| What are cutaneous adverse drug reactions? | undesirable clinical manifestations to a drug, which include predictable or unanticipated side effects, with or without systemic involvement | July/ 2022 Cutaneous adverse drug reactions (cADR) are undesirable clinical manifestations to a drug, which include predictable or unanticipated side effects, with or without systemic involvement Standard Treatment Workflow (STW) CUTANEOUS ADVERSE DRUG REACTIONS- PART A | 55 | definition | 0.980 | July/ 2022 Cutaneous adverse drug reactions (cADR) are undesirable clinical manifestations to a drug, which include predictable or unanticipated side effects, with or without systemic involvement Standard Treatment Workflow (STW) CUTANEOUS ADVERSE DRUG REACTIONS- PART A | 1 | page=1,block=26 | 0.700 | valid |
| What is the typical progression of an erythematous maculopapular eruption? | Typically starts on the trunk, spreads symmetrically to extremities. Dependent areas may have purpuric lesions | SECONDARY LEVEL CARE • Continue treatment as described at primary care level • If severe: add short course of oral steroids: Prednisolone 0.5 mg-1 mg/kg for 3-5 days • Abrupt onset, erythematous maculopapular eruption • Typically starts on the trunk, spreads symmetrically to extremities. Dependent areas may have purpuric lesions • Usually accompanied by mild systemic symptoms- pruritus, low grade fever, mild eosinophilia • All drugs taken in the last 4 weeks are suspects. | 220 | summary | 0.970 | SECONDARY LEVEL CARE • Continue treatment as described at primary care level • If severe: add short course of oral steroids: Prednisolone 0.5 mg-1 mg/kg for 3-5 days • Abrupt onset, erythematous maculopapular eruption • Typically starts on the trunk, spreads symmetrically to extremities. Dependent areas may have purpuric lesions • Usually accompanied by mild systemic symptoms- pruritus, low grade fever, mild eosinophilia • All drugs taken in the last 4 weeks are suspects. | 1 | page=1,block=16 | 0.700 |
| What does STW represent in the context of ICMR? | Standard Treatment Workflow | Dr Lokesh Sharma ICMR Standard Treatment Workflow (STW) CUTANEOUS ADVERSE DRUG REACTIONS - PART A Neonatology; CUTANEOUS ADVERSE DRUG REACTIONS; ICMR; STW Adobe Illustrator 26. (Windows) ICMR Standard Treatment Workflow (STW) CUTANEOUS ADVERSE DRUG REACTIONS - PART A | 22 | definition | 0.940 | Dr Lokesh Sharma ICMR Standard Treatment Workflow (STW) CUTANEOUS ADVERSE DRUG REACTIONS - PART A Neonatology; CUTANEOUS ADVERSE DRUG REACTIONS; ICMR; STW Adobe Illustrator 26. | | pdf-properties | 0.700 | valid |
| What laboratory tests are used at secondary care to confirm a diagnosis of a drug reaction? | CBC (Eosinophilia supports the diagnosis), LFT, serum creatinine, urine M/E | RED FLAG SIGNS • Mucosal involvement • Purpuric lesions • Bullous lesions • Skin tenderness • Facial/ acral edema • Erythroderma • Systemic symptoms - High grade fever, hepatitis, renal involvement, significant eosinophilia PRIMARY CARE • Withdraw the suspect drug(s) • Pheniramine maleate 25 mg TID • Calamine lotion • Refer to higher center if symptoms persist or red flag signs present SECONDARY CARE • Confirm the diagnosis by history and clinical findings • Admit if red flag signs are present • Laboratory tests: CBC (Eosinophilia supports the diagnosis), LFT, serum creatinine, urine M/E • Treatment: in severe cases, prednisolone 0.5-1 mg/ kg/ day x 5-7 days (after ruling out infection) TERTIARY CARE • Admit if red flag signs are present • Confirm diagnosis of drug rash • Additional lab tests if required: ANA, HIV, skin biopsy • Consider DRESS if rash is progressing or significant organ involvement is evident | 519 | list | 0.820 | RED FLAG SIGNS • Mucosal involvement • Purpuric lesions • Bullous lesions • Skin tenderness • Facial/ acral edema • Erythroderma • Systemic symptoms - High grade fever, hepatitis, renal involvement, significant eosinophilia PRIMARY CARE • Withdraw the suspect drug(s) • Pheniramine maleate 25 mg TID • Calamine lotion • Refer to higher center if symptoms persist or red flag signs present SECONDARY CARE • Confirm the diagnosis by history and clinical findings • Admit if red flag signs are present • Laboratory tests: CBC (Eosinophilia supports the diagnosis), LFT, serum creatinine, urine M/E • |
