Topical drug-induced acute generalized exanthematous pustulosis misdiagnosed as an oral drug-related eruption.

Acute generalized exanthematous pustulosis (AGEP) is characterized by acute onset of fever with a generalized erythematous pustular eruption. It seems that more than 90% of cases with AGEP are drug-induced [1]. The most frequently involved drugs are aminopenicillins, macrolides, antimycotic drugs, calcium channel blockers, carbamazepine, and paracetamol. We report a severe case of topical drug–induced AGEP that was misdiagnosed as an oral drug–related eruption. A 48-yearold woman who developed a generalized cutaneous eruption without fever was attended several times in the emergency department and was fi nally admitted. Physical examination revealed diffuse edematous erythema with nonfollicular pustules all over the body. The patient had been taking telmisartan and torasemide for several years and reported having taken ibuprofen 7 days before onset. She denied having taken any other drugs during the previous weeks. The hemogram showed a total white blood cell count of 25 700/mL with 85% neutrophils and 5% eosinophils. The results of serology testing and other laboratory investigations were negative. The skin biopsy was compatible with AGEP. Antihypertensive drugs and arylpropionic nonsteroidal anti-infl ammatory drugs (NSAIDs) were stopped, and the patient was treated with parenteral corticosteroids (6-methylprednisolone), antihistamines, and amoxicillin-clavulanic acid. She improved slowly and was discharged from the dermatology department after 14 days taking oral and topical corticosteroids (prednisone and methylprednisolone aceponate). In our allergy department we performed patch testing with the standard series and 7 NSAIDs including ibuprofen. Reactions were evaluated according to International Contact Dermatitis Research Group guidelines. The results were positive to nickel sulfate (D2–, D3+), caine mix (D2+++, D3+++), ethylenediamine dihydrochloride (D2+++, D3+++), and tixocortol pivalate (D2+++, D3+++) (Figure).