A 32-year-old woman presents to urgent care with a 2-day history of a diffuse itchy rash. She denies fever, skin pain, mouth sores, eye pain, facial swelling, dyspnea, or dizziness. She reports no recent medication changes and initially states that she is not taking any medications, except for a daily multivitamin. Her vital signs are: temperature, 98.6°F; heart rate, 82 beats/min; blood pressure, 122/76 mm Hg; respiratory rate, 16 breaths/min; and SpO₂, 99% on room air. Physical examination reveals a symmetric morbilliform eruption involving the trunk and proximal extremities without blistering, mucosal involvement, facial edema, or lymphadenopathy. The patient appears well and is in no acute distress.
When asked to review all the medications she has taken during the previous 2 months, she eventually recalls completing a 10-day course of trimethoprim-sulfamethoxazole for a urinary tract infection approximately 5 weeks earlier. She has taken no other new medications. You conclude that the timing and morphology are most consistent with an exanthematous drug eruption secondary to trimethoprim-sulfamethoxazole.
Which of the following is the most appropriate next step in management for this patient?
- Document the suspected culprit medication in her chart and advise her to avoid it in the future.
- Order a skin biopsy.
- Refer the patient to the emergency department for higher level of management.
- Provide supportive care and prescribe a systemic corticosteroid.
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Correct answer: a. The suspected culprit medication should be documented and avoided in the future.
Rationale: Exanthematous drug eruptions may develop after a drug has been discontinued, and severe cutaneous adverse reactions such as drug-induced hypersensitivity syndrome can occur weeks after drug initiation, so it is important to elicit a complete medication history covering at the least the past 2 months.
After the culprit medication was discontinued, treatment consisted of symptomatic management with a topical corticosteroid and a second-generation antihistamine for pruritus. Because this patient lacked red-flag symptoms concerning for a severe cutaneous adverse reaction, laboratory testing was not required. She was discharged home with return precautions for fever, mucosal erosions, skin pain, blistering, facial swelling, or worsening rash.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
