Drug induced skin disorders is defined as any skin disorders caused by a drug or medication. It is estimated that 2—3 percent of hospitalised patients are affected by a drug eruption, and that serious drug eruptions occur in around 1 in 1000 patients.

1. DRUG INDUCED SKIN DISORDERS
V I S H W A N A T H G O U D A
1 S T M . P H A R M
P H A R M A C Y P R A C T I C E
N G S M I P S
N I T T E U N I V E R S I T Y
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Anatomy of Skin

3. What is Drug induced skin
disorders?Drug induced skin disorders is defined as any skin
disorders caused by a drug or medication.
It is estimated that 2—3 percent of hospitalised
patients are affected by a drug eruption, and that
serious drug eruptions occur in around 1 in 1000
patients.
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4. Mechanisms
 Caused by over dosage or failure to excrete or
metabolize.
 Cumulative effects.
 Altered skin ecology.
Pharmacological
Allergic
 IgE-mediated
 Cytotoxic
 Immune complex-mediated
 Cell-mediated
Idiosyncratic
Exacerbation of pre-existing skin conditions
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5. Non-allergic drug reactions:
Some drug reactions are a result of overdosage, others to the
accumulation of drugs, or to unwanted pharmacological effects, e.g.
stretch marks from systemic steroids.
Other reactions are idiosyncratic (an odd reaction peculiar to one
individual), or a result of alterations of ecological balance.
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6. Cutaneous reactions can be expected from the nature of some drugs.
These are normal but unwanted responses.
For example:
 Methotrexate - Mouth ulcers
 Silver-based preparations - Argyria
 Antibiotics - Acute vaginal candidiasis
 Dapsone or rifampicin - Erythema nodosum leprosum
They affect many, or even all, patients taking the drug at a
sufficient dosage for a sufficient time.
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7. Allergic drug reactions
:
Occur in only a minority of patients and even with low doses.
Usually appear after the latent period required for an immune
response.
Chemically related drugs may cross-react.
 Allergic drug reactions present in only a limited number of forms;
urticaria and angioedema, vasculitis, erythema multiforme, or a
morbilliform erythema.
 Rarer allergic reactions include bullae, erythroderma, pruritus,
toxic epidermal necrolysis and the hypersensitivity syndrome
reaction.
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8. Allergic drug reactions : (Cont….)
For example:
 Ampicillin - Morbilliform rash
 Penicillin - Severe anaphylactic reactions
 Minocycline - Brown or grey color in the mucosa
 Minocycline can rarely cause the hypersensitivity
syndrome reaction, hepatitis, worsen lupus
erythematosus, or elicit a transient lupus-like syndrome.
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9. Some common skin reaction
patterns and drugs which can
cause them:
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10. 1. Urticaria :
 Many drugs may cause this but salicylates are the most common,
often working non-immunologically as histamine releasers.
 Antibiotics are also cause Urticaria.
 Insect repellents and nitrogen mustards can cause urticaria on
contact.
 Urticaria may be part of a severe and generalized reaction
(anaphylaxis) that includes bronchospasm and collapse.
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11. 2. Erythema multiforme :
 Target-like lesions appear mainly on the extensor aspects of the
limbs, and bullae may form.
 In the Stevens–Johnson syndrome, the patients are often ill and
the mucous membranes are severely affected.
 Sulphonamides, barbiturates, lamotrigine and phenyl-
butazone are known offenders.
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12. 3.Toxic (reactive) erythema :
This common type of drug eruption, looking sometimes like
measles or scarlet fever, and sometimes showing prominent
urticarial or erythema multiforme-like elements.
Drugs include antibiotics (especially ampicillin), sulphonamides
and related compounds (diuretics and hypoglycaemics),
barbiturates, phenylbutazone and para-aminosalicylate (PAS).
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13. 4. Purpura :
 Itchy brown petechial rash on dependent areas that is
characteristic reactions.
 Thiazides, sulphonamides, phenylbutazone, sulphonylureas,
barbiturates and quinine are among the drugs reported to cause
purpura.
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14. 5. Eczema :
Eczema is a condition where patches
of skin become inflamed, itchy, red,
cracked, and rough. Blisters may
sometimes occur. It affects a large
section of the American population to a
lesser or greater degree.
Penicillin, sulphonamides, neomycin, phenothiazines and local
anaesthetics should be considered.
Exfoliative dermatitis is redness and
peeling of the skin over large areas of
the body. The term “exfoliative” refers
to the exfoliation, or shedding, of the
skin. Dermatitis means irritation or
inflammation of the skin.
6. Exfoliative dermatitis :
This can be caused by drugs (particularly phenylbutazone, PAS,
isoniazid and gold), but can also be caused by widespread psoriasis
and eczema.
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15. 7. Fixed drug eruptions :
Round, erythematous or purple, and sometimes bullous
plaques recur at the same site each time the drug is taken.
Pigmentation persists between acute episodes.
The glans penis seems to be a favored site. Paracetamol,
trimethoprim-sulfa, Non-steroidal anti-inflammatory drugs
(NSAIDs; including aspirin), antibiotics, systemic antifungal agents
and psychotropic drugs are possible offenders
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16. 8. Acneiform eruptions :
Lithium, iodides, bromides, oral
contraceptives, androgens or
glucocorticosteroids,
antituberculosis and
anticonvulsant therapy may
cause an acneiform rash.
9. Lichenoid eruptions :
A lichenoid eruption is a skin disease
characterized by damage and infiltration
between the epidermis and dermis.
Examples include lichen planus, lichen
sclerosus and lichen nitidus. It can also
be associated with abrasion or drug use.
Consider antimalarials, NSAIDs, gold, phenothiazines and
PAS.
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17. 10. Toxic epidermal necrolysis (TEN) :
 Toxic epidermal necrolysis (TEN) is a potentially life-threatening
dermatologic disorder characterized by widespread erythema,
necrosis, and bullous detachment of the epidermis and mucous
membranes, resulting in exfoliation and possible sepsis and/or
death.
 Mucous membrane involvement can result in gastrointestinal
hemorrhage, respiratory failure, ocular abnormalities, and
genitourinary complications.
 Causative drugs includes sulphonamides, barbiturates,
phenylbutazone, oxyphenbutazone, phenytoin, carbamazepine,
lamotrigine or penicillin.
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18. 11. Hair loss (alopecia) :
This is a predictable side-effect of acitretin and cytotoxic agents, an
unpredictable response to some anticoagulants, and sometimes seen with
antithyroid drugs.
Diffuse hair loss may occur during, or just after, the use of an oral
contraceptive.
12. Excessive hair (Hypertrichosis) :
This is a dose-dependent effect of diazoxide,minoxidil and cyclosporin A.
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19. 13. Pigmentation :
The skin's colour can be altered by drugs: hyper-pigmentation, hypo-
pigmentation and discoloration can all potentially be induced by a
variety of medicines.
 Chloasma may follow an oral contraceptive plus sun exposure.
 Heavy metals can cause a generalized
browning. Clofazimine makes the skin red.
 Mepacrine turns the skin yellow.
 Minocycline turns leg skin a greenish grey color.
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21. Antibiotics :
• Penicillins and sulphonamides are among the drugs most
commonly causing allergic reactions.
• These are often morbilliform, but urticaria and erythema multiforme
are common too.
• Viral infections are often associated with exanthems, and many
rashes are incorrectly blamed on an antibiotic when, in fact, the
virus was responsible.
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22. Penicillamine :
Like penicillin itself, this can cause morbilliform eruptions or urticaria,
but the drug has also been incriminated as a cause of haemorrhagic
bullae at sites of trauma, extrusion of elastic tissue through the skin,
pemphigus.
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23. Oral contraceptives
: It can cause telogen effluvium.
 Chloasma,
 hirsutism,
 erythema nodosum,
 acne
 and photosensitivity are other
reactions.
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24. Gold :
 Its side-effects range from pruritus to morbilliform eruptions, to
curious papulosquamous eruptions such as pityriasis rosea or
lichen planus.
 Erythroderma, erythema nodosum, hair fall and stomatitis may
also be provoked by gold.
Pityriasis
rosea
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25. Steroids :
Cutaneous side-effects from systemic
steroids include a ruddy face,
cutaneous atrophy, striae, hirsutism,
an acneiform eruption and a
susceptibility to cutaneous infections,
which may be atypical.
Ruddy face
Cutaneous atrophy25

