case study 7 -- photosensitive rash and resistant hypertension

Elizabeth Ho Moon Liang

CASE STUDY 7 Hypertension Drugs Allergy

Dated: 25 June 2007

Patient’s Name: Cheng H.Y. NIRC: S00*****D

TABLEOFCONTENTSPage

1. Patient Profile 2

2. Health Assessment 2

3. Physical Examination 5

4. Diagnosis 5

5. Management 6

6. Evaluation 9

7. APN reflections and learning points 10

A 54-yearold lady with hypertension presented with photosensitive rashes on 3 February 2007.This case study will be focusing on the 1) approach to photosensitive rash and 2) management of

persisting hypertension.


PATIENT PROFILE

Ms Catherine Cheng (S0054278D), a 54-year old lady, has hypertension for about 3 years. She

was also diagnosed having proteinuria and renal impairment with a CCT of 46ml per minute. She

was attended on the 3 February 2007 for her hypertension control and rashes. This case study

will be focusing on the 1) approach to photosensitive rash and 2) management of persisting

hypertension.

HEALTHHISTORY

Chief Complains:Ms Catherine came for a follow-up appointment for hypertension and rashes

review. She complained that her left leg swells usually at about 4pm after she took the Nifdepine

LA 60mg in the morning. Her skin rashes are still persisting but have resolved slightly. They are

still very itchy but there are no new areas of rashes appearing.

Clinical History:Ms Catherine has been following up in Hougang polyclinic for high blood

pressure control. From 2 Feb 2006 to 3 Feb 2007, her clinic blood pressure readings range from

150/90mmHg to 200/105mmHg. She had tried (1) Beta Blockers: Atenolol, (2) ACE-inhibitors:

Enalapril and Valsartan, (3) Calcium channel blockers: Adalat LA and Amoldipine and (4)

Diuretics: Hydrocholrothiazide and (5) Combination drugs: Losartan/ Hydrochlorthiazide

(Hyzaar amd Hyzaar Forte). During the consult on 3 February, her blood pressure was

160/108mmHg and 170/110mmHg with antihypertensive medications. She denies having

headache, nausea, vision disturbances and neurological symptoms during consult.

It was noted that papular rashes appeared on Catherine’s upper limbs on 06 January 2007. The

rashes were papular and pruritic in nature. The distribution of rashes is in photosensitive areas,

predominantly over the neck, upper limbs, face, bridge of nose and feet. The medications she

was taking every morning once a day during that period of time were 1) Losartan/

Hydrochlorthiazide 100mg/ 25mg 2) Atenolol 50mg 3) Calcium and Vitamin D 1 tablet and 4)

Glucosamine 1500mg. Losartan/ Hydrochlorthizaide combination drug was prescribed to

Catherine since November 2006 which she had tolerated the medications with no side effects

reported. She was also prescribed Atenolol from 2004 to 2006 with no allergy reported. She was

only restarted back on Atenolol with Losartan/ Hydrochlorthiazide combination on the previous

consult prior to developing rashes. She claimed there was no changes in the topical agents that


she was using. She was referred to the National Skin Center with an appointment date on the 9th

February.

She reported that the rashes were better during this consult. However, she is experiencing

swelling of the feet usually around 4pm after taking Nifedipine LA 60mg in the morning. The

swelling resolves usually the next morning. There is no report of shortness of breath or exertional

dyspnea.

Catherine has no history of chronic skin problems. There is also no other significant medical

history of note. She works as a factory operator dealing with packaging of batteries for more than

1 year. There is no exposure of batteries contents during the course of work. There are no

reported joint pains. Review of other systems is negative.

Current Medications:

1) Losartan/ Hydrochlorthiazaide 100mg every morning

2) Nifedipine LA 60mg every morning

3) Hydroxyzine 10mg morning and afternoon, 25mg in the evening

4) Betamethasone Valerate 0.025% cream

Drug Allergy:

Nil reported. However, from her medical notes, it has been noted that Catherine seems to

develop side effects to the following medications.

1) Enlapril – cough

2) Valsartan – headache and cough

3) Amolodipine – pedal edema

She exhibited rashes from enalapril with mild cough and pedal edema from amlodipine. She also

complained having cough and headache with Valsartan. On one of the consults that she

verbalized unhappiness with Adalat LA and hydrocholrothiazide regimen. See Table 1 for the

summary of polyclinic consults.


