Patients can be extremely suffering because of the pain induced by skin and mucosal detachment. Google Scholar. Increased peripheral blood flow can result in high-output cardiac failure. A population-based study of StevensJohnson syndrome. 2011;128(6):126676. Pharmacogenomics J. Panitumumab Induced Forearm Panniculitis in Two Women With Metastatic Theoretically, any drug can trigger a reaction, but the medications most associated with this disorder are: Allopurinol; Antiepileptic medications; Barbiturates Oliveira L, Zucoloto S. Erythema multiforme minor: a revision. Pyrazinamide-Induced Exfoliative Dermatitis in a Patient on - Hindawi The more common forms of erythroderma, such as eczema or psoriasis, may persists for months or years and tend to relapse. Ann Intern Med. 2015;13(7):62545. Ardern-Jones MR, Friedmann PS. Article Int J Dermatol. Infectious agents are the major cause of EM, in around 90% of cases, especially for EM minor and in children. Exfoliative dermatitis has been reported in association with hepatitis, acquired immunodeficiency syndrome, congenital immunodeficiency syndrome (Omenn's syndrome) and graft-versus-host disease.2,1517, In reviews of erythroderma, a significant percentage of patients (about 25 percent) do not receive a specific etiologic diagnosis. 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. Skin conditions. Manganaro AM. First of all, Sassolas and coauthors proposed an algorithm of drug causality (ALDEN) in order to improve the individual assessment of drug causality in TEN and SJS [71]. Kano Y, et al. Lymphocyte transformation test (LTT) performed as described by Pichler and Tilch [77] shows a lower sensitivity in severe DHR compared to less severe DHR [78] but, if available, should be performed within 1week after the onset of skin rash in SJS and TEN [79]. Wetter DA, Davis MD. https://doi.org/10.1186/s12948-016-0045-0, DOI: https://doi.org/10.1186/s12948-016-0045-0. In EM a lymphocytic infiltrate (CD8+ and macrophages), associated with vacuolar changes and dyskeratosis of basal keratinocytes, is found along the dermo-epidermal junction, while there is a moderate lymphocytic infiltrate around the superficial vascular plexus [20]. Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. MalaCards based summary: Exfoliative Dermatitis is related to holocarboxylase synthetase deficiency and dermatitis, and has symptoms including exanthema An important gene associated with Exfoliative Dermatitis is SPINK5 (Serine Peptidase Inhibitor Kazal Type 5). Downey A, et al. HLA-A* 3101 and carbamazepine-induced hypersensitivity reactions in Europeans. Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. CAS These include a cutaneous reaction to other drugs, exacerbation of a previously existing condition, infection, metastatic tumor involvement, a paraneoplastic phenomenon, graft-versus-host disease, or a nutritional disorder. statement and Lonjou C, et al. 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]. Fitzpatricks dermatology in general medicine. Abstract Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. Int Arch Allergy Immunol. PDF Drug induced exfoliative dermatitis: state of the art Usually the amount of calories is 15002000kcal/day and the velocity of infusion is gradually increased based on patients tolerability [92]. No uniformity of opinion exists concerning the best treatment for cutaneous T-cell lymphoma. Detection of a herpes simplex viral antigen in skin lesions of erythema multiforme. If after 4days there is not an improvement it is advised to consider the association of steroid or its replacement with one of the following drugs [49, 93]: Intravenous immunoglobulins (IVIG): play their role through the inhibition of FasFas ligand interaction that it is supposed to be the first step in keratinocytes apoptosis [33]. The exact role of FasL in the pathogenesis of toxic epidermal necrolysis is still questionable especially because a correlation between serum FasL levels and disease severity has not been established and because its levels have been found to be increased also in drug-induced hypersensitivity syndrome and maculopapular eruption [36]. Huang SH, et al. J Allergy Clin Immunol. Mayo Clin Proc. Association of HLA-B*1502 allele with carbamazepine-induced toxic epidermal necrolysis and StevensJohnson syndrome in the multi-ethnic Malaysian population. 