Msi Week 4: Derm Drug Reactions

Front 1

List 6 medications that are known known for causing cutaneous reactions.

Back 1

1. Antimicrobials
2. NSAIDs
3. Chemotherapy agents
4. Anticonvulsants
5. Psychotropic agents
6. Cytokines

Front 2

Which type of immunologically mediated reactions are immunoglobulin E (IgE) dependent reactions which result in urticaria, angioedema, and anaphylaxis?

Back 2

Type I

Front 3

Which type of immunologically mediated reactions result in hemolysis and purpura?

Back 3

Type II (cytotoxic)

Front 4

Which type of immunologically mediated reactions reactions result in vasculitis, serum sickness, and urticaria?

Back 4

Type III (immune complex reactions)

Front 5

Which type of immunologically mediated reactions result in contact dermatitis, exanthematous reactions, and photoallergic reactions?

Back 5

Type IV (delayed-type reactions)

Front 6

T or F.

Most drug eruptions are mild, self-limited, and usually resolve after the offending agent has been discontinued.

Back 6

TRUE

Front 7

What type of patients have an increased prevalence of adverse drug reactions?

Back 7

Elderly and HIV patients

Front 8

What rash is the most common drug hypersensitivity reaction?

Back 8

Morbilliform rash

Front 9

List 3 alternative names for Morbilliform rash.

Back 9

1. Maculopapular drug eruption
2. Morbilliform exanthem
3. Maculopapular exanthem

Front 10

Which group of drugs are the MOST common triggers of morbilliform rashes?

Which other drugs are also common triggers?

Back 10

Beta lactam antibiotics
(*penicillins, cephalosporins)

Other common triggers:
1. Sulfonamides
2. Allopurinol
3. Anti-epileptic
4. NSAIDs

Front 11

Which drug reactions comprise 95% of all drug-induced skin reactions?

Back 11

Morbilliform drug eruptions

Front 12

On the first occasion, a morbilliform rash usually appears how many weeks after starting a drug?

Back 12

1-2 weeks

Front 13

In general, a morbilliform skin rash in an adult is usually due to a _______, but in a child is more likely be _______.

Back 13

adult --> DRUG

child --> VIRAL

Front 14

Where do morbilliform drug eruptions usually appear first on the body?

They can then spread where?

Back 14

Usually appear on the trunk first

Then spreads to the limbs and neck in a symmetrical pattern

Front 15

What membranes are NOT affected by morbilliform rashes?

Back 15

Mucus membranes

Front 16

Is a biopsy of a morbilliform rash specific or non-specific?

Back 16

Usually non-specific

Front 17

What does a morbilliform rash look like?

Back 17

Widespread pink-to-red flat spots (macules) or raised bumps (papules) that blanch with pressure

*The spots may cluser and merge to form sheets over several days

Front 18

Will morbilliform rashes blanch with pressure?

Back 18

YES

Front 19

List 3 possible outcomes of continuing drug therapy despite the occurrence of a morbilliform rash.

Back 19

1. Might resolve despite drug use
2. Might persist without change
3. Progress to erythroderma, exfoliative dermatitis, and possibly other types of skin rashes

Front 20

What type of allergic reaction is morbilliform drug eruption?

Back 20

Type IV
(CD4+ T cells and release of pro-inflammatory factors)

Front 21

What treatment is used for a morbilliform rash?

Back 21

No specific treatment is required, but topical corticosteroids or anti-histamines might give symptomatic relief

Front 22

What type of rash involves recurrent transient odematous dermal papules and plaques with individual lesions persisting less than 24 hours?

Back 22

Urtecaria (wheals)

Front 23

What can accompany urticaria, resulting from edema of dermis and subcutaneous tissue?

Back 23

Angioedema
(rapid swelling of dermis, subcutaneous tissue, and mucosa)

Front 24

What is the duration of acute urticaria

Chronic urticaria?

What is the significance of this distinction?

Back 24

Acute = < 6 weeks

Chronic = > 3 months

*It is easier to figure out the cause of acute urticaria (usually IgE-mediated Type 1 hypersensitivity reactions)

Front 25

What sort of shape do urticaria lesions have?

Back 25

Polymorphic

Front 26

What treatment is used for urticaria?

Back 26

(Stop medication)

Prescribe:
Oral antihistamines

For more severe cases:
Topical corticosteroids
Epinephrine shot

Front 27

What type of drug reaction is a fixed drug eruption?

Back 27

Type II Cytotoxic

Front 28

Which rash consists of one or more annular or oval erythematous patches after systemic drug exposure?

Back 28

Fixed drug eruption

Front 29

Which type of skin lesion typically resolves with hyperpigmentation and may recur at the same site with re-exposure to the drug?

