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Fixed Drug Eruption and Generalised Erythema Following Etoricoxib

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Fixed Drug Eruption and Generalised Erythema Following Etoricoxib Letters to the Editor recommended quantity makes the sunscreen less of application of Sun Protection Factors. In: Lowe NJ, Shaath effective. Excessive quantity makes the sunscreen NA, Pathak MA, editors. Sunscreens: development, evaluation and regularly aspects. New York: Marcel Dekker; 1997. p. 583- more expensive, and also more uncomfortable. We 8. calculated that the mean cost of 1 ml of sunscreen of 5. Stenberg C, Larko O. Sunscreen application and is importance 10 brands is approximately Rs. 3 to 4. It is more for the Sun Protection Factor. Arch Dermatol 1985;121:1400-2. expensive if the patient uses the sunscreen repeatedly, or in excessive quantity. We recommend 1 ml of C. R. Srinivas, Surendranath Lal, sunscreen for the female, and 1.5 ml for the male M. Thirumoorthy, during each application. It is possible to calculate the Shanmuga V. Sundaram, sunscreen to be applied over any given area e.g., arm, Prabhu S. Karthick Department of Dermatology, PSG Hospitals, Coimbatore, back, etc. Figure 2 shows how a string is placed over Tamil Nadu, India the forearm. The same length of thread can be arranged in form of a circle. Once the area is Address for correspondence: Dr. CR Srinivas, Department of Dermatology, PSG Hospitals, Coimbatore - 641 004, determined, the amount of sunscreen can be easily Tamil Nadu, India. E-mail: [email protected] calculated. This method actually measures the perimeter of the skin, and assumes it to be a circle. In general, an oval surface would encompass a lesser Fixed drug eruption and area than a circular surface of the same perimeter. This method would thus result in a larger calculated generalised erythema following area than the actual, and in the case of the forearms, etoricoxib we would use more sunscreen than is necessary. However, this may not make a significant difference. Sir, Non steroidal anti-inflammatory drugs (NSAIDs) are We do not feel justified to recommend specific among the most widely used medications – both by amount of sunscreen for the exposed area of arms, prescription and over the counter. The newer NSAIDs, and upper and lower back, as there would be a inhibitors of the cyclo-oxygenase enzyme-2 (COX-2 considerable individual variation in the area exposed inhibitors), are fast becoming the drugs of first choice to sunlight. The string method can also be helpful in in the treatment of acute pain, chronic pain and most keeping track of increase or decrease in various rheumatic conditions. These compounds blunt irregular shaped skin lesions including ulcers. prostaglandin production through inhibition of cyclooxygenase-2 (COX-2) while sparing ACKNOWLEDGMENTS cyclooxygenase-1 (COX-1), and have been shown to cause significantly fewer serious gastrointestinal Dr. Sasidharan Nair, Professor, Department of Physics, PSG adverse events such as ulceration and bleeding, than Technology, Peelamedu, Coimbatore. the nonselective NSAIDs.[1] Etoricoxib, one of the newer COX-2 inhibitors, has enhanced biochemical REFERENCES COX-2 selectivity over that of the other drugs in this category: rofecoxib and celecoxib.[2] Though, adverse 1. Azurdia RM, Pagliaro JA, Diffey BL, Rhodes LE. Sunscreen cutaneous effects to celecoxib and rofecoxib have been application by photosensitive patient is inadequate for protection. Br J Dermatol. 1991;140:255-8. reported, there has been no report of cutaneous side 2. Bech-Thomsen N, Wulf HC. Sunbather’s application of sunscreen effects to etoricoxib so far. We report a case of fixed is probably inadequate to obtain the sun protection factor drug eruption and generalized erythema occurring assigned to the preparation. Photodermatol Photoimmunol simultaneously following etoricoxib. Photomed 1993;9:242-4. 3. Diffey BL, Gride J. The influence of sunscreen type of photoprotection. Br J Dermatol 1997;137:103-5. A 38-year-old female, doctor by profession, developed 4. Gottlieb A, Bourget TD, Lowe NJ. Sunscreen: effects of amounts a 1.5 cm size, well circumscribed, round, erythematous Indian J Dermatol Venereol Leprol|July-August 2006|Vol 72|Issue 4 307 Letters to the Editor patch on the right forearm, 3 days following ingestion with a larger area of residual pigmentation. The of etoricoxib that was prescribed for bursitis of right erythema over the rest of the body subsided leaving knee. In the next few days, the center of the patch behind no residual pigmentation. developed a blister and necrosis which later healed with residual hyperpigmentation. She had taken Since a reliable positive oral re-challenge had already various NSAIDs many times in the past and rofecoxib taken place, although inadvertently; further on more than two occasions. Celecoxib had been confirmatory tests were not carried out immediately. taken at least for one week, once, about two years However, a patch test with etoricoxib 10% in back. Etoricoxib was taken once, for one week, 5 petrolatum was done six months later. Erythema and months back. There were no adverse effects to any of edema which was double the size of the old patch the drugs previously. Therefore the possibility of a was seen within eight hours, over the healed FDE drug eruption was not thought of and a diagnosis of lesion, whereas the non-lesional control area did not ‘insect bite reaction’ was considered. Two months react. after the lesion healed, the patient took a single tablet of etoricoxib again. She noticed erythema, itching Fixed drug eruption (FDE) characteristically presents and burning over the old lesion within two hours as a round, sharply circumscribed, pruritic or burning, [Figure 1]. In addition, over the next three to four edematous patch with violaceous or dusky hours she developed generalized itching and burning erythema.