Two cases of acute generalized exanthematous pustulosis related to oral terbinafine and an analysis of the clinical reaction pattern

Eyler, Jennifer; Squires, Stephen; Fraga, Garth; Liu, Deede; Kestenbaum, Thelda

doi:10.5070/d38cr0t2kh

Cited by 14 publications

(13 citation statements)

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“…56 Given this favourable risk-benefit profile, oral terbinafine remains the safest, and most effective systemic treatment for dermatophytosis. 5 However, an awareness of terbinafine-induced AGEP is important given the 5% mortality associated with AGEP, especially regarding its use in patients who have recently received vaccines. A severe cutaneous eruption poses a considerable risk for morbidity and mortality for affected patients.…”

Section: Discussionmentioning

confidence: 99%

“…Five cases of patients who had psoriasis were excluded, as terbinafine might also trigger pustulous psoriasis, the main differential diagnosis with AGEP. 5,[11][12][13][14] One manuscript lacked information regarding the patient's demographics, evolution, and treatment 15 and it was also excluded. Finally, one manuscript 16 reported a case that did not match Sideroff´s criteria to AGEP and it has been questioned in a commentary manuscript (also excluded).…”

Section: Literature Reviewmentioning

confidence: 99%

“…The first reports are attributed to Baker 3 and Macmillan, 4 that described druginduced generalised pustular rashes. [3][4][5] However, the term "Acute Generalized Exanthematous Pustulosis" was coined by Beylot, who described specific clinical criteria of an acute rash in individuals without previous history of psoriasis, after infection or use of drugs, with spontaneous remission. 6 The cutaneous eruption usually appears in axillary, inguinal, and submammary intertriginous areas, evolving to a more generalised…”

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confidence: 99%

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What to expect when AGEP is induced by terbinafine? Case report and critical review of the literature

Oliveira

Maia

Leão

et al. 2022

Mycoses

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Background Acute Generalised Exanthematous Pustulosis (AGEP) is a rash with multiple sterile intraepidermal or subcorneal non‐follicular pustules on edematous papules, with a sudden development and rapid evolution, triggered by drugs, vaccination, insect bites, exposure to mercury, and allergens. Objectives and Methods We describe a female patient who developed extensive and abnormally prolonged AGEP following exposure to terbinafine and SARS‐CoV vaccine. A detailed review of terbinafine‐induced‐AGEP cases was performed, with the aim of evaluating if the AGEP criteria would follow a different pattern when the disease is triggered by this drug. A PubMed search helped retrieve all terbinafine‐induced AGEP case reports. AGEP‐specific Sideroff criteria were analysed in terbinafine‐induced cases and compared to other trigger causes. Conclusions When the AGEP causative drug was terbinafine, a delay in recovery was observed, compared to the existing AGEP criteria when other causes are considered. Terbinafine frequently leads to delayed resolution AGEP probably due to the presence of the drug in the skin for several weeks after exposure, even after discontinuation, and the disease severity may be potentialised by additional factors such as concomitant viral infections or vaccination.

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Section: Discussionmentioning

confidence: 99%

Section: Literature Reviewmentioning

confidence: 99%

mentioning

confidence: 99%

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What to expect when AGEP is induced by terbinafine? Case report and critical review of the literature

Oliveira

Maia

Leão

et al. 2022

Mycoses

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“…► Pustular psoriasis is very similar to AGEP in its presentation. 16 AGEP has an acute onset, is a single episode, and…”

Section: Differential Diagnosismentioning

confidence: 99%

“…Pustular psoriasis is very similar to AGEP in its presentation. 16 AGEP has an acute onset, is a single episode, and resolves within 2 weeks; whereas pustular psoriasis is a chronic condition with frequent flare ups and has a slower onset. 17 Skin biopsy results in our patient lacked characteristic histological findings seen in psoriasis such as tortuous dilated blood vessels, psoriaform acanthosis, Munro’s microabscesses and increased mitotic figures.…”

Section: Differential Diagnosismentioning

confidence: 99%

Multisystem organ failure secondary to acute generalised exanthematous pustulosis (AGEP) with atypical presentation resembling septic shock

2022

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A woman was admitted for sepsis secondary to cellulitis. After clinical improvement of sepsis, non-follicular small pustules were observed on the trunk, limbs and face while vesicles/bullae and skin exfoliation were noted on upper extremities. Larger systemic manifestations included fever, hypertension and tachycardia. Laboratory results revealed neutrophilic leukocytosis, eosinophilia, mild transaminitis and acute renal failure. Despite treatment for potential sepsis and discontinuation of offending agents, her condition worsened leading to haemodynamic instability and renal failure requiring vasopressor support, intubation and continuous veno-venous haemodialysis. Skin biopsy revealed a diagnosis of acute generalised exanthematous pustulosis (AGEP), a rare condition usually caused by antibiotic treatment. The suspected offending drug was clindamycin, with possible combined effects by metronidazole and/or vancomycin. Improvement of skin manifestations were seen within 48 hours of starting systemic steroids. Here, we present an uncharacteristic case of AGEP clinically presenting with atypical skin lesions, severe systemic involvement mimicking septic shock, which culminated in multisystem organ failure.

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Terbinafin

Mayser

2016

Hautarzt

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Based on the technical information that oral terbinafine must be used with caution in patients with pre-existing psoriasis or lupus erythematosus, the literature was summarized. Terbinafine belongs to the drugs able to induce subcutaneous lupus erythematosus (SCLE)-with a relatively high risk. The clinical picture of terbinafine-induced SCLE may be highly variable and can also include erythema exsudativum multiforme-like or bullous lesions. Thus, differentiation of terbinafine-induced Stevens-Johnson syndrome or toxic epidermal necrolysis may be difficult. Therefore, terbinafine should be prescribed with caution in patients who show light sensitivity, arthralgias, positive antinuclear antibodies or have a history of SLE or SCLE. Case reports include wide-spread, but mostly nonlife-threatening courses, which did not require systemic therapy with steroids or antimalarials in every case. Terbinafine is also able to induce or to aggravate psoriasis. The latency period seems to be rather short (<4 weeks). Terbinafine therefore is not first choice if a systemic therapy with antimycotics is indicated in a patient with psoriasis or psoriatic diathesis. Azole derivatives according to the guidelines may be used as an alternative.

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Two cases of acute generalized exanthematous pustulosis related to oral terbinafine and an analysis of the clinical reaction pattern

Cited by 14 publications

References 0 publications

What to expect when AGEP is induced by terbinafine? Case report and critical review of the literature

What to expect when AGEP is induced by terbinafine? Case report and critical review of the literature

Multisystem organ failure secondary to acute generalised exanthematous pustulosis (AGEP) with atypical presentation resembling septic shock

Terbinafin

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