| What are some danger signs in drug reactions that require immediate medical attention? | Mucosal lesions, purpuric lesions, skin tenderness, bullous lesions (peeling/ sloughing of skin) | all drugs should be kept in suspect list • Concomitant viral infection or illnesses affecting drug metabolism or excretion (eg. chronic kidney disease) • Common presentation: Sudden onset of an itchy rash that is symmetrically distributed and spreads rapidly. May have had a previous similar allergic reaction. • Withdraw: The offending drug(s) immediately, except life saving drugs (if they are not the suspected drugs) • Take necessary measures to prevent similar events (record on patient’s medical chart, educate, provide allergy card etc.) • Recognize danger signs » Mucosal lesions, purpuric lesions, skin tenderness, bullous lesions (peeling/ sloughing of skin) » Systemic symptoms: High grade fever, jaundice, decreased urine output • Action required: Prompt and urgent care at a specialised centre. | 572 | list | 0.820 | • Withdraw: The offending drug(s) immediately, except life saving drugs (if they are not the suspected drugs) • Take necessary measures to prevent similar events (record on patient’s medical chart, educate, provide allergy card etc.) • Recognize danger signs » Mucosal lesions, purpuric lesions, skin tenderness, bullous lesions (peeling/ sloughing of skin) » Systemic symptoms: High grade fever, jaundice, decreased urine output • Action required: Prompt and urgent care at a specialised centre. |
| What systemic symptoms are considered warning signs in drug reactions? | High grade fever, jaundice, decreased urine output | all drugs should be kept in suspect list • Concomitant viral infection or illnesses affecting drug metabolism or excretion (eg. chronic kidney disease) • Common presentation: Sudden onset of an itchy rash that is symmetrically distributed and spreads rapidly. May have had a previous similar allergic reaction. • Withdraw: The offending drug(s) immediately, except life saving drugs (if they are not the suspected drugs) • Take necessary measures to prevent similar events (record on patient’s medical chart, educate, provide allergy card etc.) • Recognize danger signs » Mucosal lesions, purpuric lesions, skin tenderness, bullous lesions (peeling/ sloughing of skin) » Systemic symptoms: High grade fever, jaundice, decreased urine output • Action required: Prompt and urgent care at a specialised centre. | 690 | list | 0.820 | • Withdraw: The offending drug(s) immediately, except life saving drugs (if they are not the suspected drugs) • Take necessary measures to prevent similar events (record on patient’s medical chart, educate, provide allergy card etc.) • Recognize danger signs » Mucosal lesions, purpuric lesions, skin tenderness, bullous lesions (peeling/ sloughing of skin) » Systemic symptoms: High grade fever, jaundice, decreased urine output • Action required: Prompt and urgent care at a specialised centre. |
| What are some common drugs that cause fixed drug eruption? | Sulfonamides, tetracyclines, quinolones, NSAIDS, dapsone, antimalarials, barbiturates, nitroimidazoles | Resolve with persistent hyperpigmentation • Clinical variants: bullous, generalised, pure mucosal • Common drugs that cause FDE: Sulfonamides, tetracyclines, quinolones, NSAIDS, dapsone, antimalarials, barbiturates, nitroimidazoles | 129 | list | 0.820 | Resolve with persistent hyperpigmentation • Clinical variants: bullous, generalised, pure mucosal • Common drugs that cause FDE: Sulfonamides, tetracyclines, quinolones, NSAIDS, dapsone, antimalarials, barbiturates, nitroimidazoles | 1 | page=1,block=16 | 0.700 | valid |
