CASE REPORT ERYTHRODERMA CAUSED DRUG ALLERGIES Asrawati Sofyan, Sitti Nur Rahmah, Asnawi Madjid Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar ABSTRACT Erythroderma is inflammation skin disease characterized by erythema and scales almost or all over the body. Erythroderma is Caused by many etiologies such as extended skin diseases, allergic drug, systemic diseases and idiopathic. About 5-40% erythordermic caused by allergic drug. Regardless of the underlying disease, eryhtrodermic patient should be hospitalized. Erythroderma due to allergic drug has a good prognosis, if the offending drug could be established and withdrawn. We reported a case of erythroderma due to drug eruption in a 56 year old woman. The management of this patient include withdrawn the offending drugs, intravenous dexamethasone. Topical corticosteroids as a dexosimethasone 0.025% ointment and hydrocortisone 2.5% cream, have given a satisfying result. Keywords: erythroderma, allergic drug, dexamethasone iv, hydrocortisone 2.5% cream, desoximethasone 0.25% ointment 27
Asrawati Sofyan Erythroderma Caused Drug Allergies INTRODUCTION Erythroderma is a skin disorder that belongs to a group papulosquamous eruption, characterized by erythema and squama which extends more than 90% body surface area. (1-4) Another name for this disease is exfoliative dermatitis, pityriasis rubra (Hebra), erythroderma ( Wilson- Brocq), and erythema scarlatiniform. 1.5 Erythroderma can be caused by the expansion of skin and systemic disease, psoriasis 23%, spongiotic dermatitis 20%, drug hypersensitivity reactions 15%, CTCL (cutaneous T-cell lymphoma) or Sezary syndrome 5%, seborrheic dermatitis idiopathic 4%. (4) The incidence of erythroderma varied, ranging from 0.9 to 71 cases per 100,000 people. (1) From the data of a study from 1981 to 2000, obtained results which men are more often affected than females with a ratio of 2.2: 1. ( 6) The average age of patients with this disease between 41-61 years old, in which children are the exclusion criteria in this disease in previous studies (1). The pathogenesis of the erythroderma is unclear. In general it can be said that the pathophysiology of erythroderma is almost the same regard-less of the underlying disease. (4) In ery-throderma turnover increased epidermal cells (epidermal turn over), so that the transit time required keratinocytes through the epidermis becomes shorter. Because rapid succession, the stratum corneum, there are a number of components that are normally absorbed or metabolized. (7) In addition, the increased circulation erythroderma epidermis and dermis, and vascular permeability. (8) The presence of cytokines in dermal infiltration can vary depending on the basis of erythroderma disease. Mild erythroderma showed the presence of T helper-1 cytokines, whereas Sezary syndrome showed a T helper-2 cytokine by different pathophysiological mechanisms. (1) Interleukin (IL) - 1, IL-2, IL-8 cellular adhesion molecule (ICAM) - 1, tumor necrosis factor and interferon gamma is a cytokine that plays a role in erythroderma. Increased expression of adhesion molecules increased epidermal proliferation and production of inflammatory mediators. (7) Erythroderma management in general is based on the etiology of erythroderma itself. Hospitalization, where dermatological care available, as well as supporting facilities and adequate laboratory, generally can be a treatment option for patients with erythroderma. Erythroderma can be a serious medical cases and endanger the patient, and requires hospitalization. (1,4,9) This case reported a case erythroderma caused by drug eruption, in a woman, 56 years old. Patient respond well to systemic and topical corticosteroids. CASE REPORTS A woman, 56 years, came to Bhayangkara Hospital Makassar, with complaints of reddish spots on the entire body experienced since 6 days ago. Originally itching felt on both hands, 11 days ago, the patient went to Sungguminasa hospital and treated with cefadroxil, loratadine, and desoximethasone ointments. But there is no improve-ment, itching and redness accompanied by swelling widespread. Redness was originally found in mouth and face and then the rest of the body. Fine scales showed up all over the body and extremities later. Patient complaint pain of eye and pain during urination.patient complained of nausea. No fever. History of fever 2 days 28
IJDV Vol.1 No.4 2013 before entering hospital and patient took paracetamol. Based on history, pasient had consumption of drugs / herbs before itching and redness raised up. History of drug allergies and food allergies were denied. History of suffering with the same complaint is denied. No previous skin disease. A family history of similar complaints denied. History of diabetes and erythematous macular and fine scales. And on face area is found erythematous, squama and crusting. From the results of laboratory tests found a leukocytosis (28.700/µl), and other laboratory tests in normal. The results of histopathological examination showed psoriasiform hyperplasia epidermal, hyperkeratosis, parakeratosis, many neutrophil hypertension is denied, the patient had a history of suffering from sinusitis and polip nasal. On physical examination found the patient's general state of ill being, consciousness composmentis, sufficient nutrition. Vital signs within normal limits. Dermatology examination on the entire surface of the body (generalized) is found 29 accumulation in this area, focal hypogranulosis, spongiosis, papillary dermal blood vessels dilate, containing erythrocytes. Upper dermis contained dense infiltrates of inflammatory lymphocytes, eosinophils, neutrophils perivasculer. In conclusion : chronic spongiotic dermatitis drug eruption.
