Lesson 2 Derm UF PA

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created 7 years ago by stefan_mcfarland
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Adverse Drug Reaction
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1
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Exanthem or Morbilliform Rash
The most common type of drug eruption
itchy or asymptomatic, +/- low-grade fever
Usually begins within 7-14 days after initiation of the drug
Dx - Pink macules and papules that may become confluent on trunk and extremities (mucus membranes spared)
Tx - oral antihistamines and bland emollients; discontinue the drug if possible

2
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Urticaria - associated with hypersensitivity responses and appear as wheals, welts, or hives.
Drugs can cause urticaria by immunologic (abx) and non-immunologic (dye) mechanisms
Dx - Pruritic, transient wheals, each lasting < 24 hours-can occur anywhere (even palms, soles, scalp)
Tx - Oral Antihistamines (H1 and H2 blockers)
STOP OFFENDING MEDICATION - DO NOT RE-CHALLENGE
Treat for Anaphylaxis as required

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Erythema Multiforme -an acute inflamm of skin and mucous membranes with lesions that appear target-like with alternating rings of edema and inflamm.
Dx - acrofacial target lesions, sometimes on trunk.
Tx - Topical, systemic antihistamines/corticosteroids, prophylactic

4
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Stevens Johnson Syndrome (SJS)
A true “dermatologic emergency.”
Dx - Characterized by severe and widespread mucosal involvement in addition to areas of blistering and epidermal detachment (<10 %)
+ Nikolsky sign (skin sloughs or blisters when rubbed) +prodrome
Patients complain that their skin hurts
Occurs 7-21 days after initiation of drug
Tx - STOP OFFENDING; admit to ICU/Burn; IV Ig

5
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Toxic Epidural Necrolysis (TEN)
Dx - Similar to Stevens-Johnson except more widespread, > 30% BSA
ACUTE onset of widespread bullae and sheet like epidermal sloughing of skin
+Nikolsky sign; VERY tender skin
Tx - STOP OFFENDING; ICU/Burn unit; IV Ig

6
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Exfoliative Erythroderma aka Red Man Syndrome
Diffuse erythema followed by desquamation (scaling of skin)
SCALP-ID - DDx
Complications of protein/fluid loss
Tx - STOP OFFENDING, bland emollients

7
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Hypersensitivity Syndrome (DRESS)- severe skin reaction with systemic symptoms
Most commonly associated with anticonvulsants and sulfonamides, minocycline
Dx -Cutaneous involvement usually begins with morbilliform eruption with associated fever
Multiple edematous pink papules are seen
Develops 2-6 weeks after drug initiation (later onset)
Facial edema is a frequent finding and is a hallmark of DRESS
Possible liver complication and fulminant jaundice
Tx - STOP OFFENDING; Long Taper Systemic Corticosteroids

8
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Fixed Drug Eruption
Dx - Usually solitary well-circumscribed, erythematous or “dusky” macules that may evolve into plaques or bullae; most common sites: face and genitalia
With subsequent exposure, they develop within 24 hours
Areas may burn or itch
Eruption appears in the same spot each time the drug is taken
Tx - Stop offending, topical steroids

9
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Vasculitis
"Palpable purpura" - most often lower extremities
Drug-induced vasculitis is thought to involve deposition of immune complexes (antibody vs drug-related haptens) in post-capillary venules
Complications include involvement of kidney, liver, GI tract, joints and CNS
May be life threatening
Tx - Discontinue suspected drug

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Photosensitivity

Cutaneous inflammation caused by reaction of drug to UV light/radiation. Can be phototoxic or photoallergic reactions.

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Phototoxic Reaction
Occur in any person following sufficient drug and UVR
UVR reacts with drug and unstable singlet or triplet state leads to ROS (reactive oxygen species)
The ROS are responsible for cell damage
Exaggerated sunburn followed by hyperpigmentation
Caused by meds and foods
Tx - Dose at bedtime, decrease meds or sun exposure or both.

12
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Photoallergic eruption
UVR is required to convert the drug into an immunologically active compound
Dx - Delayed onset (up to 2 weeks- a period of sensitization)
May appear weeks to months after drug exposure
Occurs only in sensitized persons on sun-exposed sites
Shows histologic pattern of contact dermatitis
Tx - Drug withdrawal, sun avoidance, cold compress, bland emollients, topical steroids.