- Email: [email protected]
Nonpigmenting solitary fixed drug eruption caused by pseudoephedrine hydrochloride
Journal of the American Academy of Dermatology Volume 38, Number 3
2. 3.
4. 5. 6. 7.
8. 9. 10.
after renal transplantation in the Netherlands. Transplantation 1990;49:506-9. Boyle J, MacKie RM, Briggs JD, Junor BJR. Cancer, warts, and sunshine in renal transplant patients: a casecontrol study. Lancet 1984; 1:702-5. King GN, Healy CM, Dent B, Glover MT, Kwan JTC, Williams DM, et al. Increased prevalence of dysplastic and malignant lip lesions in renal transplant recipients. N Engl J Med 1995;332:1052-7. Regev E, Zeltser R, Lustmann J. Lip carcinoma in renal allograft recipient with long-term immunosuppressive therapy. Oral Surg Oral Med Oral Pathol 1992;73:412-4. Redondo Bellon P, V~izquez-Doval J. Treatment of squamous cell carcinoma of the lip in a kidney transplant patient. Arch Dermatol 1994; 130:428-30. Gupta AK, Cardella C J, Haberman HE Cutaneous malignant neoplasms in patients with renal transplants. Arch Dermatol 1986; 122:1288-93. Hardie IR, Strong RW~ Hartley LCJ, Woodruff PWH, Clunie CJA. Skin cancer in caucasian renal allograft recipients living in a subtropical climate. Surgery 1980;87:177. Mullen DL, Silverberg SG, Penn I, Hammond WS. Squamous cell carcinoma of the skin and lip in renal homograft recipients. Cancer 1976;37:729-34. Harris JR Penn I. Immunosuppression and development of malignancies of the upper airway and related structures. Laryngoscope 1981 ;91:520-8. Hermanek P, Henson DE, Hutter RVP, Sobin LH. TNM Supplement 1993. New York: Springer-Verlag; 1993. p. 25.
Brief communications 499 11. Coebergh JWW, Neumann HAM, Vrints LW, van der Heijden L, Meijer WJ, Verhagen-Teulings MTh. Trends in the incidence of non-melanoma skin cancer in the SE Netherlands 1975-1988: a registry-based study. Br J Dermatol 1991;125:353-9. 12. Thomas DW, Seddon SV, Sheperd JR Systemic immunosuppression and oral malignancy: a report of a case and review of the literature. Br J Oral Maxillofac Surg 1993;31:391-3. 13. Barr BBB, Benton EC, McLaren K, Bunney MH, Smith IW, Blessing K, et al. Human papillomavirus infection and skin cancer in renal allograft recipients. Lancet 1989;1:124-8. 14. Bouwes Bavinck IN, Vermeer BJ, van der Woude FJ, Vandenbroucke JR Schreuder GMTh, Thorogood J, et al. Relation between skin cancer and HLA antigens in renaltransplant recipients. N Engl J Med 1991;325:843-8. 15. De Jong-Tieben LM, Berkhout RIM, Smits HL, Bouwes Bavinck IN, Vermeer B J, van der Woude FJ, et al. High frequency of detection of epidermodysplasia verruciformis-associated human papillomavirus DNA in biopsies from malignant and premalignant skin lesions from renal transplant recipients. J Invest Dermatol 1995;105: 367 -71. 16. Rowe DE, Carroll RJ, Day CL. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. J Am Acad Dermatol 1992;26:976-90.
Nonpigmenting solitary fixed drug eruption caused by pseudoephedrine hydrochloride U~ur Hindio~lu, M D , and S e d e f ~ahin, M D
P s e u d o e p h e d r i n e , an effective decongestant, is c o m m o n l y f o u n d in o v e r - t h e - c o u n t e r cold m e d ications. A d v e r s e c u t a n e o u s reactions c a u s e d b y p s e u d o e p h e d r i n e s e e m to be rare. W e describe a nonpigmenting solitary fixed drug eruption caused by pseudoephedrine hydrochloride.
