1996;35(4):2346. The time interval between the appearance of exfoliative dermatitis and the appearance of cutaneous T-cell lymphoma lesions can vary from months to years or even decades. 2008;128(1):3544. Eosinophils from Physiology to Disease: A Comprehensive Review. Szary syndrome, the leukemic variant of mycosis fungoides, is also associated with exfoliative dermatitis. Erythema multiforme (EM), Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. These molecules may play a role in amplifying the immune response and in increasing the release of other toxic metabolites from inflammatory cells [48]. The long-term prognosis is good in patients with drug-induced disease, although the course tends to be remitting and relapsing in idiopathic cases. Antitumour necrosis factor-alpha antibodies (infliximab) in the treatment of a patient with toxic epidermal necrolysis. Paulmann M, Mockenhaupt M. Severe drug-induced skin reactions: clinical features, diagnosis, etiology, and therapy. ), Phenolphthalein (Agoral, Alophen, Modane), Rifampin (Rifadin, Rimactane; also in Rifamate), Trimethoprim (Trimpex; also in Bactrim, Septra). Federal government websites often end in .gov or .mil. In the 5 studies that concluded negatively for IVIG, the dosage was below 0.4g/kg/day and treatment was maintained for less than 5days. Br J Dermatol. Moreover, transpiration and thermoregulation are greatly impaired with an elevated loss of fluids, proteins and electrolytes through the damaged skin and mucosae. Analysis for circulating Szary cells may be helpful, but only if the cells are identified in unequivocally large numbers. 2012;43:10115. J Am Acad Dermatol. By using this website, you agree to our Acute and chronic leukemia may also cause exfoliative dermatitis. [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. Wetter DA, Camilleri MJ. EMs mortality rate is not well reported. Indian J Dermatol. A serious cutaneous adverse drug reaction namely exfoliative dermatitis (erythroderma) is associated with isoniazid use . In some studies, the nose and paranasal area are spared. Toxic epidermal necrolysis: review of pathogenesis and management. 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]. The applications of topical cyclosporine and autologous serum have also been showed to be useful in refractory cases [103]. Applications of Immunopharmacogenomics: Predicting, Preventing, and Understanding Immune-Mediated Adverse Drug Reactions. A recently published meta-analysis by Huang [110] and coworkers on IVIG in SJS/SJS-TEN/TEN reviewed 17 studies with 221 patients and compared the results obtained with high-dosage IVIG (>2g/kg) compared to lower-dosage IVIG (<2g/kg). A pseudolymphoma reaction with fever, arthralgias, lymphadenopathy, hepatosplenomegaly, anemia and erythroderma may develop as a result of hypersensitivity to dapsone or antiepileptic drugs. Among drug related cases, the main triggering factors are sulfonamides, nonsteroidal anti-inflammatories (NSAIDs), penicillins, and anticonvulsants (Table1) [59]. -, Schwartz RA, McDonough PH, Lee BW. A population-based study with particular reference to reactions caused by drugs among outpatients. It was used with success in different case reports [114116]. Also, physicians should be vigilant about possible secondary infection, whether cutaneous, pulmonary or systemic. Typical laboratory values include mild anemia, leukocytosis, eosinophilia, elevated erythrocyte sedimentation rate, abnormal serum protein electrophoresis with a polyclonal elevation in the gamma globulin region, and elevated IgE levels.13,68. ADRJ,2015,17(6):464-465. 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 . CAS 2013;168(3):55562. Oral hygiene with antiseptic and painkiller mouthwash (chlorhexidine+lidocaine+aluminum hydroxide) together with aerosol therapy with saline and bronchodilators can reduce upper airways symptoms. The most notable member of this group is mycosis fungoides. Each of these physiologic disruptions is potentially life-threatening. In addition to all these mechanisms, alarmins, endogenous molecules released after cell damage, were found to be transiently increased in SJS/TEN patients, perhaps amplifying the immune response, including -defensin, S100A and HMGB1 [47]. Google Scholar. Int J Dermatol. 