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Competing Interests: CONFLICTS OF INTEREST None to report.

Adverse cutaneous reactions to medications are not uncommon and may resemble viral infection and vice versa, complicating diagnosis. We describe the case of a 79-year-old male with cholangiocarcinoma with liver and presumed lung metastasis who presented with abdominal pain and was admitted with ileitis with partial small bowel obstruction. He had a widespread papulovesicular rash with hemorrhagic center, mostly on his face, chest, and back. The rash was initially thought to be a drug eruption, but was eventually diagnosed via dermatopathological examination as disseminated varicella zoster virus (VZV) infection. Steroid treatment was discontinued, and airborne precautions were initiated. Polymerase chain reaction for VZV was obtained and intravenous acyclovir treatment was begun. This case of VZV, initially suspected to be an adverse drug reaction, highlights the importance of early identification of a highly infectious lesion and the importance of early infection control measures, given the implications of exposure to VZV for health care personnel.

5-Fluorouracil (5-FU) is an antineoplastic agent that is used topically to treat actinic keratoses. Although topical 5-FU frequently causes irritant contact dermatitis at the site of application, distant skin reactions are rare and could relate to accidental transfer or systemic absorption of the drug. We present a patient who developed a painful scrotal dermatitis after applying the topical cream to actinic keratoses on his chest. Upon discontinuation of topical 5-FU, the reaction resolved over a four-week period with oral prednisone and topical betamethasone ointment. The patient was re-challenged with topical 5-FU one year later and again developed scrotal pain and erythema similar to the initial reaction. Scrotal dermatitis is a rare adverse effect of topical 5-FU therapy that can be associated with significant distress and disruption of daily activities.

Background: Scabies is a parasitic skin disease. Its clinical diagnosis may be challenging., Methods: In a prospective observational study, we enrolled all consecutive patients ≥16 years of age with a presumptive diagnosis of scabies and all patients ≥16 years of age with a diffuse itchy dermatosis lasting for more than 1 week. We investigated whether patients with scabies were more prone to scratch themselves during the consultation than patients with other pruritic dermatoses., Results: We observed that a significant proportion of patients (25/62, 40%) with scabies had to scratch while talking or being examined. This clinical sign was less frequently noticed in patients with pruritic dermatoses of other origins (26/196, 13%) (P < 0.001)., Conclusions: The observation of a patient scratching himself during the consultation should prompt serious consideration of scabies. This easily observable clinical sign may be especially useful in low-resource settings, where scabies is known to be very prevalent., (© 2020 the International Society of Dermatology.)

