Eczematous drug eruption from carbamazepine: coexistence of contact and photocontact sensitivity

We report a 46-year-old patient with an eczematous eruption on sun-exposed areas which we believe was caused by carbamazepine intake. Oral provocation with the drug produced papulo-vesicular eruptions that were greatly potentiated by long-wave ultraviolet irradiation. Positive reactions to carbamazepine were elicited by patch and photopatch tests and by lymphocyte stimulation tests 6 months after cessation of the intake of carbamazepine.     

Photoallergic Drug Eruption Due to Pyridoxine Hydrochloride

Photoallergy to vitamin B₆ is very rare; only a few cases of contact dermatitis and one case of photosensitive dermatitis due to pyritinol have been reported. We report here the first case of photoallergy drug eruption due to pyridoxine hydrochloride. A 71-year-old man developed papulo-squamous erythemata which were confined to sun-exposed sites. Photopatch testing, together with the clinical course, was helpful in reaching the initial diagnosis; this was confirmed by an oral challenge test. Photoallergic drug eruption due to vitamin B₆ should be considered a rare cause of photosensitive dermatitis.     

Two patients with isoniazid-induced photosensitive lichenoid eruptions confirmed by photopatch test

Causative agents of drug eruptions are frequently unknown, and skin tests with candidate drugs would be useful before systemic challenge. It remains to be clarified how phostosentive lichenoid drug eruptions are induced, but allergy, including delayed type allergy, has been suggested. Two patients who had taken anti-tuberculous drugs developed a lichenoid drug eruption, primarily on sun-exposed skin. Patch and photopatch tests were performed with each of the ingested drugs (10% in petrolatum). Photopatch tests to isoniazid (INH) were positive. These were confirmed by oral challenge followed by irradiation with UVA. In conclusion, photopatch tests facilitated identification of the causative drug in two patients with photosensitive lichenoid eruptions to INH.     

A Case of Drug Eruption Caused by the Crude Drug Boi® (Sinomenium Stem/Sinomeni Caulis et Rhizoma)

We report a case of drug eruption caused by the crude drug Boi®. A 41-year-old female patient had been diagnosed with chronic rheumatoid arthritis in the department of internal medicine. After ingestion of a decoction of the crude drug Boi® for the alleviation of arthralgia, a slight fever developed, which was followed by systemic edematous erythema with itching. HPLC showed that the main components of the crude drug Boi® are sinomenine and magnoflorine. The results of patch tests were negative for all oral drugs that the patient had been taking. Oral ingestion tests showed that the patient showed positive reactions to the as-is Boi® boiling-water decoction and 1/10-volume sinomenine. Based on this, the drug eruption was judged to be caused by sinomenine. It is considered the first time that the causative component of a drug eruption was confirmed by oral ingestion tests with components of a crude drug of Kampo medicine (Sino-Japanese traditional medicine).     

Persistent edematous-plaque photosensitivity observed with sitagliptin phosphate (Januvia®)

Photosensitivity to sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, is reported. No previous reports of photosensitivity to any DPP-4 inhibitors are known. Physical examination of the patient revealed edematous plaques confined to sun-exposed areas of the skin. An unusual finding in this case was the spongy sensation upon palpation of the plaques. Histopathology revealed parakeratosis and abundant eosinophils, supporting the clinical impression of cutaneous drug sensitivity. The eruption finally cleared, approximately two years after onset.     

Systemic photosensitivity due to a contraceptive patch

Hormonal contraceptives are a known but rarely reported cause of photosensitivity. A 35-year-old female developed several episodes of a prurigionous papulovesicular eruption located on sun-exposed areas that resolved without scarring in days. She had been using a transdermal contraceptive (EVRA^®: norelgestromin and ethinyloestradiol) for 3 years, and once it was stopped, the patient became asymptomatic. She had another episode after the use of oral contraceptives (YAZ^®: ethinyloestradiol and drospirenone). The biopsy of the lesions showed a spongiotic dermatitis. Minimal erythema dose was diminished when the patient was using EVRA^® and YAZ^® and became normal when they were withdrawn. Phototesting with UVA, photopatch testing and blood porphyrins were normal. Antinuclear antibodies were 1/80 initially and were 1/320 6 months later. Anti-deoxyribonucleic acid antibodies, extractable nuclear antigens, anti Ro and Anti La were negative and no systemic symptoms had developed. When all hormonal contraceptives were stopped, the patient became asymptomatic. We report a case of systemic photosensitivity induced by the contraceptive patch. To the best of our knowledge, no other cases induced by transdermal contraceptives have been reported previously.     

