First multifocal bullous fixed drug eruption due to etodolac.

Fixed drug eruption (FDE) usually appears as a solitary/small number of pruritic, well circumscribed, erythematous--violaceous macules that evolve into oedematous plaques which typically resolve after the discontinuation of the offending drug, leaving residual hyperpigmentation. This eruption is considered pathognomonic of a drug-induced dermatosis and is triggered within a few minutes or up to several hours after medicine intake. Lesions re-occur on exactly the same sites when the offending drug is re-administered. FDE can occasionally present itself through a wide spectrum of clinical manifestations, but multifocal bullous FDEs are rare and require differentiation from other blistering diseases, like herpes labialis, localised bullous pemphigoid, discoid lupus erythematosus and toxic epidermal necrolysis (TEN). Etodolac, a pyranocarboxylic acid, known as a COX-2 selective inhibitor, is a widely used analgesic-antipyretic with a consistent safety profile. Its cutaneous side effects are rare, varying from pruritus or rash to fatal TEN. There are only two publications so far about etodolac-induced FDE, with non-pigmenting/pigmenting limited cutaneous lesions, however, multifocal bullous FDE has not been previously described as one of them. A 30-year-old man with perennial mild allergic rhinitis was referred to our unit with a 6-month history of recurrent angio-oedema/urticaria episodes, which occurred 30 min and 13 h after flurbiprofen and paracetamol intake, respectively. His medical history revealed frequent nonsteroidal anti-inflammatory drugs (NSAIDs) intake for his headaches and two attacks of orogenital bullous ulcerations along with erythematous eruption over his extremities in the last 12 months. Lesions were recurrent at the same locations, always occurring 5--7 h after taking etodolac and then resolving in 2 weeks; and the last attack was eight months before. His family practitioner diagnosed these lesions as herpes infection, and prescribed acyclovir. There was no other significant medical history. At the time of clinical evaluation his physical examination