Acute generalizedexanthematouspustulosis inducedby bufexamac in anatopic girl

Contact Dermatitis 2008: 58: 247–248

H. Belhadjali1, N. Ghannouchi1, L. Njim2,M. Mohamed1, A. Moussa2, F. Bayou1,M. Chakroun1, A. Zakhama2 and J. Zili1

1Research Unit 22–08/UR/03, Departmentof Dermatology, and 2Department ofHistopathology, Fattouma BourguibaHospital, Monastir, Tunisia

Key words: acute generalized exanthema-tous pustulosis; allergic contact dermatitis;atopic dermatitis; bufexamac; patch test.

Acute generalized exanthematouspustulosis (AGEP) is characterizedby acute onset of a widespread ery-thematous pustular eruption (1). Itis drug-induced in more than 90%of cases (1). Exceptionally, it can becaused by the application of topicalmedicines (2, 3). We report a case of

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AGEP induced by the application ofbufexamac.

Case Report

A 3-year old girl, suffering for mod-erate atopic dermatitis since the ageof 2 years, received topical bufexa-mac (Parfederm�) twice a day fora mild eczema of the cheeks. 2 daysafter, she developed erythematousand pustular lesions, which were inthe beginning localised on the faceand rapidly spread to the rest of thebody. She had also a rise of tempera-ture (38.5 celsius). The parents deniedthe intake of other medications dur-ing the last weeks. Laboratory inves-tigations showed a total white bloodcell count at 20 000 ml with 90% neu-trophils. C-reactive protein was nor-mal. Blood, urine and pustule cultureswere negative. The diagnosis of AGEPwas suspected and confirmed by a skinbiopsy, which showed neutrophil-containing subcorneal pustules associ-ated with perivascular infiltrates withneutrophils and eosinophils. Conse-quently, we stopped the applicationof bufexamac and prescribed a localcorticosteroid (Locatop�). The pus-tules, erythema, and subsequent des-quamation resolved completely within7 days. 6 weeks later, we performedpatch testswith theEuropean standardseries (except primin), bufexamac (5%pet. provided by Trolab, Germany)and Parfederm�. Reactions were eval-uated atD2 andD3 according to Inter-national Contact Dermatitis ResearchGroup (ICDRG) guidelines. Weobtained positive reactions (þþ) atD2 and D3 with bufexamac andParfederm�. Thus, the diagnosis ofAGEP induced by the application ofbufexamac was confirmed.

Discussion

The diagnosis of AGEP was estab-lished according to clinical, bio-logical, and histological criteria andalso to the favourable evolution afterstopping the application of bufexa-mac. The diagnosis of AGEP wasabsolutely certain according to theEuroSCAR group criteria (Score of10/12) (1). Bufexamac is a potentnon-steroidal anti-inflammatory top-ical drug. However, it is consideredas a frequent sensitizer (4–6). In ourcase, the responsibility of bufexamacin the AGEP was confirmed by theresults of patch tests. To the best of

our knowledge, only 1 case of AGEPinduced by topical application ofbufexamac has been reported (2).

References

1. Sidoroff A, Halevy S, Bavinck J N Bet al. Acute generalized exanthematouspustulosis (AGEP) – a clinical reac-tion. J Cutan Pathol 2001: 28: 113–119.

2. Roujeau J C, Bioulac-Sage P, BourseauC et al. Acute generalized exanthema-tous pustulosis. Arch Dermatol 1991:127: 1333–1338.

3. ChavarriaMur E,Gonzalez-CarrascosaBallesteros M, Suarez Fernandez R,Bueno Marco C. Generalized exan-thematous reaction with pustulosisinduced by topical corticosteroids.Contact Dermatitis 2005: 52: 114–115.

4. Kranke B, Derhaschnig J, KomerickiP, Aberer W. Bufexamac is a frequentcontact sensitizer. Contact Dermatitis1996: 34: 63–64.

5. Kranke B, Szolar-Platzer C, KomerickiE et al. Epidemiological significance ofbufexamac as a frequent and relevantcontact sensitizer. Contact Dermatitis1997: 36: 212–215.

6. Barbaud A, Trechot P, Aublet-CuvelierA et al. Bufexamac and diclofenac: fre-quency of contact sensitization andabsence of cross-reactions. ContactDermatitis 1998: 39: 272–273.

Address:Dr Hichem BelhadjaliDepartment of DermatologyFattouma Bourguiba HospitalMonastir 5000TunisiaTel: þ216 73461144 ext. 1290Fax: þ216 73460678e-mail: belhadjalihichem@yahoo.fr

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