Background: Erythema multiforme (EM), an acute dermatologic condition frequently encountered in the Emergency Department, classically presents with a targetoid rash. We reviewed all recent EM cases seen at the LAC-USC County Hospital in order to ascertain the proportion of Herpes associated EM (HAEM) cases and to inform the diagnostic workup of these patients., Methods: ICD-9 and ICD-10 codes were used to extract a list of EM cases at our institution from 2013 to 2019. Two non-blinded abstractors screened records to confirm an EM diagnosis and entered patient data utilizing a standardized data abstraction form. Cohen's kappa statistic was used to measure inter-rater reliability on various variables. Kappa (κ) values ranged from 0.803 to 1.0., Results: 70 pediatric and 56 adult EM patients were included in the study. A likely etiology was ascribed to 63% of pediatric and adult EM cases. Pediatric EM was most commonly attributed to upper respiratory infection (URI) (n = 23; 33%), Mycoplasma pneumoniae infection (n = 5; 7%), and medications (n = 4; 6%). Adult EM was most commonly attributed to HSV infection (n = 11; 20%), medications (n = 5; 9%), URIs (n = 4; 7%), and other infections (n = 4; 7%)., Conclusion: HSV-1/2 serologic testing should be considered in most EM patients to potentially prevent repeated ED visits. In EM cases not clearly attributable to herpes or drug exposure, physicians can consider further workup: Mycoplasma serology, nasal PCR, and a respiratory viral panel in pediatric patients. Identification of an etiologic cause may suggest a different treatment approach and prevent mislabeling of medication allergies in patient charts., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Bullous haemorrhagic dermatosis (BHD) induced by heparin is a rare and benign side effect of which we report two cases., Patients and Methods: Case 1: an 81-year-old man presented haemorrhagic bullae on the limbs and trunk 7 days after starting enoxaparin. The laboratory haemostasis assessment was normal. A diagnosis was made of BHD induced by enoxaparin and the patient's treatment was switched to apixaban, resulting in a favourable outcome with resolution of the lesions within 15 days. Case 2: a 71-year-old woman hospitalised for pulmonary embolism was given tinzaparin. At two months of treatment, haemorrhagic bullae were observed on her forearms at distance from the injection sites. A diagnosis of BHD induced by tinzaparin was made. Treatment with tinzaparin was continued and the lesions resolved within 15 days., Discussion: Heparin-induced BHD is a rare entity initially described in 2006. Ninety-five cases of heparin-induced BHD have been reported. It is characterized by multiple haemorrhagic bullae at a distance from the injection sites. Time to onset of lesions after heparin initiation ranges from 24h to 4 months. Laboratory assessment should be routinely performed to rule out any haemostasis disorders. Lesions subside within 15 days whether heparin is continued or withdrawn., Conclusion: Heparin-induced BHD is a rare but benign side effect of heparins. In the absence of recommendations, therapeutic management should be adapted to the individual situation., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Lichenoid cutaneous reactions to antituberculosis drugs are rare. Herein we report a new case., Patients and Methods: A 41-year-old patient was seen for a profuse and pruriginous rash occurring 2 weeks after administration of rifampicin and isoniazid for pulmonary tuberculosis. Dermatological examination revealed polymorphic erythemato-squamous plaques with lichenoid, psoriatic and eczematous features, associated with cheilitis, erosions on the cheeks and diffuse onychodystrophy. The skin biopsy confirmed a lichenoid reaction. The pharmacovigilance investigation incriminated isoniazid and rifampicin. The patient was treated with topical corticosteroids and UVB phototherapy. The outcome involved complete regression of the eruption but with secondary anonychia., Discussion: Antituberculosis drugs including isoniazid and rifampicin are known to induce lichenoid reactions. It is difficult to distinguish the results from lichen planus. The clinical polymorphism of the rash as well as the patient's drug intake militate in favour of a diagnosis of lichenoid reaction. Widespread ungual involvement, which is extremely rare, warranted early management in order to avert irreversible anonychia., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: T helper (Th) type 17 and Th2 cells mediate psoriasis and eczema, respectively. Some dermatoses exhibit overlapping clinicopathologic features, and their immunopathology is relatively unexplored., Objective: To determine whether Th17 and Th2 subsets and interleukin (IL) 36 and β-defensin 2 (BD-2) markers of IL-17 signaling expression can discriminate between biopsy samples of psoriasis and eczematous/spongiotic dermatitis and to use those markers to immunophenotype cases with clinicopathologic overlap., Methods: A retrospective study was performed on biopsy samples of psoriasis, eczema/spongiotic dermatitis, sebopsoriasis, tumor necrosis factor α inhibitor-associated psoriasiform dermatitis, and ambiguous cases diagnosed as spongiotic psoriasiform dermatitis. Dual CD4/GATA3 and CD4/RORC, IL-36, and BD-2 immunohistochemistry was performed., Results: IL-36 and BD-2 were strongly expressed in biopsy samples of psoriasis compared with eczema/spongiotic dermatitis. No significant differences were observed in the percentages of Th2 and Th17 cells between disease types. Strong expression of IL-36 and BD-2 was observed in a subset of spongiotic psoriasiform dermatitis, sebopsoriasis, and tumor necrosis factor α inhibitor-associated psoriasiform dermatitis biopsy samples., Limitations: This was an exploratory study with a small sample size. No multiple testing adjustment was done. Clinical follow-up was limited., Conclusions: In cases with clinicopathologic overlap between psoriasis and spongiotic dermatitis, IL-36, and to a lesser extent BD-2, may be used to assess for a psoriasis-like/IL-17 phenotype, which could inform therapeutic clinical decisions., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Severe cutaneous adverse reactions (SCAR) are uncommon and acute and frequently represent a drug reaction. For years, allopurinol use has remained the highest risk factor for SCARs worldwide. There are multiple risk factors for allopurinol-induced SCARs, including genetic and non-genetic factors. Renal failure has been found to be an important factor resulting in allopurinol-induced SCARs with greater severity and poorer prognosis. An 80-year-old female was admitted to our hospital after administration of allopurinol in December 2018. She developed erythaematous skin of the epidermis of the hips, which rapidly extended over the trunk and limbs, resulting in itching and flaking. The presumptive diagnosis was a drug-induced SCAR. Despite treatment with glucocorticoids and kidney support therapy, the skin lesions extended over the entire body. Fortunately, the progression of pruritic erythema was stopped by double-filtration plasmapheresis (DFPP). DFPP was discontinued after the signs of skin inflammation were no longer visible. Her skin, but not kidney function, recovered after 10 days of hospitalization. She tolerated DFPP well without development of any severe complications. We present here a case of allopurinol-induced SCAR, which was successfully treated with DFPP., (© 2020 S. Karger AG, Basel.)

