What are the skin side effects of propranolol (beta-blocker)?

Skin Side Effects of Propranolol

Propranolol can cause various skin side effects ranging from mild to severe, including psoriasiform eruptions, urticaria, and in rare cases, serious conditions like Stevens-Johnson syndrome and toxic epidermal necrolysis. 1

Common Skin Side Effects

• Cold extremities - a frequent side effect due to peripheral vasoconstriction caused by beta-blockade 2
• Exanthematous (widespread) rashes 1
• Urticaria (hives) 1, 3
• Psoriasiform eruptions (rashes resembling psoriasis) 1, 4, 5

Severe Skin Side Effects

• Stevens-Johnson Syndrome 1
• Toxic epidermal necrolysis 1
• Exfoliative dermatitis 1
• Erythema multiforme 1

Mechanism of Skin Side Effects

• The exact pathogenetic mechanism for propranolol-induced skin reactions is not fully understood 6
• Possible mechanisms include:
  • Blockade of epidermal cell beta-receptors 6, 4
  • Immunologic or allergic reactions 6
  • Direct toxic effects on skin cells 6

Special Considerations in Pediatric Patients

• In infants treated for infantile hemangiomas (IH), skin side effects are less commonly reported than other adverse effects 2
• A case report describes a 12-month-old girl who developed a psoriasiform rash one week after starting propranolol for infantile hemangioma 5
• When treating infantile hemangiomas, clinicians should monitor for potential skin reactions along with more common side effects like sleep disturbances and bronchial irritation 2

Time Course and Characteristics

• Psoriasiform eruptions typically develop after prolonged therapy (average 10 months) 4
• Skin reactions may resolve within 1-5 weeks after discontinuation of propranolol 4
• Challenge tests (reintroduction of the drug) often reproduce the skin reaction within 2-4 days 4

Management of Skin Side Effects

• For mild reactions, dose reduction may be sufficient 2
• For severe reactions, discontinuation of propranolol is recommended 1
• In cases of psoriasiform eruptions, switching to a different beta-blocker (e.g., atenolol or bisoprolol) may be effective 3, 5
• For infantile hemangioma treatment, alternative options include:
  • Topical timolol (for superficial lesions) 2
  • Systemic corticosteroids 2

Clinical Pearls

• Always examine patients on beta-blockers for skin changes during follow-up visits 4
• Early skin changes may precede more serious complications 4
• Patients with a history of psoriasis or other skin conditions may be at higher risk for developing skin reactions 7
• Skin reactions to propranolol may be similar to those seen with other beta-blockers, particularly practolol 6, 4

Monitoring Recommendations

• Regular skin examinations for patients on long-term propranolol therapy 4
• Patient education about potential skin side effects and when to seek medical attention 2
• Particular vigilance in patients with pre-existing skin conditions 7