From the Guidelines
Topical corticosteroids are the first-line treatment for maculopapular drug eruptions, with Class I topical corticosteroid (clobetasol propionate, halobetasol propionate, betamethasone dipropionate cream or ointment) for body and Class V/VI corticosteroid (aclometasone, desonide, hydrocortisone 2.5% cream) for face, as recommended by the Society for Immunotherapy of Cancer (SITC) toxicity management working group 1. When managing maculopapular drug eruptions, the following key points should be considered:
- For grade 1 eruptions, covering less than 10% of the body surface area (BSA), treatment with oral antihistamines such as cetirizine/loratidine 10 mg daily or hydroxyzine 10-25 mg QID, along with topical corticosteroids, is recommended 1.
- For grade 2 eruptions, covering 10-30% of the BSA, a non-urgent dermatology referral is suggested, and treatment with oral antihistamines and topical corticosteroids should be continued 1.
- For grade 3 eruptions, covering more than 30% of the BSA, immediate action is required, including holding the immune checkpoint inhibitor (ICI), same-day dermatology consultation, and initiation of systemic corticosteroids such as prednisone 0.5-1 mg/kg/day until the rash resolves to grade 1 or less 1. It is essential to discontinue the offending medication immediately to prevent progression of the eruption and to monitor patients closely for improvement within 48-72 hours of treatment initiation. If symptoms worsen or include mucosal involvement, fever, or blistering, immediate medical attention is required to rule out more severe reactions.
From the Research
Maculopapular Drug Eruption Treatment with Steroid
- The use of steroids in treating maculopapular drug eruptions is supported by several studies 2, 3, 4.
- In a study published in 2006, it was found that patients who received high-dose corticosteroids as part of their chemotherapy protocol did not develop maculopapular skin rashes 2.
- A case report published in 2022 described a patient who developed a maculopapular drug eruption due to apalutamide, which improved after discontinuation of the drug and treatment with topical corticosteroids and systemic prednisolone 3.
- Another case report published in 2005 described a patient who developed a severe skin reaction due to mycophenolate mofetil, which was treated with high-dose steroids and discontinuation of the drug 4.
Histopathologic Features
- A study published in 2011 described the histopathologic features of exanthematous drug eruptions of the macular and papular type, which included mild spongiosis, hyperplasia, and a dermal perivascular inflammatory infiltrate 5.
- The study found that the perivascular infiltrate was typically mild and composed of lymphocytes, eosinophils, and neutrophils 5.
Treatment Outcomes
- The studies suggest that treatment with steroids can be effective in improving maculopapular drug eruptions 2, 3, 4.
- Discontinuation of the offending drug is also an important part of treatment 3, 4.
- In some cases, treatment with topical corticosteroids and systemic prednisolone may be necessary to manage the eruption 3.