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Drug Eruptions Flashcards

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1
Q

What is Stevens-Johnson syndrome?

A

severe systemic reaction affecting the skin and mucosa that is almost always caused by a drug reaction.

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2
Q

Features of SJS?

A

rash is typically maculopapular with target lesions being characteristic. May develop into vesicles or bullae
mucosal involvement
systemic symptoms: fever, arthralgia

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3
Q

Causes of SJS?

A 
penicillin
sulphonamides
lamotrigine, carbamazepine, phenytoin
allopurinol
NSAIDs
oral contraceptive pill
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4
Q

Mx SJS?

A

hospital admission is required for supportive treatment

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5
Q

What is Toxic epidermal necrolysis?

A

Toxic epidermal necrolysis (TEN) is a potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction. In this condition, the skin develops a scalded appearance over an extensive area.

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6
Q

What is a +ve Niklosky’s sign?

A

epidermis separates with mild lateral pressure

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7
Q

Features of TEN

A

systemically unwell e.g. pyrexia, tachycardic

positive Nikolsky’s sign

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8
Q

Drugs known to induce TEN

A 
phenytoin
sulphonamides
allopurinol
penicillins
carbamazepine
NSAIDs
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9
Q

Mx TEN?

A

stop precipitating factor
supportive care
often in an intensive care unit
volume loss and electrolyte derangement are potential complications
intravenous immunoglobulin has been shown to be effective and is now commonly used first-line
other treatment options include: immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapheresis

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10
Q

What is acanthosis nigricans?

A

Describes symmetrical, brown, velvety plaques that are often found on the neck, axilla and groin.

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11
Q

Drugs causes of acanthosis nigricans?

A

combined oral contraceptive pill

nicotinic acid

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12
Q

causes of acanthosis nigricans?

A 
type 2 diabetes mellitus
gastrointestinal cancer
obesity
polycystic ovarian syndrome
acromegaly
Cushing's disease
hypothyroidism
familial
Prader-Willi syndrome
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13
Q

pathophysiology of acanthosis nigricans?

A

insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)

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14
Q

Erythema ab igne is a skin disorder caused by

A

over exposure to infrared radiation.

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15
Q

Erythema ab igne, Characteristic features include

A

reticulated, erythematous patches with hyperpigmentation and telangiectasia.

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16
Q

Erythema ab igne, typical history

A

an elderly women who always sits next to an open fire.

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17
Q

Erythema ab igne is self limiting

A

false

If the cause is not treated then patients may go on to develop squamous cell skin cancer.

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18
Q

What is erythema multiforme?

A

Erythema multiforme is a hypersensitivity reaction which is most commonly triggered by infections

It may be divided into minor and major forms.

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19
Q

Features of erythema multiforme

A

target lesions
initially seen on the back of the hands / feet before spreading to the torso
upper limbs are more commonly affected than the lower limbs
pruritus is occasionally seen and is usually mild

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20
Q

Causes of erythema multiforme

A 
viruses
idiopathic
bacteria
drugs
connective tissue disease e.g. Systemic lupus erythematosus
sarcoidosis
malignancy
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21
Q

Viruses & bacteria that cause erythema multiforme

A

viruses: herpes simplex virus (the most common cause), Orf is a skin disease of sheep and goats caused by a parapox virus
bacteria: Mycoplasma, Streptococcus

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22
Q

Drugs that cause erythema multiforme?

A

penicillin, sulphonamides, carbamazepine, allopurinol, NSAIDs, oral contraceptive pill, nevirapine

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23
Q

The more severe form, erythema multiforme major is associated with

A

mucosal involvement.

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24
Q

Describe Erythema nodosum

A

inflammation of subcutaneous fat
typically causes tender, erythematous, nodular lesions
usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs)
lesions heal without scarring

