Icodextrin Cutaneous Hypersensitivity Report of 3 Psoriasiform Cases

OBSERVATION Icodextrin Cutaneous Hypersensitivity Report of 3 Psoriasiform Cases

Annabel Valance, MD; Be´ne´dicte Lebrun-Vignes, MD; Vincent Descamps, MD, PhD; Guillame Queffeulou, MD; Be´atrice Crickx, MD

Background: Icodextrin is proposed as a new osmotic patient 1, the results of a rechallenge with icodextrin were agent for use in peritoneal dialysis. Because of its recent positive. Icodextrin therapy was discontinued in all pa- use, adverse reactions are not well known. Cutaneous ad- tients. verse effects have been described. We report 3 cases of cutaneous hypersensitivity to icodextrin and discuss the Conclusions: Some cases of cutaneous reactions to ico- pathogenesis of this reaction. dextrin have been reported in the literature, but they are rare. As in our cases, most eruptions are psoriasiform, Observations: The cutaneous adverse reaction was pso- limited to the palms and soles, or extensive. Although riasiform in our 3 cases. The eruption was generalized the etiology is unclear, a hypersensitivity reaction, with with acute generalized exanthematous pustulosis in 1 case, the formation of immunocomplexes, is probable. and limited to the palms and soles in 1 case. It occurred 10 to 15 days after icodextrin therapy was initiated. In Arch Dermatol. 2001;137:309-310

CODEXTRIN IS a maltodextrin glu- rent rash in 48 hours, requiring its defini- cose polymer (Extraneal; Baxter tive withdrawal. HealthCare, Deerfield, Ill) that has been available for use in peri- CASE 2 toneal dialysis in Europe since I1994. It offers many advantages com- A 45-year-old woman had systemic lupus pared with glucose solution and allows bet- erythematosus with renal involvement, lead- ter control in cases of diabetes. Since 1996, ing to peritoneal dialysis in 1997. Icodex- some cases of cutaneous reactions to ico- trin was introduced to her treatment regi- dextrin have been published. We report men on February 17, 1999. On March 2, she 3 cases of psoriasiform eruption due to ico- developed a generalized pruritic erythem- dextrin use. atous eruption with milky nonfollicular pustules (Figure 2), oral and genital mu- cous involvement, and fever. Laboratory REPORT OF CASES tests revealed leukocytosis (neutrophils, 13.0ϫ109/L). Bacteriological samples were CASE 1 negative for organisms. A skin biopsy speci- men showed superficial and intraepithe- A 50-year-old woman with diabetes devel- lial spongiform pustules without vasculi- oped renal failure that led to peritoneal di- tis, compatible with a diagnosis of acute alysis in 1996.1 Icodextrin was introduced generalized exanthematous pustulosis. The to her treatment regimen on February 15, evolution was desquamative, with onycholy- 1998, and 11 days later, a widespread macu- sis, and the rash disappeared within 15 days lopapular rash was noted that became pso- after the icodextrin treatment was discon- riasiform, with onycholysis (Figure 1) and tinued. Icodextrin was not reintroduced to From the Departments of involvement of the palms and soles. Labo- the regimen, and the results of epicutane- Dermatology (Drs Valance, ratory tests revealed leukocytosis (neutro- ous tests with icodextrin were negative. Lebrun-Vignes, Descamps, and ϫ 9 ϫ 9 Crickx) and Nephrology phils, 8.1 10 /L; eosinophils, 0.64 10 /L). (Dr Queffeulou), Hoˆpital The symptoms improved as soon as the ico- CASE 3 Bichat-Claude Bernard, dextrin treatment was discontinued, and Assistance Publique-Hopitaux there was complete healing in 1 week. Re- A 45-year-old man began peritoneal di- de Paris, Paris, France. challenge with icodextrin showed a recur- alysis in 1996 for end-stage renal failure.

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Figure 1. Case 1. Exfoliative eruption of the hands and onycholysis of the Figure 2. Case 2. Acute generalized exanthematous pustulosis with fingernails. nonfollicular pustules.

Icodextrin was introduced to his treatment regimen on lase in maltose. In our 3 cases, it is likely that there was April 17, 1999, and 12 days later, he developed exfolia- a hypersensitivity reaction to icodextrin, with the for- tive dermatitis that affected his palms, with onycholysis mation of immunocomplexes and skin localization, simi- and pachyonychy. The icodextrin treatment was discon- lar to reactions to dextran, a molecule that is closely re- tinued, but the dermatitis had spread to the patient’s soles. lated to icodextrin. However, reactions to dextran are very He slowly recovered, with desquamation. Icodextrin was different in that there are anaphylactic manifestations. not reintroduced. The results of epicutaneous and intra- Biochemical mechanisms are suggested for drugs known dermal tests with icodextrin were negative. to induce psoriasiform lesions. Such mechanisms may exist with icodextrin. COMMENT In our 3 cases, the imputability of icodextrin is very likely. Accepted for publication September 12, 2000. The chronology of events, with the onset of symptoms in Corresponding author: B. Lebrun-Vignes, MD, Ser- 10 to 15 days, the rapid healing after discontinuation of vice de Dermatologie, Hoˆpital Bichat-Claude Bernard, the icodextrin treatment, and the rapid recurrence after 46 rue Henri Huchard, 75018 Paris, France (e-mail: rechallenge in 1 case, indicates that icodextrin is respon- [email protected]). sible. The eruption was always psoriasiform and either limited to the palms and soles (case 3) or extensive, with eryth- REFERENCES roderma (case 1) and acute generalized exanthematous pustulosis (case 2). Seven previous published cases were 1. Queffeulou G, Bernard M, Vrtovsnik F, et al. Severe cutaneous hypersensitivity also psoriasiform and self-limited,2 and 2 other cases3,4 of requiring permanent icodextrin withdrawal in a CAPD patient. Clin Nephrol. 1999; severe cutaneous hypersensitivity were reported. Of 102 51:184-186. 2. Wilkie ME, Brown CB. Polyglucose solutions in CAPD. Perit Dial Int. 1997;17 patients who had been exposed to icodextrin, 3 pre- (suppl 2):47-50. sented with a generalized exfoliative eruption 1 to 4 days 3. Lam-Po-Tang MKL, Bending MR, Kwan JTC. Icodextrin hypersensitivity in a CAPD after the onset of icodextrin treatment, with complete heal- patient. Perit Dial Int. 1997;17:82-84. ing 3 weeks after the treatment was discontinued.5 4. Fletcher S, Stables GA, Turney JH. Icodextrin allergy in a peritoneal dialysis patient. Nephrol Dial Transplant. 1998;13:2656-2658. Cutaneous reactions to icodextrin remain rare. Ico- 5. Goldsmith D, Jayawardene S, Sabharwal N, Cooney K. Allergic reactions to the dextrin is slowly absorbed via the lymphatic system, from polymeric glucose-based peritoneal dialysis fluid icodextrin in patients with re- the peritoneal cavity, and is rapidly hydrolyzed by amy- nal failure. Lancet. 2000;355:897.

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