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Pruritus & Urticaria • Drug Eruptions • Other Common Rashes

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Pruritus & Urticaria • Drug Eruptions • Other Common Rashes Medical Dermatology • Pruritus & Urticaria • Drug Eruptions • Other Common Rashes • Recognize & Refer Nishit Patel, M.D. CONFLICTS OF INTEREST • No Relevant Conflicts Special Thanks to Leigh Ann Scalf, MD OBJECTIVES • Learn to diagnose and manage pruritus without a primary eruption • Diagnosis and treatment of urticaria • Identify features of common drug eruptions • Identify drug rashes that constitute dermatologic emergencies OVERVIEW Pruritus = “Itching” Urticaria = “Hives” PRURITUS WITHOUT PRIMARY LESIONS In other words…”just itching and scratching.” So, now what?? COMMON PRESENTATION Butterfly area over scapulae often spared because the patient cannot reach the area to scratch. Beware: some patients are very flexible and CAN reach this area!! “BY THE BOOK” The million dollar work-up can be found in any text book But…. PRACTICAL PRURITUS WORK UP CBC (anemia) LFT (Hepatic dysfunction) BUN/Cr (Renal dysfunction) TSH (Hypothyroidism) ANA (Lupus) CXR (Cancer) All “age appropriate” cancer screenings Get a complete “ROS” URTICARIA GROUPING OF URTICARIA • Acute Urticaria (<6 wks) • Chronic Urticaria (>6 wks) • Cause • Cause • 50% idiopathic/unknown • 60% - idiopathic/unknown, • 40% Upper respiratory tract autoimmune, infection related infections • 35% physical urticaria • 9% drug reaction • 5% urticarial vasculitis • 1% food related • Prognosis – 50% of patients with • Prognosis – Excellent, usually resolves chronic urticaria will resolve in 1 year. within days to weeks Can be very difficult to manage. URTICARIA / ANGIOEDEMA Pruritic wheals Individual lesions disappear within 24 hours. DERMATOGRAPHISM https://upload.wikimedia.org/wikipedia/commons/thumb/4/42/Dermatographic_urticaria.jpg/1200px- Dermatographic_urticaria.jpg URTICARIA / ANGIOEDEMA May be associated with: Angioedema Anaphylaxis with bronchospasm, laryngospasm, or hypotension URTICARIA / ANGIOEDEMA If the patient gives a history of anaphylaxis (throat swelling, difficulty breathing): Give Rx for Epi-Pen (Twin Ject) and “Emergency Plan” Refer to Allergist URTICARIA / ANGIOEDEMA Immunologic Most commonly associated with penicillin and beta- lactam antibiotics Nonimmunologic Aspirin and NSAIDS are the most common causes. Also caused by radiocontrast. (*Pre-testing does NOT exclude the possibility of an anaphylactoid reaction to radiocontrast.) URTICARIA / ANGIOEDEMA ACE inhibitors can cause angioedema African Americans at nearly 5 times greater risk than caucasians Lisinopril and enalapril > captopril Blockade of kininase II by ACE inhibitors may increase the tissue kinin levels, thus enhancing urticarial reactions and angioedema. OTHER “URTICARIAS” • Physical Urticaria • Urticarial Vasculitis “EMPHASIS ON TREATMENT…” URTICARIA • Anti-Histamines (non/low-sedating), over-the-counter • Loratidine (Claritin), Cetirizine (Zyrtec), Fexofenadine (Allegra), Levocetirizine (Xyzal) • Anti-Histamines (non/low-sedating), prescription only • Desloratidine (Clarinex) 5mg daily (AM or PM) • Anti-Histamines (sedating, use at night only) • Diaphenhydramine (Benadryl) 25mg (at bedtime) • *Hydroxyzine (Atarax) 10mg/25mg/50mg (at bedtime) • *Doxepin 10mg/25mg (at bedtime) • Additional Tx Considerations: • *Anti-Histamines (H2- Blockers), Prednison, *Montelukast (Singulair), Omalizumab (Xolair) * off label usage EMPHASIZE TRIGGER AVOIDANCE • Avoid NSAIDs (non-steroidal anti-inflammatory medications Aspirin, Ibuprofen (Motrin), Aleve (naproxen), Meloxicam, Celebrex, etc. • Avoid triggers of mast-cell degranulation (histamine release) • Medications = Opioids (narcotic pain medications), contrast dyes (radiology imaging), anticholinergic medications, polymyxin B sulfate ( in topical antibiotics) • Heat/friction • Alcohol OTHER WORKUP TO CONSIDER • CBC • C3, C4 • CMP • C1-Inh (qualitative/quantitative) • ESR • • ANA C1q • • TSH Anti-C1q • CH50 • IgE PEARLS 1) Pruritus without primary lesions should be worked up to rule out any underlying etiology. 2) Urticaria: Individual lesions disappear within 24 hours. 3) Immunologic urticaria: Most commonly associated with penicillin and beta-lactam antibiotics 4) Non-immunologic urticaria: Aspirin and NSAIDS are the most common causes. 