Asrawati Sofyan Erythroderma Caused Drug Allergies Patients diagnosed with erythroderma due to drug eruption, erythroderma d ue to psoriasis vulgaris. Based on history, physical examination and histopathological examination, the diagnosis is established erythrodermi ec drug eruptions. Treatment was given with cessation of the suspected drugs, infusion of Ringer's lactate (20 drops per minute), intravenous injection dexamethasone 1 ampoule (5mg/ml) per 12 hours, ranitidine 1 ampoule per 12 hours, mebhidrolin naphadisilate 50mg twice a day. Topical treatment desoximethasone 0.025% ointment, and hydrocortisone 2.5% cream for face area. Treatment for post-biopsy given erythromycin 500 mg 3 times a day, and sodium diclofenac tablet 3x1. The second day of treatment patient was consulted to the eye s doctor with a diagnosed as dry eye and was given cendo teen eye drops, patient was also consulted to internist for chest pain. Fourth day of treatment, itching was obtained, and erythema and squama reduced, treatment was continued. Sixth day of treatment, sometimes itchy. Erythema and skin squama greatly reduced. Because the lesions began to improve, dexamethasone replaced with oral medication methylprednisolone 20 mg per day. Seventh day of treatment, the patient was allowed to go home, and results dermatology examination showed fine scales on the body, and only minimal erythema in the region of vertebral and recommended for visite an outpatient clinic Bhayangkara hospital. Patient was diagnosed erythroderma caused by drug allergies. Treatment was continued methylprednisolone 20 mg per day, mebhydrolin naphadisilat 2x 50 mg daily (if itchy) and topical treatment desoximethasone ointment. DISCUSSION From the history and physical examination was found erythematous and squama on almost the entire body, which according to the existing literature on the presence of symptoms of an erythematous erythroderma and squama in the whole body or most of the body. Erythroderma classified into two, namely, primary erythrodermic / idiopathic (20%) the cause 30
IJDV Vol.1 No.4 2013 is unknown and secondary erythroderma (80%) with a known cause, such as the expansion of skin disease that has been there before, medicines, basic disorders or other systemic diseases. 1.410. In this case, erythroderma is caused by an allergic reaction of medication. Prevalence of erythroderma induced by different drugs in various populations. In a study conducted by E. Euch D et al on 127 cases of erythroderma in Tunisia, 13 percent of the cause is obscure. Meanwhile, from the other literature mentioned that the prevalence of drug-induced erythroderma is about 5 to 40 percent of all cases of erythroderma. 10th There are many drugs that can cause erythroderma. From various literature mentioned that drugs that often cause erythroderma include calcium channel blockers, antiepileptic, antimicrobial (cephalosporin, goals. Penicillin, sulfonamides, vancomycin), allopurinol, gold, lithium, quinidine, cimetidine, NSAIDs and dapsone. (1, 11.12). Drugs most suspected as the cause of erythroderma in these patients is cefadroxil and did not rule out with an unknown medication medicine names, paracetamol and herbs. However, in order to diagnose the type of drug suspects, one of them to do patch test. Squama formed in erythroderma varied, depending on the stage of erythroderma and underlying disease. In erythroderma due to an allergic reaction drugs, squamas were found to be thinner. (13) In this case, initially redness of the lips and face, and then spreads throughout the body, within a few days. Redness of the skin is also followed by the formation of a thin squama. Laboratory findings in erythrodermic generally does not help to establish a specific diagnosis. Abnormalities are often found were anemia, leukocytosis with eosinophilia, erythrocyte sedimentation rate (ESR) increased, hypoalbuminemia, increased levels of uric acid. (13) In the case of laboratory results showed leukocytosis (28.700/µl). In this case, the results of histopathological examination a chronic spongiotic dermatitis because drug eruption. In the literature it is said that a skin biopsy of erytroderma due to drugs showed parakeratosis, the disappearance of the granular cell layer and psoriasiform hyperplasia. Histopathological examination can not distinguish with certainty the cause of erythroderma. Biopsy specimens of erythroderma tend to exhibit nonspecific description such as hyperkeratosis, parakeratosis, acanthosis and chronic inflammatory infiltration. This discovery is often covered histological of the underlying disease. One third of the biopsy specimen failed to demonstrate basic disease erythroderma diagnosis. Accurate diagnosis of 50% established by dermatopathologist without obvious clinical information. Therefore, multiple biopsies recommended to increase the likelihood of a histopathologic diagnosis. 