ARTICLE
Several cutaneous disorders can have a linear
distribution corresponding to Blaschko's lines. We describe here a case
of linear drug eruption induced by ibuprofen, following the Blaschko embryological
lines, with an unusual course.
Case report
A 19-year-old Caucasian woman was referred with a pruriginous linear
eruption on her right arm and trunk of 5 days duration. The first physical
examination disclosed a pruritic, linear, whorled, erythematosus, papular
eruption on the right side of her trunk, back and arm, from the shoulder
downward along the inner aspect of the flexural surface of the arm to
the hand, affecting the second and fifth fingers (Figs.
1 and 2). After five days
the lesions became generalized (Fig.
3). Histopathological examination was not performed, because the
patient did not give permission. No systemic abnormalities were found
on physical and routine laboratory examination. She had received oral
ibuprofen (400 mg every 12 hrs) during the previous four days, for dismenorrhea.
She had a history of ibuprofen intake every month during the last year.
After withdrawal of ibuprofen and treatment with dexametasone (0.2 mg
every 8 hrs) and clemastine (1 mg every 12 hrs) for fifteen days in tapering
dosages, the lesions cleared without residual hyperpigmentation.
Six weeks later, topical provocation tests were performed. Tape-stripping
occlusive patch testing with ibuprofen without dilution in white petrolatum,
with pure petrolatum as negative control, gave no reaction on previously
affected skin.
Discussion
Several cutaneous disorders can have a linear distribution, such as
lichen planus, lichen striatus, epidermal nevi including inflammatory
linear verrucous epidermal nevus, and incontinentia pigmenti [1]. In these
disorders the distribution of the lesions corresponds to Blaschko's lines,
suggesting that a postzygotic mutation is related to this phenomenon [1,
2]. However, on the extremities, linear inflammatory skin diseases run
in a perpendicular pattern. Reviewing the literature, we found some reports
of linear dermatosis related to drugs as linear fixed drug eruption caused
by trimethoprim [3] and cephazolin [4], or related with chronic cutaneous
graft-versus-host disease [5] and a case of lichen planus induced
by nicergoline [6], but without generalization of the eruption. Our patient
initially disclosed a linear eruption following Blaschko's lines but,
after several days, the lesions became generalized, related to the ibuprofen
treatment. The linearity seen in our patient did not occur in dermatomes
previously affected by herpes zoster or other dermatosis. Grosshans et
al. [7] proposed the term blaschkitis for those acquired lesions that
follow Blaschko's lines and suggested that the linear distribution might
be explained by cellular mosaicism. During fetal life, a mutation may
have caused a clone of cells with a different histocompatibility antigen
to populate a specific area of skin. An immunological tolerance to aberrant
cellular clones may exist, but several factors may induce a specific cellular
clone to acquire different features, such as a membrane antigen that would
induce the immune response causing the dermatosis [7, 8]. To the best
of our knowledge, this report represents the first case of linear drug
eruption that later evolved in a disseminated rash.
REFERENCES
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drug eruption. Br J Dermatol 1997; 137: 1028-9.
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drug eruption. Br J Dermatol 1988; 118: 849-58.
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chronic cutaneous graft-versus-host disease. J Am Acad Dermatol
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eruption after bone marrow transplantation: an unmasking of tolerance
to an abnormal keratinocyte clone. J Am Acad Dermatol 1993; 28:
888-92.
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