Your patient who is taking psychotropics suddenly develops a rash. Rapidly identifying the cause is crucial to your decision to either stop the drug and risk decompensation or continue it and deal with the rash.
Adverse cutaneous drug reactions (ACDRs) develop in 2% to 5% of patients taking psychotropics1 and can occur with all drug classes.2 Most “drug eruptions” are benign and easily treated, but they can distress patients and lead to medication nonadherence. Other ACDRs can be disfiguring or life-threatening and require emergent medical treatment.
In this first installment of a 2-part article, we explain how to identify and manage benign ACDRs associated with psychotropics. In part 2, we’ll cover serious ACDRs—those that result in persistent or significant disability or are life-threatening3—as well as risk-reduction strategies.
Overall strategy
A psychiatric patient with a suspected drug eruption needs to be examined by you and, if necessary, another physician. Identify the lesion by taking a history and performing a physical examination (Box 1).4,5 If you are unable to perform this examination, promptly refer the patient to a primary care provider or dermatologist.
Once a rash is identified, determine its cause. Consider nonpharmacologic origins such as:
- infections
- insect bites
- collagen vascular disease
- neoplasms
- exposure to sun, toxins, etc.
Look for red flags that may indicate a serious reaction (Table 2).5,7 Treatment of a serious drug reaction may require care by physicians with training and clinical expertise likely to be beyond the scope of psychiatric practice. However, your responsibility is to ensure that the patient gets a timely—emergent, if indicated—referral so that treatment is not delayed. If an ACDR clearly is benign, follow the guidelines outlined below; otherwise, consult with a dermatologist, infectious diseases clinician, or other appropriate specialist.
Table 1
Benign rashes associated with psychotropics*
| Rash | Suspect drugs/classes |
|---|---|
| Exanthematous reactions | Any druga |
| Urticaria | Any druga |
| Fixed drug eruption | Any druga |
| Photosensitivity | Alprazolam,b antipsychotics,c bupropion,d carbamazepine,e citalopram,e eszopiclone,d fluoxetine,d oxcarbazepine,e paroxetine,e sertraline,e topiramate,e TCAs,d valproic acid,e zaleplon,d zolpideme |
| Acneiform eruptions | Antidepressants (most),d,e,f aripiprazole,e clonazepam,e eszopiclone,e lamotrigine,e lithium,g oxcarbazepine,e quetiapine,e risperidone,e topiramate,e zaleplon,e zolpideme |
| Pigmentation changes | Amitriptyline,h carbamazepine,e citalopram,e clomipramine,i desipramine,j,k eszopiclone,e fluoxetine,e lamotrigine,e paroxetine,e phenothiazines,a,c,d sertraline,e SGAs (most)e, thioridazine,l thiothixene,d topiramate,e venlafaxine,e zaleplone |
| Alopecia | Aripiprazole,e carbamazepine,e citalopram,e clonazepam,e dexmethylphenidate,e duloxetine,e escitalopram,e eszopiclone,e fluoxetine,a,e fluvoxamine,e haloperidol,d lamotrigine,e lithium,g,l methylphenidate,e mirtazapine,d olanzapine,e oxcarbazepine,e paroxetine,e risperidone,e sertraline,n trazodone,d TCAs,d valproic acid,e venlafaxine,e zaleplon,d ziprasidonee |
| Psoriaform eruptions | Carbamazepine,d fluoxetine,o lithium,b olanzapine,p oxcarbazepine,d paroxetine,q valproic acidd,r |
| * Suspect any drug with any reaction | |
| SGAs: second-generation antipsychotics; TCAs: tricyclic antidepressants | |
| Source: Click here to view references | |
Red flags: Warning signs of a serious drug rash
| Constitutional symptoms: fever, sore throat, malaise, arthralgia, lymphadenopathy, cough |
| Erythroderma |
| Facial or mucous membrane involvement |
| Skin tenderness or blistering, particularly if there is full-thickness epidermal detachment |
| Purpura |
| Source: References 5,7 |
Is your patient’s rash drug-related?
Table 3When a patient presents with a suspected adverse cutaneous drug reaction, take a history to determine the rash onset, timing, relationship between symptoms and drug ingestion, associated symptoms, and history of previous drug reactions.
Ask your patient:
- What are your symptoms?
- How did the rash look initially?
- How has it changed?
- Have you used any new soaps, perfumes, cosmetics, medications, or supplements, or been exposed to insects, foliage, or someone with an illness?
Next, perform a physical examination. In addition to the photos and descriptions in this article (Table 3), review up-to-date textbooks, journal articles, and online resources to aid identification. Look for rashes that affect the mucosa and for lymphadenopathy or signs of internal organ involvement. Seek laboratory abnormalities, including elevated creatinine, positive fecal occult blood test, or hematuria. These and other red flags may indicate a serious rash that requires urgent treatment (Table 2). Consultation with a dermatologist may be indicated.
Dermatologic glossary
| Angioedema: a vascular reaction involving the deep dermis or subcutaneous or sub-mucosal tissue that results in localized swelling |
| Comedones: noninflammatory acne lesions; also called ‘blackheads’ |
| Effluvium, anagen: hair shedding during the growth phase of the hair cycle |
| Effluvium, telogen: hair shedding during the resting phase of the hair cycle |
| Erythema: skin redness |
| Macule: a discolored skin lesion that is not elevated above the surface |
| Papule: a small, circumscribed, superficial, solid elevation of the skin |
| Purpura: red or purple skin discolorations caused by bleeding underneath the skin |
| Pustule: a visible collection of pus within or beneath the epidermis |
| Wheal: a smooth, slightly elevated area that appears redder or paler than surrounding skin, is often accompanied by severe itching, and usually disappears within a few hours |
| Source: Dorland’s illustrated medical dictionary, 30th ed. Philadelphia, PA: Saunders; 2003 |