Skin eruptions in children: Drug hypersensitivity vs viral exanthema

Abstract

Childhood rashes or exanthemas are common and are usually relatively benign. There are many causes of rash in children, including mainly viruses, and less often bacterial toxins, drugs, allergens and other diseases. Viral exanthema often appears while children are taking a medication in the course of a viral infection; it can mimic drug exanthema and is perceived as a drug allergy in 10% of cases. In the vast majority of cases, the distinction between virus‐induced and drug‐induced skin eruption during the acute phase is not possible. The drugs most commonly implicated are beta‐lactams (BL) and non‐steroidal anti‐inflammatory drugs (NSAIDs). Viruses, commonly Epstein‐Barr virus (EBV), human herpesvirus 6 (HHV6) and cytomegalovirus (CMV), and the bacterium, Mycoplasma pneumoniae, may cause exanthema either from the infection itself (active or latent) or because of interaction with drugs that are taken simultaneously. Determination of the exact diagnosis requires a careful clinical history and thorough physical examination. Haematological and biochemical investigations and histology are not always helpful in differentiating between the two types of exanthema. Serological and polymerase chain reaction (PCR) assays can be helpful, although a concomitant acute infection does not exclude drug hypersensitivity. A drug provocation test (DPT) is although considered the gold standard for the diagnosis and is not preferred by the patients. Skin tests are not well tolerated, and in vitro tests, such as the basophil activation test and lymphocyte transformation, are of low sensitivity and specificity and their relevance is debatable. Based on current evidence, we propose a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous eruption while receiving a drug.

Kleine Ursache – große Wirkung: Spättyp-Hauttests mit Medikamenten als Auslöser von disseminierten Rezidivexanthemen

“…Dafür sprechen die kurzen Latenzzeiten bei der Re-Exposition mit den beiden Substanzen und die überschießend positiven Hauttests verbunden mit einem Exanthem auf Amoxicillin. Entgegen früherer Annahme scheinen Antibiotika bei akuter EBV-Infektion zumindest bei Kindern nicht gehäuft zu Exanthemen zu führen [8,10], bei einem EBVassoziierten Exanthem unter Aminopenicillinen kann es jedoch zur persistierenden Sensibilisierung auf das Antibiotikum kommen [9].…”

“…Deshalb wurden die Penicilline damals nicht getestet. Soforttyphauttests waren für Moxifloxacin und die Makrolide Clarithromycin und Erythromycin positiv.Eine Therapie mit Amoxicillin-Clavulansäure ein Jahr später wegen eines febrilen Infektes rief innerhalb eines Tages ein ausgeprägtes Exanthem hervor, was für eine frühere Sensibilisierung spricht, als beitragend wurde die Reaktivierung eines EBV-Infektes interpretiert[8][9][10]. Die später durchgeführten Hauttests mit Betalaktamen fielen für Aminopenicilline in der Spätablesung stark positiv aus (▶ Abb.…”

Patch testing for cutaneous adverse drug reactions in a paediatric population: A retrospective review

“…1,2 In children, diagnosing CADRs is a common challenge for physicians, as childhood rashes are more often due to viral infections but frequently mimic CADRs. 1,2 A proper diagnosis and identification of the culprit drug avoids misdiagnosis, therefore, preventing unnecessary drug avoidance or replacement, and guides for potential alternatives reducing morbidity from CADRs. [1][2][3] Patch tests (PT) are considered useful for diagnosing non-immediate CADRs, however, few paediatric studies have been published.…”

“…1,2 A proper diagnosis and identification of the culprit drug avoids misdiagnosis, therefore, preventing unnecessary drug avoidance or replacement, and guides for potential alternatives reducing morbidity from CADRs. [1][2][3] Patch tests (PT) are considered useful for diagnosing non-immediate CADRs, however, few paediatric studies have been published. [2][3][4][5][6] This may be related to the lower incidence of CADRs in children, the lack of PT standardization especially for severe cutaneous adverse reactions (SCARs) and controversies on PT safety, particularly in this population.…”

Comments on pollen season changes, vegetable consumption and asthma, and exercise‐induced reactions after oral immunotherapy to foods

“…A common problem seen in clinic by pediatric allergists is the child who presents with a rash during antibiotic treatment. The second review discusses on two possible diagnoses (drug hypersensitivity vs viral exanthema) and proposes a clinical approach for differential diagnosis and management of rashes in children while receiving an antibiotic 2 . The following rostrum proposes an analytical framework to determine the plausibility of viral transmission by breastmilk based on the principle of Koch's postulate 3 .…”