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Acneiform Drug Eruption

Drug-Induced Acne

An acneiform drug eruption is an atypical form of acne seen in association with numerous pharmacological agents, such as antimicrobials, corticosteroids, and many immunomodulating/chemotherapeutic drugs. The clinical presentation includes a papulopustular rash accompanied by pruritus, usually within a few days after administration of the mentioned medications. The typical presence of comedones prior to the development of these lesions in acne is absent, which is one of the main distinguishing features from acne. Clinical assessment, potentially supported by a histopathological examination, is crucial in order to make the diagnosis.


Presentation

An acneiform drug eruption is considered to be an important cutaneous drug-induced adverse effect. It has been described in patients taking both topical and systemic drugs [1], with the most involved classes being antimicrobials (tetracycline, streptomycin, isoniazid, clofazimine, and antimycotics), central nervous system (CNS)-acting agents (lithium, phenobarbital, and hydantoin derivatives such as phenytoin), chemotherapeutics (epidermal growth factor receptor - EGFR inhibitors such as cetuximab, erlotinib, and gefitinib, but also cyclosporin A), interferon (IFN), gold salts, etc. [1] [2] [3] [4]. Corticosteroids, in topical as well as systemic formulations, are particularly associated with an acneiform drug eruption in women [1]. The typical signs are characterized by the onset of skin lesions within several days after the introduction of drugs [5]. Erythematous follicular papules are the hallmark of an acneiform drug eruption [1] [3] [5] [6]. These lesions develop on the face, but also on the extremities, particularly on the forearms and buttocks, whereas the shoulders, the retroauricular area, and the superior portion of the trunk might serve as additional locations [1] [3] [5] [6]. The papules are further differentiated from acne vulgaris by the formation of punctiform vesicles in the center, followed by vesiculopustular progression [1]. Additional findings that exclude acne vulgaris are the absence of comedones that should normally precede the formation of acne, the older age of the patient (acne are primarily seen in adolescence), accompanying signs of systemic drug toxicity (eg. fever or malaise), and resolution of lesions after discontinuation of the drug [1] [5].

