What is the treatment for a skin eruption caused by medication?

Treatment for Medication-Induced Skin Eruptions

The treatment approach depends critically on the severity and type of skin eruption, with mild reactions managed with topical therapies while continuing the medication, moderate reactions requiring oral antibiotics and possible drug interruption, and severe reactions (≥30% body surface area or with systemic symptoms) necessitating immediate drug discontinuation and systemic corticosteroids. 1

Initial Assessment and Grading

Grade the severity using body surface area (BSA) involvement, symptoms, and functional impact: 1

• Grade 1 (Mild): <10% BSA, minimal symptoms
• Grade 2 (Moderate): 10-30% BSA or limiting instrumental activities of daily living
• Grade 3 (Severe): >30% BSA with moderate-severe symptoms, limiting self-care
• Grade 4 (Life-threatening): Requires hospitalization, mucosal involvement, or systemic complications

Immediately assess for severe cutaneous adverse reactions (SCARs) including Stevens-Johnson syndrome, toxic epidermal necrolysis, or DRESS syndrome—these require emergency management. 1 Look specifically for skin pain resembling sunburn, mucosal involvement (eyes, mouth, genitals), blistering, skin sloughing, fever, or systemic symptoms. 1

Management by Severity

Grade 1 (Mild Reactions)

Continue the causative medication and initiate topical therapy: 1

• Topical antibiotics: Clindamycin 2%, erythromycin 1%, metronidazole 0.75%, or nadifloxacin 1% 1
• Moisturizers: Hypoallergenic, urea-based (10%) or glycerin-based emollients applied at least once daily 1
• Topical corticosteroids: Mild-to-moderate potency (e.g., hydrocortisone) for inflammatory lesions 1, 2
• Avoid: Hot showers, excessive soap use, alcohol-containing lotions, and mechanical/chemical skin irritants 1

Reassess after 2 weeks—if worsening or no improvement, escalate to Grade 2 management. 1

Grade 2 (Moderate Reactions)

Continue the medication with close monitoring, but prepare to hold if no improvement: 1

• All Grade 1 interventions plus:
• Oral antibiotics (minimum 2 weeks): Doxycycline 100 mg twice daily OR minocycline 100 mg twice daily 1
• Short-term topical corticosteroids: Higher potency such as prednicarbate cream 0.02% 1
• Oral antihistamines: Cetirizine, loratadine, fexofenadine, or clemastine for pruritus 1
• Consider oral prednisone: 0.5-1 mg/kg daily, tapered over 4 weeks if symptoms are significant 1

Reassess after 2 weeks—if worsening or no improvement, refer to dermatology and escalate to Grade 3 management. 1

Grade 3 (Severe Reactions)

Hold or reduce the causative medication dose per protocol: 1

• Dermatology consultation mandatory 1
• High-potency topical corticosteroids 1
• Oral prednisone: 1 mg/kg daily, tapering over at least 4 weeks 1
• Continue oral antibiotics and supportive care 1
• For severe pruritus without rash: Consider gabapentin, pregabalin, aprepitant, or dupilumab 1

Reassess after 2 weeks—if worsening or no improvement, proceed to Grade 4 management. 1

Grade 4 (Life-Threatening Reactions)

Permanently discontinue the causative medication immediately: 1

• Admit to burn unit or ICU with urgent dermatology consultation 1
• IV methylprednisolone: 1-2 mg/kg daily, convert to oral when stable, taper slowly 1
• For Stevens-Johnson syndrome/toxic epidermal necrolysis: Consider IVIG or cyclosporine in steroid-unresponsive cases 1
• Supportive care: Fluid/electrolyte management, wound care, infection prevention 1
• Multidisciplinary consultation: Ophthalmology, urology, gynecology as needed for mucosal involvement 1

Specific Eruption Types

Acneiform Rash (EGFR Inhibitors)

This is the most common reaction with EGFR inhibitors, affecting >50% of patients: 1

• Prophylaxis: Start moisturizers immediately when beginning EGFR therapy 1
• Treatment follows the grading system above 1
• Note: Avoid topical retinoids and greasy creams that may worsen folliculitis 1

Xerotic (Dry) Skin Reactions

Prevent dehydration and restore moisture: 1

• Soap-free cleansers and bath oils 1
• Urea 10% or glycerin-based moisturizers applied liberally 1
• For inflammatory xerotic dermatitis: Higher-potency topical steroids (prednicarbate, mometasone furoate) 1
• Oral antihistamines for associated pruritus 1

Hand-Foot Skin Reactions

Preventive measures are critical: 1

• Avoid mechanical stress: No prolonged walking, use cushioned shoes and gloves 1
• Urea 10% cream at least twice daily 1
• Cooling of hands/feet during chemotherapy infusions 1
• For established reactions: High-potency topical steroids twice daily 1

Fissures

Aggressive local wound care: 1

• Propylene glycol 50% in water for 30 minutes under occlusion nightly, followed by hydrocolloid dressing 1
• Antiseptic baths: Potassium permanganate 1:10,000 or povidone-iodine 1
• Topical silver nitrate solutions 1
• Consider oral antibiotics for Grade 2 or higher 1

Critical Pitfalls to Avoid

Do not use topical acne medications or systemic retinoids—these worsen drug-induced eruptions through excessive drying. 1

Do not use topical steroids without dermatology supervision for prolonged periods—risk of perioral dermatitis and skin atrophy. 1

Do not delay recognition of SCARs—any mucosal involvement, blistering, or skin sloughing requires immediate drug discontinuation and emergency management. 1

Do not rechallenge with medications that caused urticarial, bullous, or erythema multiforme-like eruptions—this can be life-threatening. 3

For secondary bacterial infection (impetiginization with Staphylococcus aureus most common), obtain bacterial swabs and start calculated antibiotic therapy. 1