26. Anticonvulsants :
 There may be cross-reactivity between phenytoin,
carbamazepine and phenobarbitol.
 Skin reactions are common and include erythematous,
morbilliform, urticarial and purpuric rashes.
 Toxic epidermal necrolysis, erythema multiforme, exfoliative
dermatitis, the hypersensitivity syndrome reaction and a
lupus erythematosus-like syndrome are rare.
 A phenytoin-induced pseudolymphoma syndrome has also
been described in which fever and arthralgia are
accompanied by generalized lymphadenopathy and
hepatosplenomegaly.
 Long-term treatment with phenytoin may cause gingival
hyperplasia.
Gingival hyperplasia
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27. Course :
 If a reaction occurs during the first course of treatment, it
characteristically begins late, often about the ninth day, or even
after the drug has been stopped. In such cases, it has taken
that lag time to induce an immune reaction.
 In previously exposed patients the common morbilliform
allergic reaction starts 2–3 days after the administration of the
drug.
 The speed with which a drug eruption clears depends on the
type of reaction and the rapidity with which the drug is
eliminated.
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28. Treatments :
 The first approach is to withdraw the suspected
drug. This is not always easy as sometimes a drug
is necessary and there is no alternative available.
 Chronic urticaria is treated with antihistamines. You may have
to take them regularly for as long as your symptoms last.
 Mild cases of erythema multiforme (EM) require only symptomatic
treatment in the emergency department (ED), which may include
analgesics or nonsteroidal inflammatory drugs (NSAIDs); cold
compresses with saline or Burrow solution; topical steroids; and
soothing oral treatments such as saline gargles, viscous lidocaine.
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29.  For Lichenoid eruptions treatment includes antihypertensives, diuretics,
NSAIDS, Phenothiazine derivatives are recommended.
 For Toxic epidermal necrolysis - Tumor necrosis factor–alpha (TNF-
alpha) inhibitors. Intravenous immune globulin (IVIg)
 Intravenous fluids to correct dehydration.
 Purpura - Treatments include medications and sometimes a
splenectomy, or surgery to remove the spleen.
 Systemic antihistamines and topical corticosteroids may be all
that are required.
Treatments : (Cont…)
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30. Treatments : (Cont…)
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References
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Therapeutics- The Clinical Use of Drugs. In: Kubota D S, Chan J editor.
Drug induced pulmonary disorders.9th edition:25.1-25.13
2. Walker R and Whittlesea C. Clinical Pharmacy and Therapeutics. In:
Dyker A J, editor. Hypertension. Great Britain: Churchill Livingstone. 5th
sep 2011; 5th edition: 295-311.
3. Helms R A, Quan D J, Herfindal E T, Gourley D R, Text book of
therapeutics drug and disease management, 8th edition, Lippin cott
Wiliams And Wilkins; 883-892
4. Dipiro J T, Talbert R L, Yee G C, Matzke G R, et al.Pharmacotherapy- A
Pathophysiological Approach. In: Raissy H H, Harkins M,editor.Drug induced
pulmonary diseases New York: Mc Graw Hill Professional.9th edition

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