CASE REPORT A 10-year-old boy was referred to our dermatology department for evaluation of an edematous, erythematous 3.5 x 7.0 cm plaque in his right groin that had appeared suddenly 2 days earlier (Fig. 1). There had From the Department of Dermatology,Hacettepe University Faculty of Medicine. Reprint requests: UfgurHindio~lu, MD, Prof. MuammerAksoy caddesi, No: 3t5 Alpan Apt., Bah~elievler 06500, Ankara, Turkey. J Am Acad Dermatol 1998;38:499-500. Copyright © 1998 by the AmericanAdacemy of Dermatology,Inc. 0190-0622/98/$5.00 + 0 16/54/87617
Ankara, Turkey been no similar eruption before. The patient's mother stated that he had had an upper respiratory infection for a few days before the eruption emerged and that the only medication he had been given was tablets containing triprolidine hydrochloride 2.5 mg and pseudoephedrine hydrochloride 60 rag. She added that he had not previously taken these tablets. The lesion cleared completely without treatment within 2 weeks leaving no residual pigmentation. Then an oral challenge test was conducted, and an identical eruption at the same site developed 4 hours after administration of pseudoephedrine hydrochloride 30 mg. The provoked eruption resolved without any pigmentary change during the next 2 weeks. The patient was instructed to avoid all pseudoephedrine-containing medications. DISCUSSION F i x e d drug eruption is a specific type o f reaction with characteristic r e c u r r e n c e at the s a m e site
Journal of the American Academy of Dermatology
500 Brief communications
March 1998
Fig. 1. Fixed drug eruption caused by pseudoephedrine in the right inguinal region. of the skin or mucous membranes whenever the causative drug is taken. When the acute phase resolves, it usually leaves behind residual hyperpigmentation that becomes more prominent after each recurrence. However, in nonpigmenting fixed drug eruption, no pigmentary change occurs and the site of the drug hypersensitivity response is hypothesized to be dermal, t Although oral provocation is the most reliable means of confirming the suspected cause of a fixed drug eruption, topical open provocation on postlesional skin presents an alternative for patients who refuse oral rechallange. 2 Pseudoephedrine is widely used in many overthe-counter cold preparations for alleviation of nasal congestion. Despite its frequent use, adverse skin reactions appear to be unusual. Our search of the literature revealed 13 cutaneous reactions caused by pseudoephedrine. A severe generalized eruption (morphologic condition not specified) accompanied by joint swelling, 3 a recurrent pseudoscarlatina with distal desquamation, 4 a recurrent toxic shock syndrome,5 and a systemic contact dermatitis 6 have been reported. Fixed drug eruptions have also been known to occur in response to pseudoephedrine.,127• -11 Our patient's clinical features are in sharp contrast to other nonpigmenting fixed drug reactions caused by pseudoephedrine, which were all characterized by multiple, usually symmetric lesions. Since Shelley and Shelley 1 defined nonpigmenting fixed drug eruption as a separate entity and
emphasized its symmetric distribution, our patient's solitary lesion that faded without any pigmentation is unusual. We propose that the nonpigmenting dermal type of fixed drug eruption does not always occur in a symmetric fashion but can also appear as a solitary plaque just like the pigmenting epidermal type. REFERENCES
1. Shelley WB, Shelley ED. Nonpigmenrlng fixed drug eruption as a distinctive reaction pattern: examples caused by sensitivity to pseudoephedrine hydrochloride and tetrahydrozoline. J Am Acad Dermatol 1987; 17:4037. 2. Alanko K, Kanerva L, Mohell-Talolahti B, Jolanki R, Estlander T. Nonpigmented fixed drug eruption from pseudoephedrine. J Am Acad Dermatol 1996;35:647-8. 3. Frankland AW. Allergy to pseudoephedrine. Practitioner 1978;211:828-9. 4. Taylor BJ, Duf-fill MB. Recurrent pseudo-scarlatina and allergy to pseudoephedrine hydrochloride. Br J Dermatol 1988;118:827-9. 5. Cavanah DK, Ballas ZK. Pseudoephedrine reaction presenting as recurrent toxic shock syndrome. Ann Intern Med 1993; 119:302-3. 6. Tomb RR, Lepoittevin JP, Espinassouze F, Heid E, Foussereau J. Systemic contact dermatitis from pseudoephedrine. Contact Dermatitis 1991 ;24:86-8. 7. Brownstein MH. Fixed eruptions due to an ephedrine isomer. Arch Dermatol 1968;97:115-9. 8. Camisa C. Fixed drug eruption due to pseudoephedrine. Curls 1988;41:339-40. 9. Hauken M. Fixed drug eruption and pseudoephedrine. Ann Intern Med 1994;120:442. 10. Krivda SJ, Benson PM. Nonpigmenting fixed drug eruption. J Am Acad Dermatol 1994;31:291-2. 11. Quan MB, Chow WC. Nonpigmenting fixed drug eruption after pseudoephedrine. Int J Dermatol 1996;35:36770.
