adverse drug reactions ( adrs ) are important cause of morbidity , hospitalization , increased health expenditure and even death . a meta - analysis found serious adrs accounting for 6.7% of hospitalized admissions in usa . adrs accounted for 0.7% of total admissions and 1.8% of total deaths in a south indian hospital . studies have found the incidence of cadrs in developed countries as 13% , while the incidence in developing countries is supposed to be higher between 2 and 5%.[35 ] adr reporting leads to an increased general vigilance and may influence the recommendations for drug use through regulatory authorities . a prospective , observational study over a period of 6 months ( january  june , 2008 ) was conducted after the approval of the institutional ethics committee at a tertiary care teaching hospital located in north india . the study was conducted by the department of pharmacology with the help of dermatology department and used spontaneous reporting of adr for the collection of data . all patients presenting to the dermatology opd with cutaneous manifestations after drug consumption and those referred from other departments were included in the study . causality assessment of the reported adr was done by establishing the drug use with elaborate elicitation of the history , temporal association with adr , response following stoppage and rechallenge . it was performed following stoppage of the drug for certain period of time depending upon the clinical status of the patient and considering the risk  benefit ratio . adrs were graded as definite , possible and probable according to who causality assessment scale . cutaneous reactions due to drug abuse , errors in drug administration and in patients with incomplete history were not included in the final analysis . patients were specifically asked about the intake of any alternative medicine as they do have high potential to cause cadrs . all reactions were classified into dermatologically distinct morphological patterns by a senior dermatologist on duty and recorded by a pharmacologist in a prefixed proforma for the study . all the patients were given adequate treatment ( soothing lotions , local / oral antibiotics or steroids ) depending upon the severity of cadr . of the total 91 cases reported during the study , 47 ( 51.7% ) were females and 44 ( 48.3% ) were males . the maximum number of cases was seen in the age group 2130 years ( 25.27% ) followed by the age group 3140 years ( 23.07% ) [ figure 1 ] . relation of frequency of cadrs with age the drugs most commonly responsible for cadrs were antimicrobials ( 48.30% ) , followed by nonsteroidal anti - inflammatory drugs ( nsaids ) ( 21.90% ) and anti - epileptics ( 13.20% ) [ figure 2 ] . other drugs presenting with cadrs included ramipril ( n = 1 , 1.09% ) , enalapril ( n = 1 , 1.09% ) , amlodipine ( n = 1 , 1.09% ) , steroids ( n = 2 , 2.19% ) , lithium ( n = 2 , 2.19% ) , oral contraceptives ( n = 1 , 1.09% ) , folic acid ( n = 1 , 1.09% ) , benzoylperoxide ( n = 1 , 1.09% ) , and chlorpromazine ( n = 1 , 1.09% ) . fixed drug combinations causing cutaneous manifestations included tetracycline and ibuprofen ( n = 1 , 1.09% ) , diclofenac and allopurinol ( n = 1 , 1.09% ) , rifampicin and isoniazid ( n = 1 , 1.09% ) , and dapsone and clofazimine ( n = 1 , 1.09% ) . one fatal cadr , toxic epidermal necrolysis ( ten ) , was seen with ciprofloxacin which was prescribed for a case of suspected enteric fever . drug groups causing cadrs maculopapular rash was the most common cadr ( n = 39 , 42.85% ) , followed by fixed drug eruption ( fde ) ( n = 19 , 20.87% ) , urticaria ( n = 11 , 12.08% ) and photosensitivity ( n = 4 , 4.39% ) . bullous eruption , erythema multiforme , lichenoid eruption , and ten were seen in 1 ( 1.09% ) patient each . other cadrs accounted for 14 ( 15.38% ) cases [ tables 1 and 2 ] . incidence of different cadrs incidence of different cadrs with commonly used drugs the lag period between starting the drug and appearance of cutaneous reactions varied between 2 and 14 days in maximum number of cases ( n = 73 , 80.2% ) , within 2 days in 2 ( 2.19% ) and between 15 and 30 days in 16 ( 17.58% ) cases . of all the 91 cases , 3.29% were classified as definite ( n = 3 ) , 76.98% as probable ( n = 70 ) and 19.78% as possible ( n = 18 ) . outcome of cadr showed 65 ( 71.42% ) patients cured , 25 ( 27.47% ) improved and 1 ( 1.11% ) expired . . a wide spectrum of cutaneous manifestations ranging from maculopapular rashes to ten can be produced by different classes of