Track

Case Reports

Abstract

Symmetric Drug-Related Intertriginous and Flexural Exanthema (SDRIFE) is an infrequent cutaneous drug reaction. As the name describes, SDRIFE clinically presents as a characteristic symmetrical erythematous rash on the intertriginous and flexural region of the skin. SDRIFE exhibits variable histologic features but spongiosis, orthokeratosis, perivascular lymphocytes, and dermal eosinophils are most commonly reported. Several medications have been reported to possibly induce SDRIFE, with beta-lactams as the predominant cause. We present a case of SDRIFE with hydroxychloroquine as the implicated drug. To our knowledge, hydroxychloroquine has not been reported as a causative agent for SDRIFE.

A 66-year-old female with history of rheumatoid arthritis presented with a rash. Exam revealed symmetrical eczematous patches of the bilateral forearms and axillae with muddy brown background hyperpigmentation. Symptom onset was noted after starting hydroxychloroquine therapy. Punch biopsy of the forearm showed slight acanthosis and mild spongiosis of the epidermis. The overlying cornified layer showed predominantly orthokeratosis, with only focal parakeratosis. There were superficial and deep dermal perivascular infiltrates of lymphocytes and many interstitial eosinophils. Focal intraepidermal Langerhans cell collections were also present. No interface activity was appreciated. Although Langerhans cell microabscesses may be more commonly associated with allergic contact dermatitis, they can also be seen in SDRIFE. Contact dermatitis was clinically excluded. A diagnosis of SDRIFE, likely hydroxychloroquine-induced, was achieved through clinicopathologic correlation.

Discontinuation of hydroxychloroquine significantly improved the rash. Although skin manifestations, including rash, are not uncommon with hydroxychloroquine, reports of an SDRIFE presentation are limited.