Inflammation
  • Typical findings include spongiosis, disruption of the follicular epithelium and a nonspecific inflammatory reaction with both lymphocytes and neutrophils, whereas a suppurative follicular inflammation with a dense neutrophilic infiltrate is reported[symptoma.com]
  • Bacteria and inflammation. Increased numbers of acne bacteria ( Propionibacterium acnes ) accumulate in the duct and contribute to the inflammation that develops in the pimples. Genetics.[dermcoll.edu.au]
  • Although histology of INAH and steroid induced lesions showed several similarities like follicular plugging, retention cysts and perifollicular inflammation; the damage to the luminal cells and suppuration of the follicular wall which were demonstrated[ijdvl.com]
  • Etanercept works by acting as a decoy receptor for TNF-α, thereby preventing it from binding cell surface receptors and subsequently decreasing inflammation.[mdedge.com]
  • ACNE PAPULOSA acne papulosa Acne characterized by formation of papules with very little inflammation.[medical-dictionary.thefreedictionary.com]
Fever
  • Additional findings that exclude acne vulgaris are the absence of comedones that should normally precede the formation of acne, the older age of the patient (acne are primarily seen in adolescence), accompanying signs of systemic drug toxicity (eg. fever[symptoma.com]
  • Chlorothiazide, meprobamate, anticoagulants Serum sickness–type drug reaction A type III immune complex reaction Acute urticaria and angioedema more common than morbilliform or scarlatiniform eruptions Possibly polyarthritis, myalgias, polysynovitis, fever[merckmanuals.com]
  • Serum Sickness–Like Reactions: These reactions present with fever, an urticarial rash, arthralgias, and lymphadenopathy. 5,6 The reaction occurs 1 to 3 weeks post initial drug exposure.[uspharmacist.com]
  • They resolve spontaneously and rapidly, with fever and pustules lasting 7-10 days before desquamation over a few days.[patient.info]
  • […] and fever may accompany the rash. • Culprits include antibiotics (especially ampicillin), sulphonamides and related compounds (diuretics and hypoglycaemics) and barbiturates 11.[slideshare.net]
Physician
  • The diagnosis of an acneiform drug eruption rests on the ability of the physician to identify the key findings and establish the underlying cause.[symptoma.com]
  • *Medscape Business of Medicine Academy Survey, September 2015 Learn from Experienced Professionals Courses were developed especially for physicians by business health experts and experienced physicians.[medscape.com]
  • Isotretinoin (an oral retinoid) is used in patients with severe nodular acne that is unresponsive to oral antibiotic therapy and may result in prolonged remissions; however, because of teratogenicity, isotretinoin should be administered only by physicians[ime.acponline.org]
  • It is not intended nor implied to be a substitute for professional medical advice and shall not create a physician - patient relationship. If you have a specific question or concern about a skin lesion or disease, please consult a dermatologist.[aocd.org]
  • The patient discontinued use of etanercept and subsequently was started on oral minocycline (50 mgonce daily) by his primary care physician. After 6 weeks of minocycline therapy, the patient reported gradual improvement of his cystic acne.[mdedge.com]
Malaise
  • Additional findings that exclude acne vulgaris are the absence of comedones that should normally precede the formation of acne, the older age of the patient (acne are primarily seen in adolescence), accompanying signs of systemic drug toxicity (eg. fever or malaise[symptoma.com]
  • Important clues are sudden onset within days, widespread involvement, unusual locations (forearm, buttocks), occurrence beyond acne age, monomorphous lesions, sometimes signs of systemic drug toxicity with fever and malaise, clearing of inflammatory lesions[karger.com]
  • […] herpes simplex virus but, when caused by drugs, it is usually penicillins or sulfonamides. [ 8 ] Clinical features are similar in all causes: The reaction often starts with fever, sore throat, chills, headache, arthralgia, vomiting and diarrhoea and malaise[patient.info]
  • Mucosal involvement includes the eyes, lips and mouth Drug Hypersensitivity syndrome (also known as the DRESS syndrome ) - systemic upset such as malaise and fever, a rash of variable appearance (widespread papules and plaques is the most common presentation[pcds.org.uk]
  • ., fever, malaise, anorexia, weight loss) symptoms. 17,18 Certain agents are more closely linked with specific clinical findings of hepatic abnormalities, pleuritis, and cutaneous symptoms. 17 Cutaneous symptoms such as the classic butterfly rash are[uspharmacist.com]
Swelling
  • Skin lesions that resemble those of acne vulgaris They can be papulopustular (small swellings with pus), nodules (larger swellings) and cysts (fluid filled swellings). 2. The absence of comedones Black head and white heads and not present. 3.[skinspecialistsonline.com]
  • Treatments may include moisturizers, lotions, baths, cortisone creams that relieve swelling, and antihistamines, which relieve itching.[icdlist.com]
  • In contrast, angioedema is defined by involvement of dermal and subcutaneous tissues and is described as pale or pink swelling that affects the face, buccal mucosa, tongue, larynx, and pharynx.[uspharmacist.com]
  • Paronychia is another troublesome side effect, reflecting an aberrant vascular response affecting the nail folds. [16], [17] Inflammation of proximal and lateral nail folds can cause redness, swelling, and sometimes exuberant granulation tissue formation[e-ijd.org]
  • Angioedema causes swellings of deeper tissues, often affecting the face (lips, tongue and eyelids) or other areas such as the genitalia (especially in men) Stevens-Johnson syndrome / Toxic epidermal necrolysis - painful red areas of skin with local erosions[pcds.org.uk]
