Drug eruptions: Is your patient’s rash dangerous or benign?
Photo-illustrated guide helps you identify easily treated reactions, spot 'red flags' of serious conditions.
Laser treatment has successfully improved pigmentation changes associated with imipramine without the patient discontinuing the offending drug.21 Pigmentation changes associated with chlorpromazine have resolved when the drug was replaced by haloperidol22 or phenothiazines, used individually or in combination.23
© 2001-2008, DermAtlas Alopecia is diffuse nonscarring hair loss (Photo 7). Anagen effluvium results in rapid hair loss, as seen with chemotherapeutic agents. Telogen effluvium may not occur until months after a drug is started. Frequently, patients experience only partial hair thinning.
Although alopecia is usually considered benign, patients may find it distressing. Improvement usually occurs within several months after the offending medication is discontinued.1,25 The benefits of continuing a medication associated with alopecia may outweigh the risks; discuss this with the patient.
© 2001-2008, DermAtlas Psoriasis presents as pruritic erythematous patches with scale (Photo 8). Psoriasis may appear at the beginning of drug therapy, or pharmacotherapy may worsen preexisting disease.2,26
Restarting a medication
By accurately identifying a rash and quickly determining its cause, you may avoid unnecessarily discontinuing a patient’s stabilizing medication (Box 2). If you need to discontinue a drug that is causing an ACDR, try to wait 2 weeks before initiating another drug. If this is not possible, cross-tapering a different medication from another class may diminish the risk of drug-rash relapse. To decrease the risk of drug-related rash, follow the manufacturer’s dosing recommendations28 and use the lowest effective dose.
Educate office and hospital staff about specifics pertaining to drug rashes to help ensure that:
- vital information gets to you immediately
- evaluation and treatment can start promptly.
While visiting the psychiatry clinic to complete paperwork, a patient receiving lamotrigine for bipolar disorder asks the office staff to tell her doctor she has a new rash on her face and in her mouth. Mrs. L, age 52, has been on the same lamotrigine dose (200 mg/d) for >1 year and was also taking lansoprazole (dosage unknown); loratadine, 10 mg/d; bupropion, 300 mg/d; quetiapine, 200 mg/d; clonazepam, 0.5 mg bid; atorvastatin, 10 mg/d; valsartan, 160 mg/d; and gabapentin, 300 mg/d. She has had no recent medication changes. Mrs. L leaves the office after finishing the paperwork.
Because lamotrigine carries an FDA “black-box” warning about serious, potentially life-threatening rashes, the psychiatrist attempts to contact Mrs. L immediately as soon as she learns of her symptoms. By phone, Mrs. L describes painful red lesions on her face and sores in her mouth that began the day before. She says she isn’t sure if these lesions have gotten worse. She denies having fever, chills, muscle aches, arthralgia, cough, neck stiffness, shortness of breath, or any other constitutional symptoms.
The psychiatrist tells Mrs. L she may be having a serious skin reaction to lamotrigine and instructs her to stop taking the drug and visit the ER immediately. She also explains that abruptly stopping lamotrigine might cause a relapse of Mrs. L’s bipolar disorder.
The ER physician examines Mrs. L, diagnoses herpes zoster, and prescribes the antiviral famciclovir, 500 mg tid for 7 days, and hydrocodone/acetaminophen, 7.5 mg/500 mg, as needed for pain. Three days later, Mrs. L sees the psychiatrist for a follow-up visit and resumes taking lamotrigine. She has no further complications.
- Dermatology Image Atlas. www.dermatlas.org.
- American Academy of Dermatology. www.aad.org.
- Alprazolam • Xanax
- Amitriptyline • Elavil
- Aripiprazole • Abilify
- Atorvastatin • Lipitor
- Bupropion • Wellbutrin
- Carbamazepine • Tegretol
- Chlorpromazine • Thorazine
- Cimetidine • Tagamet
- Citalopram • Celexa
- Clomipramine • Anafranil
- Clonazepam • Klonopin
- Desipramine • Norpramin
- Dexmethylphenidate • Focalin
- Diphenhydramine • Benadryl
- Duloxetine • Cymbalta
- Escitalopram • Lexapro
- Eszopiclone • Lunesta
- Famciclovir • Famvir
- Fluoxetine • Prozac
- Fluvoxamine • Luvox
- Gabapentin • Neurontin
- Haloperidol • Haldol
- Hydrocodone/acetaminophen • Vicodin
- Hydroxyzine • Atarax
- Imipramine • Tofranil
- Lamotrigine • Lamictal
- Lansoprazole • Prevacid
- Loratadine • Claritin
- Methylphenidate • Ritalin
- Mirtazapine • Remeron
- Olanzapine • Zyprexa
- Oxcarbazepine • Trileptal
- Paroxetine • Paxil
- Quetiapine • Seroquel
- Ranitidine • Zantac
- Risperidone • Risperdal
- Sertraline • Zoloft
- Thioridazine • Mellaril
- Thiothixene • Navane
- Topiramate • Topamax
- Trazodone • Desyrel
- Valproic acid • Depakote
- Valsartan • Diovan
- Venlafaxine • Effexor
- Zaleplon • Sonata
- Ziprasidone • Geodon
- Zolpidem • Ambien