Background: Human immunodeficiency virus (HIV) infection in children is becoming a common occurrence. Worldwide, limited studies have been done on the mucocutaneous manifestations in HIV-positive children. The aim of our study was to analyze the spectrum of mucocutaneous manifestations of pediatric HIV infection and correlate to degree of immunosuppression., Material and Methods: One hundred and sixty-five children under 18 years with HIV, who presented to the departments of dermatology and pediatrics, were examined for mucocutaneous manifestations. Patients were classified into four groups of immunodeficiency such as normal, mild, advanced, and severe, based on NACO guidelines of immunosuppression. The most recent CD4 count (within 6 months of study period) was considered., Results: One hundred and sixty-five patients were examined, and skin manifestations were seen in 100 (61%) of them.The highest incidence of mucocutaneous manifestations was in 6-10 age group. Papular pruritic eruptions (PPE) (16%) was the most common condition, with highest prevalence in severe CD4 category (38%). Molluscum contagiosum (MC) (10%) was the most common infectious condition, with highest prevalence in advanced CD4 category (14%). Severe cutaneous adverse reactions (SCAR) caused by nevirapine were seen in three children. The percentage of skin manifestations was highest in the advanced (107%) and severe (100%) CD4 category. There was no significant difference in manifestations between those who were on antiretroviral therapy (ART) and those not., Conclusion: The percentage of skin manifestations increased with degree of CD4 depletion. PPE was found to be the hallmark of severe immunosuppression. However, opportunistic infections did not correlate with severity of immunodeficiency., (© 2019 The International Society of Dermatology.)

Failure to control these dermatologic changes can lead to lower dosages of cancer agents or an interrupted course of Tx. These steps can help you to head off trouble.

A fixed drug eruption consists of erythematous patches that appear on the skin and/or mucous membranes following administration of a drug which, once healed, leaves residual hyperpigmentation. We report a 76-year-old male who presented to the Thriasio General Hospital, Athens, Greece, in 2016 with erythema, oedema and blistering of the lower lip and glans penis following the administration of silodosin for benign prostatic hyperplasia. The eruption regressed two weeks after silodosin was discontinued.

Epidermal growth factor receptor (EGFR) inhibitors are part of an emerging class of anticancer medicines known as "targeted therapy," which target pathways more specific to neoplastic proliferation than traditional chemotherapeutic agents. Adverse effects of such treatments are thought to be less severe, but can still be significant. Because EGFR is preferentially expressed in epithelial tissues, including the skin and hair follicle, cutaneous side effects of these agents are quite common. Not only can these toxicities severely affect patients' quality of life, but in some specific instances, they can be associated with increased response to therapy. It is of paramount importance that clinicians familiarize themselves with and understand the basic management of the range of cutaneous adverse effects caused by these drugs.

We present the case of a 12-year-old-girl who developed lichenoid dermatitis approximately 1 year after starting leflunomide for juvenile idiopathic arthritis. The eruption resolved promptly with discontinuation of the suspected culprit agent, supportive of a lichenoid drug eruption, but she subsequently developed markedly dystrophic nails with lichen planus-like features. A biopsy of her cutaneous findings at the time of initial presentation demonstrated lichenoid dermatitis, and a nail matrix biopsy was deferred given clinical correlation. Prominent nail changes in lichenoid drug eruptions, particularly in children, are rare but should be considered in children with new-onset nail dystrophy., (© 2017 Wiley Periodicals, Inc.)