2014;70(3):53948. Article 2022 May;35(5):e15416. Case Rep Dermatol Med. 2008;58(1):3340. In conclusion, therapy wth IVIG should be started within the first 5days and an high-dosage regimen should be preferred (2.54g/kg for adults and 0.251.5g/kg in children divided in 35days). Perforin/granzyme B pathway: Nassif and colleagues have proposed a role for perforin/grazyme B in keratinocyte death [37]. ), Phenolphthalein (Agoral, Alophen, Modane), Rifampin (Rifadin, Rimactane; also in Rifamate), Trimethoprim (Trimpex; also in Bactrim, Septra). Main discriminating factors between EMM, SJS, SJS-TEN, TEN and SSSS is summarized in Table3 [84]. Chemicals and Drugs 61. 1996;135(2):3056. J Dtsch Dermatol Ges. Despite improved knowledge of the immunopathogenesis of these conditions, immune-modulatory therapies currently used have not been definitively proved to be efficacious [49, 107], and new strategies are urgently needed. Abe J, et al. Medication use and the risk of StevensJohnson syndrome or toxic epidermal necrolysis. Am J Dermatopathol. 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. Mona-Rita Yacoub. Australas J Dermatol. Usually, but not always, the palms of the hands, the soles of the feet and the mucous membranes are spared. Clinical practice. In an open trial on cyclosporine in 29 patients with TEN, the use of Cys A for at least 10days led to a rapid improvement without infective complications [112]. Partial to full thickness epidermal necrosis, intraepidermal vesiculation or subepidermal blisters, due to spongiosis and to the cellular damage of the basal layer of the epidermis, can be present in the advanced disease [49] Occasionally, severe papillary edema is also present [20]. Toxic epidermal necrolysis and StevensJohnson syndrome. 2007;62(12):143944. Avoid rubbing and scratching. 1995;5(4):2558. doi: 10.1016/j.jaad.2013.05.003. 2008;12(5):3559. Drugs that have been implicated in the causation of LPP include captopril, cinnarizine, ramipril, simvastatin, PUVA, and antituberculous medications. 2008;59(5):8989. Erythema multiforme. The drug level peaks after 1- 4 h in plasma after ingestion with 95% protein binding. Severe adverse cutaneous reactions to drugs. Epilepsia. J Am Acad Dermatol. Int J Dermatol. J Immunol. The taper of steroid therapy should be gradual [93]. StevensJohnson syndrome and toxic epidermal necrolysis: assessment of medication risks with emphasis on recently marketed drugs. These molecules may play a role in amplifying the immune response and in increasing the release of other toxic metabolites from inflammatory cells [48]. Epilepsia. Loss of normal vasoconstrictive function in the dermis, decreased sensitivity to the shivering reflex and extra cooling that comes from evaporation of the fluids leaking out of the weeping skin lesions all result in thermoregulatory dysfunction that can cause hypothermia or hyperthermia.6 The basal metabolic rate also is increased in patients with exfoliative dermatitis. Nutritional support. Chung WH, Hung SI. 2013;168(3):53949. Allergol Int. View ABRIGO_Worksheet #8 Drug Study_Endocrine System.pdf from NCM 06 at Southern Luzon State University (multiple campuses). Combination of infliximab and high-dose intravenous immunoglobulin for toxic epidermal necrolysis: successful treatment of an elderly patient. In more severe cases continuous iv therapy can be necessary. Plasmapheresis may have a role in the treatment of ED because it removes Fas-L [96], other cytokines known to be implied in the pathogenesis (IL-6, IL-8, TNF-) [97, 98]. Intravenous administration is recommended. J Am Acad Dermatol. This has been called the nose sign.18, Once the erythema is well established, scaling inevitably follows (Figure 1). 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. Toxic epidermal necrolysis (Lyell syndrome). A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus. In this study, 965 patients were reviewed. 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. In acute phase it is crucial to assess the culprit agent, in particular when the patient was assuming several drugs at time of DHR. 1990;126(1):3742. Generalized exfoliative dermatitis, or erythroderma, is a severe inflammation of the entire skin surface. PubMed Central Disclaimer. 2, and described below. