Pruritic rash

Allergic reactions are rare and usually occur within 8 weeks of initiating therapy. They manifest as maculopapular, erythematous, or pruritic rashes. Drug discontinuation and topical steroids are recommended when they occur. 

Auranofin Diarrhea (50%), pruritic rash (26%), abdominal pain (14%), stomatitis (13%), nausea (10%)... 

Adverse reactions to the thioamides occur in 3-12% of treated patients. Most reactions occur early, especially nausea and gastrointestinal distress. An altered sense of taste or smell may occur with methimazole. The most common adverse effect is a maculopapular pruritic rash (4-6%), at times accompanied by systemic signs such as fever. Rare adverse effects include an urticarial rash, vasculitis, a lupus-like reaction, lymphadenopathy, hypoprothrombinemia, exfoliative dermatitis, polyserositis, and acute arthralgia. Hepatitis (more common with propylthiouracil) and cholestatic jaundice (more common with methimazole) can be fatal, although asymptomatic elevations in transaminase levels also occur. 

Penicillamine (29) can be effective in patients with refractory RA and may delay progression of erosions, but adverse effects limit its usefulness. The most common adverse side effects for penicillamine are similar to those of parenteral gold therapy, ie, pruritic rash, protein uria, leukopenia, and thrombocytopenia. Decreased or altered taste sensation is a relatively common adverse effect for penicillamine. A monthly blood count, platelet count, and urinalysis are recommended, and also hepatic and renal function should be periodically monitored. Penicillamine is teratogenic and should not be used during pregnancy. 

The most common side effects associated with the administration of delavirdine are macular, papular, erythematous pruritic rashes involving trunk and extremities and severe dermatitis. Fatal hepatitis is not associated with its use, but elevated hepatic transaminases have been reported. Other rare side effects of delavirdine include Stevens-Johnson syndrome and neutropenia. 

A 47-year-old postmenopausal woman developed eczematous lesions at the sites of application of an estradiol transdermal system and subsequently at the sites of application of an estradiol gel (55). She was therefore given oral estrogen instead, but this promptly elicited a systemic pruritic rash. The causal link was in all instances confirmed by patch-testing. 

Allergic skin reactions have been described with all sulfonylureas. They include pruritic rashes, erythema nodosum, urticaria, blisters (100), erythema multiforme, exfoliative dermatitis, Quincke s edema, erythroderma, and itching, while lichenoid drug reactions with ulceration have occurred after chlorpropamide and tolazamide (124). More generalized hypersensitivity reactions may prove fatal, but rarely. 

A 17-year-old boy took amfebutamone (dose unstated) for attention deficit disorder and 1 week later developed a generalized pruritic rash, but continued to take amfebutamone (27). After a further week he presented as an emergency with large joint tenderness and joint swelling. A punch biopsy of a skin lesion showed urticaria with vasculitis. Amfebutamone was withdrawn and a single dose of methylprednisolone sodium succinate was given. His symptoms resolved completely within 36 hours. 

A 24-year-old man with acute malaise and fever had a pruritic rash with multiple erythematous circumscribed weals on the trunk, arms, legs, neck, and scalp. He admitted to using intranasal cocaine 6 months, 4 days, and 1 day before the onset of the symptoms. His temperature was 39° C. His erythrocyte sedimentation rate was 80 mm in the first hour, C-reactive protein was 283 mg/1 (reference range below 10), and the white blood cell count was 12.4 x 109/1 with 89% neutrophils. A biopsy of an urticarial lesion showed a perivascular inflammatory infiltrate in the upper and middle dermis. Bed rest, oral prednisone, oral hydroxyzine, and topical polidocanol led to improvement within 24 hours. 

A 56-year-old Caucasian developed acute delirium having taken diphenhydramine 300 mg/day for 2 days to treat a pruritic rash. He subsequently developed visual and auditory hallucinations with erratic aggressive behavior. The author concluded that the drug-induced delirium was associated with the combination of treatment for an infected wound with linezolid with diphenhydramine given for secondary drug-induced rash (74). 

A 19-year-old man with infectious mononucleosis developed a maculopapular, non-pruritic rash after one dose of azithromycin 500 mg (38). 

A 55-year-old non-alcoholic obese woman, who was allergic to sulfa drugs, presented with a 5-day history of jaundice, malaise, and a pruritic rash that began 3 weeks after she started to take celecoxib 200 mg/day for radicular pain (7). There were marked increases in liver enzymes and bilirubin and a peripheral eosinophi-lia. Liver biopsy showed marked intrahepatocyte cholestasis with eosinophil-rich inflammation, consistent with a drug reaction. Her symptoms and laboratory abnormalities completely resolved after withdrawal of celecoxib but took a long time (4 months) to normalize. 

Anaphylactoid reactions can occur with intravenous ciclosporin, sometimes after the first dose. Reported symptoms included pruritic rash, respiratory symptoms, chest pain, and, rarely, cardiopulmonary arrest. The presence of Cremophor EL, polyoxyethylated castor oil used as a solvent, is likely to account for this life-threatening reaction. The mechanism is still unclear, and results of skin tests were available in only three of 22 previously published patients. 

