Discontinuing triggering treatment may improve acute generalized exanthematous pustulosis

Acute generalized exanthematous pustulosis is usually triggered by new antimicrobials and is often improved with the discontinuation of the causing drug, according to a study.

“Acute generalized exanthematous pustulosis (AGEP) is a rare, severe cutaneous adverse reaction with an estimated incidence of 1 to 5 cases per million people per year,” Andrew Creadore, MD, of the department of dermatology at Brigham and Women’s Hospital, and colleagues wrote. “The reaction is defined by acute development of generalized erythema with dozens to hundreds of overlying sterile pustules that begin to resolve after the offending agent, usually a new medication, is discontinued.”

The retrospective case series of 340 patients with AGEP attempted to identify potential causes, types of treatment and any systemic involvement.

The study found 52.4% (n = 178) of patients developed AGEP while hospitalized, while the remaining patients were subsequently hospitalized.

Mucosal involvement was found in 5.9% (n = 20) of patients and 64.7% (n = 220) experienced desquamation as part of their treatment.

A medication was the suspected causative agent in 85.6% (n = 291) of patients with 61.9% (n = 180) narrowed to a single medication. In 151 patients (44.4%) where a single medication was suspected, 114 (75.4%) were antimicrobials. This included 63 (41.7%) suspected to be from B-lactam antimicrobial. Non-B-lactam microbials made up 33.8% (n = 51) of cases, while anticonvulsants were 6% (n = 9), analgesics were 3.3% (n = 5), calcium channel blockers were 3.3% (n = 5) and hydroxychloroquine was 2.6% (n = 4).

An intravenous contrast agent was the suspected cause in seven cases (2.1%) and infection in three patients (0.9%).

No suspected causative agent could be found for 39 (11.5%) cases.

An acute elevation of aspartate aminotransferase and alanine aminotransferase levels were recorded in 25 of 298 patients who had their values checked at least once during their AGEP treatment. In addition, in 86 patients who had baseline and AGEP course creatinine levels recorded, 25 (29.1%) had an increase of at least 1.5 times the baseline.

The most common treatment used was corticosteroids with 81.5% (n = 277) of patients receiving them in addition to stopping the suspected medication.

“The results of this retrospective case series analysis of 340 patients with AGEP support many previous hypotheses surrounding the cutaneous adverse reaction,” the authors wrote. “The onset is acute and usually triggered by a new antimicrobial, the discontinuation of which leads to improvement or complete resolution in most patients.”