Background: Fixed drug eruption (FDE) represents a drug-related cutaneous reaction.Many drugs been associated with this clinical entity, with continually evolving documentation of implicated agents and clinical presentations. A bullous form can occur although it is rare.Objectives: To assess the epidemiological and clinical characteristics of FDE.
Methods: We retrospectively analysed all FDE cases who presented to the ClinicalPharmacology Department at the University Hospital, Monastir, Tunisia, for allergy workup.Results: The mean age of the 41 confirmed FDE cases was 43.8 ± 15.5 years. The time between first lesion onset and FDE diagnosis was less than 1 month for 13 patients (31.7%). Fifteen patients had bullous lesions. The upper limbs were the most common location (65.9% of cases). The patch tests were positive in 27 cases; a provocation test yielded a positive response in the four cases tested. Nonsteroidal anti-inflammatory drugs (NSAIDs) were involved in 51.2%, antibiotics in 24.4%, and other analgesics in 19.5%. The most common offending drug was mefenamic acid in 24.4% of cases. Bullous lesions were significantly associated with paracetamol intake (P = .014; odds ratio 16.7; 95% confidence interval: 1.76-158).Conclusions: NSAIDs and antibiotics were the most implicated in inducing FDE; paracetamol was associated with bullous lesions.
K E Y W O R D Sepidemiology, fixed drug eruption, oral rechallenge, patch test
Background: Non-steroidal anti-inflammatory drugs constitute a main cause of fixed drug eruption (FDE). A few cases of piroxicam-induced FDE have been reported; however, the crossreactivity among oxicams has rarely been evaluated.Objectives: To describe a series of patients with piroxicam-induced FDE, mostly confirmed by a positive patch test reaction, in whom cross-reactivity to meloxicam was assessed.
Methods:We included all cases of piroxicam-induced FDE diagnosed in the department of pharmacovigilance of Monastir. Patch tests for piroxicam and meloxicam were performed in the involved skin according to the European Network on Drug Allergy recommendations. Oral provocation tests (OPTs) were performed for patients with negative skin test results.Results: Seven patients were included in this study. FDE was multiple for five patients and solitary for two. Bullous eruption was noticed in two cases. Lesional patch tests for piroxicam gave positive results in six patients. To assess cross-reactivity with meloxicam, this was patch tested.The test gave a positive result in only one patient. OPTs with meloxicam gave positive results in two patients with negative patch test results.Conclusion: Meloxicam is not a safe alternative for the treatment of piroxicam-induced FDE, and OPTs can be used to confirm tolerance before this drug is prescribed as a safer alternative.
Nonsteroidal anti‐inflammatory drugs (NSAIDs) are among the main causes of fixed drug eruption (FDE). Cross‐sensitivity between chemically unrelated NSAIDs has been rarely described in FDE. We report herein two cases of NSAID‐induced FDE confirmed by oral provocation test (OPT) with a literature review. Case 1 is a 49‐year‐old woman who took mefenamic, naproxen and acetaminophen for lumbago. On the second day, she noticed three erythematous plaques, located in the upper lip, chin and the right hand, which faded spontaneously, leaving residual patches. Three months later, she took mefenamic acid with reactivation of the same plaques. She received naproxen. On the same day, she exhibited a reactivation of lesions with the development of a new one. These lesions have disappeared leaving hyperpigmented sequelae. After negative patch test to naproxen, an OPT was performed with positive reaction, observed on the third day. To establish the cross‐reactivity, she underwent OPTs, which gave positive results to indomethacin, ketoprofen and tiaprofenic acid. Case 2 is a 52‐year‐old woman who presented painful dusky‐red macules, located in the right and left wrists, 24 hours after taking mefenamic acid. She described two similar events that occurred in the past with an undefined drug and piroxicam. Patch tests to lysine acetylsalicylate, mefenamic acid, piroxicam, naproxen and celecoxib were negative. OPTs to the same NSAIDs gave positive results to lysine acetylsalicylate, piroxicam and mefenamic acid. Thirteen case reports, seven case series and one retrospective analysis, including cases with confirmed cross‐reactivity between NSAIDs, were reported in literature. Clinicians should be aware of such phenomenon.
An allergy work-up was performed on adult patients with a history of a penicillin allergy seen by primary medical care in Monastir (Tunisia) between July 2016 and February 2018. Patients with negative skin tests were challenged with amoxicillin. Patients who were delabelled were contacted by phone after 6 months to determine outcomes after any therapeutic penicillin-class antibiotic intake.Results: A total of 39 patients were evaluated and 33 (84.6%) were delabelled. Five patients were penicillin skin-test positive and one was oral challenge positive. We succeeded in contacting 33 delabelled patients at 6 months. Twenty-two patients tolerated a subsequent therapeutic course of amoxicillin, eight patients did not retake penicillin due to a lack of therapeutic indication, and three patients refused an indicated penicillin use fearful of another reaction. Conclusion: This study highlights the importance of allergy work-up in the diagnosis of beta-lactam hypersensitivity. Most patients were excessively labelled as betalactam allergic and this mislabelling could increase healthcare costs and lead to the development of drug resistance by the use of wide-spectrum antibiotics K E Y W O R D S betalactams hypersensitivity, challenge test, drug delabling, drug hypersensitivity, skin tests 1 | INTRODUCTION Beta-lactam (BL) antibiotics are widely prescribed in the general population, particularly in outpatients, because of their effectiveness against many gram-positive, gram-negative and anaerobic infections, and their low cost.However, the prescription of these drugs is limited by the occurrence of BL immunologic hypersensitivity side effects. Indeed, previous publications have reported that 10-20% of patients in clinical practice are BL allegy label since the diagnosis of drug hypersensitivity is not confirmed by an appropriate allergy work-up in these studies. 1,2 Recent publications have demonstrated that, after a complete investigation, based on skin testing and eventually oral challenge tests, more than 90% of individuals with a history of penicillin allergy are able to tolerate penicillins. 3,4 Thus, the unnecessary avoidance of BL in patients could increase healthcare costs due to the use of more expensive and/or less effective alternative antibiotics. A recent meta-analysis demonstrated that an "antimicrobial allergy label" was associated with significant reductions in antibiotic guideline appropriateness and a worsening of hospital outcomes, ie, an increase in patient readmissions, length of stay and antibiotic costs. 5 On the other hand, BL mislabelling could lead to the development of drug resistance by the use of wide-spectrum antibiotics. In this respect, it has been demonstrated in a large Caucasian Research data are not shared The aim of the present study was to assess the outcomes of an allergy work-up of patients with a penicillin allergy label by primary care.
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