Erythema‐multiforme‐like contact dermatitis due to phenylbutazone

Abstract

A 65-year-old woman presented with a severely itchy prethoracal eruption of erythematous, edematous papules and papulovesicles. These were much more pronounced on the right side, with some presternal confluence, and had already been spreading for 3 days. She also had erythematous papules on both inner thighs. A week before the onset, she had applied the revulsive (counterirritant) cream NF V for 4 days to the right side of the thorax for muscle pain, which she stopped when the eruption started. Revulsive cream contains phenylbutazone as active ingredient and also menthol, cetyl alcohol, propylene glycol, lavender oil, and methyl nicotinate. In spite of a corticosteroid cream and an oral antihistamine, the dermatitis spread. She had also been taking diphenylhydantoin and levodopa for many years and piroxicam for I week.As she recalled a reaction I 0 years previously after using a phenylbutazone-containing ointment (Butazolid-ine®), and because of suspicion of allergy to the revulsive cream and its failure to respond to topical corticosteroids, oral methylprednisolone was given. 2 days later, the eruption had spread and become more painful. The right side of the thorax (the left being less affected) showed a monomorphic eruption of papulopustules, with confluence presternally and in the right axilla. There was a sharp delineation towards the back. A toxicoderma or viral rash was considered as the diagnosis. Systemic corticosteroid was stopped and a menthol lotion prescribed. By 5 days after the 2nd visit, however, large plaques had appeared in the precordal region, right submammary fold and under the right axilla, by confluence of erythematous macules and papules. On the right breast, cocardiform lesions were present. A potent corticosteroid ointment was prescribed, which the patient applied just once. All the lesions regressed in a week.Patch tests with the standard series and with the patient's own medications yielded the following results: D2 D3 Standard series balsam of Peru + fragrance mix ?+ ++ Own medications revulsive cream NF V ++ +++ Butazolidine® ointment ++ +++ phenylbutazone (2% pet.) ++ ++ oxyphenbutazone (5% pet.)This patient had thus developed allergic contact dermatitis from the revulsive cream, having previously been sensitized by Butazolidine® ointment. Discussion

Localized erythema‐multiforme‐like contact dermatitis from rubber gloves

“…Unlike erythema multiforme (EM), the EM‐like contact eruption does not have symmetrically acral distribution or characteristic histology (1, 2), and rarely involves the oral mucosa. In general, it is considered to be an id‐like reaction occurring with powerful sensitization, penetration‐enhancing substances, high concentrations or repeated application of allergens (3, 4). Fisher (5) has reviewed the allergens reported and we have listed recently reported cases in Table 1.…”

Allergic contact dermatitis

“…Eczema can also occur as a secondary phenomenon such as in scabies where it occurs as a reaction to the mites' feces, in phthiriasis, mycoses including candidiasis, and impetiginous infections. On the other hand, rarely ACD can also hide behind non-eczematous lesions such as erythema-multiform-like [13,14], urticarial papular plaques, lichen-planus like and lichenoid eruptions [15], purpuric petechial reactions [16], dermal reactions [17], lymphomatoid contact dermatitis [18], granulomatous and pustular reactions [19] and finally pemphigoid-like lesions [20].…”

Noneczematous Contact Dermatitis

“…Other causative drugs include sulfonamide [27, 28], promethazine [25], neomycin [25], mafenide acetate [29], ethylenediamine [25, 30], and mephenesin [31, 32]. Among nonsteroid anti-inflammatory drugs, phenylbutazone [33], bufexamac [34], and mofebutazone [35] have been reported. Among corticosteroids, budesonide [36] and triamcinolone acetonide [37] caused analogous reactions.…”