Maculopapular eruptions

The word dermatitis denotes an inflammatory erythematous rash. The disorders discussed in this chapter include contact dermatitis, seborrheic dermatitis, diaper dermatitis, and atopic dermatitis. Drug-induced skin disorders have been associated with most commonly used medications and may present as maculopapular eruptions, fixed-drug eruptions, and photosensitivity reactions. 

Ketonuria excessive amounts of ketone bodies in the urine Maculopapular eruptions skin condition characterised by a rash consisting of distinct eruptions Mania psychiatric disorder characterised by agitation and elated mood... 

Hypersensitivity Anaphylaxis angioedema arthralgia chills drug fever eczematous, erythematous, or maculopapular eruptions lupus-like syndrome associated with pulmonary reactions myalgia pruritus urticaria. 

The incidence of nonallergic ampicillin eruptions is 40 to 100% in patients with concomitant Epstein-Barr virus (mononucleosis), cytomegalovirus, acute lymphocytic leukemia, lymphoma, or reticulosarcoma. Nonallergic penicillin-associated rashes are characteristically morbilliform (symmetrical, erythematous, confluent, maculopapular) eruptions on the extremities. The onset of typical nonallergic eruptions is more than 72 hours after (3-lactam exposure. The mechanism for the nonurticarial ampicillin rash is not known and is not related to IgE or type I hypersensitivity. Penicillin skin tests are not useful in the evaluation of nonurticarial ampicillin rashes. Patients with a history of nonurticarial ampicillin rashes may receive other (3-lactam antibiotics without greater risk of subsequent serious allergic reactions. 

Adverse Reactions Hypoglycemia Gastrointestinal disturbances (nausea, diarrhea, constipation, gastralgia) Dermatologic reactions (erythema, morbilliform or maculopapular eruptions, urticaria, pruritus, and eczema) Hematologic reactions (leukopenia, agranulocytosis, thrombocytopenia, hemolytic anemia, aplastic anemia, pancytopenia) Metabolic reactions (hepatic porphyria, disulfiram-like reactions) Hyponatremia Elevated liver enzymes... 

Measles Rubeola Fever, cough, brownish pink maculopapular eruptions of skin Hyperemia, chemosis commonly associated with prodrome Kophk s spots... 

In 31 patients with Rhus allergy over a 10-year period the clinical manifestations included maculopapular eruptions (65%), erythema multiforme (32%), erythroderma (19%) pustules, purpura, wheals, and blisters (5). All the patients had generalized or localized pruritus, and other symptoms included gastrointestinal problems (32%), fever (26%), chills, and headache. Many developed a leukocytosis (70%) with neutrophilia (88%), and some had toxic effects on the liver or kidneys. All responded to glucocorticoids or antihistamines. 

There have been numerous reports of different rashes in association with ACE inhibitors. The most common skin reaction is a pruritic maculopapular eruption, which is reportedly more common with captopril (2-7%) than with enalapril (about 1.5%). This rash occurs in the usual dosage range and is more common in patients with renal insufficiency (70). Lichenoid reactions, bullous pemphigoid, exfoliative dermatitis, flushing and erythroderma, vasculitis/purpura, subcutaneous lupus erythematosus, and reversible alopecia have aU been reported (70-72). 

Maculopapular eruptions and desquamation of hands and/or feet occurred in 35% of patients with non-small cell lung cancers given docetaxel (8). 

A 29-year-old man developed an infiltrative maculo-papular eruption after 1 week of itraconazole 100 mg bd for tinea corporis (44). Itraconazole was withdrawn, and the lesions disappeared within 7 days. Scratch tests, patch tests, scratch-patch tests, and drug induced lymphocyte stimulation tests for itraconazole were negative however, rechallenge with systemic itraconazole induced a maculopapular eruption on the face, hands, and the dorsa of the feet. Empty itraconazole capsules had no cutaneous effects, suggesting an allergic reaction to a metabolite of the compound. 

Precautions are necessary to avoid ultraviolet radiation after taking photoreactive drugs (38). Metabolism of hn-comycin can lead to the formation of reactive oxygen species and cause tissue injury and damage to various cellular macromolecules, which can result in phototoxicity. Typical photosensitivity with a maculopapular eruption has been observed with hncomycin in two patients treated intramuscularly (6). 

In a 38-year-old non-atopic man, a generalized prurigi-nous maculopapular eruption with hp edema and facial erythema developed after 10 days of treatment with oral clindamycin phosphate (300 mg qds) and amoxicillin (500 mg qds) for bronchopneumonia (24). A patch test was positive 2 months later for clindamycin phosphate but negative for peniciUin, amoxiciUin, ampiciUin, and erythromycin. Prick tests and intradermal tests were all negative. Oral rechallenge with chndamycin phosphate 300 mg was positive. 

