Early diagnosis is key in vancomycin-induced linear IgA bullous dermatosis and Stevens-Johnson syndrome

Douglas H Jones, Michael Todd, Timothy J Craig
Journal of the American Osteopathic Association 2004, 104 (4): 157-63

BACKGROUND: With the emergence of highly resistant beta-lactam gram-positive organisms, vancomycin hydrochloride usage has increased considerably. Consequently, adverse drug reactions, including unfavorable cutaneous events, have also increased. Important adverse skin reactions are linear IgA bullous dermatosis (LABD) and Stevens-Johnson syndrome (SJS). These blistering disorders can have clinical manifestations that are difficult to distinguish; however, it is important to make the distinction because treatment and prognosis are different.

OBJECTIVE: The purpose of this study is to review the literature on LABD and SJS and compare important differentiating characteristics to assist physicians in making the correct diagnosis.

METHODS: The authors used MEDLINE to search for all published studies on vancomycin adverse events, and combined LABD, SJS, exanthema, and skin rashes each separately with vancomycin adverse events. Furthermore, the authors searched PubMed for all meta-analyses and randomized controlled clinical trials relating to treatment of patients with SJS.

RESULTS: Clinically, LABD and SJS both present similarly with bullae. Diagnosis is made by use of perilesional skin biopsy and direct immunofluorescence. Direct immunofluorescence shows linear IgA deposition along the basement membrane zone in LABD, whereas this is absent in SJS. The treatment for both vancomycin-induced SJS and vancomycin-induced LABD is prompt discontinuation of the drug. However, if SJS is diagnosed early, systemic corticosteroids appear to decrease morbidity.

CONCLUSIONS: In cases of SJS or LABD that are difficult to distinguish clinically, the authors recommend performing a skin biopsy and direct immunofluorescence early to confirm the diagnosis so that effective treatment can be instituted.

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