Cutaneous drug reactions

Signs and Symptoms

• Red, itchy rash, or blotches
• Hives
• Acne-like eruptions
• Skin pigmentation changes (brown or gray blotches may appear on skin)
• Dry, cracked skin, as in eczema
• Peeling skin
• Tissue death (necrosis)

What Causes It?

The following drugs might cause cutaneous reactions.

• Allopurinol (gout medication)
• Antibiotics (penicillins, tetracyclines)
• Anticonvulsants
• Antihypertensives
• Aspirin
• Barbiturates
• Biologic agents
• Chemotherapeutic agents (cancer treatments)
• Cortisones and other corticosteroids
• Diuretics (water pills)
• Heavy metals (gold, copper)
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Phenothiazines (used to treat serious mental conditions)
• Psychiatric medications (antidepressants, antipsychotics, and mood stabilizers)

What to Expect at Your Doctor's Office

Your doctor will examine your skin, mouth, and throat. You should make a list of all the drugs (prescription, nonprescription, and illegal) and herbal and vitamin supplements you've taken over the last 4 weeks. Your doctor may have you stop taking the suspected drug and prescribe something else.

Treatment Options

The treatment depends on the type of reaction you are having and how serious it is. Symptoms will often disappear once you stop taking the suspected drug or take it at a lower dosage. However, you may need treatment to recover. Your doctor may prescribe drugs to help stop the reaction, such as epinephrine, corticosteroids, antihistamines, or topical ointments. If you also have life-threatening symptoms, such as trouble breathing, you will be hospitalized until you are stable.

The kind of treatment you need depends on the type of skin reaction you are having, so it is important to see your doctor and not self treat any adverse drug reactions. If you suspect a drug is causing an adverse reaction, talk to your doctor or pharmacist immediately before stopping the drug. A cutaneous drug reaction that occurs theh first time you take a drug may cause a more severe reaction the next time you take that drug. It is important to keep a record of any drugs that cause reactions when you take them.

Drug Therapies

• Corticosteroids (applied topically, taken orally, or given intravenously), such as prednisone
• Antihistamines
• Antipruritic treatments (to stop itching)
• Epinephrine, for severe respiratory/cardiovascular implications
• Topical lotions or ointments. For itching, lesions, and other inflammatory skin reactions.
• Baths (with or without additives)
• Special treatments. For severe reactions (depending upon severity).

Surgical Procedures

Surgical removal of dead tissue may be necessary in very severe reactions.

Complementary and Alternative Therapies

Some cutaneous drug reactions may be life threatening and need immediate medical attention. Mild reactions may be safely and effectively treated with alternative therapies. However, talk to your doctor before using any therapy, as you will need to adjust the type of drug or the dose of the drug that caused the initial reaction. You should notify your doctor when a drug reaction occurs. A cutaneous drug reaction that occurs the first time you take a drug may cause a more severe reaction the next time you take that drug. It is important to keep a record of any drugs that cause reactions when you take them. If you are pregnant, or are thinking about becoming pregnant, do not use any complementary and alternative therapies (CAM) unless directed to do so by your physician.

Alternative treatments may also cause allergic reactions so it is important to follow the directions of your doctor before starting treatment. The following are some natural therapies, which, when used under a doctor's supervision for a short period of time (3 to 7 days), may promote healing.

• Vitamin C helps skin heal. Some studies suggest that vitamin C can lower histamine levels (which cause hives). Lower dose if diarrhea develops.
• B-complex with extra B12 aids in skin health. Vitamin B12 injections help reduce the severity of hives. But it is not clear whether taking B12 orally has the same effect. Vitamin B5 or pantothenic acid helps heal wounds.
• Vitamin E and zinc help skin heal. Both are also sometimes applied topically.
• Bromelain, an enzyme derived from pineapple, reduces inflammation. Avoid if you take blood-thinning medicines. Bromelain can interfere with certain antibiotics and can slow blood clotting.
• Omega-3 fatty acids, such as those found in fish oil, help maintain skin health and may have anti-inflammatory properties. If you take blood-thinning medication, talk to your doctor before taking omega-3 fatty acids.
• Rutin or quercetin may improve skin health.

