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DILI Associated with Skin Reactions

  • Drug-Induced Liver Injury (NP Chalasani and MS Ghabril, Section Editors)
  • Published:
Current Hepatology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Adverse drug reactions (ADR) frequently involve the liver and skin in the form of drug-induced liver injury or cutaneous drug eruption.

Recent Findings

Skin ADR can range from harmless rash to severe skin manifestations such as drug rash with eosinophilia and systemic symptom syndrome (DRESS syndrome), Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), all of which can be associated with severe outcome, including a 30% mortality rate in case of TEN. The association with co-occurring liver injury varies and in DRESS and SJS/TEN can contribute to substantial morbidity and mortality.

Summary

Liver and skin ADR are frequent but rarely severe; however, if severe, they are not uncommonly fatal.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. NEXAVAR (sorafenib) [package insert] Bayer HealthCare Pharmaceuticals Inc. 2010.

  2. INCIVEK (telaprevir) [package insert] Vertex Pharmaceuticals Incorporated. 2011.

  3. Carlson MK, Gleason PP, Sen S. Elevation of hepatic transaminases after enoxaparin use: case report and review of unfractionated and low-molecular-weight heparin-induced hepatotoxicity. Pharmacotherapy. 2001;21(1):108–13.

    Article  CAS  PubMed  Google Scholar 

  4. Fung M, Thornton A, Mybeck K, Wu HJ, Hornbuckle K, Muniz E. Evaluation of the characteristics of safety withdrawal of prescription drugs from worldwide pharmaceutical Markets-1960 to 1999. Therapeutic Innov Regul Sci. 2001;35:293–317.

    Google Scholar 

  5. • Benichou C. Criteria of drug-induced liver disorders. Report of an international consensus meeting. J Hepatol. 1990;11(2):272. Paper set the stage for defining criteria who to assess drug induced liver injury.–6.

    Article  CAS  PubMed  Google Scholar 

  6. Andrade RJ, Lucena MI, Fernández MC, Pelaez G, Pachkoria K, García-Ruiz E, et al. Drug-induced liver injury: an analysis of 461 incidences submitted to the Spanish registry over a 10-year period. Gastroenterology. 2005;129(2):512–21.

    Article  PubMed  Google Scholar 

  7. • Chalasani N, Bonkovsky HL, Fontana R, Lee W, Stolz A, Talwalkar J, et al. Features and outcomes of 899 patients with drug-induced liver injury: the DILIN prospective study. Gastroenterology. 2015;148(7):1340–52 e7. Key study describing improtant findigns from the first 899 patients to be enroled and adjudicated within the US-based DILI-Network.

    Article  PubMed  Google Scholar 

  8. Bessone F, Hernandez N, Lucena M, Andrade R, on behalf of the Latin DILI Network (LATINDILIN) and Spanish DILI Registry. The Latin American DILI registry experience: a successful ongoing collaborative strategic initiative. Int J Mol Sci. 2016;17(3):313.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  9. Chen YC, Chiu HC, Chu CY. Drug reaction with eosinophilia and systemic symptoms: a retrospective study of 60 cases. Arch Dermatol. 2010;146(12):1373–9.

    Article  PubMed  Google Scholar 

  10. Funck-Brentano E, Duong TA, Bouvresse S, Bagot M, Wolkenstein P, Roujeau JC, et al. Therapeutic management of DRESS: a retrospective study of 38 cases. J Am Acad Dermatol. 2015;72(2):246–52.

    Article  PubMed  Google Scholar 

  11. Peyriere H, Dereure O, Breton H, Demoly P, Cociglio M, Blayac JP, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2006;155(2):422–8.

    Article  CAS  PubMed  Google Scholar 

  12. Kardaun SH, Sekula P, Valeyrie-Allanore L, Liss Y, Chu CY, Creamer D, et al. Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. Results from the prospective RegiSCAR study. Br J Dermatol. 2013;169(5):1071–80.

    Article  CAS  PubMed  Google Scholar 

  13. Hiransuthikul A, Rattananupong T, Klaewsongkram J, Rerknimitr P, Pongprutthipan M, Ruxrungtham K. Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS): 11 years retrospective study in Thailand. Allergol Int. 2016;65(4):432–8.

