Transcript Cutaneous Adverse Drug Reaction

CUTANEOUS ADVERSE DRUG
REACTION
Name: Ng Wan Nah
29 June 2012
Staff Number: F0159
CUTANEOUS ADVERSE DRUG REACTION
(CADR)
According to Biro Pengawalan Farmaseutikal
Kebangsaan (BPFK), the most common adverse
drug reaction (ADR) reported is cutaneous
adverse drug reaction.
 The present of CADR need to report with the
ADR Report Form.

CUTANEOUS ADVERSE DRUG REACTION
Caused by a drug
 Any undesirable change in the structure or
function of the skin, its appendages or mucous
membranes
 Encompass all adverse events related to drug
eruption, regardless of the etiology

COMMON OFFENDING DRUG GROUPS
Antimicrobials
 Anticonvulsant
 Anti-Inflammatory
 Less frequent such as antipsychotics,
antihypertensives, oral contraceptives,
antidiabetic, etc.

CLASSIFICATION OF CADR
Severe CADR
Non-Severe CADR
Erythema Multiforme (EM)
Stevens-Johnson syndrome (SJS)
Toxic Epidermal Necrolysis (TEN)
‘Rash’ covering greater than or
equal to 50% of the body surface
area (BSA)
‘Rash’ covering 10 to 40% of the
BSA
CADR with non-life-threatening
sytemic synptoms
CLINICAL MANIFESTATION OF ADVERSE
DRUG REACTION

Acneiform Eruption


Rash resembling acne
Erythema multiforme

Target lesions comprising of a dark central spot
surrounded by a red

Alopecia

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Excessive hair loss
Erythema nodosum

Painful deep red nodules over the legs
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Vesiculobullous reaction

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Blistering eruption of the skin
Vasculitis

Palpable purpura

Angioedema
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Swelling of the mucous membrane (oral/ eye/
genitalia). May be associated with laryngeal oedema
if severe.
Urticaria

Eruption of hives lasting less than 24 hours

Fixed drug eruption (FDE)


A few, round erythematous patch, blisters or erosions
over the lips, face, hands, feet and genitalia. FDE
recurs at the same sites and may extend to other
areas if the drug is taken again.
Stevens-Johnson Syndrome

Serious variant of erythema multiforme with
involvement of more than 2 mucous membranes (oral/
eye/ genitalia)

Maculo-papular rash (exanthem)


Generalised small red macules and papules
Toxic epidermal necrolysis

Life-threatening variant of Stevens-Johnson Syndrome
with large areas of denuded skin
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Photosensitivity

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Erythema or rash over sun exposed areas.
Purpura

Non-blanching, dark red bruises due to bleeding from small
blood vessels.

Pigmentary changes


Colour changes of skin, hair, nails and mucous
membranes.
Pruritus

Itch of the skin without rash
MANAGEMENT OF CADR
The treatment are depending on the type of
reaction and the severity
 Generally, symptoms will often disappear once
stop taking the suspected drug or take it at lower
dosage

The therapy for most drug eruptions is mainly
supportive and treatment depends on the specific
type of reaction.
 The therapy for exanthematous drug eruptions is
supportive.
 First generation of antihistamine
(Diphenhydramine, Chlorpheniramine,
Triprolidine) is used around the clock.
 Mild topical steroids (hydrocortisone) and
moisturizing lotions (Aqueous cream, Calamine
lotion) are also used.

Severe reactions, such as Steven Johnson
syndrome and toxic epidermal necrolysis,
warrant hospital admission.
 Timing of withdrawal has been linked to
outcome.

Must be directed to fluid replacement and
electrolyte correction
 Treated with special attention to airway and
hemodynamic stability, fluid stability,
wound/burn care and pain control.
 Oral lesions can be managed with mouthwashes
 Topical anesthetics are useful in reducing pain.

CASE REPORT EXAMPLE

Ms B, a 34-year-old woman, presented to her GP
with a painful pruritic rash on her arms, legs and
neck. The rash had begun within a day or so of
sun exposure and was completely confined to sunexposed areas. The affected skin was
erythematous, with some blistering vesicles. Ms
B had no recent use of any new skincare products
or cosmetics. There was no significant medical
history. Her only prescribed medication was the
combined oral contraceptive pill, which she had
been taking for the past 10 years. Ms B also
reported taking ibuprofen when required for
painful periods; she had been taking it over the
last 24 hours.
Subjective (S)
- Pruritic eczematous eruption, oedema,
blistering.
- Rash on her arms, legs and neck is confined to
areas exposed to light.
Objective (O)
- Taking combined oral contraceptive
pill for the past 10 years.
- Taking ibuprofen when required for painful periods;
she had been taking it over the last 24 hours.
Assessment (A)
- NSAIDs are a known cause of photosensitivity
reactions.
Plan (P)
-Suspect drug should be discontinued as even minimal
amounts of further sun exposure can lead to reactions
of increasing severity.
- Mild cases may be managed with antihistamines and
topical steroids. In severe cases hospital admission may
be required.
- Paracetamol instead of ibuprofen as an analgesic can
be taken in the meantime, and to continue her oral
contraceptive.
Ms B
34
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45kg
PPUM
Ms B, a 34-year-old woman presented with pruritic rash on her arms, legs and neck within a day of sun exposure
and was confined to sun exposure area. The affected skin was erythematous, with some blistering vesicles.
She had no recent use of any new skincare products or cosmetics and no medical history. Her only
prescribed medication was the COC, which she had been taking for the past 10 years. She also takes
ibuprofen when required for painful periods; she had been taking it over the last 24 hours.
24 hours
Dd/mm/yr
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Chlorpeniramine 4mg od and hydrocort cream prn
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COC pill
oral
Product register number
xxx
Dd/mm/yy
Dd/mm/yy
Pain management
NIL
NKDA
NG
Pegawai Farmasi Gred UF41
Address
[email protected]
03-79492384
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Legs, arms and neck.
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REFERENCES
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SNayak S, Acharjya B. Adverse cutaneous drug
reaction. Indian J Dermatol [serial online] 2008
[cited 2012 June 11];53:2-8. Available
from: http://www.e-ijd.org/text.asp?2008/53/1/2/39732
Svensson CK, Cowen EW, Gaspari AA. Cutaneous
Drug Reactions. Pharmacological Review. September
1, 2001 vol. 53 no. 3 357-379.
Castro-Pastrana LI, Ghannadan R, Rieder MJ,
Dahlke E, Hayden M. Cutaneous Adverse Drug
Reactions in Children: An Analysis of Reports from
the Canadian Pharmacogenomics Network for Drug
Safety. J Popul Ther Clin Pharmacol Vol 18 (1):e106e120.
Annual Report of the Malaysian Adverse Drug
Reactions Advisory Committee (MADRAC) 2011.
[online] 2010 [cited 2012 June 11]; Available from:
URL:http://portal.bpfk.gov.my/aeimages//File/MADRA
C_Annual_Report_2010-edited_version.pdf
National Pharmaceutical Control Bureau.
Adverse skin reactions to drugs. [online] 1998
[cited 2012 June 11]; Available from:
URL:http://portal.bpfk.gov.my/index.cfm?menuid
=26&parentid=16&subid=33
 Anne L, Thompson J. Drug-induced skin
reactions. Adverse Drug Reactions, 2nd ed.
Pharmaceutical Press. 2006. pg. 151-2.
 Royal Pharmaceutical Society. Adverse drug
reaction reporting by pharmacists. 2003 Sept. pg.
2-3.
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