1,4,14,15 Differential diagnosis of erythroderma due to psoriasis removed because based on history, the rash appeared after patients taking the drug and no family who suffered the same skin diseases. This is contrast with psoriasis have a genetic predisposition. (1) Erythrodermic psoriasis begins with a typical psoriatic plaque on the area of predilection of psoriasis. In the clinical picture of this case showed fine scale, in psoriasis scales are thick and layered. (1.13) Apart from various causes, erythroderma treatment should be performed in a hospital. The principle of treatment is to 31
Asrawati Sofyan Erythroderma Caused Drug Allergies keep the skin moist, avoid scratching, avoiding trigger factors, providing topical steroids, treat basic of disease, and deal with complications that arise. That need to be monitored are the nutrients, protein and electrolyte balance, circulatory status, and body temperature. (2.7) In erythroderma due to allergic drug eruption is most important to stop the drugs suspected to be the cause of erythroderma as soon as possible and avoid unnecessary medication. (8.14) In this case, patient was hospitalized and withdrawn the suspected drugs. Control of fluid and electrolytes balances. For prevention of infections after biopsy was given erythromycin 1500 mg daily in three divided doses. In erythroderma, oral sedative antihistamines can help reduce pruritus experienced by patients. (14) In case, the patient is given mebhidrolin napadisilate 50 mg twice daily. In erythroderma due to allergic drug eruption, required systemic corticosteroids. The dosage was given is 1-2 mg / kg per day. (1) In the case of patients treated with dexametasone 1 ampoule / 12 hours intravenously, and on the sixth day was replaced with methylprednisolone 20 mg. Prognosis in erythroderma depends on the basis of existing disease. Erythroderma caused by allergic drug eruptions have relatively better prognosis, when the suspected drug is known and its use discontinued. (7) In cases patient experienced allergic reactions caused by drugs. Once known suspected drug of causing the emergence of drug eruption and dismissed. Where to find patients respond well to treatment and could be argued that in this case of erythrodermic patient had a good prognosis. REFERENCES 1. Margaret J, Bernstein ML, Rothe MJ. Exfoliative dermatitis. In: Wolff K, Goldsmith LA, Katz SI, editors. Fitzpatrick's Dermatology in General Medicine. 7 th ed. New Yo rk: Mc. Graw Hill Medical; 2008. P. 225-32. 2. Burton JL, Holden AC. Eczema, lichenification, Prurigo and Erythroderma. In; Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7 th ed. London: Blackwell Science; 1999. P.17.48-17:52. 3. Habif TP. Exfoliative Er y throderma In: Habif TP. Dermat Clinical ology: AC olour G uide to D iagnosis and T herapy. 4 th ed. Edinburg: Mosby; 2004. p. 491. 4. Richard AF, Clark TH. Papulosquamous eruptions and Exfoliative Dermatitis. In: Moachella SL, Hurley HJ, Editors. Dermatology. 3 rd ed. Philadel phia: WB Saunders Company; 1992. P. 641-7. 5. Arnold HR, Odam RB, James WD. Rosea, pityriasis rubra pilaris, and Other Papulosquamous. In: James WD, Berger TG, Elston DM, editors. Andrews' Diseases of the Skin Clinical Dermatology. tenth ed. Philadelphia: Elsevier; 2006. p. 215-6. 6. Rym BM, Mourad M, Bechir Z. Erythroderma in adults: a report of 80 cases. International Journal od Dermatology. 2004 31 March; 44 (9) :731-5. 7. Karakayli G, Beckham G, Orengo I et al. Exfoliative dermatitis. A American Family Physician 1999; 59. 8. Murphy FG. Non Infectious Diseases Vesicobullous and Vesiculopustular. 32
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