Acneiform Eruption
  • Diagnosis", publisher "Springer New York", } TY - CHAP T1 - Drug-Induced Acneiform Eruptions T2 - Drug-induced Acneiform Eruptions AU - Do, Ha K.[indiana.pure.elsevier.com]
  • Some sources consider acne vulgaris part of the differential diagnosis for an acneiform eruption. [4] Other sources classified acne vulgaris under acneiform eruption. [5] MeSH explicitly excludes perioral dermatitis from the category of "acneiform eruptions[ipfs.io]
  • What Are Acneiform Eruptions? Acneiform eruptions are skin lesions that are similar to those acne vulgaris. What Causes Acneiform Eruptions? Causes of acneiform eruptions include: 1.[skinspecialistsonline.com]
  • TY - JOUR T1 - Acneiform eruption due to "megadose" vitamins B6 and B12.[unboundmedicine.com]
  • We included all patients that received cetuximab from Acneiform eruption January to December. The most frequent cutaneous reaction was acneiform eruption. Holmes FA, O’ Shaughnessy J,.[cuhigyner.tk]
Acneiform Eruption
  • Diagnosis", publisher "Springer New York", } TY - CHAP T1 - Drug-Induced Acneiform Eruptions T2 - Drug-induced Acneiform Eruptions AU - Do, Ha K.[indiana.pure.elsevier.com]
  • Some sources consider acne vulgaris part of the differential diagnosis for an acneiform eruption. [4] Other sources classified acne vulgaris under acneiform eruption. [5] MeSH explicitly excludes perioral dermatitis from the category of "acneiform eruptions[ipfs.io]
  • What Are Acneiform Eruptions? Acneiform eruptions are skin lesions that are similar to those acne vulgaris. What Causes Acneiform Eruptions? Causes of acneiform eruptions include: 1.[skinspecialistsonline.com]
  • TY - JOUR T1 - Acneiform eruption due to "megadose" vitamins B6 and B12.[unboundmedicine.com]
  • We included all patients that received cetuximab from Acneiform eruption January to December. The most frequent cutaneous reaction was acneiform eruption. Holmes FA, O’ Shaughnessy J,.[cuhigyner.tk]
Papule
  • Erythematous follicular papules are the hallmark of an acneiform drug eruption.[symptoma.com]
  • Acne vulgaris is a polymorphic infl ammatory skin disease, clinically characterized by mixture of comedones, superficial and deep infl amed papules, pustules, and nodules. It is a chronic infl ammation of the pilosebaceous unit.[indiana.pure.elsevier.com]
  • Inflammatory papules were the predominant lesions [Table - 3] ..[ijdvl.com]
  • ACNE PAPULOSA acne papulosa Acne characterized by formation of papules with very little inflammation.[medical-dictionary.thefreedictionary.com]
  • Rosacea is characterized by erythema with telangiectasia, pustules, and papules; comedones are absent ( Plate 23 ).[ime.acponline.org]
Acne Vulgaris
  • The papules are further differentiated from acne vulgaris by the formation of punctiform vesicles in the center, followed by vesiculopustular progression.[symptoma.com]
  • Acne vulgaris is a polymorphic infl ammatory skin disease, clinically characterized by mixture of comedones, superficial and deep infl amed papules, pustules, and nodules. It is a chronic infl ammation of the pilosebaceous unit.[indiana.pure.elsevier.com]
  • The distribution of lesions was similar to that in acne vulgaris. Inflammatory papules were the predominant lesions [Table - 3] ..[ijdvl.com]
  • Patient discussion about acne vulgaris Q. what is the best treatment for acne vulgaris A.[medical-dictionary.thefreedictionary.com]
  • Some sources consider acne vulgaris part of the differential diagnosis for an acneiform eruption. [4] Other sources classified acne vulgaris under acneiform eruption. [5] MeSH explicitly excludes perioral dermatitis from the category of "acneiform eruptions[ipfs.io]
Acne Vulgaris
  • The papules are further differentiated from acne vulgaris by the formation of punctiform vesicles in the center, followed by vesiculopustular progression.[symptoma.com]
  • Acne vulgaris is a polymorphic infl ammatory skin disease, clinically characterized by mixture of comedones, superficial and deep infl amed papules, pustules, and nodules. It is a chronic infl ammation of the pilosebaceous unit.[indiana.pure.elsevier.com]
  • The distribution of lesions was similar to that in acne vulgaris. Inflammatory papules were the predominant lesions [Table - 3] ..[ijdvl.com]
  • Patient discussion about acne vulgaris Q. what is the best treatment for acne vulgaris A.[medical-dictionary.thefreedictionary.com]
  • Some sources consider acne vulgaris part of the differential diagnosis for an acneiform eruption. [4] Other sources classified acne vulgaris under acneiform eruption. [5] MeSH explicitly excludes perioral dermatitis from the category of "acneiform eruptions[ipfs.io]
Suggestibility
  • Perifollicular granuloma histologically seen with both these drugs suggested a delayed hypersensitivity mechanism.[ijdvl.com]
  • Note the yellow crusting on the nasolabial folds suggestive of bacterial infection. Treatment includes topical corticosteroids and oral antibiotics. Fig. 2: EGFR inhibitor–associated rash on the upper trunk.[ascopost.com]
  • Nonetheless, the increased Staphylococcus carrier state and/or the im paired skin barriers in patients with severe papulopustular eruption have been suggested as the possible causes for developing secondary bacterial infections. 1 In fact, a recent study[jhoponline.com]
  • Lithium does not show a clear dose- dependent relationship with follicular eruptions but high concentrations of lithium have been found in the skin, suggesting it can accumulate there and resulting in the occurrence of follicular eruptions .[dermnetnz.org]
  • Suggestions for High End Professional MonitorsMonitor do 500, 1000. Gry singleplayer trzymają się mocno. MSI GT72 2PC- 065NL 43, 9 cm Notebook- PC schwarz.[proburcionord.tk]

