Management of Psychotropic Drug–Induced DRESS Syndrome: A Systematic Review

Abstract

Drug rash with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous eruption that has been linked to several common drugs and drug categories, including antiepileptics, allopurinol, sulfonamides, and various antibiotics; however, because of a number of recent case reports linking psychotropic medications to this condition, DRESS is increasingly recognized among psychiatrists. We systematically reviewed all psychotropic drugs linked to DRESS syndrome, and this article summarizes the clinical management relevant to psychiatric professionals. A comprehensive search was performed using Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Litt's Drug Eruption and Reaction Database for articles published in English during the past 20 years (1996-2015) using the search terms (1) psychotropic drugs OR serotonin uptake inhibitors AND DRESS or (2) psychotropic drugs AND drug reaction (or rash) eosinophilia systemic syndrome, and all article abstracts were screened for inclusion and exclusion criteria by 3 reviewers. Two independent reviewers examined the full text of 163 articles, of which 96 (25 original articles, 12 review articles, 55 case reports, and 4 letters to the editor) were included in the systematic review. We identified 1072 cases of psychotropic drug-induced DRESS, with carbamazepine, lamotrigine, phenytoin, valproate, and phenobarbital being the most implicated drugs. Based on our review of the literature, we outline management principles that include prompt withdrawal of the causative drug, hospitalization, corticosteroid therapy, and novel treatments, including intravenous immunoglobulin, cyclophosphamide, and cyclosporine, for corticosteroid-resistant DRESS. Finally, we outline strategies for treating comorbid psychiatric illness after a DRESS reaction to the psychotropic medication.

Vancomycin induced DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) in a patient with tricuspid endocarditis

“…For severe disease, Mizukawa et al propose an oral prednisolone dose >50 mg/day. This is consistent with other studies that propose a dose of 1–1.5 mg/kg/day: a total dose of 60–90 mg for a 60 kg adult 11…”

“…However, there is no global consensus on the optimal steroid type, dose combination or duration of therapy. Additionally, there are also case reports of good resolution with supportive treatment alone 11. Steroids are thought to not only induce an acute response, but also to regulate autoimmune processes at the resolution stage of disease 12.…”

Severe DRESS syndrome after carbamazepine intake in a case with multiple addictions: A case report

“…This case reunited all the criteria for carbamazepine-induced DRESS: Acute skin reaction, fever above 38 degrees Celsius, and the presence of enlarged lymph nodes both in the neck and mediastinum, increased liver enzymes and eosinophilia (11). Moreover, there was lung involvement due to eosinophilic interstitial infiltration.…”

Lamotrigine-induced DRESS Syndrome Manifesting as ‘Eosinophilic Colitis’: An Uncommon Presentation of a Very Uncommon Condition

“…Since then, several reports have recommended alternative treatment options, for second-line use. Drugs such as cyclosporine, intravenous immunoglobulins, mycophenolate mofetil, cyclophosphamide, and plasmapheresis have been evaluated as alternatives [10][11][12][13]. Since viral reactivation is thought to play a role in the pathogenesis of DRESS syndrome, some experts have recommended the use of antivirals, such as ganciclovir, along with steroid treatment [14].…”