    Article  PubMed  Google Scholar 

  14. Guillaume JC, Roujeau JC, Revuz J, Penso D, Touraine R. The culprit drugs in 87 cases of toxic epidermal necrolysis (Lyell's syndrome). Arch Dermatol. 1987;123(9):1166–70.

    Article  CAS  PubMed  Google Scholar 

  15. Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333(24):1600–7.

    Article  CAS  PubMed  Google Scholar 

  16. • Mockenhaupt M, Viboud C, Dunant A, Naldi L, Halevy S, Bavinck JNB, et al. Stevens-Johnson syndrome and toxic epidermal necrolysis: assessment of medication risks with emphasis on recently marketed drugs. The EuroSCAR-study. J Investig Dermatol. 2008;128(1):35–44. Landmark study assessing probability of SJS/TEN for various medications.

    Article  CAS  PubMed  Google Scholar 

  17. Sharma VK, Sethuraman G, Minz A. Stevens Johnson syndrome, toxic epidermal necrolysis and SJS-TEN overlap: a retrospective study of causative drugs and clinical outcome. Indian J Dermatol Venereol Leprol. 2008;74(3):238–40.

    Article  PubMed  Google Scholar 

  18. Kim HI, Kim SW, Park GY, Kwon EG, Kim HH, Jeong JY, et al. Causes and treatment outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in 82 adult patients. Korean J Intern Med. 2012;27(2):203–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. • Hotz C, Valeyrie-Allanore L, Haddad C, Bouvresse S, Ortonne N, Duong TA, et al. Systemic involvement of acute generalized exanthematous pustulosis: a retrospective study on 58 patients. Br J Dermatol. 2013;169(6):1223. Largest study examining systemic involvement with acute generalized exanthematous pustulosis.–32.

    Article  CAS  PubMed  Google Scholar 

  20. Son CH, Lee CU, Roh MS, Lee SK, Kim KH, Yang DK. Acute generalized exanthematous pustulosis as a manifestation of carbamazepine hypersensitivity syndrome. J Investig Allergol Clin Immunol. 2008;18(6):461–4.

    CAS  PubMed  Google Scholar 

  21. Treudler R, Grunewald S, Gebhardt C, Simon JC. Prolonged course of acute generalized exanthematous pustulosis with liver involvement due to sensitization to amoxicillin and paracetamol. Acta Derm Venereol. 2009;89(3):314–5.

    Article  PubMed  Google Scholar 

  22. Lee T, Lee YS, Yoon SY, Kim S, Bae YJ, Kwon HS, et al. Characteristics of liver injury in drug-induced systemic hypersensitivity reactions. J Am Acad Dermatol. 2013;69(3):407–15.

    Article  CAS  PubMed  Google Scholar 

  23. Fang WC, Adler NR, Graudins LV, Goldblatt C, Goh MSY, Roberts SK, et al. Drug-induced liver injury is frequently associated with severe cutaneous adverse drug reactions: experience from two Australian tertiary hospitals. Intern Med J. 2018;48:549–55.

    Article  CAS  PubMed  Google Scholar 

  24. Morelli MS, O'Brien FX. Stevens-Johnson syndrome and cholestatic hepatitis. Dig Dis Sci. 2001;46(11):2385–8.

    Article  CAS  PubMed  Google Scholar 

  25. Stutts JT, Washington K, Barnard JA. Cholestatic jaundice with skin desquamation in a 12-year-old girl. J Pediatr. 1999;134(5):649–53.

    Article  CAS  PubMed  Google Scholar 

  26. Okan G, Yaylaci S, Peker O, Kaymakoglu S, Saruc M. Vanishing bile duct and Stevens-Johnson syndrome associated with ciprofloxacin treated with tacrolimus. World J Gastroenterol. 2008;14(29):4697–700.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Srivastava M, Perez-Atayde A, Jonas MM. Drug-associated acute-onset vanishing bile duct and Stevens-Johnson syndromes in a child. Gastroenterology. 1998;115(3):743–6.

    Article  CAS  PubMed  Google Scholar 

  28. Garcia M, Mhanna MJ, Chung-Park MJ, Davis PH, Srivastava MD. Efficacy of early immunosuppressive therapy in a child with carbamazepine-associated vanishing bile duct and Stevens-Johnson syndromes. Dig Dis Sci. 2002;47(1):177–82.

