How to manage a maculopapular rash induced by hydroxychloroquine (HCQ)?

From the Guidelines

Discontinuation of hydroxychloroquine is the most appropriate management for a maculopapular rash induced by the medication, as it can trigger an immune-mediated hypersensitivity response in some patients. The rash typically resolves within 1-2 weeks after discontinuing HCQ 1. For mild rashes, topical corticosteroids such as triamcinolone 0.1% cream applied twice daily for 7-14 days may provide relief. Oral antihistamines like cetirizine 10mg daily or diphenhydramine 25-50mg every 6 hours can help control itching. In moderate to severe cases, a short course of oral corticosteroids such as prednisone 20-40mg daily for 5-7 days with a taper may be necessary. Cool compresses and emollients can provide symptomatic relief.

Key Considerations

• The American College of Rheumatology, American Academy of Dermatology, Rheumatologic Dermatology Society, and American Academy of Ophthalmology emphasize the importance of effective communication between healthcare providers in the management of HCQ 1.
• HCQ is considered safe at doses deemed proper for the treatment of rheumatic diseases in conjunction with appropriate eye screening 1.
• Rechallenge with hydroxychloroquine is generally not recommended as the reaction may recur with greater severity.
• For patients who require antimalarial therapy for their underlying condition, alternative medications like methotrexate or sulfasalazine may be considered after consultation with a specialist.

Screening and Monitoring

• The 2016 revision of recommendations on screening for chloroquine and hydroxychloroquine retinopathy suggests that annual screening can be deferred until there has been 5 years of exposure, unless there are major risk factors 1.
• It is essential to check the dosage relative to weight at every visit and to verify signs of damage with more than one test or by repeat testing whenever results are suspicious but not definitive 1.

From the FDA Drug Label

Serious Skin Reactions Inform the patient that severe, life-threatening skin reactions have been reported with the use of hydroxychloroquine sulfate. Advise the patient to seek medical attention immediately if experiencing any of the following signs and symptoms: blisters on the skin, eyes, lips or in the mouth, itching or burning, with or without fever [see Warnings and Precautions (5. 3)].

To manage a maculopapular rash induced by hydroxychloroquine (HCQ), seek medical attention immediately if experiencing any signs and symptoms of severe skin reactions, such as:

• Blisters on the skin, eyes, lips, or in the mouth
• Itching or burning, with or without fever It is essential to consult a healthcare professional for proper evaluation and guidance on managing the rash and determining the best course of action, which may include discontinuing the use of hydroxychloroquine sulfate 2.

From the Research

Management of Maculopapular Rash Induced by Hydroxychloroquine (HCQ)

• The management of a maculopapular rash induced by HCQ typically involves discontinuation of the drug, as the rash often disappears within a few weeks after stopping the medication 3.
• In some cases, treatment with oral and topical steroids, as well as supportive measures, may be necessary to manage the rash, especially in severe cases 4.
• It is essential to monitor patients for any signs of severe cutaneous adverse reactions, such as acute generalized exanthematous pustulosis, drug rash with eosinophilia and systemic symptoms, Stevens-Johnson syndrome/toxic epidermal necrolysis, and to discontinue the drug immediately if any of these reactions occur 3, 4.

Cutaneous Adverse Events Associated with HCQ

• The most common cutaneous adverse effect of HCQ is a maculopapular and erythematous rash, which typically occurs within 4 weeks of initiating the medication 3.
• Other cutaneous adverse events associated with HCQ include hyperpigmentation, psoriasiform dermatitis, photodermatitis, stomatitis, melanonychia, and hair loss 3.
• Rare but severe cutaneous manifestations, such as acute generalized exanthematous pustulosis and Stevens-Johnson syndrome/toxic epidermal necrolysis, can also occur 3, 4.

Importance of Patient Education

• It is crucial to educate patients about the potential cutaneous side effects of HCQ before initiating treatment, as severe reactions can occur, even with a drug considered relatively benign 4.
• Patients should be informed about the signs and symptoms of severe cutaneous adverse reactions and instructed to seek medical attention immediately if they experience any of these reactions 3, 4.