title: Annular erythema and photosensitivity as manifestations of efavirenz-induced cutaneous reactions: a review of five consecutive cases.
abstract: OBJECTIVE
  In HIV-infected persons, a rash is the most common manifestation of drug hypersensitivity reactions. Non-nucleotide reverse transcriptase inhibitors are a major cause of cutaneous reactions. While the characteristics of nevirapine-associated cutaneous adverse drug reactions (CADRs) have been well described, there are limited data on efavirenz-associated CADRs. The objective of this study was to characterize the clinical features of consecutive cases of efavirenz-associated CADRs in a single referral centre diagnosed over a 3 year period.
  
  
  METHODS
  We retrospectively reviewed the clinical records of 231 patients admitted with CADRs to a tertiary dermatology ward in Cape Town, South Africa.
  
  
  RESULTS
  In 42/231(18%) cases, there had been exposure to efavirenz in the preceding 8 weeks. Of these, 5/42 (12%) patients were diagnosed with probable efavirenz-associated CADRs based on the Naranjo score. The median exposure to efavirenz before the onset of the rash was 12 days (range 2-48). All the patients were female, with a median age of 31 years and a median CD4 cell count of 300 cells/mm(3) (range 81-887). Four had a photo-distributed eruption and one had a confluent indurated erythema affecting the face, trunk and limbs. In three out of five cases, there were annular plaques with raised erythematous edges and dusky centres, which were photo-distributed. Two patients had a mild transaminitis and another a mild eosinophilia. Histological features were non-specific, with perivascular lymphocytes the only consistent feature. In all five cases, efavirenz was withdrawn and potent topical steroid was the only CADR-specific intervention. The eruptions resolved on discharge from hospital, with no sequelae except for residual post-inflammatory hyperpigmentation.
  
  
  CONCLUSIONS
  Photo-distribution and annular erythema should alert clinicians to the possibility of efavirenz-associated CADRs.
authors.affiliation: Division of Dermatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: Thuraya
authors.initials: T
authors.lastname: Isaacs
authors.forename: Mzudumile R
authors.initials: MR
authors.lastname: Ngwanya
authors.forename: Sipho
authors.initials: S
authors.lastname: Dlamini
authors.forename: Rannakoe J
authors.initials: RJ
authors.lastname: Lehloenya
mesh_terms: D000328:Adult; D000480:Alkynes; D019380:Anti-HIV Agents / Q000009:adverse effects* / Q000627:therapeutic use; D048588:Benzoxazines / Q000009:adverse effects* / Q000627:therapeutic use; D003521:Cyclopropanes; D004890:Erythema / Q000139:chemically induced* / Q000473:pathology; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy*; D006801:Humans; D008297:Male; D010787:Photosensitivity Disorders / Q000139:chemically induced* / Q000473:pathology; D012189:Retrospective Studies; D012873:Skin Diseases, Genetic / Q000139:chemically induced* / Q000473:pathology; D013019:South Africa
chemical_list: D000480:Alkynes; D019380:Anti-HIV Agents; D048588:Benzoxazines; D003521:Cyclopropanes; C098320:efavirenz
keywords: HIV; drug eruptions; photo-distribution