Rash and desquamation associated with risperidone oral solution.

Sir: Antipsychotic agents are known to cause adverse cutaneous reactions in approximately 5% of the individuals for whom they are prescribed,1 and there have been some reports of dermatologic disorders associated with conventional antipsychotics.2–5 Although atypical antipsychotics cause fewer dermatologic symptoms than typical antipsychotics,6 some recent reports have associated olanzapine7–9 and clozapine10–13 with skin lesions. To our knowledge, there have not been any reports of adverse cutaneous reactions associated with risperidone or risperidone oral solution. We present a case in which adverse cutaneous reactions were developed after the initiation of risperidone oral solution treatment and soon disappeared after discontinuation of this antipsychotic agent. Case report. Mr. A, a 37-year-old man with DSM-IV bipolar I disorder, was referred to our inpatient clinic in July 2007. His first manic episode had developed at the age of 23 and he had experienced several manic episodes since then. Mr. A was euphoric and irritable. His speech was rapid. He continuously complained about politicians, and said that God had given him an enormous power to punish them. His sleep and appetite were severely disturbed. We started treatment with risperidone oral solution 2 mg at bedtime, lithium 900 mg/day, diazepam 15 mg/day, zolpidem 10 mg at bedtime, and procyclidine hydrochloride 5 mg at bedtime. On the third day of treatment, Mr. A complained of the facial flushing, and we could find rashes under both eyes. On the fourth day of treatment, risperidone oral solution was titrated to 4 mg/day, and lithium was titrated to 1200 mg/day due to his persisting manic symptoms. Other medications were maintained at previous doses. On the fifth day of treatment, the rashes had spread over Mr. A's whole face and neck, and areas of desquamation had developed over his face. On the sixth day of treatment, risperidone oral solution treatment was stopped, and quetiapine 150 mg/day was started and titrated up to 600 mg/day to manage his manic symptoms. On the second day after risperidone oral solution treatment was stopped, Mr. A's skin lesions had completely disappeared. Lithium 1200 mg/day was maintained and serum lithium level was 0.73 mmol/L. Some studies have indicated that several cutaneous adverse effects, which may be dose dependent, are associated with lithium treatment.14,15 In our case, although lithium was coadministered with risperidone oral solution, the immediate improvement of the skin lesions after stopping risperidone oral solution suggests that the adverse skin reactions were because of risperidone oral solution rather than lithium. The combined effect of risperidone oral solution and lithium on the skin cannot be completely excluded, however, and further studies are needed. After the replacement of risperidone oral solution with quetiapine, the skin lesions did not recur. We think that quetiapine is relatively safer than risperidone oral solution in view of the dermatologic adverse effect. The majority of adverse cutaneous events are benign and easily treated.1 However, these adverse events may impact compliance. Our case suggests that risperidone oral solution may cause adverse skin reactions like rashes and desquamation and that quetiapine can be an alternative choice in such cases. Beang-Jin Chae, M.D. Department of Psychiatry, Daedong Hospital, Daegu, Republic of Korea Byung-Jo Kang, M.D. Department of Psychiatry, School of Medicine, Kyungpook National University, Daegu, Republic of Korea