What to do if a patient develops a rash while taking Augmentin (amoxicillin-clavulanate)?

Management of Augmentin (Amoxicillin-Clavulanate) Rash

Immediately discontinue Augmentin and assess the rash for severity—most cases are benign maculopapular eruptions requiring only symptomatic treatment, but you must rule out serious hypersensitivity reactions that require emergency intervention. 1

Immediate Assessment: Rule Out Severe Reactions

First, examine for features indicating life-threatening hypersensitivity:

• Blistering, skin sloughing, or mucosal involvement (eyes, mouth, genitals) suggests Stevens-Johnson syndrome or toxic epidermal necrolysis—these require immediate hospitalization 2
• Facial swelling, tongue swelling, or respiratory symptoms indicate anaphylaxis—administer epinephrine and call emergency services 1
• Fever, malaise, or organ involvement (hepatitis, renal dysfunction) suggest drug reaction with eosinophilia and systemic symptoms (DRESS) 2

If any of these severe features are present, discontinue Augmentin immediately and institute appropriate emergency therapy. 1

Determine Rash Type and Context

Mononucleosis-Associated Rash (Non-Allergic)

• If the patient has or recently had infectious mononucleosis or Epstein-Barr virus, there is a 30-100% chance of developing a non-pruritic morbilliform rash with amoxicillin 2
• This is NOT a true allergy but a unique virus-drug interaction 2
• Do NOT label this as "penicillin allergy"—this type of rash does not predict future penicillin reactions 2
• Discontinue Augmentin, but document clearly that this was a virus-drug interaction, not an IgE-mediated allergy 2

Mild Maculopapular Rash (Most Common)

• Typically appears 7-10 days after starting antibiotics 2
• Non-blistering, no mucosal involvement, no systemic symptoms 2
• May be pruritic but patient is otherwise well 2

Treatment for Mild Maculopapular Rash

Discontinue Augmentin immediately 1

Topical Management

• Apply topical low-to-moderate potency corticosteroids:
  • 1-2.5% hydrocortisone to affected areas 2
  • Use hydrocortisone on the face to avoid skin atrophy 3
  • Medium- to high-potency steroids (triamcinolone, clobetasol) can be used on the body 3
• Apply emollients at least once daily to prevent xerosis and secondary eczema 2
  • Ointments are more effective for dry, irritable rashes because they improve the skin's lipid barrier 3
  • Avoid very greasy emollients as they may increase folliculitis risk 3, 2

Systemic Management

• Oral antihistamines for pruritus:
  • Non-sedating agents (cetirizine, loratadine, fexofenadine) for daytime use 2, 4
  • Sedating antihistamines (clemastine) for nighttime pruritus 2
• Acetaminophen or ibuprofen for associated fever or discomfort 2

Avoid Common Pitfalls

• Do NOT use hot showers or excessive soap—these worsen xerosis 2
• Do NOT apply topical acne medications or retinoids—they cause irritation and drying 2
• Do NOT apply alcohol-containing lotions—they further dry the skin 3

Documentation and Future Antibiotic Selection

Critical Documentation Points

• Document the reaction characteristics in detail: timing (day of onset), morphology (maculopapular vs. urticarial), severity, body surface area affected, and associated symptoms 2
• Do NOT label as "penicillin allergy" if this was a mild delayed maculopapular rash without urticaria, angioedema, or systemic features 2
• This distinction is critical—mislabeling benign late-appearing rashes as true allergies leads to unnecessary use of broader-spectrum, more expensive, and potentially more toxic antibiotics in the future 2

Future Antibiotic Management

• For mild maculopapular rashes, future penicillin use is generally safe after negative skin testing or graded challenge if needed 2
• Reserve formal allergy evaluation (skin testing, graded challenge) for patients with severe reactions such as anaphylaxis, Stevens-Johnson syndrome, or toxic epidermal necrolysis 2
• If penicillin avoidance is necessary, alternative antibiotics depend on the indication (fluoroquinolones, macrolides, or cephalosporins if no cross-reactivity concern) 2

When to Escalate Care

• Immediate hospitalization: Any signs of blistering, mucosal involvement, facial/tongue swelling, or respiratory compromise 2, 1
• Dermatology referral: Persistent or worsening rash despite treatment, uncertain diagnosis, or need for formal allergy evaluation 2
• Reassess at 2 weeks: If no improvement with topical steroids and antihistamines, consider alternative diagnoses or escalate to dermatology 4