What medications can cause a facial rash in the elderly?

From the Guidelines

Elderly patients with facial rashes should initially receive emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema, as recommended by the British Association of Dermatologists' guidelines 1. When considering the management of facial rashes in elderly patients, it is essential to prioritize the most recent and highest quality evidence. The British Association of Dermatologists' guidelines from 2018 provide recommendations for the investigation and management of generalized pruritus in adults without an underlying dermatosis, including those with elderly skin 1.

Key Recommendations

• Patients with pruritus in elderly skin should initially receive emollients and topical steroids for at least 2 weeks to exclude asteatotic eczema (Strength of recommendation D) 1.
• Moisturizers with high lipid content may be preferred in the elderly (Strength of recommendation D) 1.
• Patients with pruritus in elderly skin may benefit from gabapentin (Strength of recommendation D) 1.
• Patients with pruritus in elderly skin should not be prescribed sedative antihistamines (Strength of recommendation C) 1.

Medication-Induced Rashes

Common culprits of facial rashes in elderly patients include:

• Antibiotics (particularly sulfonamides, penicillins, and fluoroquinolones)
• Antihypertensives (especially ACE inhibitors like lisinopril and enalapril)
• Diuretics (hydrochlorothiazide)
• Statins (atorvastatin, simvastatin)
• Non-steroidal anti-inflammatory drugs (NSAIDs)

If a medication-induced rash is suspected, the patient should consult their healthcare provider before discontinuing any medication. Treatment typically involves stopping the offending medication when possible and may include topical corticosteroids like hydrocortisone 1% cream applied twice daily for 7-10 days to reduce inflammation. Antihistamines such as cetirizine 10mg daily or diphenhydramine 25mg every 6 hours may help relieve itching, but sedating antihistamines should be avoided in elderly patients 1.

Severe Reactions

Severe reactions with breathing difficulties, facial swelling, or widespread rash require immediate medical attention. Elderly patients are more susceptible to medication reactions due to age-related changes in metabolism, reduced kidney function, and polypharmacy. Any new medication started within 4-6 weeks before rash onset should be considered suspect.

In summary, the management of facial rashes in elderly patients should prioritize the exclusion of asteatotic eczema with emollients and topical steroids, and consider the potential for medication-induced rashes. The British Association of Dermatologists' guidelines provide a framework for the investigation and management of generalized pruritus in adults without an underlying dermatosis, including those with elderly skin 1.

From the FDA Drug Label

Hypersensitivity AlIergic reactions in the form of rash, urticaria, angioedema, and, rarely, erythema multiforme, Stevens-Johnson syndrome, or toxic epidermal necrolysis have been observed.

• Rash is a possible side effect of cephalexin, which could manifest as a facial rash in elderly patients.
• The decision to prescribe cephalexin to an elderly patient should take into account the potential risk of hypersensitivity reactions, including rash.
• If a facial rash occurs in an elderly patient taking cephalexin, the drug should be discontinued and alternative treatments considered 2.

From the Research

Possible Medications for Facial Rash in Elderly

• Topical treatments and emollients may be recommended for elderly patients with facial rash, with consideration of specific adverse effects and alternatives 3
• Topical antipruritics (eg menthol 1% in aqueous cream) and topical corticosteroids may prove useful in managing pruritus associated with facial rash 4
• Oral antihistamines may be used to relieve itching and reduce the risk of scratching and further skin damage 4
• Phototherapy may be considered as a treatment option for certain skin conditions that cause facial rash in elderly patients 4

Medications to Avoid

• Systemic medications pose a higher risk of adverse effects and many are contraindicated in the elderly for this reason 3
• Certain medications, such as calcium channel blockers and hydrochlorothiazide, can cause pruritic skin eruptions in older patients and should be used with caution 5

Important Considerations

• Elderly patients with facial rash should be evaluated for dermatological, systemic, and neurological etiologies of itch 5
• Age-related changes in barrier function, immunosenescence, and neuronal changes and neuropathies are common predisposing factors to chronic itch in elderly patients 3
• Co-morbid diseases, particularly of the renal, hepatobiliary, or hematologic systems, psychologic conditions, or medications may contribute to chronic itch in elderly patients with facial rash 3