Clinical Characteristics of Acute Generalized Exanthematous Pustulosis

The clinical characteristics of acute generalized exanthematous pustulosis (AGEP) were summarized in results from a cohort study published in JAMA Dermatology. In a retrospective case series of nearly 350 patients, AGEP onset was acute and typically triggered by initiation of a new antimicrobial agent. Discontinuation of the causal medication resulted in resolution or improvement in the majority of patients.

Investigators conducted a retrospective case series analysis using medical records from 10 academic dermatology departments. Any patient presenting with suspected AGEP from January 2000 to 2020 was included. All potential cases were scored using the EuroSCAR scoring system; individuals with a score of greater than 5 were considered to have definite or probable AGEP and were included in subsequent analyses.

The suspected cause of each AGEP case was identified by reviewing medical records and notes from each consultation. Systemic involvement was determined by reviewing blood levels of creatinine, alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Treatment records were examined to determine treatment type, duration, and outcome. Descriptive statistics were used to summarize AGEP characteristics across patients.

The final study cohort included 340 patients of mean age 58 ± 17.4 years, of whom 62.9% were women, 37.1% were men, 60.6% were White, and 70.3% were non-Hispanic. A significant percentage of patients had a history of diabetes (28.5%), chronic kidney disease (23.2%), or psoriasis (7.1%). More than half (52.4%) of patients developed AGEP while hospitalized; the remaining patients were eventually hospitalized for treatment. Median EuroSCAR score was 8 (interquartile range [IQR], 7-9), with 37.6% of patients receiving a score of “probable” AGEP and 62.4% receiving a score of “definite” AGEP.

Medication was the suspected cause in the majority of cases (85.6%), with 61.9% of cases narrowed down to a single medication. The most commonly involved medications were antimicrobials, which were confirmed as the causative agent in 151 patients. Additional causative medications included anticonvulsants (6.0%), analgesics (3.3%), calcium channel blockers (3.3%), and hydroxychloroquine (2.6%). Median (IQR) time from medication initiation to AGEP was 3 (0-79) days.  Additional causes included an intravenous contrast agent (2.1%) and infection (0.9%). In the remaining 11.5% of patients, no causative agent could be determined.

More than half of patients presented with a fever. Neutrophilia and eosinophilia were present in 85.1% and 52.1% of cases, respectively. Elevated creatinine levels were observed in 29.1% of patients who underwent testing during the AGEP course, suggesting kidney involvement. Further, it was noted, among patients with available data on liver enzymes, 20.1% displayed elevated levels of ALT and/or AST.

In addition to cessation of causal agent, the most common treatment for AGEP was topical corticosteroids (81.5%). Supportive care only was used for 10.5% of patients. AGEP had completely resolved or improved in nearly all patients during follow-up. Median (IQR) length from initial presentation to complete pustular resolution was 8 (5-12) days. A total of 12 patients died during follow-up, though no deaths were suspected to be due to AGEP.

Results from this retrospective case series analysis outline the clinical characteristics of AGEP. The researchers found that onset was acute and typically followed initiation of a new antimicrobial; symptoms typically resolved with cessation of the causative agent. Kidney and liver complications were observed in some patients, although this outcome appeared rare. No deaths attributable to AGEP were observed.

“The results of this retrospective case series analysis of 340 patients with AGEP support many previous hypotheses surrounding the cutaneous adverse reaction,” investigators wrote.

Disclosure: Several study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Creadore A, Desai S, Alloo A, et al. Clinical characteristics, disease course, and outcomes of patients with acute generalized exanthematous pustulosis in the US. JAMA Dermatol. Published online January 5, 2022. doi:10.1001/jamadermatol.2021.5390