Severe cutaneous adverse drug reactions. Challenges in diagnosis and treatment

PhD ceremony: Ms. S.H. Kardaun, 12.45 uur, Academiegebouw, Broerstraat 5, Groningen

Dissertation: Severe cutaneous adverse drug reactions. Challenges in diagnosis and treatment

Promotor(s): prof. M.F. Jonkman

Faculty: Medical Sciences

Cutaneous adverse drug reactions, although rather frequent, are generally mild and transient. Incidentally however, they may present a severe, life threatening manifestation (SCAR) in which, apart from cessation of the causative agent, also therapeutic interventions are needed. Diagnosis can be complicated because of mutual features of several SCAR or a strong resemblance to other diseases. Investigated were:

•         Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), characterized by blistering and detachment of large areas of skin and mucosae with mortality rates up to over 40%.

•         Acute generalized exanthematous pustulosis (AGEP), characterized by extensive redness combined with tiny, sterile pustules and a mortality between 1 and 5%.

•         Drug reaction with eosinophilia and systemic symtoms (DRESS), characterized by a long lasting course and internal organ involvement with a mortality rate of about 10%.

Early recognition and differentiation are important, considering their serious character and differences in treatment, course, prognosis and causative medication. Concerning SJS/TEN and AGEP, this thesis focussed on its differentiation from other entities, whereas for SJS/TEN, also treatment with high doses dexamethasone pulse therapy was studied. Treatment with corticosteroids was regarded highly controversial at that time. DRESS or drug hypersensitivity syndrome was known under various case definitions. In this thesis, we introduced a distinct and unifying case definition and validation score, enabling comparative international studies. The presented case definition and validation score have become widely accepted internationally. In addition, the introduction provides an elaborate review on the current understanding of SJS/TEN, AGEP, and DRESS.