    Article  PubMed  Google Scholar 

  29. Reau NS, Jensen DM. Vanishing bile duct syndrome. Clin Liver Dis. 2008;12(1):203–17. x

    Article  PubMed  Google Scholar 

  30. Tsunoda N, Iwanaga T, Saito T, Kitamura S, Saito K. Rapidly progressive bronchiolitis obliterans associated with Stevens-Johnson syndrome. Chest. 1990;98(1):243–5.

    Article  CAS  PubMed  Google Scholar 

  31. • Devarbhavi H, Raj S, Aradya VH, Rangegowda VT, Veeranna GP, Singh R, et al. Drug-induced liver injury associated with Stevens-Johnson syndrome/toxic epidermal necrolysis: patient characteristics, causes, and outcome in 36 cases. Hepatology. 2016;63(3):993. Largest series of liver injury and SJS/TEN.–9.

    Article  CAS  PubMed  Google Scholar 

  32. Engelhardt SL, Schurr MJ, Helgerson RB. Toxic epidermal necrolysis: an analysis of referral patterns and steroid usage. J Burn Care Rehabil. 1997;18(6):520–4.

    Article  CAS  PubMed  Google Scholar 

  33. Halebian PH, et al. Improved burn center survival of patients with toxic epidermal necrolysis managed without corticosteroids. Ann Surg. 1986;204(5):503–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Pereira FA, Mudgil AV, Rosmarin DM. Toxic epidermal necrolysis. J Am Acad Dermatol. 2007;56(2):181–200.

    Article  PubMed  Google Scholar 

  35. Schneck J, Fagot JP, Sekula P, Sassolas B, Roujeau JC, Mockenhaupt M. Effects of treatments on the mortality of Stevens-Johnson syndrome and toxic epidermal necrolysis: a retrospective study on patients included in the prospective EuroSCAR study. J Am Acad Dermatol. 2008;58(1):33–40.

    Article  PubMed  Google Scholar 

  36. Walsh S, Creamer D. IVIg in TEN: time to re-evaluate the efficacy of intravenous immunoglobulin in the management of toxic epidermal necrolysis. Br J Dermatol. 2012;167(2):230–1.

    Article  CAS  PubMed  Google Scholar 

  37. Fernando SL. The management of toxic epidermal necrolysis. Australas J Dermatol. 2012;53(3):165–71.

    Article  PubMed  Google Scholar 

  38. Saeed H, Mantagos IS, Chodosh J. Complications of Stevens-Johnson syndrome beyond the eye and skin. Burns. 2016;42(1):20–7.

    Article  PubMed  Google Scholar 

  39. Fujita M, Takahashi A, Imaizumi H, Hayashi M, Okai K, Kanno Y, et al. Drug-induced liver injury with HHV-6 reactivation. Intern Med. 2015;54(10):1219–22.

    Article  PubMed  Google Scholar 

  40. Tohyama M, Hashimoto K, Yasukawa M, Kimura H, Horikawa T, Nakajima K, et al. Association of human herpesvirus 6 reactivation with the flaring and severity of drug-induced hypersensitivity syndrome. Br J Dermatol. 2007;157(5):934–40.

    Article  CAS  PubMed  Google Scholar 

  41. • Lin IC, Yang HC, Strong C, Yang CW, Cho YT, Chen KL, et al. Liver injury in patients with DRESS: a clinical study of 72 cases. J Am Acad Dermatol. 2015;72(6):984. Largest series examing liver injury in DRESS.–91.

    Article  PubMed  Google Scholar 

  42. Mennicke M, Zawodniak A, Keller M, Wilkens L, Yawalkar N, Stickel F, et al. Fulminant liver failure after vancomycin in a sulfasalazine-induced DRESS syndrome: fatal recurrence after liver transplantation. Am J Transplant. 2009;9(9):2197–202.

    Article  CAS  PubMed  Google Scholar 

  43. Descloux E, Argaud L, Dumortier J, Scoazec JY, Boillot O, Robert D. Favourable issue of a fulminant hepatitis associated with sulfasalazine DRESS syndrome without liver transplantation. Intensive Care Med. 2005;31(12):1727–8.