2. 3.
4. 5. 6. 7.
8. 9. 10.
after renal transplantation in the Netherlands. Transplantation 1990;49:506-9. Boyle J, MacKie RM, Briggs JD, Junor BJR. Cancer, warts, and sunshine in renal transplant patients: a casecontrol study. Lancet 1984; 1:702-5. King GN, Healy CM, Dent B, Glover MT, Kwan JTC, Williams DM, et al. Increased prevalence of dysplastic and malignant lip lesions in renal transplant recipients. N Engl J Med 1995;332:1052-7. Regev E, Zeltser R, Lustmann J. Lip carcinoma in renal allograft recipient with long-term immunosuppressive therapy. Oral Surg Oral Med Oral Pathol 1992;73:412-4. Redondo Bellon P, V~izquez-Doval J. Treatment of squamous cell carcinoma of the lip in a kidney transplant patient. Arch Dermatol 1994; 130:428-30. Gupta AK, Cardella C J, Haberman HE Cutaneous malignant neoplasms in patients with renal transplants. Arch Dermatol 1986; 122:1288-93. Hardie IR, Strong RW~ Hartley LCJ, Woodruff PWH, Clunie CJA. Skin cancer in caucasian renal allograft recipients living in a subtropical climate. Surgery 1980;87:177. Mullen DL, Silverberg SG, Penn I, Hammond WS. Squamous cell carcinoma of the skin and lip in renal homograft recipients. Cancer 1976;37:729-34. Harris JR Penn I. Immunosuppression and development of malignancies of the upper airway and related structures. Laryngoscope 1981 ;91:520-8. Hermanek P, Henson DE, Hutter RVP, Sobin LH. TNM Supplement 1993. New York: Springer-Verlag; 1993. p. 25.
Brief communications 499 11. Coebergh JWW, Neumann HAM, Vrints LW, van der Heijden L, Meijer WJ, Verhagen-Teulings MTh. Trends in the incidence of non-melanoma skin cancer in the SE Netherlands 1975-1988: a registry-based study. Br J Dermatol 1991;125:353-9. 12. Thomas DW, Seddon SV, Sheperd JR Systemic immunosuppression and oral malignancy: a report of a case and review of the literature. Br J Oral Maxillofac Surg 1993;31:391-3. 13. Barr BBB, Benton EC, McLaren K, Bunney MH, Smith IW, Blessing K, et al. Human papillomavirus infection and skin cancer in renal allograft recipients. Lancet 1989;1:124-8. 14. Bouwes Bavinck IN, Vermeer BJ, van der Woude FJ, Vandenbroucke JR Schreuder GMTh, Thorogood J, et al. Relation between skin cancer and HLA antigens in renaltransplant recipients. N Engl J Med 1991;325:843-8. 15. De Jong-Tieben LM, Berkhout RIM, Smits HL, Bouwes Bavinck IN, Vermeer B J, van der Woude FJ, et al. High frequency of detection of epidermodysplasia verruciformis-associated human papillomavirus DNA in biopsies from malignant and premalignant skin lesions from renal transplant recipients. J Invest Dermatol 1995;105: 367 -71. 16. Rowe DE, Carroll RJ, Day CL. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. J Am Acad Dermatol 1992;26:976-90.
Nonpigmenting solitary fixed drug eruption caused by pseudoephedrine hydrochloride U~ur Hindio~lu, M D , and S e d e f ~ahin, M D
P s e u d o e p h e d r i n e , an effective decongestant, is c o m m o n l y f o u n d in o v e r - t h e - c o u n t e r cold m e d ications. A d v e r s e c u t a n e o u s reactions c a u s e d b y p s e u d o e p h e d r i n e s e e m to be rare. W e describe a nonpigmenting solitary fixed drug eruption caused by pseudoephedrine hydrochloride.
