SKIN

FOCUS

FIXED DRUG ERUPTION

ME Docrat, MB ChB, MMed(Derm)

Dermatologist
Wale Street Chambers, Cape Town
A fixed drug eruption (FDE) is an adverse cutaneous
reaction to an ingested drug. Lesions develop 1-2
weeks after a first exposure, and with subsequent
exposures, they appear within 24 hours. FDE is characterised by the formation of one or a few, round, sharply
demarcated erythematous and oedematous plaques,
bulla, or erosions (Figs 1 and 2). The lesions usually
occur on the lips, face, hands, feet and genitalia. If the
patient is rechallenged with the offending drug, the
FDE occurs repeatedly at the identical skin site (i.e.
fixed). Lesions occur from 30 minutes to 8 hours after
ingestion of the drug in a previously sensitised individual. They fade over several days, leaving a residual
post-inflammatory hyperpigmentation.

- Metronidazole (Flagyl)
- Nystatin
Non-steroidal anti-inflammatory drugs including
salicylates and phenylbutazone
Psychotropic drugs including barbiturate
Oral contraceptive pill
Quinine (including quinine in tonic water)
Many other commonly used drugs have also been
reported to cause FDE.

Food: peas, beans and lentils have been implicated.

Food colouring in food and medications can also cause
a reaction. The offending drug in food-dye-induced
FDE may be difficult to identify, i.e. yellow dye in
Galliano liqueur, phenolphthalein in maraschino cherries, quinine in tonic water.

Duration of lesion(s)
The lesions resolve a few weeks after the drug is discontinued. However, if the drug is continued, then the
lesions may persist.

Differential diagnosis
Solitary genital erosion: Recurrent herpetic lesion,
arthropod bite reaction
Multiple erosions: Stevens-Johnson syndrome, toxic
epidermal necrolysis
Oral erosions: Aphthous stomatitis, primary herpetic
gingivostomatitis, erythema multiforme

Diagnosis
The diagnosis of FDE is usually evident from the history and clinical examination. Readmission of the drug
confirms the diagnosis, but should be avoided.
However, if one is in doubt, a biopsy may be performed.
Histopathology reveals a superficial and deep interstitial and perivascular infiltrate in the dermis composed
of lymphocytes and eosinophils. There may be necrotic keratinocytes in the epidermis. Dermal melanophages are often the only histological finding in noninflammatory lesions.
Patch test: The suspected drug can be placed as a
patch test at a previously involved site; an inflammatory response occurs in 30% of cases.
Figs 1 and 2. Post-inflammatory pigmentation from
fixed drug eruption.

Aetiology
Drugs most commonly implicated include:
Phenolphthalein-containing laxatives
Antimicrobial agents
- Tetracyclines and minocycline
- Sulfonamide antibiotics; crossreactions with
antidiabetic drugs (sulphontyl urea) and diuretics or the thiazide group
Correspondence: Dr ME Docrat, Wale Street Chambers, c/o Wale
and Long Streets, Cape Town 8001. Tel 021-423-3180/90,
fax 021-423-2323, email medocrat@intekom.co.za

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Management
Identify and withhold the offending drug.
Treatment of lesion(s): A newly erupted lesion of FDE
presents as an inflammatory plaque, with or without
erosion. Non-eroded plaques can be treated with a
potent topical corticosteroid. Erosions can be treated
with fucidic acid (Fucidin) or mupirocin (Bactroban) and
a dressing until the site is re-epithelialised. Post-inflammatory hyperpigmentation may persist for years and
the patient should be advised to avoid excessive exposure and to use sunblock cream.

FURTHER READING
Fitzpatrick, Atlas of Dermatology
Bolognia JL, Jorizzo JL, Rapini RP. Dermatology Vol.1.
Philadelphia: Mosby, 2003: 344-346.

Current Allergy & Clinical Immunology, March 2005 Vol 18, No.1