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Dermatological changes are a common observation in patients who use hydroxychloroquine for a short period, and usually resolve upon treatment cessation.
Common Manifestations of Dermatological Toxicity
Common Manifestations of Dermatological Toxicity
Drug eruptions
Pruritus
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)
Acute generalised exanthematous pustulosis (AGEP)
Hyperpigmentation1.
Drug eruptions
Drug eruptions
These are often maculopapular (flat), erythematous (reddened) and / or urticarial (itchy red patches). Most eruptions will resolve without stopping hydroxychloroquine treatment, but some cases require cessation of treatment and gradual reintroduction2.
Pruritus
Pruritus
Pruritus is the medical term for itching3. This does not usually require medical treatment.
SJS / TEN
SJS / TEN
These conditions are different stages in a continuum, with SJS being the mild form of the condition and TEN being more severe. They result in painful erosions to the skin, and may spread to the mucous membranes and conjunctiva4.
AGEP
AGEP
AGEP is denoted by the accumulation of small pustules on an erythematous base such as the head. If cessation does not improve symptoms, it can be treated with topical / systemic steroids, dependent on where the reaction has occurred5.
Hyperpigmentation
Hyperpigmentation
A recent systematic review found that 100% of 116 cases of hydroxychloroquine induced hyperpigmentation involved a blue-grey discolouration of the skin. It is postulated that hyperpigmentation with hydroxychloroquine use is facilitated by bruising, due to the increased levels of iron and melanin in areas that have been bruised1-2.
Other Dermatological Toxicities
Other Dermatological Toxicities
Dermatological toxicity is not limited to the skin, it can also affect the appearance of the:
Hair
Mucosa
Nails
Hair loss is a common adverse effect, although bleaching and hyperpigmentation have also been reported in several cases. Ulceration and hyperpigmentation of the mucosa, and melanonychia of the nails (a black-brown pigmentation of the nail palate) are also reported with hydroxychloroquine use1.
References:
- Sharma AN, Mesinkovska NA, Paravar T. Characterizing the adverse dermatologic effects of hydroxychloroquine: a systematic review. Journal of the American Academy of Dermatology. 2020, 83(4): 291-292.
- Chew CY, Mar A, Nikpour M, Saracino AM. Hydroxychloroquine in dermatology: new perspectives on an old drug. Australasian Journal of Dermatology. 2019; 61(2): 150-157.
- NHS Inform. Itching. [Online]. 2021. [Date accessed 21/11/21]. Available from: https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/itching.
- Harr T, French LE. Stevens-Johnson syndrome and toxic epidermal necrolysis. Chem Immunol Allergy. 2012; 97:149-166.
- Feldmeyer, L., Heidemeyer, K., & Yawalkar, N. Acute Generalized Exanthematous Pustulosis: Pathogenesis, Genetic Background, Clinical Variants and Therapy. International journal of molecular sciences. 2016;17(8): 1214.
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