    Article  PubMed  Google Scholar 

  44. Amante MF, Filippini AV, Cejas N, Lendoire J, Imventarza O, Parisi C. Dress syndrome and fulminant hepatic failure induced by lamotrigine. Ann Hepatol. 2009;8(1):75–7.

    Article  CAS  PubMed  Google Scholar 

  45. Walsh S, Diaz-Cano S, Higgins E, Morris-Jones R, Bashir S, Bernal W, et al. Drug reaction with eosinophilia and systemic symptoms: is cutaneous phenotype a prognostic marker for outcome? A review of clinicopathological features of 27 cases. Br J Dermatol. 2013;168(2):391–401.

    Article  CAS  PubMed  Google Scholar 

  46. Devarbhavi H, Karanth D, KS P, CK A, Patil M. Drug-induced liver injury with hypersensitivity features has a better outcome: a single-center experience of 39 children and adolescents. Hepatology. 2011;54(4):1344–50.

    Article  CAS  PubMed  Google Scholar 

  47. Torii H, Sueki H, Kumada H, Sakurai Y, Aoki K, Yamada I, et al. Dermatological side-effects of telaprevir-based triple therapy for chronic hepatitis C in phase III trials in Japan. J Dermatol. 2013;40(8):587–95.

    Article  CAS  PubMed  Google Scholar 

  48. McHutchison JG, et al. Telaprevir with peginterferon and ribavirin for chronic HCV genotype 1 infection. N Engl J Med. 2009;360(18):1827–38.

    Article  CAS  PubMed  Google Scholar 

  49. Roujeau JC, Mockenhaupt M, Tahan SR, Henshaw J, Martin EC, Harding M, et al. Telaprevir-related dermatitis. JAMA Dermatol. 2013;149(2):152–8.

    Article  PubMed  Google Scholar 

  50. Suda G, Yamamoto Y, Nagasaka A, Furuya K, Kudo M, Chuganji Y, et al. Serum granulysin levels as a predictor of serious telaprevir-induced dermatological reactions. Hepatol Res. 2015;45(8):837–45.

    Article  CAS  PubMed  Google Scholar 

  51. Chung WH, Hung SI, Yang JY, Su SC, Huang SP, Wei CY, et al. Granulysin is a key mediator for disseminated keratinocyte death in Stevens-Johnson syndrome and toxic epidermal necrolysis. Nat Med. 2008;14(12):1343–50.

    Article  CAS  PubMed  Google Scholar 

  52. Fujita Y, Yoshioka N, Abe R, Murata J, Hoshina D, Mae H, et al. Rapid immunochromatographic test for serum granulysin is useful for the prediction of Stevens-Johnson syndrome and toxic epidermal necrolysis. J Am Acad Dermatol. 2011;65(1):65–8.

    Article  CAS  PubMed  Google Scholar 

  53. Joly P, Janela B, Tetart F, Rogez S, Picard D, D'Incan M, et al. Poor benefit/risk balance of intravenous immunoglobulins in DRESS. Arch Dermatol. 2012;148(4):543–4.

    Article  CAS  PubMed  Google Scholar 

  54. Hirashima R, Itoh T, Tukey RH, Fujiwara R. Prediction of drug-induced liver injury using keratinocytes. J Appl Toxicol. 2017;37(7):863–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Takikawa H, Murata Y, Horiike N, Fukui H, Onji M. Drug-induced liver injury in Japan: an analysis of 1676 cases between 1997 and 2006. Hepatol Res. 2009;39(5):427–31.

    Article  PubMed  Google Scholar 

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Correspondence to Sahand Rahnama-Moghadam.

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Conflict of Interest

Sahand Rahnama-Moghadam declares no conflicts of interest. Hans L. Tillmann reports that his spouse is a full-time employee of AbbVie; reports grants from NIH-NIDDK, during the conduct of the study; reports personal fees from AbbVie, Abbott, and Gilead for stocks; and reports personal fees from Novartis and Novo Nordisk for consulting, outside the submitted work.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Drug-Induced Liver Injury

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Rahnama-Moghadam, S., Tillmann, H.L. DILI Associated with Skin Reactions. Curr Hepatology Rep 17, 225–234 (2018). https://doi.org/10.1007/s11901-018-0414-x

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