Alopecia diagnosis is difficult because it may be due to underlying disease, such as? (list 4)
Thyroid disease (hypothyroidism)
Infections
Anemia
Trauma
why does alopecia happen?
disturbance of the hair growth cycle
can be immediate or delayed depending on which part of cycle is interrupted
What are treatment option for alopecia? Provide counseling points as well
avoid drugs that cause it (if necessary, use lowest possible dose)
minoxidil topical solution (+/- tretinoin): 2% for women, 5% for men
counseling: upon d/c of minoxidil (+/- tretinoin), you will lose hair all over again within 3 months
Finasteride may be used for drug induced alopecia in men. T or F
F
NOT effective
Which antihypertensive drug may cause alopecia?
beta blocker
Which anticonvulsant drug may cause alopecia?
carbamazepine
valproate
Antidepressant may cause alopecia. T or F
T
could also be due to underlying disease so be careful
Antithyroid drug does not cause alopecia. T or F
False
whenever body senses the removal of thyroid, alopecia may occur
Oral contraceptive does not cause alopecia. T or F
F
change of hormone occurs with contraceptive so it may directly affect alopecia
Interferons may cause alopecia. T or F
T
Warfarin induced skin necrosis occurs predominantly in ____ (male/female).
female
How fast does warfarin-induced skin necrosis occur?
between 3rd and 10th day of treatment
usually with initializing therapy
fairly early
mostly in in-patient setting
May begin with localized skin tingling, pain, sensation of pressure then well-demarcated erythematous lesions usually progress to purpuric and hemorrhagic areas
warfarin induced skin necrosis
Warfarin induced skin necrosis has lesions in what kind of tissues?
areas of subcutaneous fatty tissue
common area: breasts, thigh, buttock, penis
Warfarin induced skin necrosis is related to warfarin dose. T or F
F: unrelated to warfarin dose
but seems to happen more with a higher dose of warfarin
Clinical course of warfarin induced skin necrosis will subside upon discontinuation of warfarin. T or F
False
you would be lucky...
Warfarin induced skin necrosis is associated with ____ deficiency. This leads to _____ in microvasculature.
protein C/S deficiency
coagulation/thrombosis
Purple toe syndrome is a rare complication of which drug?
warfarin
Purple toe syndrome lesions typically develops _____ weeks after initiation of drug.
3-8 weeks
due to warfarin
Sudden onset of bilateral discoloration on the toes and side of feet
Affected area is cold and tender to touch What is this?
purple toe syndrome
How do you treat warfarin induced skin necrosis?
discontinue anticoagulation therapy immediately.
MUST initiate IV heparin when d/c warfarin
If warfarin induced skin reaction is found early, what additional therapy can you consider?
vitamin K may be initiated
Once warfarin induced skin necrosis occurs, you cannot use warfarin again.
T or F
False
re-initiation of warfarin at lower doses has been well documented
initiation phase is most sensitive: start low and slow
testing for protein c/s deficiencies may be warranted.
How can you prevent warfarin induced skin reaction?
fully heparinize patient to therapeutic aPTT before starting warfarin
avoid large loading dose of warfarin
Maculopapular eruption
Immunologic or nonimmunologic?
immunologic
mild-mod
Urticaria
Immunologic or nonimmunologic?
immunologic
mild/mod
Angioedema
Immunologic or nonimmunologic?
immunologic
mild-mod
Anaphylaxis
Immunologic or nonimmunologic?
immunologic
mild/mod
Fixed drug eruption
Immunologic or nonimmunologic?
immunologic
mild/mod
Vasculitis
Immunologic or nonimmunologic?
immunologic
mild/mod
Acute generalized exanthematous
Immunologic or nonimmunologic?
immunologic
mild/mod
Pustulosis
Immunologic or nonimmunologic?
immunologic
mild/mod
Systemic lupus erythematosus (SLE)
Immunologic or nonimmunologic?
immunologic
mild/mod
Exanthematous/morbiliform reaction is also known as _____ _____.
maculopapular reaction
Most common drug induced skin reaction?
maculopapular reaction
What reaction is this?
