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Clinical Scenario
Drug Eruption
Last Updated: 01/09/2010
E930 – Drugs, medicinal and biological substances causing adverse effects in therapeutic use
Lichenoid drug eruptions are distinctive eruptions with violaceous, scaling papules. Often these lesions are very pruritic and may be widely distributed. Lichenoid drug eruptions may progress to exfoliative erythrodermas. This eruption can occur from weeks to months after initiating treatment.
A number of medications have been reported to cause lichenoid eruptions including: beta adrenergic blockers, captopril, thiazide diuretics, furosemide, phenothiazines, gold, antimalarials, quinidine, chlorpropamide, d-penicillamine, phenytoin, carbamazepine, isoniazid, ethambutol, and tetracycline.
Violaceous, scaling (sometimes flat-topped) papules, often beginning on the trunk and then spreading to the extremities. Palms and soles can be severely affected. Lesions are usually more psoriaform than the lesions of idiopathic lichen planus.
Unlike lichen planus, patients with lichenoid drug eruptions rarely have mucosal involvement. Wickham's striae (fine white scale within the center of the flat topped papules) are rarely seen in lichenoid drug eruptions.
A skin biopsy can be helpful and often shows a mononuclear cell infiltrate at the epidermal-dermal junction, "sawtooth changes" of the epidermis with an admixture of eosinophils.
Discontinuation of the offending medication is critical for improvement. Resolution of the eruption may take weeks to months.
Topical medium strength corticosteroids (triamcinolone 0.1% ointment) with or without occlusion. Antihistamines for itching (hydroxyzine 25-50 mg q 4-6 hours or cetirizine 10-20 mg bid). UVB and or PUVA therapy may be necessary. For rapidly advancing eruptions, prednisone 1 mg/kg/d tapered over weeks after resolution of the eruption.
Pua VS, Scolyer RA, Barnetson RS. Pravastatin-induced lichenoid drug eruption. Australas J Dermatol. 2006 Feb;47(1):57-9. PubMed Id: 16405486

Sánchez-Borges M, Capriles-Hulett A, Caballero-Fonseca F. Risk of skin reactions when using ibuprofen-based medicines. Expert Opin Drug Saf. 2005 Sep;4(5):837-48. PubMed Id: 16111447

Fox GN, Harrell CC, Mehregan DR. Extensive lichenoid drug eruption due to glyburide: a case report and review of the literature. Cutis. 2005 Jul;76(1):41-5. PubMed Id: 16144288

Nigen S, Knowles SR, Shear NH. Drug eruptions: approaching the diagnosis of drug-induced skin diseases. J Drugs Dermatol. 2003 Jun;2(3):278-99. PubMed Id: 12848112

McCartan BE, McCreary CE. Oral lichenoid drug eruptions. Oral Dis. 1997 Jun;3(2):58-63. PubMed Id: 9467343

Halevy S, Shai A. Lichenoid drug eruptions. J Am Acad Dermatol. 1993 Aug;29(2 Pt 1):249-55. PubMed Id: 8335745

Heymann WR, Lerman JS, Luftschein S. Naproxen-induced lichen planus. J Am Acad Dermatol. 1984 Feb;10(2 Pt 1):299-301. PubMed Id: 6232297
Appearance
No Acute Distress

Body Location
Arm
Leg
Trunk

Distribution
Primarily Truncal
Widespread

Lesion
Papule
Scale Fine

Medications
Acebutolol
Adalimumab
Allopurinol
Amlodipine
Aspirin
Auranofin
Captopril
Carbamazepine
Chlorothiazide
Chlorpropamide
Chlortetracycline
Clopidogrel
Cycloserine
Dactinomycin
Diflunisal
Enalapril
Etanercept
Ethambutol
Fenofibrate
Flurbiprofen
Furosemide
GCSF
Gold & Gold Compounds
Heparin
Hydrochlorothiazide
Hydroxychloroquine
Hydroxyurea
Ibuprofen
Imatinib
Infliximab
Interferon
Isoniazid
Ketoconazole
Labetalol
Lansoprazole
Levamisole
Mesalamine
Methamphetamine
Methyldopa
Naproxen
Nebivolol
Nifedipine
Omeprazole
Orlistat
Pantoprazole
Penicillamine
Phenobarbital
Phenylbutazone
Phenytoin
Pindolol
Pravastatin
Propranolol
Pyrazinamide
Pyrimethamine
Quinacrine
Quinidine
Quinine
Ranitidine
Salsalate
Sildenafil
Simvastatin
Sotalol
Sparfloxacin
Spironolactone
Sulfamethoxazole + Trimethoprim
Sulfasalazine
Tetracycline
Thiazides
Ticlopidine
Tiopronin
Tocainide
Tolazamide
Torsemide
Trimethoprim
Ursodiol

Signs and Symptoms
No Fever (Afebrile, Apyrexial)

Temporal
Developed Acutely Over Days to Weeks
Eruption 1 Month to 1 Year After Drug
Eruption 6 to 30 Days After Drug
Eruption More Than 1 Year After Drug


Authors
Michael D. Tharp MD, Neil Shear MD