The use of herbs is a time-honored approach to strengthening the body and treating disease. However, herbs can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider. Always tell your doctor about any herbs you may be taking.

Talk to your doctor to find out which treatments are best for your particular skin condition.

Applied topically

Some of the following herbs also can be combined into a poultice or skin wash. Avoid contact with the eyes, mouth, and nose:

• Aloe (Aloe vera), as a cream or gel.
• Agrimony (Agrimonia eupatoria or procera), an astringent, applied as a poultice. Boil 1 tsp. dried herb in 1 cup water for 5 to 10 minutes. Cool and apply to a clean, soft cloth, and place on affected area.
• Calendula (Calendula officinalis), or marigold, as an ointment or a tea applied topically. To make tea from tincture, use 1/2 to 1 tsp. diluted in 1/4 cup water. Test skin first for any allergic reaction.
• Marshmallow (Althaea officinalis) as a topical ointment to help wounds heal and fight inflammation.
• Tea tree oil (Melaleuca alternifolia) as a commercially prepared formula of oil or cream. Apply 2 times per day to reduce inflammation.
• Astragalus (Astragalus membranaceus) as an ointment containing 10% of the herb.
• Burdock (Arctium lappa) as a compress. Use 1 tsp. herb in 1 cup boiling water. Cool and apply to clean, soft cloth. Place on affected area.
• Chamomile (Matricaria recutita) as an ointment containing 10% of the herb, or as a tea applied topically, to reduce itching. To make tea, boil 3 g of herb in 1 cup water. Cool and apply to a clean, soft cloth. Place on affected area.
• Gotu kola (Centella asiatica) as a cream containing 1% of the herb, to help heal wounds.
• Echinacea or coneflower (Echinacea angustifolia or purpurea) as a gel or ointment containing 15% of the juice of the herb.
• Slippery elm bark (Ulmus rubra or fulva) as a poultice. Mix 1 tsp. dried powder in 1 cup boiling water. Cool and apply to a clean, soft cloth. Place on affected area.

To relieve itching and help skin heal, you can combine chamomile with marigold or echinacea.

For further skin relief, add powdered oatmeal (or 1 cup of oatmeal in a sock) to a lukewarm bath.

Taken orally

• Evening primrose oil (Oenothera biennis) may help fight skin inflammation. DO NOT take evening primrose oil if you take blood-thinning medication, or if you have a history of seizures.
• Pycnogenel (Pinus pinaster), an extract of the bark of a particular type of pine tree, helps promote skin health. May not be suitable for people with autoimmune disease.
• Thyme (Thymus vulgaris). DO NOT take thyme if you take blood-thinning medication. Never take oil of thyme, which can be toxic. Thyme may have hormone-like effects in the body. People who have a history of hormone-sensitive cancers, or other hormonal issues, should use caution.
• Burdock (Arctium lappa) is an anti-inflammatory and antioxidant. DO NOT take burdock if you have diabetes, or if you take blood-thinning medication or a diuretic (water pills). People who are allergic to ragweed may be sensitive to burdock.
• Gotu kola (Centella asiatica) helps improve skin health. DO NOT take gotu kola if you have high blood pressure or experience anxiety, or if you have a history of liver disease.
• Cat's claw (Uncaria tomentosa) has anti-inflammatory and antioxidant effects. Cat's claw may worsen autoimmune disorders and leukemia, and it may interact with several medications. DO NOT take cat's claw if you have high or low blood pressure, are on blood pressure medication, or take blood-thinning medication.

