Photo-induced Stevens-Johnson syndrome
Authors: Sara Moghaddam, Deirdre Connolly
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: A 19-year-old woman with no past medical history developed a phototoxic rash with progression to Stevens-Johnson Syndrome (SJS) due to ciprofloxacin therapy for a recent vaginal infection. The patient completed a 10-day course of ciprofloxacin and received a 1-time dose of fluconazole on the 10th day of treatment; she was on no other medications and no other risk factors for SJS were present. The day after treatment completion, a red rash concentrated on her chest developed. She complained of difficulty and painful swallowing, which prompted her to visit our emergency department (ED). No facial swelling was present, and she was discharged from the ED and given an oral prednisone taper, famotidine, and diphenhydramine. She took 60 mg prednisone for 2 days and 40 mg prednisone for 1 day; her rash progressed and became more severe. She again presented to the ED for evaluation of her worsening skin condition. On physical examination, the patient had well demarcated dusky violaceous patches confined to sun-exposed areas on her chest, back, arms, and legs, sparing her bikini swimsuit area and watch distribution, as well as other dependent surfaces not exposed to sunlight (Fig 1). Scattered vesiculation was present on her upper back, chest, and upper arms, sparing her face and ears; skin pain was present. She also had white vesicles and erosions on the lips and ulcers of the oral mucosa accompanied by erythematous patches within the labia. There were no target lesions, and palms and soles were not involved. The patient stated she had gone to the beach 2 days before development of the initial rash; she did not apply sunscreen. Skin biopsy showed intact stratum corneum with interface dermatitis and full thickness epidermal necrosis compatible with SJS (Fig 2). Prednisone 60 mg/day was started, and she completed a 7-day course without taper. Her skin lesions and associated pain improved, and skin sloughing occurred on less than 5% her body surface.Fig 2Photo-induced Stevens-Johnson syndrome in a patient treated with ciprofloxacin. Acute stratum corneum full-thickness necrosis of the epidermis and mild inflammatory infiltrate of lymphocytes. (Hematoxylin-eosin stain.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) This case is characterized by two different patterns of adverse cutaneous drug reaction: phototoxicity and SJS, also known as photo-induced SJS. The observed reaction to ciprofloxacin was deemed phototoxic because the lesions appeared as an exaggerated burnlike rash in areas of sun-exposed skin, noticeably sparing areas protected from the sun. These lesions progressed to include dusky patches with vesiculation and desquamation consistent with photo-induced SJS. While multiple cases of photosensitivity, phototoxicity, and SJS have been reported with ciprofloxacin therapy,1Hällgren J. Tengvall-Linder M. Persson M. Wahlgren C.F. Stevens-Johnson syndrome associated with ciprofloxacin: a review of adverse cutaneous events reported in Sweden as associated with this drug.J Am Acad Dermatol. 2003; 49: S267-S269Abstract Full Text Full Text PDF PubMed Google Scholar to our knowledge no case of photo-induced SJS has been reported with ciprofloxacin therapy. Few other cases of photo-induced SJS have been documented and the mechanism behind this reaction remains elusive. Reported cases have been associated with a sulfasalazine, clobazam, hydroxychloroquine, and naproxen.2Borras-Blasco J. Navarro-Ruiz A. Matarredona J. Devesa P. Montesinos-Ros A. Gonzales-Delgado M. Photo-induced Stevens–Johnson syndrome due to sulfasalazine therapy.Ann Pharmacother. 2003; 37: 1241-1243Crossref PubMed Scopus (13) Google Scholar, 3Ortel B. Sivayathorn A. Honigsmann H. An unusual combination of phototoxicity and Stevens-Johnson syndrome due to antimalarial therapy.Dermatologica. 1989; 178: 39-42Crossref PubMed Scopus (25) Google Scholar, 4Redondo P. Vicente J. Espana A. Subira M.L. De Felipe I. Quintanilla E. Photo-induced toxic epidermal necrolysis caused by clobazam.Br J Dermatol. 1996; 135: 999-1002Crossref PubMed Scopus (60) Google Scholar, 5Mansur A. Aydingoz I. A case of toxic epidermal necrolysis with lesions mostly on sun-exposed skin.Photodermatol Photoimmunol Photomed. 2005; 21: 100-102Crossref PubMed Scopus (11) Google Scholar One mechanism proposed is that UVB induces cytokines that recruit cytotoxic T lymphocytes to the epidermis, resulting in the epidermal damage.4Redondo P. Vicente J. Espana A. Subira M.L. De Felipe I. Quintanilla E. Photo-induced toxic epidermal necrolysis caused by clobazam.Br J Dermatol. 1996; 135: 999-1002Crossref PubMed Scopus (60) Google Scholar It is also possible that the phototoxic effects of ciprofloxacin may represent a Koebner phenomenon in which lesions of SJS are confined to the sun-exposed areas. Photo-induced SJS is an extremely rare entity. Only a few cases exist in the literature. This is a report of photo-induced SJS due to ciprofloxacin. If SJS associated with ciprofloxacin therapy is suspected, treatment should be discontinued immediately.