Date ConsultationNotes Medications02 Feb 06 Wants polyclinic for hypertension follow up care.

BP: 160/100mmHgAtenolol 50mg OM TCU:3mths

18 Feb 06 BP: 160/100mmHg (pre-meds) Atenolol 50mg OMTCU:3mths

10 Jul 06 BP: 160/100mmHg (post-meds) Atenolol 50mg OM. AddEnalapril 2.5mg OM.TCU: 2 weeks

22 Jul 06 BP: 130/70mmHg Same meds for 3mths.

02 Sep 06 BP: 150/96mmHgDevelop itchy rash for few months on and off.Rash and itch were worsened with enalapril.Also has mild cough.

Stop Atenolol and Enalapril.Start Valsartan 40mg OM.TCU: 2 weeks

13 Sep 06 BP: 200/105mmHgNo complains with Valsartan.

Increase Valsartan 80mgOM. TCU: 2 weeks

30 Sep 06 BP: 190/100mmHg (Missed meds for 2 days)Tolerated Valsartan.

Increase Valsartan 120mgOM. TCU: 2 weeks

14 Oct 06 BP: 160/100mmHg. (Post meds) Increase Valaartan 160mgOM.TCU: 2 weeks

27 Oct 06 BP: 160/90mmHgItch and cough, patient claims due to meds.

Start Valsartan.Start Adalat LA 30mg OMand HCTZ 12.5mg OM.TCU: 8 days.

4 Nov 06 BP: 190/100mmHg (pre-meds)Not happy with meds. Still coughing

Off Adalat and HCTZ.Start Amlodipine 5mg OMand Losartan/HCTZ 50mgOM.TCU: 1 week

11 Nov 06 BP: 160/100mmHgWell on meds.

Increase Amlodipine to10mg OM.Losartan/HCTZ 50mg OMremain.TCU: 1 month.

09 Dec 06 BP: 150/90mmHgHas pedal edema for 3 weeks on Amlodipine.

Stop Amlodipine.Increase Losartan/HCTZ100mg OM.TCU: 1 month

06 Jan 07 BP: 170/100mmHg Start Atenolol 50mg OM.Losartan/ HCTZ 100mg OMremain.TCU: 1 month

13 Jan 07 BP: 150/100mmHg (pre meds)Rashes started on upper limb.

Off Atenolol.Losartan/ HCTZ 100mg OMremain.TCU: 2 weeks

27 Jan 07 BP: 160-120mmHg (post meds)Rashes spreading to photosensitive areas.

Losartan/ HCTZ 100mg OMremain.Add Nifedipine LA 60mgOM.Refer NSC.TCU: 1 week

Table 1: Summary of Polyclinic Consult


PHYSICALEXAMINATION

General appearance – Type:Urticaria Erythematous Papules, Shape: round and dome shaped,

Arrangement:Diffuse involvement, Distribution: Sun-exposed region.

Temperature – Afebrile.

Nails –No nails changes. No pallor and clubbing seen.

Eyes – No conjunctivae pallor noted. No papilloedema noted.

Tongue – Moist. Not cyanosis.

a) CVS examination

Pulse – 90 beats per minute. Regular in nature.

Blood Pressure – 160/ 108mmHg and 170/ 110mmHg (post-meds)

Heart – Apex beat palpable between 4th and 5th intercostals space. No thrills and heave felt. S1

and S2 sounds heard. No murmurs detected. Jugular venous pressure not raised. No pedal edema.

b) Lungs examination

Lungs – Respiration rate 12 breaths per minute. Trachea is not deviated. Chest expansion is

bilaterally equal. Vesicular breath sounds hear. No wheezes or rhonchi are detected upon

auscultation.

c) Abdomen examination

Abodmen is not distended. Soft and non-tender. There is no organmegaly. Kidneys are not

ballotable. No renal bruits are detected.

d) Neurological examination

No abnormalities noted.

DIAGNOSES

Principal Diagnosis: Persistent hypertension

Probable Diagnosis: Photosensitivity Dermatitis secondary to drug allergy.

Differentials:Contact Dermatitis, Rosacea, Lupus Erythamous and Dermatomyositis

The urgency to rule out drug allergy is important in Ms Catherine’s case as drug allergy can lead

to other severe complications e.g. anaphylactic shock. In addition, her hypertension management

needs to be optimized. On 2 occasions in September and October 2006, she complained about

itch and rash. The clinical symptoms seem to coincide with addition of ACE and ARBs to the

treatment plan. However, there is a possibility that recurrent episodes of itch and rash can be

triggered from of an unknown primary irritant resulting in contact dermatitis.


MANAGEMENT

Approach to Photosensitive Rashes. Identification of light playing a role in the development of

rash is essential before the approach to photosensitive rash can be used. This involves

recognizing the distribution of the rashes mainly noted on forehead, tip of nose, upper cheeks, V

of chest, outer arms and dorsa of hands. Shaded areas like trunk, axilla regions and flexures tend

to be spared. According to Kwok (2002), photodermatoses can be divided into 4 major groups

and the morphology of rash narrows the differential diagnoses (See Table 2 and 3).

Retrospectively reflecting, in Ms Catherine’s case, which she presented with erythema, urticaria

and papules, drug-induced photosensitivity rash as the probable and the list of differentials seem

appropriate.

Drug photosensitivity

Systemic phototoxicitySystemic photoallergy

Phototoxic contactdermatitis Photoallergiccontact dermatitis

Photo-aggravated dermatoses

Endogenous eczema

Collagen vascular disease

Idiopathic acquired photodermatoses

Polymorphic light eruptionActinic prurigoHydroa vacciniforme

Solar urticariaChronic actinic dermatitis

Genodermatoses &Metabolic disorders

PorphyriasGenodermatoseso Xeroderma pigmentosum

o Cockayne's syndromeo Bloom's syndrome

Nutrional deficiencies

o Pellagrao Hartnup disease

Table 2: 4 Major Classification of Photodermatoses


Morphology Differential Diagnoses

Erythema Sunburn

Drug phototoxicityLupus erythematosusDermatomyositis

Urticaria Solar urticariaErythropoietic protoporphyria

Porphyria cutanea tardaDrug induced urticaria

Oedema Solar urticariaPolymorphic light eruptionLupus erythematosus

Papules Polymorphic light eruptionSystemic lupus erythematosus

Actinic prurigo

Blisters Polymorphic light eruption

Hydroa vacciniformePorphyria cutanea tardaDrug phototoxicity

Phototoxic contact dermatitis

Eczema Chronic actinic dermatitis

Photoaggravated eczemaLupus erythematosusDermatomyositis drug photoallergy

Photoallergic contact dermatitis

Scars Discoid lupus erythematosus

Actinic prurigoHydroa vacciniformePorphyria cutanea tarda

Erythropoietic protoporphyria

No rash Polymorphic light eruption

Sine eruptioneErythropoietic protoporphyriaDrug induced phototoxicity

Table 3: Morphological Clues in Photodermatoses

Dermatomyositis is a rare idiopathic disorder that includes characteristics skin manifestation and

inflammatory myopathy. These patients usually present with other symptoms like proximal

muscle weaknes, dysphonia or disphagia. Other possible symptoms include respiratory muscle

weakness, visual changes and abdominal pain. Patients diagnosed with dermatomyositis have a

6.5-fold increased risk of malignancy. This risk is further increased if the age of diagnosis is


after 45 years of age. Ovarian and gastric cancer, and lymphoma are highly associated with

dermatomyositis. A complete initial gynecologic evaluation with repeated gynecology screening

is thus necessary for a woman with dermatomyositis (Koler and Montemarano, 2001).

Thus, a presentation of photosensitive rash in the primary care setting requires health history

taking and physical examination covering aspects of malignancy, joints and musculoskeletal

involvement. Family history of malignancy and collagen vascular disorders like SLE might also

give an estimate picture of the risk profile.

Hypertension Drug and Skin Rash. Thiazides, captopril and frusemide are noted to commonly

cause serious reactions. Certain anti-hypertensive drugs are associated with specific morphologic

patterns. Other anti-hypertensive drugs that are noted to cause skin rashes include: ACE

inhibitors (particularly Enalapril), calcium channel blockers (particularly Diltazem, amlodipine

and nifedipine) and beta blockers (particularly Propanolol). Hydralazine is note to be commonly

associated with drug-induced SLE (Blume, 2007).

Treatment. Besides determining the cause of the photosensitive rashes. Stopping the suspicious

causative agent to the development or aggravation of the rashes is important. From the medical

history notes, it has been noted that the physicians had immediately stopped the agent that they

thought has caused the eruptions. This conclusion is usually derived from the health history and

analyzing the onset of rashes in respect to the timing that the medication has been started.

Drug-induced RashMedications.Most of drug eruptions treatment is mainly supportive in

nature. Antihistamines can help block the release of histamine and provide symptomatic relief of

the pruritus. Topical corticosteroid agents can also provide symptomatic relief of pruritus.

Hydroxyzine 10mg for morning, afternoon and 25mg for night and Bethamethasone valerate

0.025% cream were prescribed in the previoius consult.

HypertensionManagement. Excluding complications and determining causes for persistent high

blood pressure is necessary approach to patient with very high blood pressure reading. An APN

should refer the patients who fall into this category and manage under the supervision of the

physician.


In Ms Catherine’s case, home monitoring was strongly encouraged. The comparison of the home

monitoring versus the clinical reading will be useful, in view that a proportion of the patients

have white coat hypertension. Her last creatinine level was 96umol/L on 06 January 2007, which

had dropped from 109umol/L in October 2006. The serum potassium was within normal range

and there was no evidence of fluid congestion. As pedal edema was present only after the

introduction of Nifedipine LA 60mg in the prior visit, the drug was taken of the prescription list.

Hydralazine 25mg three times a day was added to the hypertension treatment regimen.

The following medications were prescribed to Ms Catherine on 3 February 2007:

1) Continue Hydroxyzine 10mg morning and afternoon, 25mg in the evening

2) Continue Betamethasone Valerate 0.025% cream

3) Continue Losartan/ Hydrochlorthiazaide 100mg every morning

4) Add Hydralazine 25mg three times a day

EVALUATION

Follow up visits for Ms Catherine was scheduled to return 2 weeks later in view of her high

blood pressure reading and her skin manifestations. The next follow up visit will include

assessing the resolution of the skin rashes and high blood pressure management. From the

National Skin Centre report, hydrochlorothiazide seems to be the most probable agent to cause

Ms Catherine’s photosensitive rash. Most literature stated that the onset of reaction is rarely less

than 1 week or more than 1 month (Riedl and Casillas, 2003). However, Catherine had started on

thiazide since 27 October 2006. The time period between the introduction of drug and the onset

of reaction is about 3 months. The polyclinic physicians knew this information in the subsequent

visit.

Assessing complications of high blood pressure, like renal and cardiac problems, stroke and

papilloedema is also part of the care. The decision to send Ms Catherine to the specialist, in view

of her present proteinuria and mild renal impairment status, should be considered in subsequent

visits if the blood pressure is still not controlled despite treatment. Signs of fluid overload, e.g.

swelling ankles, exertional dyspnea etc. will increase the suspicion of renal deterioration and

require urgent referral to the specialist.


APN RFLECTION AND LEARNINGPOINTS

Hypertension is a very common chronic disease problem that can be seen in the polyclinic

setting. It is interesting that through the case study write up, I get to learn more about

hypertension drugs that will cause photosensitive rashes and other dermatological presentations

that some might bring. It is also important to note for an APN that the approach to photosensitive

rash can at times go beyond just dermatological origin and could be malignancy related.

REFERENCES

Blume. J.E. Drug eruptions. Retrieved on 10 June 2007 from http://www.emedicine.com/derm/topic104.htm

Koler. R.A. and Montemarano, A. (2001). Dermatomyositis. American Family Physician, 64(9),p. 1565-1572.

Kwok, C. (2000). Evaluation of a photosensitive rash. National Skin Centre Bulletin for MedicalPractitioners, 11(1). Retrieved on 14 June 2007 fromhttp://www.nsc.gov.sg/cgi-bin/WB_ContentGen.pl?id=283&gid=54

Riedl, M.A. and Casillas, A.M. (2003). Adverse drug reactions: types and treatment options.

American Family Physician, 68(9), p. 1781-1790.

case study 7 -- photosensitive rash and resistant hypertension

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