Background: Ketamine is a cyclohexamine derivative that acts as a noncompetitive N-methyl D-aspartate receptor antagonist. Its use for procedural sedation is recommended by national clinical policy. However, its immunogenic potential is not well documented., Case Report: We report a case of allergic reaction associated with the administration of intravenous ketamine for procedural sedation in a 16-year-old male. Minutes after administration, the patient developed a morbilliform, erythematous rash that extended to the upper and lower torso and resolved with intravenous diphenhydramine. It is most likely that this allergic reaction was caused by a ketamine-induced histamine release that has been described in vitro. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is the first case report in which ketamine was used as monotherapy in the emergency department for the facilitation of procedural sedation that resulted in an allergic reaction. Supportive measures, including advanced airway procedures and hemodynamic support, may be necessary in more severe anaphylactic cases. Providers should be aware of this potential adverse effect when using ketamine for procedural sedation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Rumpel-Leede phenomenon (RLP), also known as acute capillary rupture syndrome (ACRS), is a rare occurrence where distal dermal capillaries rupture in response to a proximal compressive force, such as a blood pressure cuff or tourniquet. This phenomenon has been reported to occur in states of vascular fragility such as long-term steroid use, hypertension or diabetes mellitus. Here, we provide a report of RLP occurring secondary to tourniquet application in a 26-year-old woman with adult-onset Still's disease (AOSD) and a recent drug rash. In this case, the cause of the phenomenon is most likely multifactorial. Likely contributing factors include long-term steroid use for the treatment of AOSD, and increased vascular permeability secondary to the drug rash. Patients and clinicians should be aware that the treatment of AOSD may induce a state of capillary fragility and they should work together to minimise the risk of complications., Competing Interests: Conflicts of Interest: None declared., (2017 BMJ Publishing Group Ltd.)

Background: Sorafenib is the standard first-line therapy for hepatocellular carcinoma (HCC) and probably ectopic hepatocellular carcinoma (EHCC) as well. No report involves a side effect of delayed high fever of sorafenib. This manuscript describes a case of EHCC in the thoracic and abdominal cavities, who showed a delayed high fever and maculopapules during sorafenib treatment., Case Presentation: The patient is a 63-year-old Chinese male with advanced EHCC, taking sorafenib 400 mg twice daily. On the tenth day, red maculopapules appeared all over the body. On the same day, the patient began to suffer from continuous high fever. Due to these effects, the patient was asked to cease sorafenib treatment, and the high fever and maculopapules were alleviated quickly. However, the symptoms were present again upon re-challenge of sorafenib. Prednisone was then administered to control the symptoms, with the dosage gradually reduced from 30 to 5 mg/day in 1.5 months. No recurrence of fever or maculopapules has been found. Tumor response reached partial response (PR) and progression free survival (PFS) reached 392 days + by the date of Apr. 14th, 2016., Conclusion: EHCC could be treated like orthotopic HCC by oral administration of sorafenib, which shows good tumor response and survival benefit. Delayed high fever and maculopapules are potential, rare and severe side effects of sorafenib, and could be effectively controlled by glucocorticoid.

