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Bullous drug eruption in Adult
Other Resources UpToDate PubMed

Bullous drug eruption in Adult

Contributors: Erin X. Wei MD, Melissa Danesh MD, Susan Burgin MD
Other Resources UpToDate PubMed

Synopsis

Bullous drug eruption is a term used to describe a heterogeneous group of bullous diseases that are induced by medications. The following disease entities are included under the term bullous drug eruption:
  • Bullous fixed drug eruption (BFDE) – Can be single, multiple, or generalized. Generalized bullous fixed drug eruption (GBFDE) develops in 50% of affected patients. Due to widespread blistering, it can mimic Stevens-Johnson syndrome (SJS). GBFDE tends to occur more rapidly after drug exposure (48 hours versus 1-3 weeks), have more well-circumscribed individual lesions, and have less mucosal involvement than SJS, but can be life-threatening due to widespread denudation. Compared to localized BFDE, GBFDE tends to occur in older individuals, possibly due to repeated culprit drug exposure. More than 100 medications have been implicated. Vaccinations have also been reported to be triggers. Foods can cause a similar eruption called fixed food eruption (FFE).
  • SJS / toxic epidermal necrolysis (TEN) – A rare, severe, and sometimes life-threatening drug eruption.
  • Drug-induced autoimmune blistering diseases (eg, linear IgA bullous dermatosis [LABD], drug-induced bullous pemphigoid, drug-induced pemphigus) – Autoimmune blistering disease that may be drug-induced. Penicillamine and captopril have been implicated in the causation of pemphigus vulgaris; vancomycin, lithium, angiotensin converting enzyme (ACE) inhibitors, and diclofenac have been implicated in LABD; and there are a host of less-well-studied drug associations for bullous pemphigoid.
  • Drug-induced pseudoporphyria – Photoexposed skin fragility and blistering that resembles porphyria cutanea tarda and is usually drug-induced.
  • Acute generalized exanthematous pustulosis (AGEP) – Characterized by tiny pustules on a background of erythema, AGEP may rarely have bullae and resemble SJS/TEN.
Depending on the underlying pathogenesis, bullae may be tense (eg, drug-induced bullous pemphigoid) or flaccid with a positive Nikolsky sign (eg, SJS/TEN, pemphigus vulgaris). Patients may have mucosal involvement, in which case SJS/TEN should be ruled out. Diagnosis often requires biopsy for hematoxylin and eosin (H&E) stain, often in conjunction with direct immunofluorescence (DIF) when there is concern for autoimmune blistering disease (eg, LABD, drug-induced bullous pemphigoid, drug-induced pemphigus). Prognosis varies widely based on underlying subtype of bullous disease. Of the disease entities listed, SJS/TEN carries the worst prognosis.

Codes

ICD10CM:
L27.1 – Localized skin eruption due to drugs and medicaments taken internally

SNOMEDCT:
402750008 – Bullous dermatosis precipitated by drug treatment

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed:06/22/2022
Last Updated:06/30/2022
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Bullous drug eruption in Adult
A medical illustration showing key findings of Bullous drug eruption : Erythema, Flaccid bullae, Scattered few, Scattered many, Skin erosion, Tense bullae
Clinical image of Bullous drug eruption - imageId=1102531. Click to open in gallery.
Copyright © 2022 VisualDx®. All rights reserved.