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Toxic epidermal necrolysis: effector cells are drug-specific cytotoxic T cells. One of the most common malignancies associated with exfoliative dermatitis is cutaneous T-cell lymphoma, which may not manifest for months or even years after the onset of the skin condition. f. 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. [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] Letko E, Papaliodis DN, Papaliodis GN, Daoud YJ, Ahmed AR, Foster CS. Although the etiology is often unknown, exfoliative dermatitis may be the result of a drug reaction or an underlying malignancy. Graft versus host disease (GVHD) Acute GVHD usually happens within the first 6months after a transplant. 2016 Nov 15;17(11):1890. doi: 10.3390/ijms17111890. Moreover Mawson A and colleagues hypothesized that the efficacy of plasmapheresis is able to reduce serum level of vitamin A. The balance of fluids and electrolytes should be closely monitored, since dehydration or hypervolemia can be problems. PubMed Central . Huff JC. Patients with carcinoma of the colon, lung, prostate and thyroid have presented with erythroderma. Allergol Immunopathol (Madr). Erythroderma in adults - UpToDate Scientific evidences suggest a role for HLAs and drug-induced SJS/TEN, although some racial differences have been found that can be due to variation of frequencies of these alleles and to the presence of other susceptibility genes [26]. 1). 22 Abacavir-induced hypersensitivity syndrome is strongly associated with HLA-B*5701 during treatment . Trautmann A, et al. The scales may be small or large, superficial or deep. 1991;97(4):697700. 2008;53(1):28. N.Z. Exfoliative Dermatitis Treatment & Management: Medical Care - Medscape Garza A, Waldman AJ, Mamel J. Topical treatment. Drug-induced erythroderma invariably recovers completely with prompt initial management and removal of the offending drug. Article 2015;49(3):33542. Granulysin is a key mediator for disseminated keratinocyte death in StevensJohnson syndrome and toxic epidermal necrolysis. HLA-B* 5801 allele as a genetic marker for severe cutaneous adverse reactions caused by allopurinol. (in Chinese) . Valeyrie-Allanore L, et al. . These highlights do not include all the information needed to use While nearly any medication can, in theory, cause a reaction if you're sensitive, medications linked to exfoliative dermatitis include: sulfa drugs; penicillin and certain other antibiotics . Von Hebra first described erythroderma (exfoliative dermatitis) in 1868. Mockenhaupt M, et al. Careers. 2006;19(4):18891. J Invest Dermatol. Both DRESS and SJS may have increased liver enzymes and hepatitis, but they occur in only 10% of cases of SJS compared to 80% of DRESS. journal.pds.org.ph Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (white arrows) together with atypical two-zoned lesions (black arrows). The authors declare that they have no competing interests. Correspondence to 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. 2003;21(1):195205. The erythrodermic form of mycosis fungoides and the Szary syndrome may also be difficult to distinguish from benign erythroderma. Roujeau JC, et al. 1990;126(1):437. loss of taste Derm: stevens-johnson syndrome, toxic epidermal necrolysis, rash, exfoliative dermatitis, hair . Am J Clin Dermatol. Fernando SL. Apoptosis as a mechanism of keratinocyte death in toxic epidermal necrolysis. J Allergy Clin Immunol. Tohyama M, et al. Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. Paradisi et al. 2008;23(5):54750. Li X, et al. Drug rashes are the body's reaction to a certain medicine. Contact Dermatitis. Descamps V, Ranger-Rogez S. DRESS syndrome. Burns. The timing of the rash can also vary. A serious cutaneous adverse drug reaction namely exfoliative dermatitis (erythroderma) is associated with isoniazid use . Exp Dermatol. Allergy. 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. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. A promising and complementary in vitro tool has been used by Polak ME et al. More than moderate, unresponsive to treatment, and which interferes with the Soldier's perfor-mance of duty. It is recommended to use 1.5mg/kg hydrocortisone. (sometimes fatal), erythema multiforme, Stevens-Johnson syndrome, exfoliative dermatitis, bullous dermatitis, drug rash with eosinophilia and systemic symptoms (DRESS . Samim F, et al. Pemphigus vulgaris usually starts in the oral mucosa followed by blistering of the skin, which is often painful. Ibuprofen Zentiva can be prescribed with OTC Recipe - self-medication. J Invest Dermatol. PubMed 1997;22(3):1467. These measures include bed rest, lukewarm soaks or baths, bland emollients and oral antihistamines.2527, In patients with chronic idiopathic erythroderma, emollients and topical steroids may be effective. Journal of Pharmaceutical Research and health Care. Bullous pemphigoid is characterized by large, tense bullae, but may begin as an urticarial eruption. 