There are many etiologic factors to consider in a patient who presents with symptoms or sensations of a sore burning mouth. These range from local causes within the oral cavity to underlying systemic disease, including psychologic factors. This paper aims to describe the different clinical presentations and to outline a systematic approach to the evaluation and management of such patients. The clinician will be directed to the relevant diagnosis by following the traditional medical model of taking a focused history, performing a thorough clinical examination, considering the potential differential diagnoses, and requesting pertinent and appropriate investigations. The various differential diagnoses and broad treatment options will also be discussed and outlined. This paper will not, however, discuss burning mouth syndrome (oral dysesthesia), which is a diagnosis of exclusion, whereby the oral mucosa is clinically normal and there are no identifiable medical or dental causes to account for the patient's symptoms., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Therapeutic administration of peptides may result in anti-drug antibody (ADA) formation, hypersensitivity adverse events (AEs) and reduced efficacy. As a large peptide, the immunogenicity of once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist dulaglutide is of considerable interest. The present study assessed the incidence of treatment-emergent dulaglutide ADAs, hypersensitivity AEs, injection site reactions (ISRs), and glycaemic control in ADA-positive patients in nine phase II and phase III trials (dulaglutide, N = 4006; exenatide, N = 276; non-GLP-1 comparators, N = 1141). Treatment-emergent dulaglutide ADAs were detected using a solid-phase extraction acid dissociation binding assay. Neutralizing ADAs were detected using a cell-based assay derived from human endothelial kidney cells (HEK293). A total of 64 dulaglutide-treated patients (1.6% of the population) tested ADA-positive versus eight (0.7%) from the non-GLP-1 comparator group. Of these 64 patients, 34 (0.9%) had dulaglutide-neutralizing ADAs, 36 (0.9%) had native-sequence GLP-1 (nsGLP-1) cross-reactive ADAs and four (0.1%) had nsGLP-1 neutralization ADAs. The incidence of hypersensitivity AEs and ISRs was similar in the dulaglutide versus placebo groups. No dulaglutide ADA-positive patient reported hypersensitivity AEs. Because of the low incidence of ADAs, it was not possible to establish their effect on glycaemic control., (© 2016 John Wiley & Sons Ltd.)

Drugs may cause itching as a concomitant symptom of drug-induced skin reactions or in the form of pruritus without skin lesions. Drug-induced itch is defined as generalized itching without skin lesions, caused by a drug. Itching associated with drug-induced cholestasis is among the common dermatologic adverse events (dAEs) that induce itching. Some drugs such as opioids, antimalarials, and hydroxyethyl starch are known to induce itching without skin lesions. The clinical features and underlying proposed mechanisms of itching caused by these drugs have been specifically investigated. The recent application of targeted anticancer drugs has increased the survival rate of cancer patients. These new agents cause significant dAEs such as acneiform rashes, dry skin, hand-foot syndrome, paronychia, and itching. Itching is a common side effect of epidermal growth factor receptor inhibitors. Though not life-threatening, these dAEs have a negative impact on a patient's quality of life, leading to dose reduction and possibly less effective cancer therapy. It is important to provide an effective supportive antipruritic treatment without interruption of the administration of these drugs. This chapter concludes by describing basic measures to be taken for diagnosis and treatment of drug-induced itch. The principle of treatment is discontinuation of suspected causative drugs in general except for anticancer medications. In case itching lasts long after drug withdrawal or the causative drug cannot be stopped, vigorous symptomatic antipruritic treatment and specific therapies for different types of drug-induced itch should be undertaken., (© 2016 S. Karger AG, Basel.)

Acute generalized exanthematous pustulosis (AGEP) is an acute drug eruption characterized by erythematous plaques and papules studded with numerous, pinpoint pustules. Several atypical clinical presentations and triggers of AGEP have been described in the literature. These include systemic presentations similar to toxic epidermal necrolysis (TEN) and drug-induced hypersensitivity syndrome (DIHS) and localized presentations mimicking other medication reactions. We herein aim to review atypical presentations and medication triggers of AGEP to assist clinicians in recognizing this condition and making appropriate therapeutic interventions., (© 2014 European Academy of Dermatology and Venereology.)

A man in his 40s developed a severe cutaneous adverse reaction following treatment of septic arthritis with flucloxacillin. The eruption had overlap features of cutaneous vasculitis and acute generalised exanthematous pustulosis which was complicated by renal and liver impairment. This case heightens the variation in presentation of a severe drug eruption., (2014 BMJ Publishing Group Ltd.)

