Increased cutaneous reactions to hydroxychloroquine (Plaquenil) possibly associated with formulation change: Comment on the letter by Alarcón

Abstract

presidential address (Weinblatt ME. ACR presidential address: the best of times, the worst of times, rheumatology 2001. Arthritis Rheum 2002;46:567-73) with great interest as soon as it arrived, I regret that its Tale of Two Cities metaphor inspired not only juxtaposition, but also a conflicting emotional response quite separate from its intended message. Although the address triumphantly chronicled many accomplishments and described our new challenges, I felt belittled by the comments regarding fibromyalgia. Rheumatologists have a proud tradition of walking where others fear to tread. Our participation in investigating the enigmas of breast implants, Lyme disease, tryptophan, and myriad other puzzles only hastened the eventual understanding of these problems. Who is better qualified than rheumatologists to finally unravel the daunting mystery of fibromyalgia? I believe that Dr. Weinblatt may be inaccurate when he suggests that rheumatologists provide "little value" to patients with fibromyalgia. The comments regarding Mary Betty Stevens personified my hopes and aspirations as well. While each specialty seems to be trying to discard their most emotionally challenging disorders to primary care physicians and psychiatrists, I doubt that those inspiring pioneers ever took the easy road by "restricting followup visits." We will overcome this daunting adversary called fibromyalgia. And, as with previous challenges, we will eventually be just as proud of that effort and determination. We are all committed to caring for patients with inflammatory diseases, but our past success should inspire us to conquer all of our challenges, not just to enjoy the fruits of our recent advances for a portion of our patients.

Early cutaneous eruptions after oral hydroxychloroquine in a lupus erythematosus patient: A case report and review of the published work

“…If the patient has only mild skin eruptions, as in the present case, the HCQ treatment may be continued. Even though HCQ has a very long half‐life at approximately 50 days and complete elimination requires more than 8 months after withdrawal of the drug, some patients, such as the present case, may continue the HCQ treatment under careful monitoring with improvements in symptoms and no complications . One possible explanation for this phenomenon is immune tolerance leading to a decrease in drug eruptions despite long‐lasting circulation …”

“…It may be a reactive allergic phenomenon associated with an imbalance in the immune system in an early stage after the initiation of HCQ . We summarize the characteristics of 21 reported cases of LE with cutaneous reactions due to HCQ, including our case, in Table . There were 11 cases of SLE (52.38%), eight of CLE (38.1%) and 2 of discoid lupus erythematosus (9.52%).…”

“…The withdrawal of HCQ treatments due to adverse cutaneous eruptions was previously reported in approximately 3% of patients . The mechanisms responsible for the early occurrence of cutaneous eruptions by HCQ currently remain unknown.…”

“…Otherwise, if there is more evidence to support cutaneous reactions due to HCQ, a patient's systemic symptom needs to be carefully evaluated in order to decide whether to continue, stop then restart or stop this drug completely. Based on our review of the published work, HCQ needs to be stopped completely and another systemic therapy initiated in patients with widespread severe reactions, such as widespread skin rash and/or severe irritation, widespread acute generalize exanthema pustulosis, drug rash with eosinophilia and systemic symptoms or Stevens–Johnson syndrome/toxic epidermal necrolysis . If cutaneous eruptions are accompanied by other common reactions such as headaches, nausea, vomiting, diarrhea or stomach pain, HCQ needs to be stopped for a period of time and then restarted.…”

Hydroxychloroquine enhanced urticarial reaction in a patient with discoid lupus erythematosus

“…The withdrawal of HCQ treatments due to adverse cutaneous eruptions was previously reported in approximately 3% of patients [5] . The Japanese report on side effect of HCQ from September 7, 2015 to April 30, 2017 was 165 cases of 122 pa tients (unpublished data from the company).…”