000710 - SDRIFE-like skin rash due to paracetamol

We present a case of a recurrent SDRIFE-like (symmetrical drug related intertriginous and flexural exanthema) reaction three times after intake of paracetamol (acetaminophen) in a 62-year-old male which we could reproduce with oral provocation testing. The aim of this case report is to raise awareness for a rare but frequently prescribed elicitor of SDRIFE or SDRIFE-like eruption.

Our patient experienced three episodes of skin rash in the period from October 2022 to June 2023 in association with the intake of metamizole and paracetamol. The latency of the first two episodes was around three to four days under continued use of the pain medication with skinchanges lasting two and one week, respectively. The latency of the third episode was about eight hours after taking the first dose of paracetamol with skin changes lasting for about one week. In the further course, the patient avoided both drugs, so that no statement on tolerance could be made. As an alternative, 1000 mg acetylsalicylic acid was taken later without complications.

Ten months after the last episode of skin reaction, we performed a skin test with paracetamol (prick, patch) and metamizole (prick, intradermal, patch) which was negative.

In June 2024 an oral provocation with 875 mg paracetamol in total was administered. About 20 hours later, symmetrical erythema manifested on the flexural sides of the forearms, thighs extending to the popliteal fossa, the inguinal area and the flanks for a duration of approx. 24 hours. Unfortunately the patient did not present to our allergy clinic.

One week later, an oral provocation with 875 mg metamizole in total was carried out without complications.

Three months later, we repeated the oral provocation with paracetamol, whereby after 24h a similar erythema, as observed after the first provocation, developed again.

In 1984 the term “baboon syndrome” (BS) was described whereas today the term SDRIFE is used. The term describes the typical distribution pattern of a specific skin rash that occurs after systemic exposure to drugs [1].

P. Häusermann et al. proposed five diagnostic criteria [2].

The most common culprits are Beta‐lactam antibiotics (including aminopenicillins) though the list of eliciting drugs continues to grow [3], [4].

One other case report of a 33-year-old man with SDRIFE due to paracetamol is published [1].

It is important to be aware that SDRIFE-like rashes can be caused by paracetamol.