CNS Drugs

, Volume 12, Issue 3, pp 215–236 | Cite as

Anticonvulsant-Induced Cutaneous Reactions

Incidence, Mechanisms and Management
  • James Ruble
  • Fumisuke Matsuo
Review Article


Management of patients receiving anticonvulsant drugs is often a matter of balancing medication efficacy against untoward effects. Cutaneous drug reactions (CDRs) to anticonvulsants are a widely recognised idiosyncratic effect. In spite of almost 60 years’ experience with phenytoin and greater than 80 years’ experience with phenobarbital (phenobarbitone), anticonvulsant-induced CDRs remain one of the most difficult challenges in optimising the care of patients with epilepsy and mood disorders.

Epidemiological evaluation is complicated by lack of consensus on reporting and systematic classification of these reactions. Many clinicians choose to discontinue a suspected agent at the first sign of a skin eruption, without confirmation. Time-honoured catalogues are useful for identification of common skin reactions. Broad classification of CDR as mild vs severe reactions seems to aid the clinician in managing the patient.

Both immunological and non-immunological factors contribute to CDRs. Immunological mechanisms consist of 4 types (types I through IV reactions). The most serious eruptions result from a type I or type IV immunological process. Non-immunological mechanisms have great variability, but are believed to include activation of effector pathways, as well as the alteration of pharmacodynamic and pharmacokinetic variables. Epidemiological data suggest that non-immunological CDRs are more predominant and largely reflect the incidence of mild CDRs.

While there is general agreement about discontinuation of suspected agents, issues pertaining to rechallenge and management of severe life-threatening reactions remain controversial. Of the new anticonvulsants, lamotrigine has received much attention following CDR reports. While rare severe CDRs with lamotrigine have been reported, the drug has been successfully reintroduced without precipitation of CDRs.

Severe CDRs require the successful management of fluids, nutrition and infection, and can be best managed in burn centres. Fluid and nutrition balance are typically well controlled with close monitoring of hydration and laboratory values. Prophylactic antibacterial administration is not recommended. Immunosuppressive therapy with corticosteroids to limit the extent of CDRs has received much attention. General recommendations from burn centres suggest this approach may actually promote a negative patient outcome.


Adis International Limited Carbamazepine Valproic Acid Lamotrigine Dermatol 
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Copyright information

© Adis International Limited 1999

Authors and Affiliations

  1. 1.Department of Pharmacy ServicesUniversity of Utah Hospitals and ClinicsSalt Lake CityUSA

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