Generalized Pustular Figurate Erythema - First Report in Two
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Generalized pustular figurate erythema (GPFE) is a distinctive severe cutaneous drug reaction with widespread urticarial or edematous plaques scattered over the entire body that become topped with non-follicular pustules that evolve into erythematous and sometimes atypical targetoid plaques converging into annular and arcuate patterns prominent on the trunk and extremities. It has been linked with medications, especially hydroxychloroquine.

Two COVID-19 patients on hydroxychloroquine who developed this eruption 2 and 3 weeks after the onset have been reported. A 64-year-old man with diffuse large B-cell lymphoma undergoing chemotherapy developed bilateral pneumonia from SARS-CoV-2, as did a 60-year-old woman with a history of rheumatoid arthritis on etanercept and prednisone (5mg/d).

Diagnosis was rendered by real-time reverse transcriptase-polymerase chain reaction from a nasopharyngeal swab. Both were treated with the same protocol of hydroxychloroquine and lopinavir/ritonavir and also teicoplanin, with the woman also given azithromycin. Two to three weeks after starting these medications, each developed a pruritic purpuric erythematous rash with non-follicular pustules, on the trunk and limbs, with intense involvement of armpits and scalp. The woman also had intense involvement of neck and face and targetoid lesions on the back. Nikolsky´s sign was negative in both, neither had mucosal involvement nor fever. A punch biopsy specimen was obtained from each of them and they both received 0.05% betamethasone dipropionate cream twice a day, loratadine (10 mg/d) and methylprednisolone (40 mg/d), with slow resolution over four weeks.

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