Nonspecific lesions, measles like in presentation
Erythematous, pruritic
Symmetrical, maybe flat or raised
vesicles may be present
Often start on trunk, areas of pressure or trauma
maculopapular rash
Maculopapular rash typically happens __ week after initiation of drug.
~1week
If on drug rechallenge, maculopapular rash occurs sooner. T or F
T
this is an immunologic based reaction
Maculopapular rash generally does not fade within a feww days after discontinuation on offending agent. T or F
F
it does fade upon d/c
What are some drugs that cause maculopapular rash?
sulfa antibiotic
penicillin (especially aminopenicillin)
NSAIDs
carbamazepine
phenytoin
barbiturates
gold salts
allopurinol
How do you treat maculopapular reaction?
withdraw causative drug if possible
symptomatic relief: tepid or cool water bath or compress
systemic antihistamine for itchy lesions
what would you do for a severe type of maculopapular reaction?
short course of systemic corticosteroid
What is the first indicator of anaphylaxis?
urticaria
How fast does urticaria occur? (in other words, what is the acute onset?)
12-36 hours
How fast does urticaria resolve?
within 1-3 days
What is this reaction?
Raised, well defined, pruritic, erythematous wheals (HIVES) lesions
systemic symptoms of fever, lymphadenopathy, joint swelling, arthralgia
urticaria
How do you treat urticaria?
identify offending agent and discontinue
antihistamine
Which drugs cause urticaria?
aspirin, NSAIDs, penicillin
but virtually all drugs
* remember that urticaria happens quickly so patient might have just started the drug
How fast does anaphylaxis begin?
within 30 minutes to 2 hours
late phase reactino can be seen 6-8 hours later
How long should observe a patient who may have anaphylaxis?
12 hours
What are most common drugs that cause anaphylaxis? (list 3)
NSAIDs
penicillin
aspirin
What is this condition?
urticaria, angioedema, pruritus
abdominal pain, NVD
dyspnea, wheezing
hypotension, tachycardia, arrhythmia
anaphylaxis
fatality can result from ___ (also known as laryngeal edema) or cardiovascular collapse.
aspyxia
What is this condition?
painless, nonpruritic, nonpitting, and well circumscribed area of edema due to increased vascular permeability
angioedema
Angioedema involved swelling of ___ (shallow/deeper) tissue
deeper
What is the treatment of angioedema?
withdraw causative drug
What is this condition?
painful burning sensation first then pruritis then then discoloration
erythematous, hyperpigmented, round/oval lesions
change in color (pale red to dusky red)
gray brown hyperpigmented spot persists
fixed drug eruption
During fixed drug eruption, where does the recurrence eruption upon re-exposure occur?
exact location as the previous reaction
Once the fixed drug eruptions go away, the colored lesions will subside as well. T or F
F
gray brown hyperpigmented spot persists
Fixed drug eruption can occur in any location, but most common in oral mucosa and genitalia. T or F
T
Does fixed drug eruption go away upon drug discontinuation?
Yes but could still get eruptions randomly. They seem to have mind of their own...
How do you treat fixed drug eruption?
remove offending agent, avoid in future
cool water compress
bleaching cream for hyperpigmentation
systemic corticosteroids and antihistamine can be used but they have minimal effect
NSAIDs are associated with fixed drug eruption. T or F
T
Fixed drug eruption can caused by an excipient, such as ____.
food/drug dyes
Barbiturates can cause fixed drug eruption. T or F
T
Oral contraceptives do not cause fixed drug eruption. T or F
False
Sulfonamides can cause fixed drug eruption. T or F
T
What is this condition?
purpuric papules (itchy little dots)
typically lower extremities
organ involvement can be life threatening
vasculitis
When is the onset of vasculitis?
7-21 days after drug administration
If on drug rechallenge, when is the onset of vasculitis?
less than 3 days after
which is much faster than 7-21 days for the first exposure
Does vasculitis resolve after drug withdrawal?