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25
Erythema nodosum resolves within
usually resolves within 6 weeks
26
Causes Erythema nodosum
``` infection systemic disease:sarcoidosis, inflammatory bowel disease, Behcet's malignancy/lymphoma drugs pregnancy ```
27
Erythema nodosum drugs?
penicillins sulphonamides combined oral contraceptive pill
28
Erythema nodosum infection?
streptococci tuberculosis brucellosis
29
Causes of erythroderma
``` eczema psoriasis drugs e.g. gold lymphomas, leukaemias idiopathic ```
30
What is erythrodermia?
Erythroderma is a term used when more than 95% of the skin is involved in a rash of any kind.
31
What is Erythrodermic psoriasis?
may result from progression of chronic disease to an exfoliative phase with plaques covering most of the body. Associated with mild systemic upset more serious form is an acute deterioration.
32
Erythrodermic psoriasis triggered by?
may be triggered by a variety of factors such as withdrawal of systemic steroids.
33
mx Erythrodermic psoriasis
Patients need to be admitted to hospital for management
34
What is Hirsuitism and hypertrichosis?
Hirsutism is often used to describe androgen-dependent hair growth in women, with hypertrichosis being used for androgen-independent hair growth
35
most common causes of hirsutism
Polycystic ovarian syndrome
36
Causes of PCOS?
``` Cushing's syndrome congenital adrenal hyperplasia androgen therapy obesity: thought to be due to insulin resistance adrenal tumour androgen secreting ovarian tumour drugs ```
37
Drugs that cause PCOS
phenytoin, corticosteroids
38
Assessment of hirsutism
Ferriman-Gallwey scoring system: 9 body areas are assigned a score of 0 - 4, a score > 15 is considered to indicate moderate or severe hirsutism
39
Management of hirsutism
advise weight loss if overweight cosmetic techniques such as waxing/bleaching - not available on the NHS consider using combined oral contraceptive pills such as co-cyprindiol (Dianette) or ethinylestradiol and drospirenone (Yasmin). Co-cyprindiol should not be used long-term due to the increased risk of venous thromboembolism facial hirsutism: topical eflornithine - contraindicated in pregnancy and breast-feeding
40
Causes of hypertrichosis
drugs: minoxidil, ciclosporin, diazoxide congenital hypertrichosis lanuginosa, congenital hypertrichosis terminalis porphyria cutanea tarda anorexia nervosa
41
What is Pellagra?
Pellagra is a caused by nicotinic acid (niacin) deficiency. The classical features are the 3 D's - dermatitis, diarrhoea and dementia. Pellagra may occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin) and it is more common in alcoholic
42
Features of Pellagra?
dermatitis (brown scaly rash on sun-exposed sites - termed Casal's necklace if around neck) diarrhoea dementia, depression death if not treated
43
What are Spider naevi
Spider naevi (also called spider angiomas) describe a central red papule with surrounding capillaries. The lesions blanch upon pressure. Spider naevi are almost always found on the upper part of the body. Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge .
44
Around 10-15% of people will have one or more spider naevi
true
45
Spider naevi more common in childhood
false
46
Causes of spider naevi
liver disease pregnancy combined oral contraceptive pill
47
most important causes of pruritus?
``` Liver disease Iron deficiency anaemia Polycythaemia Chronic kidney disease Lymphoma ``` ``` Other causes: hyper- and hypothyroidism diabetes pregnancy 'senile' pruritus urticaria skin disorders: eczema, scabies, psoriasis, pityriasis rosea ```
48
Describe pruritus in Liver disease?
History of alcohol excess Stigmata of chronic liver disease: spider naevi, bruising, palmar erythema, gynaecomastia etc Evidence of decompensation: ascites, jaundice, encephalopathy
49
Describe pruritus in Iron deficiency anaemia?
Pallor | Other signs: koilonychia, atrophic glossitis, post-cricoid webs, angular stomatitis
50
Describe pruritus in Polycythaemia?
'Ruddy complexion' Gout Peptic ulcer disease
51
Describe pruritus in Lymphoma?
Night sweats Lymphadenopathy Splenomegaly, hepatomegaly Fatigue
52
Describe Porphyria cutanea tarda
Porphyria cutanea tarda is the most common hepatic porphyria.
53
Causes Porphyria cutanea tarda?
It is due to an inherited defect in uroporphyrinogen decarboxylase or caused by hepatocyte damage e.g. alcohol, hepatitis C, oestrogen.
54
Features of Porphyria cutanea tarda?
classically presents with photosensitive rash with blistering and skin fragility on the face and dorsal aspect of hands (most common feature) hypertrichosis hyperpigmentation
55
Investigations of Porphyria cutanea tarda?
urine: elevated uroporphyrinogen and pink fluorescence of urine under Wood's lamp serum iron ferritin level is used to guide therapy
56
mx Porphyria cutanea tarda?
chloroquine venesection preferred if iron ferritin is above 600 ng/ml
57
What is lichen planus?
Lichen planus is a skin disorder of unknown aetiology, most probably being immune-mediated.
58
Features of lichen planus?
itchy, papular rash most common on the palms, soles, genitalia and flexor surfaces of arms rash often polygonal in shape oral involvement in around 50% of patients: typically a white-lace pattern on the buccal mucosa nails: thinning of nail plate, longitudinal ridging
59
What eponymous features will you see in Lichen Planus?
'white-lines' pattern on the surface (Wickham's striae) | Koebner phenomenon may be seen (new skin lesions appearing at the site of trauma)
60
Lichenoid drug eruptions - causes:
gold quinine thiazides
61
Mx lichen planus?
potent topical steroids are the mainstay of treatment benzydamine mouthwash or spray is recommended for oral lichen planus extensive lichen planus may require oral steroids or immunosuppression

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