Skin manifestations

The most frequent manifestations of drug allergy involve the skin. Urticaria, angioedema, exanthematous skin rashes, allergic eczematous contact dermatitis, photodermatitis, fixed drug eruptions, erythema multiforme, and the Stevens-Johnson and Lyell syndromes are the best characterized clinical manifestations. Their clinical aspects, evolution, and pathophysiological mechanisms are described in detail in the following chapter. 

Ackroyd JF (1962) The immunological basis of purpura due to drug hypersensitivity. Proc R Soc Med 55 30 

Ackroyd JF (1975) Immunological mechanisms in drug hypersensitivity. In Cell PGH, Coombs RRA, Lachmann PJ (eds) Clinical aspects of immunology, 3rd ed., Blackwell, Oxford 

Ahlstedt S, Ekstrom B, Svard PO, Sjoberg B, Kristofferson A, Oertengren B (1980) New aspects on antigens in penicillin allergy. CRC Rev Toxicol 7 219 

Akoun G, Duvaldestin P (1972) Les granulomatoses pulmonaires d origine medica-menteuse. Rev Tuberc 36 785 

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Other—urticaria, anaphylactic shock, other skin manifestations... 

Skin manifestations (e.g., petechiae, splinter hemorrhages, Osier nodes, Janeway lesions)... 

The common systemic manifestations of IBD include arthritis, anemia, skin manifestations such as erythema nodosum and pyoderma gangrenosum, uveitis, and liver disease. 

Fever is common as well as a heart murmur (sometimes new or changing). The patient may or may not have embolic phenomenon, splenomegaly, or skin manifestations (e.g, Osier s nodes, Janeway lesions). Laboratory tests... 

Non-metallic impurities, such as boron, free halogens (I2, Br2 and Cl2) and selenium in pharmaceutical substances usually contribute untoward reactions, skin manifestations and are found to be toxic to healthy tissues. 

Local skin disorders (minor Burns, insect Bites, prickly heat, skin manifestations ofchick-enpox, aBrasions), and mucous memBrane disorders (local anesthesia of oral, nasal, and laryngeal mucous memBranes local anesthesia of respiratory, urinary tract relief of discomfort of pruritus ani, hemorrhoids, pruritus vulvae) Topical Apply to affected areas as needed. 

Although antimalarials improve symptoms, there is no evidence that these compounds alter bony damage in rheumatoid arthritis at their usual dosages (up to 6.4 mg/kg/d for hydroxychloroquine or 200 mg/d for chloroquine). It usually takes 3-6 months to obtain a response. Antimalarials are often used in the treatment of the skin manifestations, serositis, and joint pains of systemic lupus erythematosus, and they have been used in Sjogren s syndrome. 

Cutaneous vasculitis is often a feature of such cases, although severe systemic manifestations often also occur. Two patients with propylthiouracil hypersensitivity presented with skin manifestations but also had renal, rheu-matological, and hematological features (66). A review of the literature showed that the symptoms and signs in patients with ANCA-associated thionamide-induced vasculitis are diverse. Acral purpuric skin lesions are typically seen recognition of these classical clinical features may allow early diagnosis and limit associated morbidity and the requirement for other therapies, particularly immunosuppression. Several other reports have described... 

Skin problems can be persistent in a proportion of patients, variously estimated at 10-59%, and this can severely limit adherence to therapy. The skin reaction can be ameliorated by concomitant use of non-steroidal anti-inflammatory drugs such as aspirin and indometacin (SEDA-15, 412). Transient exanthems, pruritus, and sometimes wheals are seen, as well a uniform dryness and scaling of the epidermis, brown pigmentation, and even on occasion an acanthosis nigricans-like dermatosis (15). Persistent rashes can also occur. Doses in excess of 5 g/day are routinely associated with skin manifestations and can on occasion cause liver damage, gout and ulcer formation. These reactions can be associated with nicotinic acid rather than nicotinamide, which is sometimes recommended as an alternative (37). Increased hair loss has been described. 

Skin manifestations of accompanying atopic eczema require a parallel local anti-inflammatory therapy, specifically with topic corticoids, anti-itching preparations and various fatty ointments. In the future, tacrolimus and pime-crolimus preparations might play a special role because they are able to substitute the application of corticoids [18]. 

Mock DM (1991) Skin manifestations of biotin deficiency. Seminars in Dermatology 10, 296-302. 

Momeni, A., Aminjavaheri, M. (1994). Skin manifestations of mustard gas in a group of 14 children and teenagers A clinical study. International Journal of Dermatology, 33(3), 184-187. 

Histoplasma capsulatum var. duboisii causes African histoplasmosis, skin manifestations being the prominent sign in this variant. Three patterns may be differentiated clinically superficial (ulcerating papules or nodules, infiltrated plaques, target phenomenon ), subcutaneous granulomas (first hot and tender, then cold, rupture) and osteomyelitic lesions, the latter often demanding surgical procedures combined with amphotericin B and ketoconazole. 

The opportunistic pathogens rarely disseminate to the skin, even if skin manifestations of cryptococcosis are not that uncommon since the appearance of the AIDS pandemic. Diagnosis may be consolidated by biopsy. 

While decontamination and supportive therapy are the mainstays of treatment, antidotes to counteract HD vapor, aerosol, or liquid exposures do not exist (Yu et al, 2003). Adult decontamination may include bleach solutions however, this method can cause greater toxicity in children. Soap and water are the preferred agents to use for decontamination in children. Supportive care consists of the management of pulmonary and skin manifestations such as the use of cough suppressants and/or topical silver sulfadiazine for bums (Yu et al, 2003 Sidell et al, 1997 Azizi and Amid, 1990). Pediatric dosage and treatment recommendations for vesicant exposures are displayed in Table 61.5. 

Eosinophilic folliculitis is a common skin manifestation associated with HIV infection, but not commonly associated with medications. 

Patients with pre-existing systemic lupus erythematosus may be more susceptible to the development of skin manifestations from griseofulvin (48). 

The authors suggested that the skin manifestations had been due to graft-versus-host disease triggered by the contrast medium and not a type-IV immunological reaction. Skin biopsy in one of the patients showed typical features of graft-versus-host disease. In addition, the reactions in these patients lasted for longer than one would expect in simple delayed reactions with skin manifestations, which usually resolve within 7-10 days. 

Skin rashes and itching occur fairly often upon decompression. The most common lesion is a mottling of the skin which spreads peripherally. The centers become erythematous and show a slight elevation in temperature. The skin manifestations are found primarily in the pectoral region, back of the shoulders, upper abdomen, forearm, and thigh. The lesions appear to be related to spasm and secondary hyperemia of the small vessels of the skin, apparently caused by bubble formation in the deeper fatty layers of the skin (F5). 

Momeni A, Enshaeih S, Meghdadi M, Amindjavaheri M. Skin manifestations of mustard gas. Arch. Dermatol. 1992 128 775-780. 

The common systemic manifestations of IBD include arthritis, anemia, skin manifestations such as erythema nodosum and pyoderma gangrenosum, uveitis, and liver disease. These problems may be related to the inflammatory process. For some of these manifestations specific therapies can be instituted, whereas for others the treatment that is used for the GI inflammatory process also addresses the systemic manifestations. 

There are no consistently recommended therapies for hver disease, skin manifestations, or uveitis associated with IBD. Some reports suggest that these manifestations are worse during exacerbations of the intestinal disease and that measures improving intestinal disease will improve these systemic manifestations. Unfortunately, this association has not been demonstrated consistently. Liver transplantation... 

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