Topical Provocation in Fixed Drug Eruption from Nonsteroidal Anti-Inflammatory Drugs

Abstract

Objective: Evaluate the importance of topical lesional provocation in the study of fixed drug eruption (FDE) from nonsteroidal anti-inflammatory drugs (NSAID). Patients and Results: We studied 14 patients with FDE imputed with high probability to piroxicam (8 patients), nimesulide (5) and feprazone (1). One patient with FDE from piroxicam suffered lesion reactivation after intravenous tenoxicam. The suspected drug and related compounds were patch tested on residual lesional skin and on the normal back skin. Positive results were obtained, only in affected areas, in 13 out of 14 patients (92.9%): in all cases due to feprazone and nimesulide and in 7/8 cases of FDE due to piroxicam. The 7 patients reactive to piroxicam also had positive tests to tenoxicam, and 1 out of 5 reacted to meloxicam. None reacted to thiosalicylic acid. Comments and Conclusions: Topical lesional provocation is a safe, sensible and specific complementary method for drug imputation in FDE from these NSAID, namely for nimesulide, as it reproduced a positive test in the 5 patients. In the case of FDE from piroxicam, our studies confirm cross-reactivity with tenoxicam whereas in piroxicam-induced photosensitivity tenoxicam can be used safely. In photosensitivity the responsible moiety is a UVA photoproduct of piroxicam antigenically and structurally similar to thiosalicylic acid, a moiety which is not involved in FDE.

Fixed drug eruption to cetirizine with positive lesional patch tests to the three piperazine derivatives

“…More than 100 drugs have been implicated in FDE; however, this side‐effect is more commonly found with tetracyclines, sulfonamides, sulfone, penicillins, pyrazolones, barbiturates, phenolphthalein, aspirin, and oral contraceptives 3–5 . In our experience, FDE is mainly caused by the nonsteroidal anti‐inflammatory drugs (NSAIDs) piroxicam and nimesulide 2,6–8 . It has also been described as a side‐effect of some anti‐H1‐antihistamine drugs, such as cyclizine lactate, diphenhydramine hydrochloride, phenothiazines, hydroxyzine, 3 and loratadine 4,9 .…”

Phototoxic and Photoallergic Reactions

“…18.2) or, often, as scattered erythematosus papules and vesicles on the face and dorsum of the hands and dyshidrosis [19,23,105,106] These patients do not react, neither on photopatch nor on drug rechallenge, to tenoxicam, meloxicam, or lornoxicam, as these oxicams do not share the thiosalicylate moiety [24,107]. Nevertheless, it is important to remember that cross-reactivity between piroxicam and these oxicams occurs regularly in fixed drug eruption [108,109].…”

Fixed drug eruption by etoricoxib confirmed by patch test

“…Alternatively, patch testing on a previously involved site may be the preferred test, 3 , especially in cases induced by NSAIDs. 3 Patch testing should be performed six weeks after the acute eruption, with lesions in remission.…”

“…3 Patch testing should be performed six weeks after the acute eruption, with lesions in remission. The culprit drug and related drugs (if possible) are applied under occlusion for 24 hours in test chambers or in open tests, in both non-lesional skin on the back and in previously involved areas.…”

“…The test is considered positive if there is erythema and pruritus, infiltration or more intense reactions. 3,4,5 In highly suspicious cases entailing negative patch tests, it is advisable to repeat the patch test on the affected area with the suspected allergen at the same or higher concentrations (up to 20%), under occlusion. If tests remain negative, oral rechallenge under strict surveillance is an option.…”