A 58-year-old man developed a pruritic rash on the body and face, with periorbital swelling 3 hours after taking codeine 20 mg, acetylcysteine 600 mg, and acetylsalicylic acid 500 mg. An oral provocation test over 2 hours with codeine phosphate (1 mg, 4 mg, and 8 mg) precipitated a pruritic scarlatiniform rash for 24 hours, with swelling of the arms, starting... 

Sensory neuropathy occurred in a 58-year-old man who had been given up to 2400 mg/day for over 5 months for the treatment of head pain (12). A mild pruritic rash had been present since starting treatment. Neuropathic symptoms included a burning sensation in the legs and hips. After withdrawal, reduced perception of tactile and noxious stimuli and neurogenic bladder dysfunction (with an associated syncopal episode) were recorded. The neuropathy improved over several months. 

A 40-year-old woman with metastatic breast cancer received cychc snbcntaneons G-CSF for chemotherapy-induced neutropenia. After 5 months she had a pruritic rash at injection sites. She did not change the injection sites and the lesions recnrred after each injection. Biopsy showed a lichenoid reaction and the lesions healed with residual pigmentation after topical steroid application and G-CSF discontinuation. GM-CSF was well tolerated. 

A 44-year-old man taking hydralazine (dose not stated) developed a pruritic rash, attributed to a drug-induced lichenoid eruption, based on biopsy findings (8). The hydralazine was withdrawn and the rash resolved in a few weeks. 

Type I allergic reactions have caused pruritic rashes and urticaria. 

Patients often develop rashes due to HIV infection or drug allergy. Sulfa desensitization is well documented, but desensitization to other medications is not as well studied. One patient taking nelfinavir developed a severe, pruritic rash management included nelfinavir desensitization over 12 days (10). 

A previously healthy 35-year-old man with conjunctival irritation had fluorescein dye instilled using a fluorescein-treated ophthalmic strip and isotonic saline. Within 30 minutes he began to notice a pruritic rash around his eye and on his arms, chest, and legs. His joints felt swollen. He had a diffuse erythematous macular rash with evidence of moderate excoriation over his arms and legs. His wrists and ankles were swollen. There were no oral lesions, and all laboratory studies, including the white blood cell count, were normal. Methylprednisolone succinate 125 mg plus diphenhydramine 50 mg produced rapid improvement. 

A 12-year-old boy with a history of a generalized pruritic rash after penicillin took penicillamine up to 500 mg/day for Wilson s disease. He had a rash after using penicillamine for 1 week. The penicillamine was stopped for 3 days. He developed nephrotic syndrome 2 weeks after restarting penicillamine. On electron microscopy, there was the typical picture of minimal change disease with extensive foot process effacement. 

A 10-year-old Malay boy with G6PD deficiency received teicoplanin (300 mg/day) for an epidural abscess and 14 days later developed an erythematous, maculopapular, non-pruritic rash over his trunk and upper limbs and a mild fever with chills (24). He had a leukocyte count of 2 x 10 /1. Teicoplanin was withdrawn and by 3 days the rash had almost completely subsided. After rechallenge with a single intravenous dose of teicoplanin 300 mg, he developed a fever (39.3°C), chills, and worsening of the rash on his arms. Teicoplanin was again withdrawn. His fever resolved after 4 days and his leukocyte count normalized by 7 days. 

Common toxic effects of tiabendazole include nausea, vomiting, and dizziness. Malaise and drowsiness are also common. Liver disorders can occur and are the most serious complications. Most systems can on occasion be affected. Allergic reactions are essentially due to parasite destruction rather than a direct effect of the drug itself. Chills, fever, lymphadenopathy, angioedema, and pruritic rashes all can occur and treatment should in that case be stopped, since otherwise more serious reactions (for example Stevens-Johnson syndrome) can follow. Tumor-inducing effects have not been reported. 

A 76-year-old non-smoking woman with giant-cell arteritis who had a normal chest X-ray was taking prednisone 45 mg/day and ticlopidine 250 mg bd for persistence of cloudy vision. After 1 month of ticlopidine therapy, she developed increasing dyspnea and a pruritic rash. Chest radiography showed diffuse interstitial... 

Toxicities associated with etoposide include dose-limiting myelosuppression (granulocytopenia and thrombocytopenia), mild to moderate nausea/vomiting, dermatologic reactions (alopecia, pruritic rash), and mucositis (which can be severe with high doses). Rapid infusion of high doses may be associated with fever, hypotension, bronchospasm, and metabolic acidosis. 

Direct skin exposure to sulfur mustards causes erythema and blistering. Generally, a pruritic rash will develop within 4-8 h followed by blistering 2-18 h later. Contact with the vapor may result in first- and second-degree burns, while contact with the liquid typically produces second- and third-degree chemical burns. An area of burn covering 25% or more of the body surface area may be fatal. 

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