Fixed drug reaction

Fixed drug reaction
Other names: Fixed drug eruption
Fixed drug reaction
SpecialtyDermatology
SymptomsOne or several red/purple skin patches in same location every time a particular drug is taken,[1] typically on face, lips, groin[2]
Usual onsetAround 2 hours after taking drug,[1] can be 2 weeks[3]
CausesType IV hypersensitivity,[4] antibiotics, non-steroidal anti-inflammatory drugs[4]
Diagnostic methodHistory, visualisation, skin biopsy, oral challenge test, patch test[4]
Differential diagnosisInsect bite reaction, bullous pemphigoid, erythema multiforme, Stevens-Johnson syndrome, herpes simplex, aphthous ulcer[4]
TreatmentIdentify and stop causative drug, topical corticosteroid[4]
FrequencyCommon, males=females, age 35-60 years[3]

A fixed drug reaction is a rash that appears in the same fixed location every time a particular drug is taken.[1] It is typically a solitary well-defined, roundish red or purplish patch.[1][2] There may however be several which can be scattered or generalized, and there may be blisters, vesicles, erosions or ulcers.[3] It can be itchy and painful and often leaves a dark mark after healing.[4] Common sites include face, lips, groin, hands, feet, eyelids, anogenital areas, tongue and hard palate.[2][4]

It is a delayed type IV hypersensitivity, usually caused by antibiotics and non-steroidal anti-inflammatory drugs.[4] A typical time from taking the drug to noticing the rash is around 2 hours,[1] but can be 2 weeks.[3] Diagnosis is by history and visualisation of the rash.[3] It may require a skin biopsy, oral challenge test with a low dose of the suspected drug or a patch test.[4] The first epiode may be mistaken for an insect bite reaction or bullous pemphigoid.[4] Other differentials include erythema multiforme, Stevens-Johnson syndrome, herpes simplex or aphthous ulcer.[4]

Treatment includes identifying and stopping the causative drug and considering applying topical corticosteroid.[4]

They are common.[1] Males are affected equally to females.[3] The most likely age group is 35 to 60 years old.[3] It was first described in 1889 and the term was coined by Brocq in 1894.[3]

Signs and symptoms

It generally looks like a solitary or a few well-defined, roundish red or purplish patches which may blister.[4] It can be itchy and painful and often leaves a mark after healing.[4] The lips, genitals, and hands are often involved. The affected person feels otherwise well.[4] Common sites include hands, feet, eyelids, anogenital areas, lips, tongue and hard palate.[4] These sites may be the location of previous trauma such as an insect bite, blood test or burn.[4]

  • Fixed drug reaction (targeted)
    Fixed drug reaction (targeted)
  • Fixed drug reaction (pigmented) on lip
    Fixed drug reaction (pigmented) on lip
  • Fixed drug reaction on hard palate
    Fixed drug reaction on hard palate
  • Fixed drug reaction (lips and penis)
    Fixed drug reaction (lips and penis)
  • Fixed drug reactio groin (erosions)
    Fixed drug reactio groin (erosions)
  • Fixed drug reaction to cotrimoxazole
    Fixed drug reaction to cotrimoxazole

Causes

It is a delayed type IV hypersensitivity, usually caused by antibiotics and non-steroidal anti-inflammatory drugs.[4] Medications inducing fixed drug reactions are usually those taken intermittently.[1] Medications that are commonly implicated as a cause of fixed drug reactions include the following:

Anti-microbials

Painkillers

Anti-hypertensive medications

  • Calcium channel blockers[4]
  • Angiotensin-converting enzyme inhibitors[4]

Anti-epileptic drugs

Other

Vaccines

  • Influenza vaccine[3]

Foods

Diagnosis

Diagnosis is by history and visualisation of the rash.[3] It may require a skin biopsy, oral challenge test with a low dose of the suspected drug or a patch test.[4]

Tests

  • Patch test to tranexamic acid
    Patch test to tranexamic acid
  • Patch test to anti-histamines
    Patch test to anti-histamines
  • A. FDR, B. 30 min after oral challenge test
    A. FDR, B. 30 min after oral challenge test

Histopathology

Histopathology show distinct changes in vacuoles and Civatte bodies in all levels of the epidermis.[2] The is melanin incontinence and neutrophils and eosinophils.[2]

  • Melanin incontinence
    Melanin incontinence
  • Basal vacuolation
    Basal vacuolation

Treatment

Treatment includes identifying and stopping the causative drug and considering applying topical corticosteroid.[4]

Epidemiology

Fixed drug reaction is common.[1] Males are affected equally to females.[3] The most likely age group is 35 to 60 years old.[3]

History

The condition was first described in 1889 and the term was coined by Brocq in 1894.[3]

See also

References

  1. 1 2 3 4 5 6 7 8 James, William D.; Elston, Dirk; Treat, James R.; Rosenbach, Misha A.; Neuhaus, Isaac (2020). "6. Contact dermatitis and drug eruptions". Andrews' Diseases of the Skin: Clinical Dermatology (13th ed.). Elsevier. pp. 120–121. ISBN 978-0-323-54753-6. Archived from the original on 2021-10-16. Retrieved 2021-10-15.
  2. 1 2 3 4 5 6 Johnstone, Ronald B. (2017). "3. Lichenoid reaction pattern". Weedon's Skin Pathology Essentials (2nd ed.). Elsevier. p. 41. ISBN 978-0-7020-6830-0. Archived from the original on 2021-05-25. Retrieved 2021-10-16.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Anderson, Hannah J.; Lee, Jason B. (September 2021). "A Review of Fixed Drug Eruption with a Special Focus on Generalized Bullous Fixed Drug Eruption". Medicina. 57 (9): 925. doi:10.3390/medicina57090925. Archived from the original on 2021-10-17. Retrieved 2021-10-16.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 "Fixed drug eruption | DermNet NZ". dermnetnz.org. Archived from the original on 13 August 2021. Retrieved 16 October 2021.
Classification
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