Published in Dermatology Journal Scan / Review · March 26, 2022 Patch Testing in DRESS Contact Dermatitis

Patch testing in Drug reaction with eosinophilia and systemic symptoms (DRESS): a literature review

Contact Derm 2022 Mar 01;[EPub Ahead of Print], AC de Groot 

Abstract

The literature on positive patch test results in drug reaction with eosinophilia and systemic symptoms (DRESS) is reviewed. 105 drugs were identified that have together caused 536 positive patch tests in 437 patients suffering from DRESS. By far most reactions (n=145) were caused by carbamazepine, followed by amoxicillin, isoniazid, phenytoin, ethambutol, fluindione, phenobarbital, rifampicin, and ceftriaxone; 43 drugs each caused a single case only. The drug classes causing the highest number of reactions are anticonvulsants (39%), beta-lactam antibiotics (20%), antituberculosis agents (11%), non-beta-lactam antibiotics (6%) and iodinated contrast media (5%). The sensitivity of patch testing (percentage of positive reactions) is high for anticonvulsants (notably carbamazepine), beta-lactam antibiotics (notably amoxicillin) and possibly iodinated contrast media. Allopurinol and sulfasalazine frequently cause DRESS, but never give positive patch tests. Patch testing in DRESS appears to be safe, although mild recurrence of DRESS symptoms, mostly skin reactions, may not be rare. Multiple drug hypersensitivity was found to occur in 16% of all patients, but it is argued that the true frequency is (far) higher. Clinical aspects of DRESS, including diagnosing the disease and identifying culprit drugs (patch tests, intradermal tests, in vitro tests, challenge tests) are also provided, emphasizing the role of patch testing. This article is protected by copyright. All rights reserved.

Written by

 

 

Jennifer K. Chen MD

Drug reaction with eosinophilia and systemic symptoms (DRESS) may result in significant morbidity and/or mortality. A critical component of management involves identification and avoidance of the culprit medication. As drug provocation tests may cause DRESS recurrence, patch testing has been employed to identify the causative drug(s). It is important to note that a positive patch test result may be helpful in confirming a possible culprit drug, while a negative result does not exclude the drug as a culprit.

In this review, the author provides a comprehensive overview of positive patch test results in DRESS patients. Reactions were seen most commonly with anticonvulsants, beta-lactam antibiotics, antituberculosis agents, non-beta-lactam antibiotics, and iodinated contrast media. The sensitivity was highest for carbamazepine (57-100%) and amoxicillin (44-100%). Allopurinol and sulfasalazine were consistently negative. Rash recrudescence was not uncommon; fortunately, systemic symptoms were infrequent, with risk factors being HIV and antituberculosis drugs. Conclusions could not be drawn regarding optimal patch test concentrations and vehicles for individual drugs, although practical recommendations are provided.

Limitations included considerable variation in terms of selection criteria, sensitivity, drugs tested, patch test concentration and vehicle, timing of readings, and duration following resolution of DRESS at time of patch testing. Patch testing data were often limited, and studies not infrequently failed to perform a delayed reading after 24 or 48 hours, which may have resulted in false negative and false positive results. Studies were geographically limited and may not be generalizable.

There is currently insufficient data to recommend for or against patch testing in the work-up of DRESS. A patch test to anticonvulsants (especially carbamazepine) and beta-lactam antibiotics (especially amoxicillin) may be high yield, while patch testing to allopurinol or sulfasalazine appears to be low yield. Patients must be counseled on the potential for recrudescence of DRESS, which in most cases is limited to the skin. Further study is warranted, given the potential ramifications of DRESS and the relative safety of patch testing outlined in this review.

TAKE-HOME MESSAGE

• This literature review characterizes the utility of patch testing in patients with drug reaction with eosinophilia and systemic symptoms (DRESS). Patch testing sensitivity is highly drug dependent with some having very high positivity (beta-lactam antibiotics and antiepileptics) and others being consistently negative (allopurinol, sulfasalazine). Patch testing can occasionally elicit a mild DRESS flare (21% in one study).

• The sensitivity of patch testing in patients with DRESS is highly dependent on the class of the culprit medication. Although typically mild in nature, flaring of DRESS with patch testing needs to be well documented.

–  Joshua R. Ortego, MD

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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