CASE REPORT A 10-year-old boy was referred to our dermatology department for evaluation of an edematous, erythematous 3.5 x 7.0 cm plaque in his right groin that had appeared suddenly 2 days earlier (Fig. 1). There had From the Department of Dermatology,Hacettepe University Faculty of Medicine. Reprint requests: UfgurHindio~lu, MD, Prof. MuammerAksoy caddesi, No: 3t5 Alpan Apt., Bah~elievler 06500, Ankara, Turkey. J Am Acad Dermatol 1998;38:499-500. Copyright © 1998 by the AmericanAdacemy of Dermatology,Inc. 0190-0622/98/$5.00 + 0 16/54/87617
Ankara, Turkey been no similar eruption before. The patient's mother stated that he had had an upper respiratory infection for a few days before the eruption emerged and that the only medication he had been given was tablets containing triprolidine hydrochloride 2.5 mg and pseudoephedrine hydrochloride 60 rag. She added that he had not previously taken these tablets. The lesion cleared completely without treatment within 2 weeks leaving no residual pigmentation. Then an oral challenge test was conducted, and an identical eruption at the same site developed 4 hours after administration of pseudoephedrine hydrochloride 30 mg. The provoked eruption resolved without any pigmentary change during the next 2 weeks. The patient was instructed to avoid all pseudoephedrine-containing medications. DISCUSSION F i x e d drug eruption is a specific type o f reaction with characteristic r e c u r r e n c e at the s a m e site
Journal of the American Academy of Dermatology
500 Brief communications
March 1998
Fig. 1. Fixed drug eruption caused by pseudoephedrine in the right inguinal region. of the skin or mucous membranes whenever the causative drug is taken. When the acute phase resolves, it usually leaves behind residual hyperpigmentation that becomes more prominent after each recurrence. However, in nonpigmenting fixed drug eruption, no pigmentary change occurs and the site of the drug hypersensitivity response is hypothesized to be dermal, t Although oral provocation is the most reliable means of confirming the suspected cause of a fixed drug eruption, topical open provocation on postlesional skin presents an alternative for patients who refuse oral rechallange. 2 Pseudoephedrine is widely used in many overthe-counter cold preparations for alleviation of nasal congestion. Despite its frequent use, adverse skin reactions appear to be unusual. Our search of the literature revealed 13 cutaneous reactions caused by pseudoephedrine. A severe generalized eruption (morphologic condition not specified) accompanied by joint swelling, 3 a recurrent pseudoscarlatina with distal desquamation, 4 a recurrent toxic shock syndrome,5 and a systemic contact dermatitis 6 have been reported. Fixed drug eruptions have also been known to occur in response to pseudoephedrine.,127• -11 Our patient's clinical features are in sharp contrast to other nonpigmenting fixed drug reactions caused by pseudoephedrine, which were all characterized by multiple, usually symmetric lesions. Since Shelley and Shelley 1 defined nonpigmenting fixed drug eruption as a separate entity and
emphasized its symmetric distribution, our patient's solitary lesion that faded without any pigmentation is unusual. We propose that the nonpigmenting dermal type of fixed drug eruption does not always occur in a symmetric fashion but can also appear as a solitary plaque just like the pigmenting epidermal type. REFERENCES
1. Shelley WB, Shelley ED. Nonpigmenrlng fixed drug eruption as a distinctive reaction pattern: examples caused by sensitivity to pseudoephedrine hydrochloride and tetrahydrozoline. J Am Acad Dermatol 1987; 17:4037. 2. Alanko K, Kanerva L, Mohell-Talolahti B, Jolanki R, Estlander T. Nonpigmented fixed drug eruption from pseudoephedrine. J Am Acad Dermatol 1996;35:647-8. 3. Frankland AW. Allergy to pseudoephedrine. Practitioner 1978;211:828-9. 4. Taylor BJ, Duf-fill MB. Recurrent pseudo-scarlatina and allergy to pseudoephedrine hydrochloride. Br J Dermatol 1988;118:827-9. 5. Cavanah DK, Ballas ZK. Pseudoephedrine reaction presenting as recurrent toxic shock syndrome. Ann Intern Med 1993; 119:302-3. 6. Tomb RR, Lepoittevin JP, Espinassouze F, Heid E, Foussereau J. Systemic contact dermatitis from pseudoephedrine. Contact Dermatitis 1991 ;24:86-8. 7. Brownstein MH. Fixed eruptions due to an ephedrine isomer. Arch Dermatol 1968;97:115-9. 8. Camisa C. Fixed drug eruption due to pseudoephedrine. Curls 1988;41:339-40. 9. Hauken M. Fixed drug eruption and pseudoephedrine. Ann Intern Med 1994;120:442. 10. Krivda SJ, Benson PM. Nonpigmenting fixed drug eruption. J Am Acad Dermatol 1994;31:291-2. 11. Quan MB, Chow WC. Nonpigmenting fixed drug eruption after pseudoephedrine. Int J Dermatol 1996;35:36770.