Acral syringomas presenting as a photosensitive papular eruption

A 43-year-old woman presented with a recurrent and remitting eruption of reddish-brown papules in the sun-exposed areas of the arms and forearms that had been present for 2 years. Results of a histopathologic examination revealed syringoma. To the best of our knowledge, this is the first case report of syringomas confined to sun-exposed areas with a recurrent and remitting course over time. We also review the literature on acral syringomas.     

Darier's disease restricted to sun-exposed areas

We report a sporadic case of Darier's disease restricted to sun-exposed areas in a 17-year-old Japanese girl. There are several clinical variants of Darier's disease including unilateral Darier's disease, localized Darier's disease, segmental Darier's disease, and acral Darier's disease, but few cases of Darier's disease restricted to sun-exposed areas have been described in the literature. Although it remains controversial whether UV irradiation can evoke the eruption of Darier's disease or not, cases of Darier's disease restricted to sun-exposed areas like our case may help to further clarify the relationship between Darier's disease, UV irradiation and photo-exacerbation of this autosomal dominant genodermatosis.     

A Challenging Case: Symmetrical Drug Related Intertriginous and Flexural Exanthem,Fixed Drug Eruption,or Both?

Abstract: We herein report a 12‐year‐old boy with amoxicillin‐induced, recurrent, site‐specific, symmetrical, sharply demarcated reddish plaques on the buttocks and the major flexural and intertriginous areas. The lesions resolved with topical corticosteroids, leaving hyperpigmentation. Histopathology showed nonspecific features of inflammation and dermal melanophages. Amoxicillin was the probable inducer based on oral provocation test with Amoksina^® tablet, however patch testing with amoxicillin on previously affected and unaffected skin remained negative. The diagnosis was challenging because of the overlapping features of symmetrical drug‐related intertriginous and flexural exanthema and fixed drug eruption. This one represents a unique and challenging one with overlapping clinical features of symmetrical drug‐related intertriginous and flexural exanthem (SDRIFE) and fixed drug eruption (FDE). We discuss the possible immunopathogenetic mechanisms leading to the simultaneous occurrence of different phenotypes of drug eruption in the same patient.     

Photocontact Allergy Due to Suprofen

A 79-year-old Japanese woman developed edematous erythema on sun-exposed areas 3 months after applying Sulprotin® ointment, which contains 1% suprofen (SP), a phenylacetic acid derivative. A patch test with Sulprotin® ointment as is was negative, but a photopatch test with Sulprotin® ointment as is was positive. A photopatch test with 10^–3% SP was positive, as was that obtained with an SP analogue, 3% ketoprofen, but that with the ointment base of Sulprotin® was negative. Photopatch tests with other SP analogues such as flurbiprofen, ibuprofen, and pranoprofen were negative. She developed abnormal erythema with monochromatic irradiation in the range from 320 to 380 nm on the uninvolved abdominal skin where 1% SP had been applied 24 hours (h) before irradiation. The action spectrum for this erythema agreed with the absorption spectrum of SP in the range of UVA. The MED after applying SP was below that after applying w. pet. in the range from 250 to 290 nm and from 300 to 320 nm. Positive intracutaneous test results were obtained with an irradiated mixture of human serum albumin (HSA) and SP at 48 and 72 h after injection and negative ones with a mixture of HSA and irradiated SP.     