Workup

The diagnosis of an acneiform drug eruption rests on the ability of the physician to identify the key findings and establish the underlying cause. For this reason, a thorough patient history and a detailed physical examination are main steps in order to raise suspicion toward this entity. Recent administration of the previously mentioned pharmacological agents is perhaps the crucial piece of information that can be obtained. Other patient details, such as age, the presence of underlying disorders for which these drugs are used, and the pattern of rash distribution are equally important for making a presumptive diagnosis. Recognition of an acneiform drug eruption is mainly based on clinical grounds, but a biopsy with subsequent histopathological examination can be performed. Typical findings include spongiosis, disruption of the follicular epithelium and a nonspecific inflammatory reaction with both lymphocytes and neutrophils [5], whereas a suppurative follicular inflammation with a dense neutrophilic infiltrate is reported by other authors [6].

Treatment

  • His PSA normalized after treatment with dutasteride and finasteride. A stool guaiac and urinalysis were normal. The physical examination revealed a large weeping eczematous plaque on the right scrotum extending to the groin andperineum (Fig 1).[semanticscholar.org]
  • Treatment consists of discontinuing the glucocorticoid or protecting the skin from the inhaled product. Initial treatment includes topical antibiotics and sulfur preparations.[ime.acponline.org]
  • There are many safe and effective acne treatments.[dermcoll.edu.au]
  • Topical therapy is usually the best place to start treatment. 12 If tolerated, benzoyl peroxide is the simplest and most cost-effective treatment. Bacterial resistance to benzoyl peroxide has not been noted.[clinicaladvisor.com]
  • Etanercept was subsequently discontinued and the patient was started on ustekinumab for treatment of psoriasis and psoriatic arthritis as well as minocycline (100 mg twice daily) for treatment of nodulocystic acne.[mdedge.com]

Prognosis

  • Prognosis Most cases resolve without complications but it may take 10-14 days for the rash to disappear. Patients with exanthematous eruptions will have mild desquamation as the rash resolves.[patient.info]