1983;8(6):76375. Arch Dermatol. Hepatobiliary: jaundice, hepatitis, including . 3. 2005;102(11):41349. Tohyama M, et al. A recent review [111] on 33 pediatric cases of TEN and 6 cases of SJS/TEN overlap showed that therapy with IVIG with a dosage of 0.251.5g/kg for 5days resulted in 0% mortality rate and faster epithelization. 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. Shiga S, Cartotto R. What are the fluid requirements in toxic epidermal necrolysis? Erythroderma | DermNet DRUG- Induced- Dermatologic-RXNS - ermatologickins Drug Induced outline 2012;51(8):889902. It characteristically demonstrates diffuse erythema and scaling of greater than 90% of the body surface area. Efficacy of plasmapheresis for the treatment of severe toxic epidermal necrolysis: is cytokine expression analysis useful in predicting its therapeutic efficacy? This content is owned by the AAFP. New York: McGraw-Hill; 2003. pp. Erythroderma - Wikipedia Google Scholar. Overall, incidence of SJS/TEN ranges from 2 to 7 cases per million person per year [9, 1820], with SJS the commonest [21]. 2007;48(5):10158. In serious cases invasive ventilation can be necessary for ARDS. Erythema multiforme StevensJohnson syndrome and toxic epidermal necrolysis. For the prevention of deep venous thrombosis; usually low molecular weight heparin at prophylactic dose are used. Drugs causing erythroderma | DermNet Nature. Immunoregulatory effector cells in drug-induced toxic epidermal necrolysis. FDA Drug information Dupixent Read time: 6 mins Marketing start date: 04 Mar 2023 . Hydration and hemodynamic balance. Tohyama M, Hashimoto K. Immunological mechanisms of epidermal damage in toxic epidermal necrolysis. Abe J, et al. The most notable member of this group is mycosis fungoides. Analysis of StevensJohnson syndrome and toxic epidermal necrolysis using the Japanese Adverse Drug Event Report database. 1993;129(1):926. Even though there is a strong need for randomized trials, anti-TNF- drugs, in particular a single dose of infliximab 5mg/kg ev or 50mg etanercept sc should be considered in the treatment of SJS and TEN, especially the most severe cases when IVIG and intravenous corticosteroids dont achieve a rapid improvement. Check the full list of possible causes and conditions now! 1). EM is a self-limited skin condition mainly associated with infections and drugs [53, 54]. Wikizero - Basal-cell carcinoma 2008;128(1):3544. N Engl J Med. [49] confirmed these results and even suggested that higher dosage regimen with 2.74g/kg seem to be more effective in survival outcome. Each of these physiologic disruptions is potentially life-threatening. A systematic review of treatment of drug-induced StevensJohnson syndrome and toxic epidermal necrolysis in children. exfoliative conditions. This compressed maturation process results in an overall greater loss of epidermal material, which is manifested clinically as severe scaling and shedding. 1998;282(5388):4903. Hospitalization is usually necessary for initial evaluation and treatment. d. Cysts and tumors. Drug induced interstitial nephritis, hepatitis and exfoliative dermatitis Delayed reactions to drugs show levels of perforin, granzyme B, and Fas-L to be related to disease severity. Histopathological and epidemiological characteristics of patients with erythema exudativum multiforme major, StevensJohnson syndrome and toxic epidermal necrolysis. Acute and chronic leukemia may also cause exfoliative dermatitis. In ED increased levels of FasL have been detected in patients sera [33]. [71] realized an algorhitm named ALDEN (algorithm of drug causality for epidermal necrolysis) which helps to establish a cause/effect relationship as probable or very probable in 70% of cases. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involv ing skin and usually occurring from days to several weeks after drug exposure. The syndrome has been described previously in association with phenindione administration, leptospirosis and heavy metal poisoning. Herpes simplex virus (HSV) 1 and 2 are the main triggers in young adults (>80% of cases), followed by Epstein-Barr virus (EBV), and Mycoplasma pneumonia [5558]. 