Bullous Drug Reactions

Abstract

This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Acta Derm Venereol 2020; 100: adv00057 Centenary theme section: BLISTERING SKIN DISORDERS SIGNIFICANCE Drug reactions with blisters (known as bullous drug reactions) are challenging for patients and physicians. Often there are early signs and symptoms that may lead to the suspicion of a bullous drug reaction before blisters and erosions of the skin and mucosa appear. Once the diagnosis is suspected, appropriate diagnostic and therapeutic procedures must be initiated. A detailed history, including clinical symptoms, drug use and infections, is crucial. In cases with drug causality, the potentially culprit agent must be withdrawn, while in cases with other aetiology, the underlying condition, e.g. infection, must be treated. In addition to best supportive care, immunomodulating therapy may be considered. Bullous drug eruptions are infrequent, but because they pose a challenge both to affected patients and to treating physicians they are considered to be the most severe cutaneous adverse reactions (SCAR). It is important to recognize these conditions and to differentiate them from other clinical entities involving blister formation. There may be early signs and symptoms that indicate a severe bullous drug eruption even before blisters and erosions of the skin and mucous membranes become obvious. Once the diagnosis is suspected, appropriate diagnostic procedures and adequate management must be initiated. The latter includes identification of the potentially inducing drug, although it should be taken into account that not all cases of bullous eruptions are drug-induced. In cases with drug causality the potentially culprit agent must be withdrawn, while in cases with other aetiology the underlying condition, e.g. an infection, must be treated appropriately. In addition to best supportive care, immunomodulating therapy may be considered.

An outside job

“…Bullous drug eruption is a rare adverse event characterized by localized or generalized blisters and erosions, which may be pruritic and painful. 1 …”

“…On review of prior medical records, symptom timeline, and the patient's cell phone photographs, the skin changes were deduced to be due to the local application of topical 0.25% capsaicin ointment, initiated at the previous hospital for pain control. Bullous drug eruption is a rare adverse event characterized by localized or generalized blisters and erosions, which may be pruritic and painful 1 …”

Generalized Bullous Fixed Drug Eruption to Fluconazole with Positive Patch Testing and Confirmed Tolerance to Itraconazole

“…GBFDE is a distinct variant of FDE belonging to Severe cutaneous adverse reactions (SCARs), along with other bullous drug reactions such as Stevens-Johnson syndrome (SJS) and Toxic epidermal necrolysis (TEN). 1 Histopathology can only confirm a clinical entity within the spectrum of bullous diseases, but cannot differentiate between the distinct diseases. The confirmation of GBFDE diagnosis is therefore possible in most cases during the disease.…”

Clonal expansion of CD4+CD8+ T cells in an adult patient with Mycoplasma pneumoniae-associated Erythema multiforme majus

“…Erythema multiforme (EM) is an acute, immunemediated mucocutaneous disease characterized by typical target or raised atypical target lesions, typically with an acral distribution [1]. EM can occur in patients of all ages, but it is most prevalent in young adults and shows a predominance for the male sex [2,3]. EM comprises a minor and a major form, with ≤ 1 (Erythema multiforme minus, EMm) or ≥ 2 (Erythema multiforme majus, EMM) mucosal sites involved, respectively [1].…”

“…EM comprises a minor and a major form, with ≤ 1 (Erythema multiforme minus, EMm) or ≥ 2 (Erythema multiforme majus, EMM) mucosal sites involved, respectively [1]. EMM may also be accompanied by general illness such as fever or fatigue [2,3]. In most cases, EM is preceded by infection/reactivation with herpes simplex virus (HSV) and is thought to be caused by HSV DNA fragments, transported to the skin by Langerhans cell precursors [4,5].…”