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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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 22 | 8 | 30 |
| 2024 Outubro | 127 | 66 | 193 |
| 2024 Setembro | 152 | 78 | 230 |
| 2024 Agosto | 164 | 113 | 277 |
| 2024 Julho | 165 | 102 | 267 |
| 2024 Junho | 115 | 64 | 179 |
| 2024 Maio | 87 | 66 | 153 |
| 2024 Abril | 104 | 93 | 197 |
| 2024 Março | 113 | 74 | 187 |
| 2024 Fevereiro | 128 | 90 | 218 |
| 2024 Janeiro | 96 | 57 | 153 |
| 2023 Dezembro | 74 | 63 | 137 |
| 2023 Novembro | 82 | 87 | 169 |
| 2023 Outubro | 70 | 103 | 173 |
| 2023 Setembro | 79 | 85 | 164 |
| 2023 Agosto | 62 | 34 | 96 |
| 2023 Julho | 101 | 44 | 145 |
| 2023 Junho | 74 | 29 | 103 |
| 2023 Maio | 74 | 19 | 93 |
| 2023 Abril | 69 | 13 | 82 |
| 2023 Março | 68 | 54 | 122 |
| 2023 Fevereiro | 46 | 43 | 89 |
| 2023 Janeiro | 76 | 51 | 127 |
| 2022 Dezembro | 68 | 35 | 103 |
| 2022 Novembro | 75 | 49 | 124 |
| 2022 Outubro | 147 | 53 | 200 |
| 2022 Setembro | 77 | 77 | 154 |
| 2022 Agosto | 63 | 56 | 119 |
| 2022 Julho | 64 | 72 | 136 |
| 2022 Junho | 72 | 60 | 132 |
| 2022 Maio | 52 | 57 | 109 |
| 2022 Abril | 90 | 52 | 142 |
| 2022 Março | 74 | 67 | 141 |
| 2022 Fevereiro | 75 | 43 | 118 |
| 2022 Janeiro | 109 | 84 | 193 |
| 2021 Dezembro | 98 | 64 | 162 |
| 2021 Novembro | 107 | 68 | 175 |
| 2021 Outubro | 131 | 93 | 224 |
| 2021 Setembro | 149 | 103 | 252 |
| 2021 Agosto | 41 | 46 | 87 |
| 2021 Julho | 8 | 13 | 21 |
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