Photo-accentuated eruption and vascular deposits of immunoglobulin A associated with hepatitis A virus infection

Skin rash associated with hepatitis A virus infection has rarely been reported. We describe a patient with hepatitis A virus infection who presented a rubelliform rash markedly accentuated in sun-exposed areas; direct immunofluorescence studies of the lesion revealed immunoglobulin (Ig) A deposition on the endothelial cells in the upper dermis. Oral rechallenge tests of the previously administered drugs failed to reproduce the eruption. The preferential setting of immune complexes containing IgA at sites of sun exposure and sunlight as a triggering factor might have been responsible for the development of the eruption in this patient. Eruptions associated with hepatitis A virus infections may be more frequent than commonly thought. Because of difficulty to exclude the possibility of drug eruptions, these cases might have been overlooked. In patients with such a disorder, a careful clinical workup such as IgM antibodies for hepatitis A virus at diagnosis and during follow-up is especially recommended.     

Topical provocation in 31 cases of fixed drug eruption: change of causative drugs in 10 years

The pathomechanism of fixed drug eruption remains to be clarified, but patch testing has been used to determine the causative drug. 31 patients with fixed drug eruption were investigated to evaluate the diagnostic value of patch testing and to compare the causative drugs over the 10 years between the late 1980s and the late 1990s. 22 of them were given an oral provocation test to confirm the results of patch testing. A reaction showing definite infiltration, which occurred in 13 of 22 patients, reliably indicated the causative drug. In contrast, a patch test reaction without definite infiltration was not always correlated with systemic provocation. All except 1 patient found out their causative drug. The most frequent causative drug was sulfamethoxazole-trimethoprim in the late 1980s, but it had become chlormezanone 10 years later.     

Polymorphic light eruption sine eruptione

We describe seven patients, four female and three male, who developed intense pruritus on sun-exposed skin without visible change. The clinical features resembled those of polymorphic light eruption (PLE) without rash. Four patients also occasionally developed typical PLE upon sun exposure, but sun-induced pruritus alone occurred most frequently. No patient was taking any drug therapy. One patient developed similar pruritus following solar simulated irradiation, and one following PUVA therapy. All other laboratory investigations were negative. Treatment with low dose UVB phototherapy or PUVA therapy was effective. The condition, which we have called polymorphic light eruption sine eruptione (PLESE), appears to be a variant of PLE not previously reported.     

Scarified photopatch testing in lomefloxacin photosensitivity

We report the results of scarified photopatch testing in 3 patients with photosensitivity to lomefloxacin, a new quinolone antibacterial agent introduced onto the Japanese market in April 1990. The patients developed pruritic eczematous lesions on sun-exposed areas 5 days to 3 weeks after they had started taking lomefloxacin. 2 cases reacted positively to lomefloxacin on scarified photopatch testing down to 0.1% pet., and 1 patient down to 10% pet. One of them also showed positive reactions on conventional photopatch testing. Scarified photopatch testing with 7 other pyridone carbonate derivatives in 2 of the 3 cases, however, did not show any positive reactions. Patch and scarified patch testing were negative in all patients. The clinical course, clinical and histological findings and results of skin tests in these patients suggest that photoallergic mechanisms are involved. This is the 1st report of positive reactions on scarified photopatch testing, which appears to be a useful method of detecting the causative drug in drug-induced photosensitivity.     

Flutamide photosensitivity

Flutamide is a non-steroid antiandrogen used in advanced prostate cancer. This drug induces liver toxicity. Other side effects have been reported, especially four cases of photosensitivity. Our patient presented a sun-exposed eruption that disappeared when flutamide was discontinued and relapsed when it was rechallenged. Photopatch tests were negative. UVA MED was much lower during the treatment and the rechallenge of flutamide. The action spectrum of the drug seems to be in the UVA range. According to the literature, this photosensitivity is probably due to a photoallergic mechanism.     

Photolocalized tinea facialis.