drugs . reactions include pruritis , maculopapular and morbilliform rashes , erythema multiforme , exfoliative dermatitis and others . most drug - induced skin eruptions can be described as erythematous , morbilliform or maculopapular in nature . in the present study , this number may not represent the true prevalence of cadrs during this period as patients with incomplete history and doubtful diagnosis were not included . moreover , the exclusion of many minor cutaneous reactions which do not require hospitalization and underreporting by patients might have contributed to the decreased prevalence of cadrs in this study . mild predominance of cadrs was seen in females as compared to males in concordance with other studies . this difference may be attributed to the fact that the females may be more conscious of any cutaneous reactions and report it , while males tend to ignore or not notice minor cutaneous reactions . similar results have been obtained in other studies where antimicrobials were responsible for 38.6% of cadrs , while some have reported incidence of antimicrobials as a causative factor for cadrs as 56.9% and 55.88% . in a study of hospitalized patients , antimicrobials as the causative factor for cadrs cotrimoxazole continues to be the drug commonly implicated in cadrs , with 23.07% of the cases in the study . predominance of sulfonamides as causative agents for cadrs has been reported from a multicentric analysis from italy and a 6-year study from chandigarh , india . there was one fatal cadr in the form of ten due to ciprofloxacin in the present study . a higher incidence of fatal cadrs  ten and steven johnson syndrome ( sjs )  as 11.4% was found in the study by sharma et al . the incidence of ten and sjs was reported to be 0.2% and 1.82% , respectively , by the italian study . the study by sharma et al . reported nsaids as a cause for cadrs in 18% of the patients . of the various cutaneous manifestations of drug reactions , maculopapular rash was seen most commonly in 42.8% of the patients , followed by fde in 20.8% and urticaria in 12.08% of the patients in the present study . maximum incidence of maculopapular rash was seen in cases of antimicrobial use , followed by nsaid use . anticonvulsants as the most common cause of maculopapular rash were reported by sharma et al . the present study also documented the most common cadr following antiepileptic use as maculopapular rash . fde was most commonly due to cotrimoxazole use and similar results have been reported in other studies . only one case of fde was seen due to tetracycline use , in a patient who had used fixed drug combination of tetracycline and ibuprofen . cutaneous manifestations of adrs have been remarkably similar for most drugs and have been seen to be consistently associated with them . in conclusion , they increase the burden of work and can be fatal at times adding to the common person 's negative perception of allopathy . with the number of drugs being marketed increasing every year , it is of paramount importance to have an in - depth understanding of their possible adverse reactions and this is possible only when the physician is trained adequately and is actively looking for any adrs . a robust mechanism for reporting of adrs is required while the clinician is to be always on the lookout for adrs . so , anticipating , preventing , recognizing and responding to adrs should be the prime concern of the clinicians so as to minimize the incidence of adrs .
background : cutaneous manifestations of adverse drug reactions are a common occurrence and need to be differentiated from other causes of similar manifestations . 
 active search is essential for identification of these as patients may tend to downplay the causal association between drug use and the subsequent cutaneous manifestation.purpose:to study the incidence of cutaneous adverse drug reactions ( cadrs ) in a tertiary care teaching hospital in north india.methods:a prospective , observational study was conducted over a period of 6 months ; using self - reporting method for selection of cases . 
 the cadrs were graded as definite , possible and probable.results:during the study period , 91 cases of cadrs were observed . maximum incidence of cadrs was seen with antimicrobials ( 48.30% ) , followed by nonsteroidal anti - inflammatory drugs ( 21.90% ) . 
 maculopapular rash was the most common cutaneous manifestation of adrs ( 42.85%).conclusion : cadrs are a common occurrence and awareness about the same is essential for diagnosis and prevention .