Fixed Drug Eruption: Easily Overlooked but Needing New Respect
Fixed Drug Eruption: Easily Overlooked but Needing New Respect
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固定药疹：很容易被忽视，但需要新的尊重
DOI：
10.1159/000063891
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发表时间：
2002
期刊：
影响因子：
3.4
通讯作者：
Y. Mizukawa
中科院分区：
文献类型：
--
作者：
T. Shiohara;Y. Mizukawa
经典的固定性药疹 (FDE) 很容易通过色素沉着过度病变来识别，每次使用致病药物时，这些病变都会在完全相同的区域复发。然而，在皮肤病变缺乏这种特征性色素沉着过度的情况下，很难记录病变是否已“固定”：因为色素沉着的色调往往会随着每次后续恶化而变得更暗，因此在浅色皮肤患者中，在几次发作后识别 FDE 病变将是相当困难的。在浅色皮肤中，即使多次发作后，这种病变的颜色仍会保持紫灰色。在这方面，Shelley 和 Shelley [1] 描述了 FDE 的一种非色素沉着变体，其中病变是对称的，并且随后不出现色素沉着。尽管这种非色素沉着形式最初被定义为显示对称分布，但很明显，非色素沉着形式也可以表现为孤立的病变，就像经典形式一样[2]。然而，由于该实体的渗透率相对较低，这些不寻常的形式经常被误诊为特发性皮肤病，具体取决于临床表现的模式。那么，除非在鉴别诊断中考虑到药疹的可能性，否则如何诊断这些不寻常的形式？为了提供解决这些难题的框架背景，重要的是要考虑为什么 FDE 皮损最初发现于特定的好发区域。在本期《皮肤病学》中，我们发现一些多发性 FDE 病变最初出现在先前受过创伤的皮肤部位，例如烧伤疤痕和昆虫叮咬 [3]。本病例报告深入了解了 FDE 的发病机制，对其病因学具有重要意义。重点包括能够产生 FDE 损伤的起始事件的性质，以及与“同构”或“同位素反应”现象的类比：术语“同构”和“同位素”反应描述了一种新的、“不相关”疾病的发生，该疾病分别与先前已经治愈的疾病具有完全相同的形态特征和完全相同的位置。 疾病。文献中的许多报告描述了先前暴露于辐射、创伤、烧伤、疫苗接种或病毒性疾病（带状疱疹或单纯疱疹）的区域发生“第二种”疾病。 “同构”或“同位素”现象在多形红斑 (EM) 中已得到充分记录：在大多数 EM 病例中，皮肤病变优先发生在先前皮肤外伤和最近阳光照射的部位 [4]。值得注意的是，近年来，在不同术语“回忆”或“类回忆”现象下也报道了类似的现象 [5, 6]：在后者中，药物反应发生在先前晒伤的部位，其中晒伤引起的炎症早在回忆事件之前就已经消退了 [7]。 EM 的皮损也可能与 FDE 相似，特别是非色素沉着形式，并且一些表现出“同构”或“照片回忆样现象”的 EM 病例实际上可能是 FDE，皮损仅限于先前受过外伤或晒伤的皮肤（图 1）。事实上，之前的报告描述了被认为代表典型 EM 的皮肤损伤是通过致病药物的攻击而重现的 [8]，并且儿童中常见的大疱性 FDE 最常被误诊为昆虫叮咬反应 [9]。因此，不寻常形式的初始皮肤病变（例如非色素性 FDE）很容易被忽视，除非临床医生特别注意识别这种不寻常形式的存在。因为这会是……
Classic fixed drug eruptions (FDE) are easily identified by hyperpigmented lesions that recur in exactly the same areas on each administration of the causative drug. In cases with skin lesions lacking this characteristic hyperpigmentation, however, identification of the lesions as being ‘fixed’is difficult to document: because the shade of the pigmentation tends to become darker with each succeeding exacerbation, it would be quite difficult to recognize the FDE lesions after a few episodes in patients with lighter-hued skin. In lighter-hued skin, the color of such lesions would remain purplish gray even after numerous episodes. In this regard, Shelley and Shelley [1] described a nonpigmenting variant of FDE, in which the lesions are symmetric and not followed by pigmentation. Although this nonpigmenting form was originally defined as showing a symmetric distribution, it has become clear that the nonpigmenting form can also appear as a solitary lesion, just like the classic form [2]. Nevertheless, because of the relatively low penetration of this entity, these unusual forms are frequently misdiagnosed as idiopathic skin diseases, depending on the mode of clinical presentation. How then can these unusual forms be diagnosed unless the possibility of drug eruptions is considered in the differential diagnosis?In order to provide a background for a framework on which to approach these difficult questions, it would be important to consider why FDE lesions are initially found in a particular area of predilection. In the current issue of Dermatology, we show that some multiple FDE lesions initially appeared at previously traumatized skin sites, such as burn scars and insect bites [3]. This case report provides insights into the pathogenesis of FDE with important implications for its etiology. Points of emphasis include the nature of the initiating events capable of producing FDE lesions, and the analogy with the phenomenon known as ‘isomorphic’or ‘isotopic response’: the terms ‘isomorphic’and ‘isotopic’response describe the occurrence of a new,‘unrelated’disease that appears with exactly the same morphologic features and at precisely the same location, respectively, as a previously already healed disease. Many reports in the literature describe the occurrence of a ‘second’disease in areas previously exposed to irradiation, traumas, burns, vaccination or a viral disease (herpes zoster or herpes simplex). The ‘isomorphic’or ‘isotopic’phenomenon has been well documented in erythema multiforme (EM): in most cases of EM, skin lesions preferentially occur at sites of previous skin trauma and recent sun exposure [4]. Careful attention should be given to the fact that in recent years similar phenomena have been reported under the different term ‘recall’or ‘recall-like’phenomenon [5, 6]: in the latter, the drug reactions occur at sites of previous sunburns in which the sunburn-induced inflammation has resolved long before the recall event [7]. Skin lesions of EM may also bear resemblance to FDE, particularly a nonpigmenting form, and some cases of EM showing the ‘isomorphic’or ‘photo recall-like phenomenon’may actually be FDE with skin lesions confined to previously traumatized or sunburned skin (fig. 1). Indeed, previous reports describe that skin lesions thought to represent typical EM were reproduced by challenge with the causative drug [8], and that the generalized bullous form of FDE seen in children was most often misdiagnosed as insect bite reaction [9]. Thus, initial skin lesions of unusual forms such as a nonpigmenting form of FDE would be easily overlooked unless clinicians take special care to recognize the presence of such unusual forms. Because it would be …