Cross‐reactivity between nonsteroidal anti‐inflammatory drugs in fixed drug eruption: Two unusual cases and a literature review

Abstract

Nonsteroidal anti‐inflammatory drugs (NSAIDs) are among the main causes of fixed drug eruption (FDE). Cross‐sensitivity between chemically unrelated NSAIDs has been rarely described in FDE. We report herein two cases of NSAID‐induced FDE confirmed by oral provocation test (OPT) with a literature review. Case 1 is a 49‐year‐old woman who took mefenamic, naproxen and acetaminophen for lumbago. On the second day, she noticed three erythematous plaques, located in the upper lip, chin and the right hand, which faded spontaneously, leaving residual patches. Three months later, she took mefenamic acid with reactivation of the same plaques. She received naproxen. On the same day, she exhibited a reactivation of lesions with the development of a new one. These lesions have disappeared leaving hyperpigmented sequelae. After negative patch test to naproxen, an OPT was performed with positive reaction, observed on the third day. To establish the cross‐reactivity, she underwent OPTs, which gave positive results to indomethacin, ketoprofen and tiaprofenic acid. Case 2 is a 52‐year‐old woman who presented painful dusky‐red macules, located in the right and left wrists, 24 hours after taking mefenamic acid. She described two similar events that occurred in the past with an undefined drug and piroxicam. Patch tests to lysine acetylsalicylate, mefenamic acid, piroxicam, naproxen and celecoxib were negative. OPTs to the same NSAIDs gave positive results to lysine acetylsalicylate, piroxicam and mefenamic acid. Thirteen case reports, seven case series and one retrospective analysis, including cases with confirmed cross‐reactivity between NSAIDs, were reported in literature. Clinicians should be aware of such phenomenon.

Nimesulide-Induced Fixed Drug Eruption Followed by Etoricoxib-Induced Fixed Drug Eruption: An Unusual Case Report and Review of the Literature

“…provided us with a comprehensive collection of relevant literature. Only publications in English were included, and the main characteristics of the studies and cases were extracted and summarized in Table 1 [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].…”

“…A total of three publications reported cross-reactivity among chemically unrelated NSAIDs [ 10 , 11 , 17 ]. Ammar et al reported two female patients, aged 49 and 52, who developed multiple lesions typical of FDE after the ingestion of different NSAIDs.…”

“…The initial workup consisted of patch tests that yielded negative results for both patients, but positive findings were observed with OPT. The first patient underwent OPT and had positive reactions for naproxen, indomethacin, ketoprofen, and tiaprofenic acid, and thus, the groups of propionic acid, fenamic acid, and indole derivates were contraindicated in this patient [ 10 ]. The second patient had positive OPT for lysine acetylsalicylate, mefenamic acid, and piroxicam and was treated accordingly [ 10 ].…”

“…The first patient underwent OPT and had positive reactions for naproxen, indomethacin, ketoprofen, and tiaprofenic acid, and thus, the groups of propionic acid, fenamic acid, and indole derivates were contraindicated in this patient [ 10 ]. The second patient had positive OPT for lysine acetylsalicylate, mefenamic acid, and piroxicam and was treated accordingly [ 10 ]. Ouni et al reported a case of a 40-year-old male that developed lesions 1 week after the initiation of mefenamic acid, paracetamol, and lansoprazole for post-traumatic knee pain.…”

“…Notably, the patient had never used nabumetone before [ 17 ]. The role of patch testing in cases of unusual cross-reactivities may be limited, as supported by the presented cases, since it did not cause any reactions and OPT was needed to point out other potentially harmful medications that needed future avoidance [ 10 , 17 ].…”