[3] Vesicles or bullae may develop. It heals sensation followed by intense erythema all over the leaving a hyper-pigmented patch and recurs at the body. Nikolsky’s sign was negative. There was no same site on drug rechallenge. The residual mucosal involvement. The patient had neither fever pigmentation and recurrence of lesion at the same nor other constitutional symptoms. No systemic site are the typical features of FDE. Additional lesions abnormalities were found on physical and routine may develop with drug rechallenge. Although a laboratory examination. A histopathological histopathological examination was not performed in examination was not performed as the patient did our patient, the typical round patch with bulla, the not consent for skin biopsy. residual pigmentation on healing and the recurrence of the rash at the same site, support a diagnosis of fixed drug eruption. The severity of the patch test A drug reaction was diagnosed and systemic steroids were administered. Though most of the symptoms reaction confirms etoricoxib as the causative drug. and signs gradually subsided in ten days, mild acral An unusual feature of this case, however, was the dusky erythema persisted for 4 weeks. The lesion over the right forearm developed a small blister and healed occurrence of two different types of cutaneous adverse reactions simultaneously to the same drug. Clinically the patient had a FDE and a generalized erythematous rash. Although very rare, occurrence of more than one type of cutaneous reactions to the same drug has been reported.[4] Most of the known adverse cutaneous reactions to coxibs have been attributed to either celecoxib or rofecoxib. They include: urticaria/angioedema (by far the most common), Sweet’s syndrome, vasculitis, erythema multiforme, Stevens Johnson syndrome, toxic epidermal necrolysis (TEN) and maculopapular rash.[5-7] To the best of our knowledge cutaneous reactions to etoricoxib have not been reported so far. Figure 1: FDE with diffuse erythema The NSAIDs and coxibs with a sulfonamide structure 308 Indian J Dermatol Venereol Leprol|July-August 2006|Vol 72|Issue 4 Letters to the Editor (celecoxib and valdecoxib) could possibly cross react Selective Cyclooxygenase-2 Inhibitors (Coxibs). Am J Ther with sulfonamides.[8] The sulfonamide-type reactions 2004;11:494-500. 6. Fye KH, Crowley E, Berger TG, Le Boit PE, Connolly MK. (erythema multiforme, Stevens Johnson syndrome, Celecoxib-induced Sweet’s syndrome. J Am Acad Dermatol toxic epidermal necrolysis (TEN) and maculopapular 2001;45:300-2. rash) were found to be twice as common with 7. Schneider F, Meziani F, Chartier C, Alt M, Jaeger A. Fatal allergic celecoxib as with rofecoxib.[5] The pathogenesis of vasculitis associated with celecoxib. Lancet 2002;359:852-3 these reactions is likely to be the same as for 8. Sarkar R, Kaur C, Kanwar AJ. Extensive fixed drug eruption to nimesulide with cross-sensitivity to sulfonamides in a child. sulfonamide induced reactions – T cell mediated type Pediatr Dermatol 2002;19:553-4. IV hypersensitivity reaction. However, Shapiro et al in their study on the safety of celecoxib in 28 patients Mary Augustine, Pooja Sharma, with a history of sulfonamide allergy found cross John Stephen, Elizabeth Jayaseelan Department of Dermatology, St. John’s Medical College reactivity between celecoxib and sulfonamides to be Hospital, Bangalore, India. low.[5] Address for correspondence: Mary Augustine, Department of Dermatology, St. John’s Medical College The coxibs have generally been found to be safe even Hospital, Sarjapur Road, Bangalore - 560 034, Karnataka, in patients allergic to the classic NSAIDs. Sanchez- India. E-mail: [email protected] Borges et al, in their review of cutaneous reactions to selective COX-2 inhibitors, reported that, among patients previously exhibiting urticaria or angioedema triggered by classic NSAIDs, only 1.6% developed Isolated scalp collagenoma urticaria or angioedema to rofecoxib and 11.2% to celecoxib.[5] However, in the present case, the patient mimicking cutis verticis gyrata had been tolerating various NSAIDs in the past but reacted to a coxib. Sir, Cutis verticis gyrata (CVG) is a descriptive term for a As the patient had taken rofecoxib on more than two condition of the scalp, in which deep furrows and occasions, with no side effects, it appears that there convolutions are seen, that resembles the outer may not necessarily be cross reactivity between surface of the cerebrum.
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