinocytes, and incontinent pigment in the dermis (X40).

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Table. Substances Implicated in Fixed Drug Eruptions

Table. Substances Implicated in Fixed Drug Eruptions

Acetaminophen	Acyclovir	Allopurinol	Allylisopropyl-acetylurea	Amide local anesthetics
Amlexanox	Amoxicillin	Anticonvulsants	Articaine	Aspirin
Atenolol	Barbiturates	Botulinum toxin	Carbamazepine	Cashew nut
Ceftriaxone	Celecoxib	Cetirizine	Chloral hydrate	Chlordiazepoxide
Chlorhexidine	Chlormezanone	Chlorphenesin carbonate	Citicoline	Clarithromycin
Clioquinol	Clopidogrel	Codeine	Colchicines	Cyclizine
Cyproterone acetate	Dextromethorphan	Dimenhydrinate	Diphenhydramine	Dipyrone
Docetaxel	Eperisone hydrochloride	Erythromycin	Ethenzamide	Feprazone
Finasteride	Flecainide	Fluconazole	Fluoroquinolones	Foscarnet
Gabapentin	Griseofulvin	Hydroxyzine	Ibuprofen	Interferon
Iodinated radiography contrast media	Iomeprol	Kakkon	Ketoconazole	Lactose
Lamotrigine	Lentils	Liquorice Lomeprol	Lopamidoln	Loratadine
Lormetazepam	Magnesium trisilicate	Mefenamic acid	Melatonin	Methaqualone
Metramizole	Metronidazole	Metaform	Minocycline	Multivitamins
Naproxen	Nimesulide	Omeprazole	Ondansetron	Opium alkaloids
Oxyphenbutazone	Paclitaxel	Pamabrom	Papaverine	Para-aminosalicylic acid
Penicillins	Phenazone	Phenolphthalein	Phenylbutazone	Phenylephrine
Phenylpropanolamine	Phenytoin	Pipemidic acid	Piroxicam	Procarbazine
Prochlorperazine	Pseudoephedrine	Quinine	Rifampin	Scopolia
Sodium benzoate	Strawberries	Sulfamethoxazole	Tartrazine	Terbinafine
Tetracyclines	Theophylline	Thiacetazone	Ticlopidine	Tinidazole
Tolfenamic acid	Tosufloxacin	Tranexamic acid	Trimethoprim	Tropisetron

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Author

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster 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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), 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, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: Biogen US (Adjudicator for study entry cutaneous lupus erythematosus); Priovant (Adjudicator for entry into a dermatomyositis study); IQVIA (Serono - adjudicator for a study of cutaneous LE) <br/>Received honoraria from UpToDate for author/editor; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for these trust accounts for: Stocks held in various trust accounts: Allergen; Amgen; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble;; Celgene; Gilead; CVS; Walgreens; Bristol-Myers Squibb.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Acknowledgements

Jordan R Ilse, MD Staff Physician, Scott and White Internal Medicine Residency Program, Scott and White Clinic, Texas A&M University College of Medicine

Jordan R Ilse, MD is a member of the following medical societies: American Medical Association and Texas Medical Association

Disclosure: Nothing to disclose.