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. Exfoliative Dermatitis | AAFP -. National Library of Medicine Allergy. In the acute phase, before determination of the etiology, treatment consists of measures to soothe the inflamed skin. Ko TM, et al. Nassif A, et al. J Pharm Health Care Sci. The therapeutic approach of EMM, SJS, TEN depends on extension of skin, mucosal involvement and systemic patients conditions. Arch Dermatol. doi: 10.1111/dth.15416. 2011;50(2):2214. UpToDate PubMed 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. Soak for 5 to 10 minutes and rinse off before patting dry. . In patients who develop complications (i.e., infection, fluid and electrolyte abnormalities, cardiac failure), the rate of mortality is often high. Clinical Considerations for Treatment and Prophylaxis of Mpox Infection Cite this article. In case of an oral mucositis that impairs nutrition, it is indicated to position a nasogastric tube. CAS Indian J Dermatol. Hypersensitivity, Delayed Drug Hypersensitivity Radiodermatitis Drug Eruptions Skin Diseases Hypersensitivity Hand-Foot Syndrome Hypersensitivity, Immediate Dermatitis, Contact Erythema Foot Dermatoses Hand Dermatoses Skin Neoplasms Dermatitis, Allergic Contact Alveolitis, Extrinsic Allergic Acneiform Eruptions Dentin Sensitivity Dermatitis Drug-induced LPP. [16] Drug-induced Liver Disease Study Group,Chinese Society of Hepatology,Chinese Medical Association. Neoplastic conditions (renal and gastric carcinoma), autoimmune disease (inflammatory bowel disease), HIV infection, radiation, and food additives/chemicals have been reported to be predisposing factor [59]. DailyMed - DICLOFENAC SODIUM- diclofenac sodium solution 2010;31(1):1004. In case of a respiratory failure, oxygen should be administrated and a NIMV may be required. Interleukin (IL)-1, IL-2, IL-8, intercellular adhesion molecule 1 (ICAM-1), tumor necrosis factor and interferon gamma are the cytokines that may have roles in the pathogenensis of exfoliative dermatitis.2. Manage cookies/Do not sell my data we use in the preference centre. Chan HL, et al. Wolkenstein P, et al. Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. Some anti-seizure medicines have also been known to cause exfoliative dermatitis. 2016;2:14. Erythema multiforme (EM), StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Cookies policy. Targeting keratinocyte apoptosis in the treatment of atopic dermatitis and allergic contact dermatitis. Two Cases in Adult Patients. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Gonzalez-Delgado P, et al. In spared areas it is necessary to avoid skin detachment. The lymphocyte transformation test in the diagnosis of drug hypersensitivity. Students also viewed Nostra aetate - Summary Theology: the basics Principles of Risk Management and Insurance Chapters 1-4 Recombinant granulocyte colony-stimulating factor in the management of toxic epidermal necrolysis. Paquet P, Pierard GE. Volume 8, Issue 1 Pages 1-90 (August 1994). In conclusion we suggest that therapy with cyclosporine is valuable option with a dosage of 35mg/kg oral or iv for 7days. What Is Exfoliative Dermatitis & How Does It Look? - SkinKraft TEN is also known as Lyell syndrome, since it was first described by Alan Lyell in 1956 [2, 60]. For SJS/TEN, corticosteroids are the cornerstone of treatment albeit efficacy remains unclear. 2012;167(2):42432. SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. 1996;134(4):7104. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Focus on the Pathophysiological and Diagnostic Role of Viruses. The administration of a single dose of 5mg/kg was able to stop disease progression in 24h and to induce a complete remission in 614days. Clin Exp Allergy. Granulysin as a marker for early diagnosis of the StevensJohnson syndrome. Furosemide or ethacrynic acid may be required to maintain an adequate urinary output [90]. Huang YC, Li YC, Chen TJ. Infliximab was used in cases refractory to high-dosage steroid therapy and/or IVIG. . Grieb G, et al. CAS In the hospital, special attention must be given to maintaining temperature control, replacing lost fluids and electrolytes, and preventing and treating infection.