Drug reaction fixe L27.1

Bourns in 1899; Brocq in 1894;

Localized, patchy or plaque-like, also bullous or exfoliative drug reaction,

• which occurs in a temporal connection with the intake of drugs (for triggering drugs, see table) in therapeutic doses
• is limited to a solitary focus or to a few foci
• tends to recur on the spot (recurrence in loco).

The immunopathogenetic mechanism of the fixed drug reaction has not yet been clarified (see also under erythema multiforme). The central role is played by CD8+ T cells, which show a phenotype similar to the effector memory T cell and are mainly responsible for the epidermal damage. CD8+ positive cells persist for years in old, already clinically healed lesions(tissue-resident memory cells) and can be expressed and activated on keratinocytes after re-exposure to the agent via a probably TNF-alpha induced upregulation of ICAM-1 (see below adhesion molecules) (see also UV reactivation reaction). The release of interferon gamma leads to an inflammatory reaction.

The apoptosis of keratinocytes (which is histologically distinct) seems to be induced by a FAS-FAS ligand interaction (see below CD classification - CD95, or CD95L).

Of note is the role of viral infections (e.g., herpes simplex infections) as cofactors for the "recurrence" of the fixed drug response. For the recurrent "in-loco occurrence" a so-called recall reactivation reaction can be assumed, although the immunological processes are also still unclear (see also under UV reactivation reaction).

Occurrence 1-2 weeks after (first) use of the drug. With repeated ingestion, occurrence within 30 min. up to 24 hours possible. The relationship between drug intake and the appearance of the lesions is not always clear.

Occurrence possible in all age groups. Predominance between 20-60 years (average in larger studies at 36-53J). No gender predilection.

Ubiquitous occurrence is possible.

Preference of the upper extremity (about 50%), followed by the lower extremity, lips, face, penis, vulva; involvement of the oral mucosa may occur very concisely (buccal mucosa, gingiva, hard and soft palate).

The mucosa of glans penis and vulva are also typical (often unrecognized) sites of manifestation.

Solitary or limited to a few foci, 2.0-5.0 cm in size (rarely up to 10 cm in size), round or oval (rarely also anular), initially saturated red, later blue- to brown-red, after healing brown (postinflammatory hyperpigmentation), sharply demarcated, succulent, itchy or also slightly painful spots or plaques. Vesicular transformation in the center is possible. Diagnosis may be complicated in intertriginous involvement because the characteristic clinical morphology there is obscured by acting local factors. Clinically, a (large-) area erosion may appear at these sites due to the detachment of the surface epithelium.

The maximum variant described is the generalized and possibly multilocular bullous fixed drug reaction (GBFDE), which can occur in adults as well as in children.

An extreme intertriginous variant is the so-called"baboon syndrome".

Upon re-exposure, the lesions reappear in exactly the same location within 24 hr. However, a refractory period may occur immediately after healing of the lesion.

To be distinguished are:

• Classic fixed drug reaction: Most common form, which heals via a long-term persistent postinflammatory hyperpigmentation.
• Non-pigmented variant of fixed drug reaction: Rarer form; usually occurring over a larger area (up to 10 cm in size) and healing without postinflammatory hyperpigmentation.
• Urticarial fixed drug reaction: Rare variant, again urticarial and recurring in loco on provocation.
• Neutrophilic fixed drug reaction: Extremely rare variant that presents histologically as neutrophilic dermatitis. Only a few case reports have been published.

Clinical picture with recurrence in loco.

Note: Eye drops should also be considered during medical history!

The results of prick-scratch tests are evaluated differently. They are performed in loco in healed lesions. In individual studies (e.g. for non-steroidal anti-inflammatory drugs), reliable positive results of 40% are reported (Andrade 2011).

Oral provocation with the drug in question is the proof.

In case of corresponding severity of the clinical picture: systemic glucocorticoids in medium dosages, e.g. 60-80 mg prednisolone equivalent per day p.o. (e.g. Decortin ®).

Later gradual dose reduction, stomach protection. For severe pruritus antihistamines such as Dimetinden, e.g. Fenistil® 2 times/day 1 amp. i.v. or Desloratadin (Aerius®) 1 time / day 1 tbl. p.o.

In larger collectives an average of 2.6 recurrences (1-10 recurrences) were anamnestized.

Medical history: A 67-year-old patient reported a treatment with Terbinafine because of a therapy-resistant onychomycosis. 2 hours after taking the 1st tablet he had noticed strongly itchy wheals on the inner side of the right upper arm. The treatment was then discontinued. The symptoms had receded.

Diagnosis: Epicutaneous and prick tests with Terbinafine o.B. When provoking the drug orally (125 mg Terbinafine) the patient developed an itchy wheal field of 6x6 cm on the inner side of the right upper arm within 3 hours. Testing was discontinued; the patient received symptomatic therapy with prednisolone and clemastine. Below this the symptoms improved within a few hours.

Diagnosis: Fixed (urticarial) drug reaction.

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14. Lee SS et al (2011) Maximal points of head's zone in fixed drug eruption. Ann Dermatol 23(Suppl 3):S383-386.

15. Pionetti CH et al (2003) Fixed drug eruption due to loratadine. Allergol Immunopathol (Madr) 31: 291-293.
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19. Sidhu-Malik NK et al (2003) Multiple fixed drug eruption with interferon/ribavirin combination therapy for hepatitis C virus infection. J Drugs Dermatol 2: 570-573
20. Tan C et al (2010) Anular fixed drug reaction. JDDG 8: 823-825
21. Vester K et al (2011) Fixed drug exanthema due to flupirtine. Abstract CD 46th DDG meeting:P02/21.