Background: Skin infiltration of different types of T lymphocytes is responsible for inflammatory profiles of nonimmediate drug hypersensitivity reactions (niDHRs). Important chemokines attracting skin-specific homing T cells include thymus activation-regulated chemokine (TARC) and cutaneous T-cell-attracting chemokine (CTACK). Interleukin-10 (IL-10) is a potent chemokine attracting CD8(+) T cells., Objective: To investigate serum levels of TARC, CTACK, and IL-10 in patients with niDHRs and evaluate the correlation among these 3 chemokines., Methods: Forty patients, including 19 patients with Stevens-Johnson syndrome and toxic epidermal necrolysis and 21 patients with maculopapular exanthema, and 21 healthy donors were recruited into the study. Clinical data of patients were obtained. Serum TARC, CTACK, and IL-10 levels were determined by enzyme-linked immunosorbent assay., Results: Serum levels of TARC, CTACK, and IL-10 were significantly elevated in patients with niDHRs compared with those in normal controls (P < .05, P < .001, P < .001, respectively). The CTACK and IL-10 levels were significantly higher (P < .05, P < .001) in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis than in normal controls. Patients with maculopapular exanthema exhibited higher levels of TARC, CTACK, and IL-10 compared with normal controls (P < .001, P < .001, P < .05). Serum CTACK levels were positively correlated with TARC levels in all 40 patients (rs = 0.3422, P < .05). Serum CTACK levels positively correlated with detachment of body surface area in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (rs = 0.510, P < .05)., Conclusion: These results support a role for TARC, CTACK, and IL-10 in the pathogenesis of niDHRs for their chemotactic ability to attract different T-cell subtypes and different functional severities in niDHRs., (Copyright © 2014. Published by Elsevier Inc.)

Background: Drug-induced hypersensitivity syndrome/drug rash with eosinophilia and systemic symptoms (DIHS/DRESS) and Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) represent contrasting poles of severe drug eruptions, and sequential reactivations of several herpesviruses have exclusively been demonstrated in the former. No previous studies, however, were extended beyond the acute stage. We sought to investigate whether herpesvirus reactivations could also be observed in SJS/TEN and beyond the acute stage of both diseases., Methods: Patients with SJS (n = 16), SJS/TEN overlap (n = 2), TEN (n = 10), and DIHS/DRESS (n = 34) were enrolled. We performed a retrospective analysis of Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), and cytomegalovirus (CMV) DNA loads sequentially determined by real-time polymerase chain reaction during a 2-year period after onset., Results: Persistently increased EBV loads were detected in SJS during the acute stage and long after resolution, but not in others. In contrast, high HHV-6 loads were exclusively detected in DIHS/DRESS during the acute stage. The dynamics of herpesvirus reactivation varied in DIHS/DRESS according to the use of systemic corticosteroids: While EBV loads were higher in patients not receiving systemic corticosteroids, CMV and HHV-6 loads were higher in those receiving them., Conclusions: Distinct patterns of herpesvirus reactivation according to the pathological phenotype and to the use of systemic corticosteroids were observed during the acute stage and follow-up period, which may contribute, at least in part, to the difference in the clinical manifestations and long-term outcomes. Systemic corticosteroids during the acute stage may improve the outcomes in DIHS/DRESS., (© 2014 The Authors. Allergy Published by John Wiley & Sons Ltd.)

Importance: Pruritus is a common problem among elderly people and, when severe, causes as much discomfort as chronic pain. Little evidence supports pruritus treatment, limiting therapeutic possibilities and resulting in challenging management problems., Objectives: To present the evidence on the etiology, diagnosis, and treatment of pruritus in the elderly and, using the best available evidence, provide an approach for generalist physicians caring for older patients with pruritus., Evidence Review: PubMed and EMBASE databases were searched (1946-August 2013).The Cochrane Database of Systematic Reviews and the Agency for Healthcare Research and Quality Systematic Review Data Repository were also searched from their inception to August 2013. References from retrieved articles were evaluated., Findings: More than 50% of elderly patients have xerosis (dry skin). Xerosis treatment should be included in the initial therapy for pruritus in all elderly patients. Calcium channel blockers and hydrochlorothiazide are important causes of pruritic skin eruptions in older patients. Neuropathic pruritus is infrequently considered but may cause localized itching (especially in the genital area) and generalized truncal pruritus (especially in patients with diabetes mellitus). Certain skin conditions are more common in elderly patients, including scabies, bullous pemphigoid, transient acantholytic dermatosis, and mycosis fungoides, and should be considered in elderly patients with pruritus., Conclusions and Relevance: It is important to evaluate elderly patients for dermatological, systemic, and neurological etiologies of itch. A simple-to-apply diagnostic and therapeutic algorithm can be used. Xerosis, drug reactions, and neuropathy should be considered when evaluating pruritus.