Yes
leads to rapid resolution
What can you give if vasculitis leads to a life threatening situation?
give systemic steroids
Is vasculitis has a high percentage of drug induced etiology?
no
only ~10%
What is this condition?
acute pustular eruption
fever and numerous small pustules
burning, itching rash
widespread edematous erythema
acute generalized exanthematous pustulosis
Does acute generalized exanthematous pustulosis have a high percentage of drug induced etiology?
yes
more than 90%
What are some drugs that cause acute generalized exanthematous pustulosis?
aminopenicillin
diltiazem
antimalarial
What is the onset of acute generalized exanthematous pustulosis?
<2 days after drug administration
What should you do when acute generalized exanthematous pustulosis happen?
withdraw drug
may use systemic antihistamine for pruritis
How fast does acute generalized exanthematous pustulosis resolve?
less than 15 days
erythema multiforme
immunologic or nonimmunologic?
immunologic
severe
Stevens johnson syndrome
immunologic or nonimmunologic?
immunologic
severe
toxic epidermal necrolysis
immunologic or non immunologic?
immunologic
severe
What is this condition?
localized typical targets or raised atypical tragets, particularly on extremities
bull's eye lesion
possible nonspecific prodromal symptoms
erythema multiforme (EM)
Erythematous multiforme can be drug induced but most likely an ___ ____.
infectious agent
particularly herpes simplx virus
The disease that causes EM often do not lead to SJS and TEN. T or F
F
most likely variants of the same disease
How fast does erythema multiforme resolve? How about complete healing?
4-5 days
completely healing in 2-4 weeks (new lesions may appear during this time)
post-inflammatory hyperrpigmentation can occur
How do you treat erythema multiforme?
withdraw drug
symptomatic relief: antihistamine, tap water compress, 1/2 strength hydrogen peroxide gargles for oral lesions
What do you tell patient if you suspect erythema multiforme?
if the lesions seem to get worse, go to ER!
What is this condition?
extensive mucosal and conjunctival edema, erosions
systemically high fever, myalgia, vomit, diarrhea, arthralgia
necrotic lesions
purpuric macules
SJS
What is the onset of SJS?
typically begins within 4 weeks of initial drug exposure
What is the % of epidermal detachment in SJS?
~10%
What are the complications of SJS?
Eye: keratitis, conjunctival scarring, blinding
pneumonia
dehydration (due to skin loss)
esophagitis (due to the effect on alimentary canal)
supportive care for ocular involvement and respiratory tract
alimentation (maybe enteral nutrition)
think about systemic absorption when using topical antibacterial or antiseptic
What is this condition?
erythema and extensive detachment of the epidermis
prodromal state with nonspecific symptoms are common (fever, cough, sore throat, pyrexia, myalgia)
involves more lower layers
toxic epidermal necrolysis
What is the acute onset of cutaneous manifestation for TEN?
1-3 days
What is the prognosis of TEN?
dependent upon patient age, extent of skin involvement, concurrent disease adn complication
high mortality in the beginning but 3% if you pass 3-4 days
TEN's clinical picture may seem similar to ____ _____ burn.
2nd degree
What are complications of toxic epidermal necrolysis?
these are all rather common
fluid and electrolyte imbalance
septicemia (very high risk)
corneal ulceration
conjunctivitis
systemic involvement
How do you treat toxic epidermal necrolysis?
immediate identification and removal of causative agent
treat like a burn patient
empirical use of short course systemic corticosteroids (controversial): early administration may stop further immunologic injury but it does not reverse programmed death
symptomatic treatment: IVIG, fluid/electrolyte maintenance, infection, ocular, aggressive nutrition support
What drug pops into your head when you think SJS and TEN?
lamotrigine!
What should you counsel when you dispense lamotrigine?
if you get rash, go to physician immediately
this may be nothing but it may be something
counsel upon your FIRST TIME DISPENSING
What drugs cause SJS/TEN?
LANCOPS
lamotrigine
allopurinol
nevirapine
carbamazepine
oxicam NSAIDs
phenytoin
sulfa antibiotic
If you have erythema multiforme, can you rechallenge the drug?
NO
If you have SJS or TEN, can you rechallenge the drug?
