Case Letter
Symmetrical intertriginous and flexural exanthema related to the use of paracetamol
Joana Alexandria Ferreira Dias, Luana Moraes Campos, Juliano Vilaverde Schmitt, Sílvio Alencar Marques
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Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
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[ "paginaInicial" => "646" "paginaFinal" => "647" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Joana Alexandria Ferreira Dias, Luana Moraes Campos, Juliano Vilaverde Schmitt, Sílvio Alencar Marques" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Joana Alexandria Ferreira" "apellidos" => "Dias" ] 1 => array:2 [ "nombre" => "Luana Moraes" "apellidos" => "Campos" ] 2 => array:2 [ "nombre" => "Juliano Vilaverde" "apellidos" => "Schmitt" ] 3 => array:4 [ "nombre" => "Sílvio Alencar" "apellidos" => "Marques" "email" => array:1 [ 0 => "silvio.marques@unesp.br" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2011 "Ancho" => 1508 "Tamanyo" => 217694 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SDRIFE: evidence of axillary involvement.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1984, Andersen et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> reported three patients who developed erythematous lesions on the gluteal region, inner thighs and armpits, without accompanying overall symptoms and who were systemically exposed to allergens to which they had previous contact sensitization. By analogy of the lesions to the gluteal morphological aspect of baboons (<span class="elsevierStyleItalic">Papio papio</span>), the name Baboon syndrome (BS) was suggested for these cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Hausermann et al., in 2004, proposed the designation symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) for cases of systemic drug sensitization, without topical exposure, clinically identical to BS, and highlighted the absence of accompanying systemic signs and symptoms.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This is the report of a 56-year-old male patient complaining of lesions on the inguinal and axillary regions that were slightly pruritic and not associated with other systemic symptoms. He reported a two-day use of paracetamol, exclusively, and a condition identical to the current one in previous exposures. Upon physical examination, well-delimited, erythematous, wine-colored lesions were observed, without signs of excoriation, with a bilateral and symmetrical distribution on the axillary, inguinocrural, gluteal regions, and lateral aspect of the thighs, including the popliteal region (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Histopathological examination of a biopsy in an axillary lesion showed epidermis with mild spongiosis, moderate dermal, lymphohistiocytic, perivascular infiltrate, and vasodilation. The absence of necrotic keratinocytes and pigmentary incontinence was observed, which ruled out fixed drug eruption (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore, the clinical, dermatological, and histopathological data allowed the diagnosis of paracetamol-induced SDRIFE. The lesions disappeared within a few weeks after drug discontinuation and the use of topical corticosteroids.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 2011, Miyahara et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> proposed the classification of Baboon syndrome into four subtypes: 1) classic BS, resulting from sensitization by contact allergens and triggered by systemic exposure to them; 2) BS induced by contact with drugs, triggered by absorption after skin re-exposure; 3) BS induced by systemic sensitization and a condition triggered by cutaneous exposure to the drug; and 4) SDRIFE, which corresponds to systemic sensitization and manifestation when there is systemic re-exposure, excluding contact allergens.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Clinically, SDRIFE is characterized by symmetrical exanthema in the gluteal, intergluteal and inguinal area, in addition to the involvement of at least one intertriginous and flexural area such as axillary, cubital, and popliteal areas. It is considered a rare and benign manifestation of a hypersensitivity reaction with an absence of systemic symptoms. The onset occurs in hours to two days after exposure to the causative agent. The most often implicated medications are beta-lactams, particularly amoxicillin, sulfamides, anti-inflammatory drugs, barbiturates, tetracyclines, and carbamazepine. In the literature, there are only two reported cases of SDRIFE associated with the use of paracetamol.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The pathogenesis is not completely understood, but, as in allergic contact dermatitis, the picture suggests a delayed hypersensitivity reaction mediated by T cells. A greater density of eccrine sweat glands in skinfold regions would explain their restricted or predominant manifestation in intertriginous locations, where the excretion of the sensitizing drug would precipitate the dermatosis. Treatment involves suspicion and interruption of the drugs being used. Topical or systemic steroids can speed up resolution. Case reports and identification of the triggering drug are useful from a instructive and epidemiological viewpoint.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Joana Alexandria Ferreira Dias: Approval of the final version of the manuscript; design and planning of the study; critical review of the literature.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Luana Moraes Campos: Approval of the final version of the manuscript; critical review of the manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Juliano Vilaverde Schmitt: Approval of the final version of the manuscript; collection, analysis and interpretation of data; critical review of the manuscript.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Silvio Alencar Marques: Approval of the final version of the manuscript; drafting and editing of the manuscript; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-08-01" "fechaAceptado" => "2020-08-18" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Dias JAF, Campos LM, Schimitt JV, Marques SA. Symmetrical intertriginous and flexural exanthema related to the use of paracetamol. An Bras Dermatol. 2021;96:646–7.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Faculdade de Medicina, Universidade Estadual Paulista, Botucatu, SP, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1200 "Ancho" => 900 "Tamanyo" => 137317 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">SDRIFE: erythematous-purpuric macules affecting the suprapubic region, lateral thighs and inguino-crural region.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2011 "Ancho" => 1508 "Tamanyo" => 217694 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SDRIFE: evidence of axillary involvement.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 171198 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">SDRIFE: Histopathology showing perivascular lymphohistiocytic infiltrate in the superficial and mid-dermis (Hematoxylin & eosin, ×100).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Baboon syndrome: systemically induced allergic contact dermatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 3 | 10 |
| 2024 October | 127 | 66 | 193 |
| 2024 September | 152 | 78 | 230 |
| 2024 August | 164 | 113 | 277 |
| 2024 July | 165 | 102 | 267 |
| 2024 June | 115 | 64 | 179 |
| 2024 May | 87 | 66 | 153 |
| 2024 April | 104 | 93 | 197 |
| 2024 March | 113 | 74 | 187 |
| 2024 February | 128 | 90 | 218 |
| 2024 January | 96 | 57 | 153 |
| 2023 December | 74 | 63 | 137 |
| 2023 November | 82 | 87 | 169 |
| 2023 October | 70 | 103 | 173 |
| 2023 September | 79 | 85 | 164 |
| 2023 August | 62 | 34 | 96 |
| 2023 July | 101 | 44 | 145 |
| 2023 June | 74 | 29 | 103 |
| 2023 May | 74 | 19 | 93 |
| 2023 April | 69 | 13 | 82 |
| 2023 March | 68 | 54 | 122 |
| 2023 February | 46 | 43 | 89 |
| 2023 January | 76 | 51 | 127 |
| 2022 December | 68 | 35 | 103 |
| 2022 November | 75 | 49 | 124 |
| 2022 October | 147 | 53 | 200 |
| 2022 September | 77 | 77 | 154 |
| 2022 August | 63 | 56 | 119 |
| 2022 July | 64 | 72 | 136 |
| 2022 June | 72 | 60 | 132 |
| 2022 May | 52 | 57 | 109 |
| 2022 April | 90 | 52 | 142 |
| 2022 March | 74 | 67 | 141 |
| 2022 February | 75 | 43 | 118 |
| 2022 January | 109 | 84 | 193 |
| 2021 December | 98 | 64 | 162 |
| 2021 November | 107 | 68 | 175 |
| 2021 October | 131 | 93 | 224 |
| 2021 September | 149 | 103 | 252 |
| 2021 August | 41 | 46 | 87 |
| 2021 July | 8 | 13 | 21 |
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