Drug Induced Rash 

• Exanthematous (morbilliform) Drug Eruption
• Acute Urticaria
• Erythema Multiforme
• Minor
• Major
• Steven Johnson Syndrom (SJS) and Toxic Epidermal Necrolysis (TEN)

Erythema Multiforme Minor

• Most common form 
• Target areas appear anywhere except for mucous membrane
• Lesions are more defined. Do not coalesce
• Usually occurs due to infectious cause ** 
• Recurrent EM often associated with herpes simplex

Erythema Multiforme Major

• Involves more body surface AND mucosa
• Patient shows systemic symptoms
• Mucous membranes may ulcerate.  Cause pain in eating swallowing

Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis

• SJS and TEN are maximal variants of EM.  
• TEN when > 30% BSA skin loss.  SJS < 10% BSA
• SJS – blisters develop over dusky or purpuric macules
• TEN - Will see edema, redness and exfoliation. May see sheet like loss of epidermis  
• Nikolsky’s sign
• Use your thumb and push the skin - skin will actually separate
• Epidermis and dermis seperation
• Life threatening (systemic involvement) .  Erosions in respiratory tract, GI tract, kidney failure etc.  

Exanthematous Drug Eruption 

• Cutaneous eruption that mimics a measles-like viral rash
• • Kids can develop this after having a high fever
  • Obtain by getting a good hx
• Systemic involvement is minimal
• • Often the reaction is on the skin
• Most common type of drug reaction. Occurs 7-10  days after drug admin
• • This rash lasts usually 2 weeks
• Symmetrically arranged, brightly erythematous macules and papules, discrete in some areas and confluent in others

Offending Drugs of Exanthematous Drug Eruption 

• Can occur with nearly any drugs
• Penicillins/Cephalosporins
• Sulfonamides
• NSAIDS

Treatment of Exanthematous Drug Reaction 

• D/C Medication
• Antihistamine
• Topical steroids or cooling lotion
• Oral steroids

Drug Induced Acute Urticaria/Angioedema

• Characterized by wheals and large edematous areas that involve the dermis and subcutaneous tissue
• Second most common drug reaction.  Occurs minutes to hours of drug admin or may take days
• Is associated with systemic anaphylaxis which is manifested by respiratory distress and death
• Angioedema – swelling of eyelids, lips, tongue

Often Drugs for Uticaria 

Most Common 

• Penicillin, NSAIDS, Radioactive contrast , Asprin , ACE inhibitors

Treatment for Uticaria

• D/C Medication
• Antihistamine
• Systemic Steroids (Prednisone)
• Make sure to do good physical exam (check mucosa), palms, soles.
• Epinephrine if severe

Offending Drugs for SJS and TEN

• Sulfa drugs 
• Anticonvulsants
• NSAIDs

Treatment of EM 

• EM Minor
• • Control of Herpes Simplex.  Oral anti-viral (Acyclovir)
  • Symptomatic relief
• EM Major
• • Oral Prednisone?
  • Symptomatic/pain relief
• SJS/TEN
• • Emergent Care. Once exfoliation begins, almost impossible to stop
  • IV Immunoglobulin G, steroids?
  • Burn unit
  • IV fluids
  • Cyclosporine
  • Treat complications (including sepsis)

Meningococcemia

• Seeding from nasopharynx; Neisseria meningitis 
• c/b fever, petechial or purpuric lesions ( 80%) , hypotension, signs of meningitis
• High morbidity and mortality 
• PE: Smudged with raised pale macular or papular centers 
• m/c trunk and extremities 
• Fulminant meningococcemia: areas of black-gray necrosis 

Meningococcemia: Treatment

• Penicillin G
• Chlorampehnical for penicillin allergic
• Contact Prophylaxis
• Rifampin, ceftriaxone, cipro

Gonococcemia

• Neisseria gonorrheae
• c/b fever, petechial or pustular acral lesions, asymmetric athralgias, tenosynovitis, septic arthritis 
• young, sexually active 
• PE: small, red macules evolving into hemorrhagic painful pustules 
• generally found in acral areas or distal extremeties

Gonococcemia: Treatment

• prevention : safe sex 
• IV abx ( ceftriaxone) 
• Presymptively txt for chalmydia 

Bacterial Endocarditis 

• Microbial infection implanted on a heart valve or on endocardium
• Caused by S. Aureus, Strep. Pneumonia, Group A Strep
• Characterized by
• Fever ,Valvular destruction ,Peripheral embolization,Several skin manifestations

Bacterial Endocarditis: Skin Manifestations

• Janeway lesions
• Osler’s Nodes
• Roth Spots
• Splinter hemorrhages
• Petechial lesions

Janeway lesions

Oslers Nodes

Roth Spots

Splinter hemorrhages

Petechial Lesions

• Nonblanching, redish brown macules
• Occurs on extremities, upper chest, mucous membrane 

Rocky Mountain Spotted Fever

• Faint macules that progress to maculopapules and then petechiae appear between day 2 and 6 of fever.
• Develops on wrists and ankles and spread inward to involve the trunk. Also involves palms and soles
• • Pin point spots
• Rickettsia infection may become disseminated and lead to vasculitis of arterioles, capillaries in skin, brain, heart and kidneys.  
• • Seizures and coma can occur if not treated

Lyme Disease

• Stage 1 – Erythema Migrans Rash
• • Occurs in 75%
  • Occurs 1 week after tick bite
  • Asymptomatic sometimes
  • Red plaque with central clearing (bull’s eye)
  • Vague viral like illness
• Stage 2 – Neurologic symptoms, Cardiologic Symptoms, musculoskeletal findings
• • Meningitis, encephalitis
  • AV block, cardiomegaly
  • Migratory pain in joints, muscles, bones
• Stage 3 – Arthritis and continuous neurologic problems
• • Occurs months to years after initial infection