| What topical steroid is suggested for treating cutaneous lesions at a primary health center? | Betamethasone valerate cream BD for cutaneous lesions | PRIMARY HEALTH CENTRE • Withdraw the drug • General management: Bullous/ moist/ oozy lesions- normal saline compresses • Topical steroid: Betamethasone valerate cream BD for cutaneous lesions • Antihistamines –Tab Pheniramine maleate 25 mg BD/TID for itching • Review patient in 1 week TERTIARY LEVEL • Admit the patient if the episode is generalized and severe • Histopathology in doubtful cases • If the oral mucositis is severe, consider parenteral steroids • Provocation tests may be done after resolution of symptoms (usually after 1-6 months) by an oral challenge with each suspected individual drug consecutively REFER TO HIGHER CENTER IF • There are atypical symptoms • Uncertain diagnosis • Severe reaction (multiple lesions, bullae, severe mucosal lesions, systemic symptoms) | 138 | factual | 0.570 | PRIMARY HEALTH CENTRE • Withdraw the drug • General management: Bullous/ moist/ oozy lesions- normal saline compresses • Topical steroid: Betamethasone valerate cream BD for cutaneous lesions • Antihistamines –Tab Pheniramine maleate 25 mg BD/TID for itching • Review patient in 1 week TERTIARY LEVEL • Admit the patient if the episode is generalized and severe • Histopathology in doubtful cases • If the oral mucositis is severe, consider parenteral steroids • Provocation tests may be done after resolution of symptoms (usually after 1-6 months) by an oral challenge with each suspected |
| When should provocation tests be conducted following the resolution of symptoms? | after resolution of symptoms (usually after 1-6 months) | PRIMARY HEALTH CENTRE • Withdraw the drug • General management: Bullous/ moist/ oozy lesions- normal saline compresses • Topical steroid: Betamethasone valerate cream BD for cutaneous lesions • Antihistamines –Tab Pheniramine maleate 25 mg BD/TID for itching • Review patient in 1 week TERTIARY LEVEL • Admit the patient if the episode is generalized and severe • Histopathology in doubtful cases • If the oral mucositis is severe, consider parenteral steroids • Provocation tests may be done after resolution of symptoms (usually after 1-6 months) by an oral challenge with each suspected individual drug consecutively REFER TO HIGHER CENTER IF • There are atypical symptoms • Uncertain diagnosis • Severe reaction (multiple lesions, bullae, severe mucosal lesions, systemic symptoms) | 493 | factual | 0.570 | PRIMARY HEALTH CENTRE • Withdraw the drug • General management: Bullous/ moist/ oozy lesions- normal saline compresses • Topical steroid: Betamethasone valerate cream BD for cutaneous lesions • Antihistamines –Tab Pheniramine maleate 25 mg BD/TID for itching • Review patient in 1 week TERTIARY LEVEL • Admit the patient if the episode is generalized and severe • Histopathology in doubtful cases • If the oral mucositis is severe, consider parenteral steroids • Provocation tests may be done after resolution of symptoms (usually after 1-6 months) by an oral challenge with each suspected |
| What step is required before performing a drug challenge? | Take a written consent prior to challenge | In the absence of any reliable in vitro test in clinical setting, oral drug challenge is the only way to detect the responsible drug Usually undertaken when drug avoidance is impractical, especially in case of polypharmacy or life saving medicines (e.g. antituberculous therapy) • Take a written consent prior to challenge • Contraindicated in active illness or pregnancy • Assess the risk benefit ratio • Caution: patients on antihistamines, oral steroids and tricy- clic antidepressants may have a modified response to the challenge • A negative test only indicates that the patient is not allergic to the drug at the time of challenge • The dose of drug for challenge depends on the severity of the previous reaction and the pharmacokinetic profile • Drug provocation should always be done - After admission/ under observation except in cases with FDE - Usually in the daytime so that the faintest erythema is appreciated - It should be treated immediately and aggressively with an appropriate dose of systemic corticosteroid which may be required for only 1-2 days - Drug provocation in cases with DRESS has to be avoided or if provoked, a prolonged retreatment is required - In case of SJS-TEN drug provocation should be done only if the drug cannot be avoided. | 281 | factual | 0.570 |