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Distinguishing Benign Rashes From Severe Skin Reactions From Anti-Seizure Medications

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Abstract

Purpose of review

This review describes risk factors for severe skin reactions to antiseizure medications (ASMs), the usage of updated tests to predict those with increased risk of a severe cutaneous reaction, and guides how to choose specific ASMs and dosing to lower the risk for these reactions. Information is given regarding specific mild versus severe reactions, initial diagnostic evaluation, and treatment. A table listing the risk of mild and severe cutaneous reaction risks as well as the management of potential seizures that may occur while stopping the culprit ASM are provided.

Recent findings

Five new ASMs have joined the total of 26 FDA-approved ASMs since 2018. Cenobamate had three patients develop a drug reaction with eosinophilia and systemic symptoms. A lower starting dosing and slower titration have resulted in no further published cases. Based on limited data, rash risk is low for fenfluramine, ganaxalone, and stiripentol. It is low-moderate for Epidiolex. Molecular tests can predict severe reactions.

Summary

Skin reactions are a relatively common side effect of ASMs with aromatic ASMs having the greatest risk. Identifying and informing high-risk patients when to seek medical attention, stopping the culprit ASM when a severe reaction looks possible, and providing appropriate medical triage can reduce morbidity and mortality from severe skin and systemic reactions.

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Authors and Affiliations

  1. Department of Neurology, Rutgers Robert Wood Johnson Medical School, 125 Paterson St, CAB Suite 6200 Neurology, New Brunswick, NJ, 08901, USA

    Ram Mani MD, MSCE, Ahmad Almelegy MD, Thu Minh Truong PharmD & Gaurav N. Pathak PharmD

  2. Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA

    Mary L. Wagner PharmD, MS

  3. Center for Dermatology, Rutgers Robert Wood Johnson Medical School, 1 World’s Fair Drive Suite 2400, Somerset, NJ, USA

    Cindy Wassef MD

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  1. Ram Mani MD, MSCE
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  2. Ahmad Almelegy MD
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  3. Thu Minh Truong PharmD
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  4. Gaurav N. Pathak PharmD
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  5. Mary L. Wagner PharmD, MS
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  6. Cindy Wassef MD
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Contributions

RM, CW, and MW provided design and outline leadership. RM, TT, GP, and AA wrote the manuscript. RM, AA, CW, and MW revised the manuscript. RM, AA, TT, GP, and MW provided information for the tables. RM and AA revised tables and figures. CW provided information for the figures. All authors reviewed the manuscript.

Corresponding author

Correspondence to Ram Mani MD, MSCE.

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Conflict of Interest

Ram Mani declares that he has no conflict of interest. Ahmad Almelegy declares that he has no conflict of interest. Thu Minh Truong declares that he has no conflict of interest. Gaurav N. Pathak declares that he has no conflict of interest. Mary L. Wagner declares that he has no conflict of interest. Cindy Wassef declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

The authors did not disclose patient identifying data in the manuscript. For the pictures in the manuscript, there is no way for a patient to be identified based on the review of the picture. No patient rights were infringed upon during the writing and publishing of this manuscript.

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Mani, R., Almelegy, A., Truong, T.M. et al. Distinguishing Benign Rashes From Severe Skin Reactions From Anti-Seizure Medications. Curr Treat Options Neurol 26, 115–138 (2024). https://doi.org/10.1007/s11940-024-00785-8

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