Management of less severe cutaneous drug reactions

Severe cutaneous drug reactions (eg acute generalised exanthematic pustulosis [AGEP], Stevens–Johnson syndrome [SJS], toxic epidermal necrolysis [TEN], drug rash with eosinophilia and systemic symptoms [DRESS]) require hospital assessment and treatment. For signs and symptoms of a severe cutaneous drug reaction, see here. Also see Management of severe cutaneous drug reactions.

Less severe cutaneous drug reactions can be managed in primary care. Refer for expert advice (allergist, immunologist or dermatologist) if unsure of the diagnosis.

For suspected less severe cutaneous drug reactions managed in primary care:

  • stop the suspected drug, if possible
  • if a likely drug is not identified, stop nonessential drugs (eg nonsteroidal anti-inflammatory drugs [NSAIDs], over-the-counter, alternative and complementary therapies)
  • advise all patients to use emollients to improve the skin condition
  • prescribe corticosteroids (topical or oral) and antihistamines to relieve symptoms.

For photosensitive reactions, advise patients to use broad-spectrum sun protection, cool compress and emollients.

For a mild rash with localised inflammation, use:

1betamethasone valerate 0.05% cream or ointment topically, once or twice daily betamethasone valerate betamethasone valerate betamethasone valerate

OR

1methylprednisolone aceponate (adult, or child 4 months or older) 0.1% cream or ointment topically, once or twice daily. methylprednisolone aceponate methylprednisolone aceponate methylprednisolone aceponate

For a mild rash with widespread inflammation, use a topical corticosteroid that is available in a larger tube. Use:

1betamethasone valerate 0.02% cream topically, up to 3 times daily betamethasone valerate betamethasone valerate betamethasone valerate

OR

1triamcinolone acetonide 0.02% cream or ointment topically, up to 3 times daily. triamcinolone acetonide triamcinolone acetonide triamcinolone acetonide

Wet dressings used with topical corticosteroids can improve response.

For a more severe rash with inflammation, use:

prednisolone (or prednisone) 25 mg orally, once daily for 5 to 7 days, then taper over 2 weeks. prednisolone prednisolone prednisolone

If the reaction includes an urticarial component or dermographism, add a less-sedating antihistamine (for doses, see Less-sedating antihistamines for urticaria).

Refer for expert advice (allergist, immunologist or dermatologist) if the rash is not improving after 2 weeks.

If a drug has caused a skin reaction with mucosal involvement, or the reaction has a history of increasing severity, do not rechallenge unless the need (indication) for use is critical and other drugs are not suitable. Any allergy testing or rechallenge must be managed by experts.