Homeopathic remedies can be used to improve symptoms of itching, burning, and swelling. While few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths may recommend one or more of the following treatments for cutaneous drug reactions based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Apis mellifica. For red rashes accompanied by hives, swelling, itching, and stinging sensations. Symptoms are relieved by cold applications. This remedy is most appropriate for individuals who tend to be very tired.
• Bryonia. For fine, dry bumps concentrated on the face. Symptoms worsen with movement. This remedy is most appropriate for individuals who are irritable.
• Croton tiglium. For inflamed, itchy skin that is tender to touch. Rash is often concentrated around the scalp, eyes, or genitals.
• Graphites. For rashes that may be cracking and even oozing liquid. Rashes that improve with graphites are often accompanied by chills and a burning sensation. Symptoms worsen with both warmth and cold, and in damp weather.
• Ledum. For severely inflamed rashes that worsen at night and improve with cool compresses.
• Rhus toxicodendron. For burning and itching that are relieved by hot applications. This remedy is most appropriate for individuals who are generally restless and irritable.
• Sepia. For a dry, brownish red rash with tiny raised lesions.
• Sulphur. For red, itchy rashes that worsen at night or when exposed to heat. This remedy is most appropriate for individuals who crave cold drinks and may be inactive and irritable.
• Urtica urens. For itchy, burning rashes that worsen with cold air.

Acupuncture can help reduce itching and inflammation of the skin. Most treatments will focus on "cooling surface heat."

Following Up

It is important to stay in touch with your health care provider until the reaction is completely cleared up. If you have severe reactions, wear medical alert jewelry stating what drugs you are allergic to.

Special Considerations

If you have any questions about any drug, whether it is prescribed by your doctor or purchased over the counter, ask your pharmacist or doctor.

Supporting Research

Ahmed AM, Pritchard S, Reichenberg J. A review of cutaneous drug eruptions. Clin Geriatr Med. 2013;29(2):527-45.

Bae EA, Han MJ, Shin YW, et al. Inhibitory effects of Korean red ginseng and its genuine constituents ginsenosides Rg3, Rf, and Rh2 in mouse passive cutaneous anaphylaxis reaction and contact dermatitis models. Biol Pharm Bull. 2006 Sep;29(9):1862-7.

Brinkhaus B, Lindner M, Schuppan D, et al. Chemical, pharmacological and clinical profile of the east Asian medical plant Centella asiatica. Phytomedicine. 2000;7:427-48.

Chularojanamontri L, Jiamton S, Manapajon A, et al. Cutaneous reactions to proton pump inhibitors: a case-control study. J Drugs Dermatol. 2012;11(10):e43-7.

Feliciano C, Verrotti A, Coscione G, et al. Skin reactions due to anti-epileptic drugs: several case-reports with long-term follow-up. Int J Immunopathol Pharmacol. 2003;16(1):89-93.

Habif. Clinical Dermatology. 5th ed. Philadelphia, PA: Elsevier Mosby; 2009.

Hagen J, Magro C, Crowson AN. Emerging Adverse Cutaneous Drug Reactions. Dermatologic Clinics. Philadelphia, PA: Elsevier Saunders; 2012:30(4).

Koh KJ, Pearce AL, Marshman G, et al. Tea tree oil reduces histamine-induced skin inflammation. Br J Dermatol. 2002;147:1212-7.

Liao PJ, Shih CP, Mao CT, et al. The cutaneous adverse drug reactions: risk factors, prognosis and economic impacts. Int J Clin Pract. 2013;67(6):576-84.

Lin YF, Yang CH, Sindy H, et al. Severe cutaneous adverse reactions related to systemic antibiotics. Clin Infect Dis. 2014;58(10):1377-85.

Mao SP, Cheng KL, Zhou YF. Modulatory effect of Astragalus membranaceus on Th1/Th2 cytokine in patients with herpes simplex keratitis. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2004 Feb;24(2):121-3.

Musette P, Kaufman JM, Rizzoli R, et al. Cutaneous side effects of antiosteoporosis treatments. Ther Adv in Musc Dis. 2011;3(1):21-41.

Newell BD. Pediatr Ann. 2010 Oct;39(10):618-25.

Sassolas B, Duong TA. Dermatology and the effects of medication on the skin. Soins. 2010 Sep;(748):42-4.

Shin YW, Bae EA, Lee B, et al. In vitro and in vivo antiallergic effects of Glycyrrhiza glabra and its components. Planta Med. 2007 Mar;73(3):257-61.

Turk BG, Gunaydin A, Ertam I, et al. Adverse cutaneous drug reactions among hospitalized patients: five year surveillance. Cutan Ocul Toxicol. 2013;32(1):41-5.

Wick JY. Drug-induced rash: nuisance or threat? Consult Pharm. 2013;28(3):160-6.