The adverse reactions
of drugs might lead to common problems such as skin eruptions or may cause a
serious health concern in patients on systemic medications. However, most drug-induced
skin disorders are mild and disappear when the causative drug is withdrawn.
Assistant Professor Pharmacy Assistant Professor, Practice Campbell University
College of Pharmacy & Health Sciences, along with other experts highlighted
the various types of drug-induced skin reactions.
Skin disorders caused
by adverse drug reactions are of two types: acute or chronic.
Acute Drug-Induced Skin Manifestations:
Urticaria is characterized as
edematous (pus filled
between the cells) and erythematous papules (red rash like inflammatory elevation of the skin
that does not contain pus) and plaques that are itchy.
In angioedema, the dermal and subcutaneous
layers are involved. The swelling is pale or pink appearing generally on face
tongue, mucous lining in
the inside of the mouth, larynx (voice box), and pharynx.
Anaphylaxis is a serious allergic reaction that
sets in rapidly and might lead to shock and death.
Discontinuing the use of the drug is the best management of
such drug-induced reactions.
Erythematous Reactions are the
commonest of the acute drug reactions. The eruptions generally occur on 4 to 14
days post drug hypersensitivity. However it may develop 1 to 2 days after the
cessation of the drug intake.
The skin lesions are either pus filled or elevated
without pus and are itchy. They normally appear on the outer trunk and
Such skin reactions are common with penicillin,
sulfonamides, anticonvulsants, cephalosporins and allopurinol.
Discontinuation of the drug is the primary
treatment of the skin lesions, however if drug is mandatory for essential
therapy, continue the use till serious symptoms appear.
Fixed-Drug Eruptions are seen as red,
raised lesions that are itchy in nature. Often burning or stinging sensation is
present with such lesions. The lesions have a sudden onset and resolve within
few days. However the hyperpigmentation (darkening of the skin due to excess melanin) might
last for months. These lesions can appear anywhere in the body and reappear if
the causative agent is re-administered.
Drug Hypersensitivity Syndrome (drug
rash with eosinophilia and systemic symptoms or DRESS) is a severe condition
with sudden rash
eruptions, fever, swollen
glands and multi-organ involvement. It is more common with African
people. Skin rash and fever are the initial symptoms. Generally, face, upper
extremities and upper trunk are affected. Topical
corticosteroids are effective in treating the local infections while systemic
corticosteroids are used if heart and lungs are involved.
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal
Necrolysis (TEN) are rare and extremely dangerous skin
responses. Genetic propensity or tendency for SJS and TEN is also reported to
exist. The skin lesions are blemish-like
and rounded bumps-type
and are itchy in nature. The
discontinuation of the offending drug is the only choice of treatment.
Warfarin-Induced Skin Necrosis is
a serious condition and usually develops 3-5 days after taking warfarin.
Necrosis, tissue blisters, ulcers and hyperpigmentation are noticed with
warfarin necrosis. Individuals with hereditary protein C deficiency are
vulnerable to warfarin necrosis. Discontinuing
warfarin and administering heparin, vitamin K and monoclonal antibody-purified
protein C concentrate improves the condition.
Drug-Induced Vasculitis (DIV) is
a drug reaction that manifests itself as palpable, itchy lesions or a red rash
with small bumps often associated with ulcers, nodules, hemorrhagic blisters or
Raynaud's disease. Symptoms subside by
withdrawing the causative drug. Immunosuppressive drugs or corticosteroids
might be needed in severe cases.
Serum Sickness-Like Reactions are
similar to urticarial rash and are accompanied with fever, joint pain and swollen glands.
Cefaclor, penicillins, minocycline and propranolol are reported to cause serum
Sickness-Like Reactions. Discontinuation
of the drugs improve the condition. Systemic steroids are administered in
Acute Generalized Exanthematous Pustulosis (AGEP) are
rare and appear as pustular eruptions. AGEP is accompanied by fever, diffuse
red rashes, itching, burning and eruptions. There is facial edema, swelling of
hands and even mucus membrane. The
treatment involves discontinuation of drug, topical steroids and anti-pruritic
Photosensitivity is a skin response
initiated by sunlight in doses that are otherwise harmless. Photosensitive
responses can either be photo-allergic or phototoxic in nature. Certain drugs
produce both types of responses. Phototoxicity refers to sudden onset of burning
sensation on the sun-exposed parts of the body. Sunburn and hyperpigmentation
are common in phototoxicity. Treatment
involves application of topical steroids and avoiding exposure to sun.
Chronic Drug-Induced Skin Disorders:
The chronic skin disorders
are as under:
Drug-Induced Lupus (DIL) is a rare
condition for which the exact cause is unknown. Common symptoms are joint pain
or muscle pain, arthritis, fever, malaise, anorexia, weight loss, itchy skin
and eruptions. Classic butterfly rash is seen.
lupus erythematosus (SCLE) is commonly seen with antihypertensive drugs such as
calcium channel blockers, ACE inhibitors, etc.
child-bearing age are commonly affected with Systemic lupus erythematosus
Immunosuppressive agents or corticosteroids are required to
treat the situation.
In Drug-Induced Acne (Acneiform Eruption) pus filled blister like
skin eruptions are seen on face and upper trunk. Comedones (blackheads or whiteheads)
are not present. In asthmatics, inhaled steroids may result in its outbreak.
Pigmentary Changes cause melanin enhancement leading to hyperpigmentary
Treatment of skin
disorders caused by drugs includes the following:
• Withdrawal of the
• Symptomatic care and
corticosteroids are useful in subsiding skin responses.
All skin reactions are
not caused by drugs, still it is important for health provider to understand
and differentiate between disorders and their causes.
The patients should be
informed about the adverse effects of the drugs and appropriate knowledge
should be given regarding the initial management of the adverse responses.
of the reaction should be made to ensure effective treatment of the skin
Drug-Induced Skin Disorders; Valerie et al; US