Drug eruptions occurred in a 56-year-old woman, a 50-year-old man, and a 66-year-old woman, who developed disseminated maculopapular eruptions with high fever after oral mexiletine (38). In all cases the hver transaminase activities were raised and there was an eosinophUia with atypical Ijmphocytes in two cases there was a lymphadenopathy. In all cases patch tests were positive. 

Urticarial rashes and erythema are the most common adverse effects of phenazone, followed by maculopapular eruptions, erythema multiforme, erythema nodosum, or even angioedema (5). 

Compared with their toxic effects, allergic reactions to the polymyxins are relatively unimportant. Nevertheless, drug fever and maculopapular eruptions and other skin lesions have been observed in few patients (23,24). 

In a 1-year prospective study of 136 patients taking ticlopidine to prevent thrombosis after coronary stenting, 16 had adverse skin reactions (28). The most common were urticaria, pruritus, and maculopapular eruptions. Three patients had previously unreported reactions a fixed drug eruption, an eiythromelalgia-like eruption, and an erythema multiforme-hke eruption. 

Allopurinol (4-hydroxypyrazolo [3, 4-d] pyrimidine) is an inhibitor of xanthine oxidase that was successfully introduced in the treatment of primary gout about 45 years ago [171]. Allopurinol continues to be accepted as standard therapy in the treatment of primary and secondary hyperuricemia. Adverse reactions occur in about 10% of patients treated with allopurinol and are relatively mild and self-limited [171,172]. A mild maculopapular eruption or gastrointestinal disorders are usually noted, which promptly regress with cessation of therapy. Isolated instances of allopecia [173], bone marrow depression [174], ocular lesions [175], acute cholangitis [176], various types of hepatic injuries [177,178] temporal arthritis [179], and xanthine stones [180] have been reported. Recently, LaRosa et al [180a] have reported a case of xanthine nephropathy during treatment of childhood T-cell ALL. 

Note Vasculitis, a part of the cytarabine syndrome, consists of fever, malaise, myalgia, conjunctivitis, arthralgia and a diffuse erythematous maculopapular eruption that occurs from 6 to 12 hours following the administration of the drug... 

The cutaneous reaction caused by allopurinol is predominantly a pruritic, erythematous, or maculopapular eruption, but occasionally the lesion is urticarial or purpuric. Rarely, toxic epidermal necrolysis or Stevens-Johnson syndrome occurs, which can be fatal. The risk for Stevens-Johnson syndrome is limited primarily to the first 2 months of treatment. Because the rash may precede severe hypersensitivity reactions, patients who develop a rash should discontinue allopurinol. If indicated, desensitization to allopurinol can be carried out starting at 10—25 fjbg/day, with the drug diluted in oral suspension and doubled every 3—14 days until the desired dose is reached. This is successjul in approjdmately half of patients. Oxypurinol is available for compassionate use in the U.S. for patients intolerant of allopurinol. The safety of oxypurinol in patients with severe allopurinol hypersensitivity is unknown it is not recommended in this setting. 

Cutaneous (skin) Erythema, urticaria, pruritus, angioedema, maculopapular eruptions, erythema multiforme, fixed drug eruptions, vasculitis... 

Immunologically, maculopapular eruptions are probably due to cell-mediated allergy (Marghescu 1978 de Weck 1974). This hypothesis is based on clinical observations, on the results of skin tests (patch and intracutaneous), and on in vitro investigations carried out by means of the lymphocyte transformation test and the... 

At present, the ampicillins must be regarded as the commonest cause of drug-induced maculopapular eruptions. Rashes develop in an average of 10% of patients treated with ampicillin. As already mentioned, the underlying disease, and possibly the dose as well, has an unmistakable influence on the frequency of rashes. Kennedy et al. (1963) found higher incidences in salmonellosis than in other bacterial infections. In infectious mononucleosis the incidence of rashes is said to be 90%-100%. 

Besides ampicillin there are numerous other drugs which cause maculopapular eruptions. The drugs most frequently mentioned are other penicillins, streptomycin, rifampicin, sulfonamides, pyrazolidine derivatives (phenylbutazone), pyrazolones, barbiturates, tricyclic antidepressants, hydantoin derivatives, indomethacin, quinine, and meprobamate (Kauppinen 1972 Korting 1972 Louis and Schulz 1973 Schuppli 1972 Thiers et al. 1964). 

As a rule, the rash clears up within a few days after discontinuation of the drug which provoked it. However, should there be any recurrence, the condition may evolve into a more serious type of cutaneous drug reaction, such as exfoliative dermatitis or even Lyell s syndrome. Maculopapular eruptions seldom persist for long periods, though Dupont and Lachapelle (1964) observed a papular eruption caused by polyvinylpyrrolidone which lasted for 4 years. 

I) The disappearance of symptoms after the withdrawal of the drug. This is of extremely variable significance, because a number of allergic reactions seem to be transient, even if the drug is continued, especially maculopapular eruptions (Hoigne et al. 1978)... 

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