DRESS syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Medical Therapy

• Drug withdrawal is the first step in the management of DRESS syndrome.
• Patients with severe skin eruptions are usually admitted to the hospital for close monitoring and fluid/electrolyte management.
• Supportive care is considered the mainstay of therapy, and administration of pharmacologic agents is usually necessary. Data from randomized clinical trials regarding the efficacy of immunosuppressive therapy in the management of DRESS syndrome is not yet available.
• Persistent DRESS syndrome often requires prolonged therapy (possible beyond 1 year).
• Patients hospitalized for DRESS syndrome require multidisciplinary care, including consultation by a dermatologist, hepatologist, and liver transplant specialist.
• The following drugs have been used in the management of DRESS syndrome:

1. Symptomatic relief

• Pruritus: Topical corticosteroids preferred over systemic steroids AND antihistamines
• Fever: Antipyretic therapy

• Note: Avoid antipyretic drugs that are cleared by the liver (e.g. acetaminophen) if liver injury is suspected and drugs cleared by the kidney (e.g. NSAIDs) if renal injury is suspected

2. Exfoliative dermatitis

• Management of exfoliative dermatitis is similar to management of burns:

• Warming
• Management of electrolyte derangements
• Intake of high-caloric diet
• Sepsis prevention

3. Liver involvement

• Unknown benefit of systemic corticosteroids
• Referral to liver transplant in cases of severe hepatic injury (> 3x ULN of LFTs)

4. Lung involvement

• Systemic corticosteroids: Prednisone 0.5-2 mg/kg/day (or equivalent) IV until clinical improvement THEN tapered slowly over 2-3 months

5. Renal involvement

• Systemic corticosteroids: Prednisone 0.5-2 mg/kg/day (or equivalent) IV until clinical improvement THEN tapered slowly over 2-3 months

Other Pharmacologic Agents

Other pharmacologic agents that have been used in DRESS syndrome are the following:

• Cyclosporin
• Intravenous immunoglobulin
• N-acetylcysteine