Cutaneous Drug Reactions in Patients Infected with Human Immunodeficiency Virus
Cutaneous adverse drug reactions (cADRs) are commonly seen in HIV-infected patients and must be carefully and expertly managed for the best possible outcomes to be realized. Although skin disorders have decreased in the highly active antiretroviral therapy (HAART) era, and newer pharmacogenetic tests have lessened the impact of at least one serious cutaneous adverse reaction (SCAR)—the abacavir hypersensitivity reaction—cADRs remain very important and challenging. Most cADRs are delayed hypersensitivity (Type IV) reactions. Lipoatrophy, lipohypertrophy, and retinoic acid metabolism-related dermal effects seen with some HIV-1 protease inhibitors are often stigmatizing and may lead to antiretroviral nonadherence or discontinuation. Stevens-Johnson syndrome/toxic epidermal necrolysis remain rare but have been described with most antiretroviral agents and especially with neviripine and trimethoprim-sulfamethoxazole (TMP-SMX). The ability to differentiate between the more common mild to moderate benign cADRs for which the implicated medication may often be safely continued or reintroduced from SCARs including drug-induced hypersensitivity syndromes (DIHS) such as those seen with TMP-SMX, abacavir, and non-nucleoside reverse transcriptase inhibitors, is critical as these cause significant morbidity and can worsen or be fatal on rechallenge.
KeywordsAdverse drug reaction Dose escalation Exanthematous eruption Graded challenge Hypersensitivity reaction Lipodystrophy Morbilliform rash Pharmacogenomic Stevens-Johnson syndrome Tolerance induction Toxic epidermal necrolysis
The author wishes to acknowledge and thank:
Carol A. Stanford, MD, for her steadfast support and encouragement and for her thoughtful comments upon reviewing the chapter manuscript.
Ian M. Stanford, for assisting in computer and other research for factual content, informatics problem solving, and technical graphics arts support including expert help with the tables and figures, and general advice and encouragement.
Ms. Chrystal Head, for her excellent help in searching the literature, obtaining access to key but difficult to obtain references, and copyright issues.
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