What does a rash caused by Lisinopril (angiotensin-converting enzyme inhibitor) look like?

Lisinopril-Induced Rash Appearance

Lisinopril-induced rash most commonly presents as angioedema, which appears as asymmetric non-pitting edema of the face, lips, tongue, and mucous membranes, and can be potentially life-threatening if not recognized and treated promptly. 1, 2

Angioedema Characteristics

• Presents as swelling of the lips, face, tongue, pharynx, and lower face without associated urticaria or pruritus 2
• Develops suddenly and can progress rapidly, often within hours of taking the medication 1
• May involve the oropharynx and larynx, potentially leading to airway obstruction in severe cases 3
• Unlike allergic reactions, typically does not present with hives, skin rashes, or itching 2
• Can occur at any time during treatment - from first dose to years after starting lisinopril 1

Other Skin Manifestations

• While angioedema is the most serious and recognizable skin reaction, lisinopril can occasionally cause other dermatological reactions:
  • Maculopapular rash (less common than angioedema)
  • Pruritus without visible skin changes
  • Facial flushing

Risk Factors

• Higher incidence reported in:
  • Black patients 4
  • Women
  • Patients with history of previous angioedema (unrelated to ACE inhibitors)
  • Patients with history of allergic reactions 5

Clinical Course and Severity

• Mild cases: Limited to lips and face without respiratory symptoms 5
• Moderate cases: More extensive facial and oral swelling with difficulty swallowing 2
• Severe cases: Laryngeal involvement with respiratory distress, stridor, and potential airway compromise 3
• Fatal cases have been reported due to complete airway obstruction 3

Distinguishing Features

• Onset: Can occur within hours to days after starting lisinopril, but may also develop after years of use 1
• No associated urticaria (unlike allergic reactions)
• Not dose-dependent
• Does not typically resolve with continued use (unlike some drug rashes that improve with time)
• Resolves within 24-48 hours after discontinuation of lisinopril and appropriate treatment 2, 5

Important Considerations

• Angioedema is a class effect of all ACE inhibitors, not just lisinopril 5
• The incidence is estimated between 0.1% and 0.5% of patients taking ACE inhibitors 2
• Some evidence suggests lisinopril may have a higher incidence of angioedema compared to captopril or enalapril 5
• Patients who experience angioedema with lisinopril should avoid all ACE inhibitors in the future 3
• Prompt recognition is critical as progression can be rapid and potentially fatal 3

Management Approach

• Immediate discontinuation of lisinopril 2
• Treatment with antihistamines and corticosteroids 4
• Close airway monitoring
• In severe cases with respiratory compromise, epinephrine administration and potential airway management may be necessary 3