Infection with human immunodeficiency virus (HIV) remains a significant problem globally. Early diagnosis and treatment with antiretroviral drugs has considerably improved health outcomes and decreased disease-related morbidity. HIV infection is associated with a wide range of skin disorders enabling dermatologists to diagnose HIV as well as associated opportunistic infections early in the course of disease. Despite concerted efforts by international health organizations to limit disease incidence, the prevalence of HIV infection remains high and is highest in sub-Saharan Africa. The diagnosis of HIV-related skin diseases is challenging as immunosuppression often results in atypical disease presentation. In addition, the clinical presentation will vary in pigmented skin types. The aim of this article is to describe disease variation in pigmented skin types., (© 2013 The Author BJD © 2013 British Association of Dermatologists.)

Background: Doxycycline is a commonly prescribed antibiotic for the treatment of acne vulgaris. Often preferred to other tetracyclines due to a safer and milder side-effect profile, doxycycline is more frequently prescribed as a treatment of this common condition., Objective: To present a case report of a young patient who developed skin eruptions over the extremities; myalgias; fatigue; swelling involving the face, hands, and feet; headache; and mood changes after 2 years of using doxycycline. She promptly developed similar symptoms after a rechallenge with doxycycline 1 year later., Results/conclusion: This important finding will make practitioners more vigilant to the side effects of this medication despite its current safety profile and regardless of the time that a patient is using it.

Drug reaction with eosinophlia and systemic symptoms (DRESS) syndrome describes a severe medication-induced adverse reaction, which shows skin, blood and solid-organ features. Up to 50 drugs have been described to cause DRESS. The main responsible drugs are carbamazepine and allopurinol. There are no previous reports associated with acenocoumarol. A 85-year-old white male, who was treated with acenocoumarol for the prevention of venous thromboembolism due to atrial fibrillation, presented 6 weeks later a maculopapular exanthema of the trunk and limbs as well as purple lesions and blisters on distal parts of his legs. Elevated creatinine, glucose, urea, International Normalized Ratio, gamma-glutamyl-transpeptidase (GGT) and eosinophilia levels were observed. Acenocoumarol was removed and enoxaparine, systemic corticosteroids, antihistamines were used as treatment with a favorable clinical evolution: 1 month later, the skin lesions had disappeared and laboratory parameters were normalized. Patch tests with warfarin and dabigatran were carried out. Two simple-blind, placebo-controlled oral challenges with warfarin and dabigatran were performed. Patch tests were negative, and single-blind, placebo-controlled oral challenges with warfarin and dabigatran were achieved without immediate or delayed reactions. We firstly describe a DRESS syndrome induced by acenocoumarol. Patch test was useful to assess alternative therapies. Tolerance to other anticoagulants (warfarin and dabigatran) was demonstrated.

Importance: Reactivations of human herpesviruses (HHVs) contribute to the development of drug reaction with eosinophilia and systemic symptoms (DRESS). Diagnosis of HHV reactivation is conventionally based on quantitative real-time polymerase chain reaction (PCR) analysis of blood samples, but these viruses are present in the oropharynx and are shed in saliva., Objective: To evaluate the use of a saliva PCR assay for demonstrating HHV shedding in patients with DRESS., Design: Shedding of HHV in saliva was prospectively studied in patients with DRESS. Reactivations of HHV, including HHV-6, HHV-7, cytomegalovirus (CMV), and Epstein-Barr virus (EBV), were studied by performing quantitative real-time PCR analysis of blood samples obtained at admission) and serial samples of saliva obtained within the first 2 weeks of DRESS; saliva samples from controls were compared., Participants: The study included 5 patients who met definite criteria for DRESS and 15 controls (5 immunosuppressed patients and 10 healthy adults)., Main Outcome Measures: DNA viral loads of HHV, including HHV-6, HHV-7, CMV, and EBV as measured with real-time PCR in blood and saliva samples from patients with DRESS and saliva samples from immunosuppressed and healthy controls., Results: The PCR assay demonstrated shedding of HHV-7, EBV, HHV-6, and CMV, listed by order of magnitude. The DNA viral loads in blood and saliva samples, also measured with real-time PCR, were found to be close. In 1 patient, reactivations in saliva preceded clinical manifestations of CMV disease. Significant production of HHV-7 and EBV was demonstrated in saliva samples from the controls, but neither HHV-6 nor CMV were detected., Conclusions and Relevance: The saliva PCR assay is a useful tool for demonstration and follow-up of HHV reactivation. The interpretation of HHV viral loads in saliva differs according to HHV type.