1999;48(5):21726. Toxic epidermal necrolysis: Part II Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment. Drug-induced hypersensitivity syndrome (DiHS) or drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe adverse drug-induced reaction characterized by various symptoms: skin rash, fever, lymph node enlargement and internal organ involvement, which starts within 2 weeks to 3 months after drug initiation. PubMed N Engl J Med. J Burn Care Res. 2012;12(4):37682. Toxic epidermal necrolysis associated with severe cytomegalovirus infection in a patient on regular hemodialysis. Options include use of PUVA light therapy, total-body electron beam irradiation, topical nitrogen mustard, systemic chemotherapy and extracorporeal photopheresis. AB, CC, ET, GAR, AN, EDL, PF performed a critical revision on the current literature about the described topic, wrote and revised the manuscript. Fritsch PO. The efficacy of intravenous immunoglobulin for the treatment of toxic epidermal necrolysis: a systematic review and meta-analysis. Pharmacogenetics studies have found an association between susceptibility to recurrent EM in response to several stimuli and human leukocyte antigen (HLA) haplotypes of class II, in particular HLA DQB1*0301 [23]. In this study, 965 patients were reviewed. 2010;163(4):84753. Br J Dermatol. 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]. New York: McGraw-Hill; 2003. p. 585600. Curr Opin Allergy Clin Immunol. The SCORTEN scale is based on a minimal set of parameters as described in the following table. 8600 Rockville Pike In spared areas it is necessary to avoid skin detachment. A significant number of these patients eventually progress to cutaneous T-cell lymphoma.8, Clinically, the first stage of exfoliative dermatitis is erythema, often beginning as single or multiple pruritic patches, involving especially the head, trunk and genital region. Hum Mol Genet. Von Hebra first described erythroderma (exfoliative dermatitis) in 1868. New York: McGraw-Hill; 2003. p. 54357. Recently, a meta-analysis based on 6 retrospective studies evaluating the role of corticosteroids alone or together with IVIG has been published [107]. The syndrome has been described previously in association with phenindione administration, leptospirosis and heavy metal poisoning. Epub 2018 Aug 22. tion in models of the types of systemic disease for S. aureus pathogenesis research is also expected to receive which anti-virulence drugs would be most desirable. Moreover, the time necessary for cells to mature and travel through the epidermis is decreased. The most commonly used steroids were methylprednisolone, prednisolone and dexamethasone. Google Scholar. Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. 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 2009;29(3):51735. Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Clin Rev Allergy Immunol. 2018 Feb;54(1):147-176. doi: 10.1007/s12016-017-8654-z. A multidisciplinary team is fundamental in the therapeutic management of patients affected by exfoliative DHR. 2015;21:13343. Exfoliative dermatitis is a dangerous form of CADR which needs immediate withdrawl of all the four drugs. 1996;134(4):7104. These studies have confirmed an association between carbamazepine-induced SJS/TEN with HLA-B*1502 allele among Han Chinese [27], carbamazepine and HLA-A*3101 and HLA-B*1511 [16], phenytoin and HLA-B*1502 [28], allopurinol and HLA-B*5801 [29]. A patch testing and cross-sensitivity study of carbamazepine-induced severe cutaneous adverse drug reactions. Continue Reading. eCollection 2018. 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]. View ABRIGO_Worksheet #8 Drug Study_Endocrine System.pdf from NCM 06 at Southern Luzon State University (multiple campuses). Drug eruptions that initially present as morbilliform, lichenoid or urticarial rashes may progress to generalized exfoliative dermatitis. Cookies policy. Chung WH, 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]. Disasters. Drug induced exfoliative dermatitis: state of the art. 3. Severe adverse cutaneous reactions to drugs. Exfoliative dermatitis may happen as a complication of other skin issues. CAS 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. Narita YM, et al. Skin and appendages: acne, bruising, erythema multiforme, exfoliative dermatitis, pruritus ani, rash, skin ulceration, Stevens . 2010;37(10):9046. Other dermatoses associated with erythroderma are listed in Table 1.2,3,68. During the acute reaction, diagnosis of ED is mainly based on clinical parameters. In: Eisen AZ, Wolff K, editors. J Am Acad Dermatol. 2008;4(4):22431. . Article 2. 2008;59(5):8989. 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. Cite this article. HLA-A* 3101 and carbamazepine-induced hypersensitivity reactions in Europeans.