Etiology

  • Perioral dermatitis, also a disorder of unclear etiology, is mainly observed in the young, white, female population as papulopustules with erythematous base.[emedicine.medscape.com]
  • […] of comedones or any apparent infectious etiology, acne vulgaris is characterized by the presence of sebum and comedones. 2-4 Like EGFR, HER-2 receptors have been shown to play a role in keratinocyte differentiations in the skin 5 ; hence, the observed[jhoponline.com]
  • Other cutaneous eruptions that may superficially resemble acne vulgaris but that are not thought to be related to it etiologically are due to infection (e.g. gram-negative folliculitis) or unknown causes (e.g. acne necrotica or acne aestivalis).[karger.com]
  • Etiology Patient Education Józwiak S, Schwartz RA, Janniger CK, Michalowicz R, Chmielik J. Skin lesions in children with tuberous sclerosis complex: their prevalence, natural course, and diagnostic significance.[emedicine.medscape.com]
  • Synonym: common acne ; acne vulgaris Etiology The cause is unknown, but predisposing factors include hereditary tendencies and disturbances in the androgen-estrogen balance.[medical-dictionary.thefreedictionary.com]

Epidemiology

  • Epidemiology [ 2 ] Hospital Episode Statistics from 1996 to 2000 logged 62,000 hospital admissions in England each year due to drug allergies and adverse drug reactions.[patient.info]
  • Drug-induced skin pigmentation: epidemiology, diagnosis and treatment. Am J Clin Dermatol. 2001;2:253-262. To comment on this article, contact rdavidson@uspharmacist.com.[uspharmacist.com]
Sex distribution
Age distribution

Pathophysiology

  • Steroid-induced acneiform eruption Member Rated 0 Patient case no. 10804 Date added 02 June 2010 Patient details Age Adult Location India Localisation Head / face Primary Lesions Comedones Erythema papules Pustule Pathophysiology inflammatory skin appendage[dermquest.com]
  • The pathophysiology of acneiform eruption is poorly understood.[e-ijd.org]
  • Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York, NY: The McGraw Hill Companies, Inc; 2008:1661-1672. 7. Chia FL, Leong KP. Severe cutaneous adverse reactions to drugs. Curr Opin Allergy Clin Immunol. 2007;7:305-309. 8.[uspharmacist.com]

Prevention

  • Prevention of acneiform rash caused by EGFR inhibitors includes topical corticosteroids (hydrocortisone 2.5%, alclometasone) and oral antibiotics (minocycline, doxycycline, or antibiotics covering skin flora) twice daily for at least the first 6 weeks[ascopost.com]
  • This is also known as a comedolytic treatment (“comedolytic” is the term used to describe a product or medication that prevents the formation of comedones such as whiteheads and blackheads).[dermcoll.edu.au]
  • All patients should be educated to avoid the offending agent to prevent further complications.[aocd.org]
  • Etanercept works by acting as a decoy receptor for TNF-α, thereby preventing it from binding cell surface receptors and subsequently decreasing inflammation.[mdedge.com]
  • "Hot Tub Rash" and "Swimmer's Ear" (Pseudomonas) (Centers for Disease Control and Prevention) Contact dermatitis (Medical Encyclopedia) Diaper rash (Medical Encyclopedia) Hot tub folliculitis (Medical Encyclopedia) Pityriasis rosea (Medical Encyclopedia[icdlist.com]

References

Article

  1. Rosa DJ, Matias FAT, Cedrim SD, Machado RF, Sá AA, Silva VC. Acute acneiform eruption induced by interferon beta-1b during treatment for multiple sclerosis. An Bras Dermatol. 2011;86:336–338.
  2. Du-Thanh A, Kluger N, Bensalleh H, Guillot B.Drug-induced acneiform eruption. Am J Clin Dermatol. 2011;12(4):233-245
  3. Pontello Junior R, Kondo RN. Drug-induced acne and rose pearl: similarities. An Bras Dermatol. 2013;88(6):1039-1040.
  4. Plewig G, Jansen T. Acneiform dermatoses. Dermatology. 1998;196(1):102-107.
  5. Segaert S, Van Cutsem E. Clinical signs, pathophysiology and management of skin toxicity during therapy with epidermal growth factor receptor inhibitors. Ann Oncol. 2005;16:1425–1433.
  6. Lee JE, Lee SJ, Lee HJ, Lee JH, Lee KH. Severe acneiform eruption induced by cetuximab (Erbitux) Yonsei Med J. 2008;49:851–852

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Last updated: 2019-07-11 20:46