Drug eruption
Drug eruption | |
---|---|
photosensitivity reaction. | |
Specialty | Dermatology |
In
The use of synthetic pharmaceuticals and biopharmaceuticals in medicine has revolutionized human health, allowing us to live longer lives. Consequently, the average human adult is exposed to many drugs over longer treatment periods throughout a lifetime.[4] This unprecedented rise in pharmaceutical use has led to an increasing number of observed adverse drug reactions.[4]
There are two broad categories of adverse drug reactions. Type A reactions are known side effects of a drug that are largely predictable and are called, pharmatoxicologic.[5] Whereas Type B or hypersensitivity reactions, are often immune-mediated and reproducible with repeated exposure to normal dosages of a given drug.[5] Unlike type A reactions, the mechanism of type B or hypersensitivity drug reactions is not fully elucidated. However, there is a complex interplay between a patient's inherited genetics, the pharmacotoxicology of the drug and the immune response that ultimately give rise to the manifestation of a drug eruption.[5]
Because the manifestation of a drug eruption is complex and highly individual, there are many subfields in medicine that are studying this phenomenon. For example, the field of pharmacogenomics aims to prevent the occurrence of severe adverse drug reactions by analyzing a person's inherited genetic risk.[6] As such, there are clinical examples of inherited genetic alleles that are known to predict drug hypersensitivities and for which diagnostic testing is available.[6]
Classification
Some of the most severe and life-threatening examples of drug eruptions are
Reaction | Description | Mediator | Mechanism | Clinical phenotype |
---|---|---|---|---|
Type I | Immediate | IgE | antigen binds to mast cell/
basophil surface receptors |
Urticarial (hives), anaphylaxis, |
TypeII | Antibody-mediated | IgM, IgG | antibody binds antigen leading to
complement-driven cell lysis |
drug-induced thrombocytopenia,
hemolytic anemia, Goodpasture's, ANCA vasculitis |
Type III | Immune complex | IgM, IgG, IgA | antigen-antibody complex deposits
in tissues-triggers recruitment of leukocytes
|
Serum sickness, Henoch-Schonlein Purpura |
Type IV | Delayed-type | T-lymphocytes | Activated T-cells produce cytokines causing
inflammation leading to tissue destruction |
Drug reaction with eosinophilia and systemic symptoms (i.e. DRESS syndrome or DIHS), Stevens–Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis
|
By appearance
The most common type of eruption is a
By mechanism
The underlying mechanism can be immunological (such as in
By drug
The culprit can be both a
Examples of common drugs causing drug eruptions are
Certain drugs are less likely to cause drug eruptions (rates estimated to be ≤3 per 1000 patients exposed). These include: digoxin, aluminum hydroxide, multivitamins, acetaminophen, bisacodyl, aspirin, thiamine, prednisone, atropine, codeine, hydrochlorothiazide, morphine, insulin, warfarin and spironolactone.[2]
Diagnosis and screening tests
Drug eruptions are diagnosed mainly from the
Drug reactions have characteristic timing. The typical amount of time it takes for a rash to appear after exposure to a drug can help categorize the type of reaction. For example,
TEN and SJS are severe cutaneous drug reactions that involve the skin and mucous membranes. To accurately diagnose this condition, a detailed drug history is crucial.[4] Often, several drugs may be causative and allergy testing may be helpful.[4] Sulfa drugs are well known to induce TEN or SJS in certain people. For example, HIV patients have an increased incidence of SJS or TEN compared to the general population and have been found to express low levels of the drug metabolizing enzyme responsible for detoxifying sulfa drugs.[5] Genetics plays an important role in predisposing certain populations to TEN and SJS. As such, there are some FDA recommended genetic screening tests available for certain drugs and ethnic populations to prevent the occurrence of a drug eruption.[5] The most well known example is carbamezepine (an anti-convulsant used to treat seizures) hypersensitivity associated with the presence of HLA-B*5801 genetic allele in Asian populations.[6]
Drug | Allele | Population | Clinical syndrome | FDA recommended Pharmacogenetic testing |
---|---|---|---|---|
Abacavir | HLA-B*5701 | US European
US African Australian |
DIHS | Yes |
Allopurinol | HLA-B*5801 | Han, Korean,
Thai, European |
SJS, TEN, DIHS | No |
Carbamezepine | HLA-B*1502 | Han, Thai,
Malaysian, Korean |
SJS, TEN | Yes |
Dapsone | HLA-B*1301 | Chinese | DIHS | No |
Lamotrigine | HLA-B*38
HLA-B*1502 |
European,
Han |
SJS, TEN | no recommendation available |
Methazolamide | HLA-B*5901 | Korean | SJS, TEN | No |
Phenytoin | HLA-B*1502 | Thai, Han | SJS, TEN | Warning |
DIHS is a delayed onset drug eruption, often occurring a few weeks to 3 months after initiation of a drug.[2] Worsening of systemic symptoms occurs 3–4 days after cessation of the offending drug.[5] There are genetic risk alleles that are predictive of the development of DIHS for particular drugs and ethnic populations.[5] The most important of which is abacavir (an anti-viral used in the treatment of HIV) hypersensitivity associated with the presence of the HLA-B*5701 allele in European and African population in the United States and Australians.[5]
AGEP is often caused by antimicrobial, anti-fungal or antimalarial drugs.[4] Diagnosis is often carried out by patch testing. This testing should be performed within one month after resolution of the rash and patch test results are interpreted at different time points: 48 hours, 72hours and even later at 96 hours and 120 hours in order to improve the sensitivity.[4]
See also
- Fixed drug reaction
- List of cutaneous conditions
- List of human leukocyte antigen alleles associated with cutaneous conditions
- Stevens–Johnson syndrome