Generalized pustular eruptions associated with oral terbinafine

An active 62-year-old man with noninsulin-dependent diabetes and chronic ti nea pedis and tinea unguium developed a painless neurotrophic foot ulcer. H is medical history was significant for mild hypercholesterolemia, chronic o bstructive pulmonary disease, and long-term tobacco and alcohol use. Oral m edications were Glyburide, Glucophage, Zestoretic, gemfibrozil, and aspirin , all of which had been administered daily for at least 8 months. There was no personal or family history of skin disease. After the ulcer failed to respond to conventional therapy, including wound care, debridement, and oral antibiotics, oral terbinafine was prescribed, 2 50 mg/day, for dermatophytosis-impaired wound healing. After 44 days of ter binafine therapy, the patient developed a generalized, erythematous, maculo papular, pruritic eruption accompanied by fatigue and chills. He denied cou gh, arthralgias, dizziness, hematuria, or exposure to anyone ill. Despite i nstructions to stop taking the medication, the patient erroneously continue d to take terbinafine. One week later, he was referred to our institution. Physical examination revealed a nontoxic appearing middle aged man with dif fuse, confluent, erythematous plaques studded with pustules, lakes of pus, and crusted erosions and a fever of 38.9 degrees C (Figs 1 and 2). Palms, s oles, and mucous membranes were unaffected, and the groin was relatively sp ared. Toenails exhibited yellow-white discoloration, subungual debris, and onychauxis. Fingernails were normal. Lymphadenopathy was absent. A 1.3 cm b y 1.7 cm superficial, painless ulcer without significant undermining was pr esent on the left sole over the first metatarsophalangeal joint. There was decreased sensation from the toes to the midleg. Pedal pulses were palpable . Laboratory analyses revealed elevated white blood cell count (10.7 x 10(3) mu L) with 11% eosinophils. Electrolytes, renal, thyroid, and liver functio n tests, urinalysis, and sedimentation rate were normal. A skin biopsy specimen showed an intraepidermal, spongiotic, vesiculopustul ar dermatitis with a superficial, perivascular, mixed inflammatory cell inf iltrate of lymphocytes, neutrophils, and scattered eosinophils (Figs 3 and 4). A periodic acid-Schiff stain was negative for fungi. Terbinafine was stopped, but all other medications were continued. Hydrothe rapy, twice-daily triamcinolone ointment, and a prednisone taper from 60 mg to 0 mg over 3 weeks were initiated. In 4 days, there was complete resolut ion of the fever and pustulosis and a significant reduction of the erythema . At 40 days, mildly pruritic, erythematous plaques persisted on the trunk and extremities. The temporal relationship strongly suggested terbinafine as the inciting ag ent in this patient. Oral provocation test was not performed due to unaccep table patient risk.