5) Antihistamines are the mainstay of treatment for urticaria. Drug Eruptions DRUG ERUPTIONS, OVERVIEW Extremely diverse Almost any drug may be capable of producing a reaction. A certain drug may also cause several different reaction patterns in different patients. IN GENERAL… DRUG ERUPTIONS Most occur within days to weeks after beginning the offending agent Occasionally a reaction begins after long-term use of a particular drug **MORBILLIFORM (AKA: EXANTHEM-LIKE, MACULAR AND PAPULAR, SCARLETINIFORM) ERUPTIONS ARE THE MOST FREQUENT OF ALL CUTANEOUS REACTIONS TO DRUGS EXANTHEMS “MORBILLIFORM” OR “SCARLETINIFORM” REACTIONS Pruritus common Usually occur with in first 2 weeks of treatment Usually start proximally (groin/axillae), then generalize within 1-2 days PATHOGENESIS NON-IMMUNOLOGIC IMMUNOLOGIC *Drug reactions : -not simply drug allergy -may result from variations in drug metabolism, immune status, coexistent diseases, and other co-administered medications. EXANTHEM-LIKE ERUPTIONS Most common culprits: Penicillins Cephalosporins Sulfonamides Carbamazepine Hydantoins Allopurinol Gold “EMPHASIS ON TREATMENT…” “Simple exanthems” (skin only!) Supportive care stop offending med, topical steroids, antihistamines FIXED DRUG ERUPTION FIXED DRUG ERUPTION Adverse reaction to an ingested drug Usually solitary Plaque, bulla, or erosion Upon rechallenge, FDE occurs at identical site within hours of ingestion FIXED DRUG ERUPTION Usually asymptomatic May be pruritic or burning Painful if eroded Post-inflammatory pigmentary alteration (PIPA) remains between flares – usually hyperpigmentation. MOST COMMONLY IMPLICATED DRUGS: Phenolphthalein Antimicrobials Tetracyclines Sulfonamides Psychoactive agents Anti-inflammatory agents OCPs Quinine Pseudoephedrine (Sudafed) FIXED DRUG ERUPTION Treatment: identify and stop offending drug Non-eroded: potent topical steroid Eroded: bacitracin or silvadene PIPA (dermal melanin) does NOT respond to hydroquinone therapy GOOD RASH GONE BAD! Occasionally, exanthem-like eruptions are associated with: Interstitial nephritis Hepatitis Lymphadenopathy So, don’t forget to do a thorough history and physical! “GOOD RASH” PEARLS 1) Drug reactions are DIVERSE. 2) Certain drugs are more likely to produce certain reactions. 3) The most common drug reaction is a moribilliform eruption. 4) Simple “skin-only” exanthems require supportive care…stop offending medication, topical steroids, antihistamines. 5) There can be systemic involvement. *Do a thorough history and physical!! 6) Fixed drug eruptions recur in the same location upon re- exposure to the offending agent OTHER COMMON RASHES Image from: https://www.merckmanuals.com/-/media/manual/professional/images/4812-pityriasis-rosea-herald-patch-public- health-image-library-high.jpg?la=en&thn=0 PITYRIASIS ROSEA • A self-limited papulosquamous eruption that is occasionally pruritic • Seen mainly in adolescents and young adults, favoring the trunk and proximal extremities • Individual lesions are usually oval in shape and their long axis is oriented along the lines of cleavage • Less common variants include inverse, vesicular, purpuric and pustular PITYRIASIS ROSEA Pathogenesis ? Viral etiology Focus on human herpesvirus-7 (HHV-7) and, less so, on HHV-6 Some studies have shown no difference in prevalence of DNA from HHV-6 or HHV-7 in pts w PR Support for viral etiology: prodromal symptoms experienced by some, clustering of cases, and almost complete absence of recurrent episodes, suggesting immunologic defense against infectious agent Epidemiology Female > male Affects otherwise healthy adolescents and young adults Typical eruption lasts 6-8 weeks, then resolves spontaneously May occasionally last > 5 months ? Slight seasonal variation PITYRIASIS ROSEA - CLINICAL “Herald Patch” Large skin- to pink- to salmon-colored patch or plaque with slightly raised advancing margin Center – fine scaling (like other lesions) Margin - larger, more obvious trailing collarette of scale with the free edge pointing inwards Often on trunk, precedes other lesions by hours to days Seen in ~50% of cases ~5% of pts experience a mild prodrome PITYRIASIS ROSEA - CLINICAL Other lesions Similar to herald patch but smaller Rapidly appear, usually on trunk and proximal extremities Long axis following Langer's lines of cleavage “Christmas tree” pattern on back More papular and hyperpigmented in pts w/ skin of color May be pustular initially Face, palms and soles usually spared PITYRIASIS ROSEA - CLINICAL Pruritus in ~25% of pts Atypical forms of pityriasis rosea Inverse - axillae and inguinal areas; sometimes the face More common in younger children and in those with darkly pigmented skin Other: urticarial, erythema multiforme- like, vesicular, pustular and purpuric variants PITYRIASIS ROSEA - CLINICAL Treatment Patient education and reassurance Pruritis Counterirritant antipruritic lotions Low- to medium-strength topical corticosteroids Severe cases UVB – reduces severity of PR but not duration or pruritus Antihistamines Short course oral steroids ERYTHEMA ANNULARE CENTRIFUGUM (EAC) • Erythema Annulare Centrifugum (EAC) • Applies to a broad spectrum of clinical findings, “default” diagnosis • Peak age: 40s • No known gender difference • Can last days-decades • Possibly represents a reaction pattern or hypersensitivity to one of many
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