Can Hydralazine Cause Flaky Skin?
Hydralazine does not typically cause simple flaky skin, but it can cause serious cutaneous reactions including bullous lesions, ulcerative rashes, and toxic epidermal necrolysis as manifestations of drug-induced lupus or ANCA-associated vasculitis.
Documented Cutaneous Reactions to Hydralazine
The skin manifestations associated with hydralazine are generally severe and distinct from simple flaky skin:
Serious Cutaneous Manifestations
Bullous lupus erythematosus has been documented with hydralazine use, presenting as blister-type lesions with hemorrhagic bullae affecting oral, nasal, and conjunctival mucosa 1
Toxic epidermal necrolysis (TEN) has been reported, characterized by well-demarcated erythematous maculopapular rashes that transform into bullous lesions with widespread erythema and necrosis 2
Diffuse bullous and ulcerative lesions can occur as part of hydralazine-induced ANCA vasculitis, presenting with severe cutaneous involvement 3
Lower extremity petechiae is commonly seen (in 67% of cases) as part of hydralazine-associated vasculitis 4
Drug-Induced Lupus Presentation
The American College of Cardiology/American Heart Association guidelines note that hydralazine is "associated with drug-induced lupus-like syndrome at higher doses," typically above 150-200 mg daily 5
Classic lupus cutaneous manifestations include malar or discoid rash rather than simple flaky skin 1
Skin involvement typically occurs alongside systemic features including cardiopulmonary manifestations, with most patients exposed to hydralazine for more than 12 months before developing symptoms 6
Clinical Context and Risk Factors
The mean age at diagnosis of hydralazine-induced lupus is 62 years, with the majority of patients exposed to the medication for more than 12 months 6
The mean cumulative dose associated with vasculitis is approximately 146 grams over an average duration of 22 months 4
Patients typically present with constitutional symptoms (dyspnea, fatigue, unintentional weight loss) alongside cutaneous findings rather than isolated skin changes 4
Important Clinical Pitfall
If a patient on hydralazine develops any new skin lesions—even if they appear as simple flaky skin—consider more serious underlying pathology. The cutaneous manifestations of hydralazine-induced autoimmune disease can begin subtly but progress rapidly to severe bullous or ulcerative lesions 2. Immediate discontinuation of hydralazine is the mainstay of therapy for any suspected drug-induced cutaneous reaction 2.