Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

serious cutaneous adverse reactions

1st line – withdrawal of suspected drug

Back
ACUTE
|
serious cutaneous adverse reactions
1st line – 

withdrawal of suspected drug

Withdrawal of the suspected drug is essential.

Plus – adrenaline (epinephrine) + supportive care

Back
ACUTE
|
serious cutaneous adverse reactions
|
acute anaphylactic reactions
Plus – 

adrenaline (epinephrine) + supportive care

Treatment recommended for ALL patients in selected patient group

Call for help and treat as an emergency.[45]​ See Anaphylaxis (Treatment algorithm).

Key considerations are as follows.

Acute anaphylactic reactions are treated by having the patient lie down if they are hypotensive, sitting them up if they are having trouble breathing, or lying them in the recovering position if they are unconscious.[45]​ The offending drug should be withdrawn, and intramuscular adrenaline given as soon as possible. A further follow-up dose of intramuscular adrenaline can be given after 5 to 15 minutes if necessary (guidelines vary on the precise timing of repeat dose[s] so check your local protocol). If required, intravenous adrenaline should be given under the guidance of a physician experienced in the use and titration of vasopressors.[45]​​[54]

Take an ABCDE approach and give high-flow supplemental oxygen and intravenous fluids (e.g., normal saline) if indicated.[45][55]​​​[56] ​If there is marked stridor, nebulised adrenaline should be administered. If the patient has persistent bronchospasm despite adrenaline, an inhaled beta-2 agonist (e.g., salbutamol) is indicated.[45][55]​​[56]

Biphasic reactions can occur.[45]​ Antihistamines and/or corticosteroids are not reliable in preventing biphasic anaphylaxis but may be considered as secondary treatment.[45]​​[54]

Primary options

adrenaline (epinephrine): consult specialist for guidance on dose

Plus – topical dressings + supportive management

Back
ACUTE
|
serious cutaneous adverse reactions
|
Stevens-Johnson syndrome or toxic epidermal necrolysis
Plus – 

topical dressings + supportive management

Treatment recommended for ALL patients in selected patient group

Withdrawal of the suspected drug is essential. Patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) should be assessed in the same way as a patient with cutaneous burns, using a structured approach to evaluate airway, breathing, and circulation. See Cutaneous burns (Diagnosis approach).

Treatment requires a multidisciplinary team so that patients receive optimal daily wound care, nutrition, critical care, pain management, and supportive care.[57] Transfer to a burn centre, a specialised wound care centre, or a dermatology intensive care unit is recommended for patients with SJS/TEN.[57][58]

Exact treatment will depend on the extent of skin involvement. See Stevens-Johnson syndrome and toxic epidermal necrolysis (Management approach).

Plus – corticosteroid

Back
ACUTE
|
serious cutaneous adverse reactions
|
DRESS (drug reaction with eosinophilia and systemic symptoms; also called drug hypersensitivity syndrome)
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Systemic treatment may be required in severe cases such as severe liver dysfunction. A topical corticosteroid (e.g., betamethasone) may be used in mild cases.

Care should be taken not to withdraw corticosteroid too early as this might result in re-occurrence.

Primary options

betamethasone valerate topical: (0.1%) children and adults: apply sparingly to the affected area(s) once daily for 7-14 days

OR

prednisolone: children and adults: 0.5 to 1 mg/kg/day orally, taper gradually according to response

non-serious cutaneous adverse reactions

1st line – withdrawal of suspected drug

Back
ACUTE
|
non-serious cutaneous adverse reactions
1st line – 

withdrawal of suspected drug

Withdrawal of the suspected drug is essential. In many cases, the lesions will resolve spontaneously thereafter, within 1 to 2 weeks.

Plus – corticosteroid

Back
ACUTE
|
non-serious cutaneous adverse reactions
|
unresponsive to withdrawal of drug
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Topical corticosteroids are often used when skin eruptions are symptomatic (especially for itch). In mild cases, hydrocortisone can be used. For more severe problems, alternatives include betamethasone, clobetasol, fluocinolone, and triamcinolone.

In severe reactions unresponsive to withdrawal of the drug, oral prednisolone can be used.

Severity refers to the intensity of the reaction. A severe (intense) headache need not be serious, and a mild arrhythmia (e.g., a ventricular extra beat) can have a serious outcome (a fatal cardiac arrhythmia).

A serious cutaneous adverse reaction affects the structure or function of the skin, its appendages, or mucous membranes.

Primary options

hydrocortisone topical: (0.5 to 1%) apply sparingly to the affected area(s) twice daily

OR

betamethasone valerate topical: (0.1%) apply sparingly to the affected area(s) once or twice daily

OR

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

OR

fluocinolone topical: (0.025%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Secondary options

prednisolone: children: 1-2 mg/kg/day orally, taper gradually over 3 weeks according to response; adults: 30-60 mg orally once daily, taper gradually over 3 weeks according to response

Plus – antihistamine

Back
ACUTE
|
non-serious cutaneous adverse reactions
|
drug-induced urticaria
Plus – 

antihistamine

Treatment recommended for ALL patients in selected patient group

Treatment of drug-induced urticaria is withdrawal of the suspected drug and possibly a brief dose of antihistamine.

A non-sedating antihistamine (e.g., cetirizine, loratadine, fexofenadine, or mizolastine) is preferred for daytime use; if nocturnal symptoms are a problem, a sedating antihistamine (hydroxyzine) can be used at night.

Primary options

cetirizine: 10 mg orally once daily

OR

loratadine: 10 mg orally once daily

OR

fexofenadine: 180 mg orally once daily

OR

mizolastine: 10 mg orally once daily

OR

hydroxyzine: 25 mg orally once daily at night

ONGOING

following acute episode

1st line – avoidance of offending drug where possible

Back
ONGOING
|
following acute episode
1st line – 

avoidance of offending drug where possible

Avoidance of the offending drug is essential where possible.

Plus – self-administered adrenaline (epinephrine) + action plan

Back
ONGOING
|
following acute episode
|
history of anaphylactic reaction
Plus – 

self-administered adrenaline (epinephrine) + action plan

Treatment recommended for ALL patients in selected patient group

All adverse drug reactions need to be meticulously recorded and the patient fully informed. For possible future anaphylactic reactions, the patient should be equipped with 2 adrenaline auto-injectors.[54]

After receiving adrenaline, the patient should present to the accident and emergency department for monitoring and further treatment as required until stable.

Primary options

adrenaline (epinephrine): children <30 kg: 0.15 mg intramuscularly as a single dose, may repeat in 10-20 minutes; children >30 kg and adults: 0.3 mg intramuscularly as a single dose, may repeat in 10-20 minutes

Plus – drug desensitisation

Back
ONGOING
|
following acute episode
|
continued drug use outweighs potential harm + no alternative therapy
Plus – 

drug desensitisation

Treatment recommended for ALL patients in selected patient group

Patients who have had an allergic reaction to a drug can prevent future reactions by strictly avoiding the drug. Attempting desensitisation is rarely necessary; it should not be attempted unless the benefit of continuing to use the drug outweighs the potential harm of desensitisation and when there is no other alternative therapy.

Recommendations for alternative therapy and desensitisation are available for specific drugs and drug classes (e.g., antibiotics, non-steroidal anti-inflammatory drugs, chemotherapy, immune checkpoint inhibitors, biological agents).[42][43]​​​[44]

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer