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Niraj Parajuli
From the Department of Dermatology and Venereology, National Academy of Medical Sciences, Bir Hospital, Mahaboudha, Kathmandu, Nepal
Correspondence Address:
Niraj Parajuli
Department of Dermatology and Venereology, National Academy of Medical Sciences, Bir Hospital, Mahaboudha, Kathmandu
Nepal
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijd.ijd_1045_21
How to cite this article:Sir,
A 54-year-old man, with a known case of hepatitis B-induced liver cirrhosis and psoriasis vulgaris under topical Clobetasol, came to the dermatology outpatient department with multiple guttate psoriatic papules for a week. The patient had two similar presentations over the last 6 months and was treated with oral cefadroxil with improvement. Hence, the patient was advised to start on oral cefadroxil for this episode as well. After a few hours of ingestion of oral cefadroxil, the patient noted redness on the whole body with associated pruritus. On examination, there was diffuse erythema present bilaterally over the axilla, groin and antecubital fossa [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Similarly, there was a flare of redness over the periphery of all the psoriatic plaques [Figure 1]e. A faint erythema was also noted all over the body excluding the palms and soles [Figure 1]f. All routine blood counts were within normal limits. The patient's liver function was slightly deranged due to the underlying liver cirrhosis. A typical distribution of erythema without systemic involvement suggests the diagnosis of symmetrical drug-related intertriginous and flexural exanthema (SDRIFE). No patch testing or provocative testing was performed.
Figure 1: (a-d) Bright distinct erythema noted over bilateral axilla, groin, suprapubic region and antecubital fossa. (e) Erythema over all of the psoriatic plaques. (f) Slight erythema of the anterior trunkOral Cefadroxil was stopped immediately. The patient was started on oral Fexofenadine and moisturisers with improvement in only 2 days [Figure 2]a, [Figure 2]b, [Figure 2]c.
SDRIFE, previously known as 'Baboon syndrome', is a benign condition caused by systemic medication without any systemic symptoms.[1] A set of diagnostic criteria has been proposed for SDRIFE, which includes exposure to a systemically administered drug for the first or repeated doses, sharply demarcated erythema of the gluteal/perineal and/or inguinal area, involvement of at least one other intertriginous/flexural areas, symmetry of affected area and absence of systemic symptoms and signs.[2]
Aminopenicillin, beta-lactam antibiotics and certain chemotherapy drugs are common culprits.[3] The exact mechanism is unknown, but it is believed to be the result of a type IV hypersensitivity reaction. The treatment of this condition is the removal of the offending agent and symptomatic relief.[4]
There is a single report of baboon syndrome in a patient taking cefadroxil, paracetamol and cough syrup where an exact aetiology was not confirmed.[5] An additional important feature noted in this case was a significant erythematous flare around the psoriatic plaques that resolved within a few days, which was similar to fixed-drug eruption.[6] This might be because the psoriatic plaques were also the target for the delayed-type hypersensitivity reactions.
This case developed SDRIFE after multiple uses of oral cefadroxil only. This case highlights SDRIFE occurrence with oral cefadroxil, a commonly used antibiotic in dermatology. It also emphasises that it can occur even after multiple episodes of ingestion. A flare-up of psoriatic plaques is unique since this phenomenon may need further investigation to find whether the disease is limited only to folds.
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