Acute generalized exanthematous pustulosis induced by the essential oil of Pistacia lentiscus.

Acute generalized exanthematous pustulosis (AGEP) is an uncommon pustular eruption characterized by small nonfollicular pustules on an erythematous background, sometimes associated with fever and neutrophilia. Over 90% of cases are drug-induced; however, it can be caused in rare cases by other agents. We report two cases of AGEP secondary to ingestion of Pistacia lentiscus essential oil, the first two such cases to our knowledge. The cutaneous morphology, disease course and histological findings were consistent with a definite diagnosis of AGEP, based on the criteria of the EuroSCAR study group. These two cases highlight the need to consider herbal extracts as a potential rare cause of AGEP and to ensure the safety of herbal medicines.

T cell-mediated acute localized exanthematous pustulosis caused by finasteride.

A 21-year-old man presented with multiple erythematous nonfollicular papules partially confluent to plaques on his breast and lower abdomen that had been present for 1 month. Grouped pustules were present under the right breast. The patient had been taking finasteride over the past 3 months for androgenetic alopecia. His medical history was negative for psoriasis. Our initial differential diagnosis included dyskeratosis follicularis Darier, allergic contact dermatitis, infectious folliculitis, varicella zoster virus infection, fixed drug eruption, and IgA pemphigus. The white blood cell count and differential were within the normal limits. Results of viral cultures and PCR, as well as bacterial and fungal cultures of skin lesions proved negative. A lesional biopsy specimen showed a slight psoriasiform acanthosis in association with spongiosis and infiltration of both the epidermis and dermis by neutrophils and eosinophils, resulting in formation of subcorneal, intraepidermal, and subepidermal pustules. The results of direct immunofluorescence were negative, excluding an IgA pemphigus. The result of a lymphocyte transformation test was positive for finasteride. On the basis of the time relationship between the administration of finasteride and the development of the skin disease in combination with symptoms resolution on cessation of the drug, the histologic findings, and the positive lymphocyte transformation test result, we consider this to be an unusual type of acute generalized exanthematous pustulosis defined as acute localized exanthematous pustulosis caused by finasteride. Within 4 weeks after withdrawal of finasteride, the rash resolved without any specific therapy. Transient discrete residual hyperpigmentation and scaling were present. The patient refused an oral provocation challenge.

Iatrogenic skin injury in hospitalized patients.

Iatrogenic skin injuries in hospitalized patients range from drug-related complications to those related to procedures. Common drug complications include drug reaction with eosinophilia and systemic symptoms (DRESS), linear immunoglobulin (Ig) A bullous dermatosis, Stevens-Johnson syndrome/toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. Contact dermatitis can result from surgical preparations of chlorhexidine and povidone-iodine, medical adhesives, topical postsurgical ointments, most commonly neomycin and bacitracin, and internal prostheses, including coronary stents, pacemakers, and metal joints. Complications arising from procedures include thrombosis caused by placement of peripherally inserted central catheters, pyoderma gangrenosum from sites of dermal trauma, and anetoderma of prematurity from cutaneous monitoring devices in neonates. Calcinosis cutis and decubitus ulcers are also hospital problems.

Acute generalized exanthematous pustulosis due to oral use of blue dyes.

Acute generalized exanthematous pustulosis is a rare severe pustular cutaneous adverse reaction characterized by a rapid clinical course with typical histological findings. It is accompanied by fever and acute eruption of non-follicular pustules overlying erythrodermic skin. The causative agents are most frequently antibacterial drugs. We present a patient with acute generalized exanthematous pustulosis caused by methylene blue and indigotin dyes.

Amicrobial pustulosis-like rash in a patient with Crohn's disease under anti-TNF-alpha blocker.

Amicrobial pustulosis of the folds (APF) is a recently described entity characterized by relapsing pustular lesions predominantly involving the cutaneous flexures and scalp. This disease typically occurs in association with systemic lupus erythematosus and a variety of other autoimmune diseases. We here describe an APF-like pustular eruption predominantly affecting the scalp, face and trunk, occurring during long-term infliximab treatment for Crohn's disease. Immunohistochemical staining of skin biopsy specimens for myxovirus resistance protein A, a marker for type 1 interferon-inducible proteins, showed increased staining in the epidermis and dermal mononuclear inflammatory infiltrate. Our observation further extends the spectrum of cutaneous adverse reactions potentially related to anti-tumor necrosis factor-α, the clinical context in which APF can occur as well as its clinical presentations.

Clopidogrel-associated acute generalized exanthematous pustulosis.

Acute generalized exanthematous pustulosis (AGEP) is a skin eruption of rapid onset and progression that is characterized by the formation of numerous sterile pustules on an erythematous background. Other features may include fever and leukocytosis, with resolution usually in less than 15 days. We present an 83-year-old woman with an erythematous pustular eruption following placement of a bare metal coronary stent and initiation of anticoagulation with clopidogrel. She was diagnosed with AGEP after a biopsy was performed and other possible causes of a pustular eruption were excluded. Two medications--carvedilol and rosuvastatin--were initially viewed as possible culprits and were temporarily discontinued. However, the patient's rash continued to worsen. Additionally, she had a persistent low-grade fever, leukocytosis, and a slow rise in her creatinine level. Clopidogrel was discontinued and replaced with ticlopidine on day 7 of hospitalization. Within 48 hours her temperature, white blood cell count, and creatinine level began to improve. Her skin subsequently desquamated and she was sent home on day 20. We discuss drug-induced AGEP and a desensitization protocol that has allowed patients to resume use of clopidogrel following a prior cutaneous reaction to this medication.

Acute generalized exanthematous pustulosis simulating toxic epidermal necrolysis: a case report and review of the literature.

BACKGROUND: Both acute generalized exanthematous pustulosis (AGEP) and toxic epidermal necrolysis (TEN) are adverse cutaneous reactions. Despite the fact that these 2 cutaneous reactions differ in presentation, prognosis, pathologic features, and treatment, overlap can exist between them, creating a diagnostic challenge. OBSERVATIONS: We describe a patient who presented with clinical features of both AGEP and TEN, and we summarize overlapping cases of AGEP-TEN that have been reported in the literature. It is essential to be able to differentiate between AGEP and TEN, as these conditions are clinically and morphologically distinct entities. They also differ considerably in their prognosis and treatment. CONCLUSIONS: Because overlap exists, AGEP should be considered in the differential diagnosis of widespread blistering and erosive conditions. A greater understanding of how to differentiate AGEP and TEN can lead to quicker diagnosis as well as more effective case management and treatment.

Allopurinol hypersensitivity syndrome with acute generalized exanthematous pustulosis manifestations.

Allopurinol hypersensitivity syndrome(AHS) is a severe form of cutaneous adverse reaction that is associated with significant morbidity and mortality. We report a case of AHS with the cutaneous manifestation of acute generalised exanthematous pustulosis(AGEP). A 47 year old gentleman, with no previous skin disease, presented with a generalized mildly pruritic erythematous rash on the trunk and all 4 limbs, with patches of superficial non-follicular pustules. Our patient fulfilled both criteria for AGEP and AHS.