Back 29

Fixed drug eruption

(With re-exposure, new lesions may develop along with "re-lighting" other lesions)

(CD8+ effector/memory T cells play an important role in reactivation of lesions with re-exposure to the offending drug)

Front 30

Which skin cells are destroyed in fixed drug eruptions?

Back 30

Keratinocytes
(leads to inflammatory response)

Front 31

List 5 drugs that can cause fixed drug eruptions.

Back 31

1. Analgesics
2. Muscle relaxants
3. Sedatives
4. Anticonvulsants
5. Antibiotics

Front 32

Which type of drug eruption is considered the second or third most common skin manifestations of adverse drug events?

Back 32

Fixed drug eruption

Front 33

What gene predisposes and individual to fixed drug eruptions?

Back 33

HLA-B22

Front 34

Where does the initial eruption of a fixed drug reaction occur on the body?

Back 34

1. Lips
2. Genitals

Front 35

How fast does a fixed drug eruption appear after the initial exposure to the drug?

How fast does the lesion reappear once the drug is reintroduced?

Back 35

Initial exposure = up to 2 weeks

Re-exposure = 30 min -- 6 hours

Front 36

How many fixed drug lesions do the vast majority of patients present with?

Back 36

1 - 30 lesions

Front 37

Is a biopsy helpful in diagnosing a fixed drug eruption?

Back 37

Yes.
HIstological examination of inflammatory/acute lesions shows an interface dermatitis w/ vacuolar change and Civatte bodies

Front 38

What treatments are used to control symptoms of fixed drug eruptions?

Back 38

Systemic antihistamines and topical corticosteroids

Front 39

Which type of rash represents a localized eruption of the skin with minimal or no mucosal involvement?

Back 39

Erythema multiforme

Front 40

What are two more severe form of Erythema multiforme?

Back 40

Stevens-Johnsons syndrome
Toxic epidermal necrolysis

Front 41

What is the hallmark of erythema multiforme?

Back 41

Target lesion
(with variable mucous membrane involvement)

Front 42

Describe the characteristics of the lesion that arises in erythema multiforme?

Back 42

Target lesion: circular erythematic ring with small papule, vesicle, or bulla in the center

Front 43

Which mucosal surfaces are most frequently affected by erythema multiforme?

Back 43

Oral mucosa
(lips, palate, and gingiva)

Front 44

List 3 frequent areas of the body that are affected by erythema multiforme.

Back 44

1. Hands
2. Feet
3. Genitals

(can spread to trunk)

Front 45

Is a biopsy useful for diagnosing erythema multiforme?

Back 45

Yes.

Front 46

Is it typically safe to continue a drug if you suspect it is the cause of erythema multiforme?

Back 46

NO. Stop the treatment ASAP

(This is different than in morbilliform rashes, where the treatment can typically be resumed)

Front 47

If your patient presents with target lesions and mucosal involvement, what type of drug reaction do you suspect, and what should you do?

Back 47

Erythema multiforme

Stop treatment!

Front 48

How do you treat erythema multiforme?

Back 48

Symptomatic treatment

1. Oral antihitamines
2. Analgesics
3. Soothing mouthwashes
4. Topical steroids

Front 49

What type of hypersensitivity reaction is involved in Stevens-Johnsons syndrome?

Back 49

Type III
(immune-complex mediated)

Front 50

In Stevens-Johnsons Syndrome and toxic epidermal necrolysis, what do the center of the lesions typically look like?

Back 50

May appear vesicular, purpuric, or necrotic

Front 51

Which type of drug reaction can result in mucosal involvement that blisters, ulcerates, swells, and can be severe enough to inhibit eating or drinking?

Back 51

Stevens-Johnsons/ toxic epidermal necrolysis

Front 52

Based on the percentage of affected skin, how can you differentiate between Stevens-Johnsons syndrom and Toxic epidermal necrolysis?

Back 52

If blisters/detachment of skin is:

<10 % body surface = Stevens Johnsons

>30% body surface = toxic epidermal necrolysis

Front 53

What is the mortality rate for Stevens Johnsons and Toxic epidermal necrylosis?

Back 53

Stevens Johnsons = 5%

Toxic epidermal necrolysis = 40%

Front 54

Where should patients with Stevens Johnsons syndrome or toxic epidermal necrolysis be treated?

Back 54

ICU or burn unit

(hospitalization should be considered for patients w/ an initially benign presentation of Stevens-Johnson syndrome)

Front 55

What drug therapy is beginning to be incorporated into the treatment of toxic epidermal necrolysis?

Back 55

IVGG
(intravenous immunoglobulin G)