Background: Drug-induced hypersensitivity syndrome (DIHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe systemic hypersensitivity reaction caused by specific drugs, in which herpesvirus reactivations and organ dysfunction occur during the course of the disease. Although recent reports have documented the development of autoimmune disease after complete resolution of DIHS/DRESS, relatively little is known about long-term outcomes after complete resolution of the disease., Objective: The aim of this study was to retrospectively analyze complications and sequelae in the early and late phases of DIHS/DRESS according to treatment., Methods: In all, 34 patients were classified into 2 groups: 14 patients with oral corticosteroid treatment; and 20 with noncorticosteroid treatment. The disease time course was divided into 2 periods: the first 6 months after onset of the drug reaction (early phase); and the period thereafter (late phase). Investigations to detect the presence of viral/bacterial infectious diseases, organ dysfunction, and autoantibodies were performed in both early and late phases., Results: Herpesvirus infections and pneumonia were detected in 6 and 2 patients, respectively, in the corticosteroid treatment group in the early phase. In the noncorticosteroid treatment group, 2 patients developed autoimmune diseases, namely lupus erythematosus and autoimmune thyroiditis. Autoantibodies were detected in 44.4% of patients examined in the late phase of the disease., Limitations: This study only evaluated a small number of autoantibodies., Conclusion: The need for anti-inflammatory effects from systemic corticosteroids should be balanced with the risk of infectious diseases and the benefits of preventing the appearance of later autoimmune conditions in patients with DIHS/DRESS., (Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Purpose: A probable case of drug reaction with eosinophilia and systemic symptoms (DRESS) associated with consecutive use of three medications for seizure control is reported., Summary: A 36-year-old woman was treated at a community hospital for a mild fever (37.9°C) and diffuse raised maculopapular rash with erythema. Three weeks previously, she had been diagnosed with a seizure disorder and initiated on phenytoin (dose unknown) at that time; about two weeks later, she developed a rash, prompting a switch from phenytoin to extended-release divalproex sodium 250 mg orally twice daily. During the week after discontinuation of phenytoin, the rash was improving, but about five days after the initiation of divalproex therapy, she had worsening rash and pruritus requiring urgent treatment; the divalproex was discontinued, and phenobarbital 30 mg three times daily was initiated for continued seizure control. Despite the discontinuation of phenytoin and divalproex, the patient's hepatic function worsened over five days, and phenobarbital therapy was discontinued. With continued deterioration of the patient's condition to fulminant hepatic failure, a transfer to a liver transplant facility was arranged. The use of the adverse reaction probability scale of Naranjo et al. in this case yielded a score of 8, indicating a probable relationship between DRESS and the serial use of phenytoin, divalproex, and phenobarbital., Conclusion: After receiving phenytoin for treatment of seizure disorder, a 36-year-old woman developed a fever and maculopapular rash with erythema. This reaction continued even after drug therapy was switched to extended-release divalproex and then phenobarbital. The patient's liver function deteriorated despite discontinuation of all seizure medications.

Eccrine squamous syringometaplasia is characterized by the metaplasia of cuboidal epithelial cells of the eccrine sweat ducts into squamous epithelial cells. It has been associated with several conditions including chemotherapy-related bilateral dermatitis, an entity that can take place in body areas rich in eccrine glands, as well as in acral erythema related to chemotherapy. Only a few cases because of cutaneous extravasation of chemotherapy have been previously reported. We report three cases of eccrine squamous syringometaplasia secondary to extravasation of docetaxel., (© 2012 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd.)

Imatinib, an antineoplastic drug used to treat certain cancers, has many side effects such as hematologic, neurologic or cutaneous toxicity. These toxicities seem to be due to a high imatinib plasmatic concentration and are frequently controlled by a discontinuation or a dosage reduction of the drug. We report here in 2 cases of cutaneous side effects induced by imatinib in order to demonstrate the necessity of drug monitoring in such cases. In our cases, imatinib is responsible in the occurrence of these side effects. Monitoring plasma levels of imatinib allowed us to judge if levels were toxic or not and to avoid discontinuation of imatinib in some cases.