The case of a 34-year-old white woman with tinea facialis that persisted for nine months prior to diagnosis is presented. The confluent plaquelike erythematous eruption of the face with eyelid lichenification that flared outdoors was thought to represent polymorphic light eruption and was refractory to antibiotics, corticosteroids (topical and systemic), and antimalarials. A KOH preparation was positive when the dermatosis spilled onto the mandibular region, and restaining of the initial skin biopsy revealed fungal hyphae. Complete resolution was accomplished with griseofulvin and MicTin. Tinea cab be added to the list of infectious agents that have a photosensitivity component. The fungus possibly "photolocalizes" to sun-damaged areas, ie, areas of increased capillary permeability. This case illustrates the importance of including tinea in considering diagnoses of sun-exposed lesions of the face.     

Eccrine squamous syringometaplasia in a patient with phytophotodermatosis

A 46-year-old man noticed, after a day of rural work, the development of burning erythematous lesions arranged in linear streaks on sun-exposed skin. Some of the lesions became vesicular and bullous over the next few hours. The patient reported that cutaneous lesions appeared in uncovered skin areas that had been in close contact with plants, except for the face and neck. When he visited our hospital, 1 week after the development of the skin eruption, he exhibited multiple linear erythematous lesions, with weeping and crusting patches, affecting the extensor aspect of the arms and legs ( Fig. 1 ). There was no history of previous allergy, photosensitivity, or drug intake. Results of all routine laboratory studies were negative or within normal limits. The patient brought the plant with him, which was classified as belonging to the family Ruthaciae.

Figure 1 Open in figure viewer PowerPoint Erythematous skin lesions arranged in linear streaks, affecting sun-exposed skin     

Rapid development of multiple squamous-cell carcinomas during chronic granulocytic leukemia.

We report a 65-year-old patient who presented a rapid eruption of keratoses on sun-exposed areas and an explosive transformation into several squamous-cell carcinomas, occurring during the accelerated phase of a chronic granulocytic leukemia. Clinical findings resembled those usually described in xeroderma pigmentosum. The role of immunosuppression, chemotherapy and possible genetic predisposition is discussed.     

Hydroa vacciniforme-like lymphoma: a case report and literature review

Hydroa vacciniforme (HV) is a photosensitivity disorder in childhood characterized by recurrent vacciniform vesicles, necrotic ulcers, and scars on sun-exposed areas. HV-like lymphoma is a rare variant of cutaneous T-cell lymphoma. HV, atypical HV and HV-like lymphoma belong to the spectrum of Epstein-Barr virus (EBV)-associated lymphoproliferative disorders. We report a fatal case of HV-like lymphoma in a 31-year-old man with a 16-year history of recurrent vacciniform papulovesicular eruption with crusts and scarring. The rash initially was confined to the sun-exposed areas. Histopathology revealed focal necrosis of the epidermis and subjacent dermis with a superficial lymphocytic infiltrate, consistent with HV. Toward the end of the clinical course, the skin lesions became persistent and spread to nonsun-exposed areas. Repeated biopsies revealed epidermal necrosis with infiltration of CD4+, CD56- lymphocytes in the dermis, some with atypical nuclei, and small blood vessel vasculitis. EBV-encoded RNA (EBER-1)-positive lymphocytes were detected. Progression of his skin lesions was associated with colon ulcers, gingival ulcers, fever, splenomegaly, leukopenia and thrombocytopenia. EBER-1-positive lymphocytes were detected in all biopsy specimens, including the skin, gingiva, and bone marrow; the last also showed infiltrate of atypical lymphocytes with T-cell receptor-γ gene rearrangement. The pathogenic role of UV-irradiation is discussed.     

破伤风抗毒素所致药疹42例临床特点分析

目的：明确破伤风抗毒素所致药疹的临床特点。方法：对42例破伤风抗毒素所致药疹的临床资料进行回顾性分析。结果：42例患者中破伤风抗毒素皮试阴性40例,阳性2例。发疹潜伏期6 ~12天,平均为6.5天,皮疹表现为注射局部红斑2例,全身泛发性皮疹40例(发疹型6例,荨麻疹型32例,多型红斑型2例)。42例患者中伴发热5例,呕吐5例,关节痛12例。糖皮质激素治疗有效。结论：破伤风抗毒素所致药疹最常见类型为荨麻疹型,可伴发热、消化道症状及关节痛。药疹的发生与皮试结果无关。