Olanzapine-induced Skin Eruptions.

Adverse cutaneous reactions are known to occur with psychotropic medications, which may lead to poor drug compliance. As compared to other group of psychotropics, there is relatively scarce literature on olanzapine-induced skin eruptions. We present a case of a 39-year-old man diagnosed with first episode mania and alcohol dependence syndrome who was started on tablet olanzapine which leads to fixed drug eruptions. Exhaustive investigations were done, all of which came out within normal limits. A diagnosis of fixed drug eruptions was made by the dermatologist. The skin eruptions subsided after stopping olanzapine. It has, thus, been emphasized that clinicians should be aware of the potential cutaneous eruptions associated with olanzapine. Early detection of the same would lead to timely management and hence better compliance with the psychotropic treatment.

INTRODUCTION

Adverse cutaneous reactions are known to occur with psychotropic medications, which may lead to poor drug compliance. As compared to other group of psychotropics, there is relatively scarce literature on olanzapine-induced skin eruptions. There are case reports that have described skin eruptions in form of pustules, vasculitis, eccrine squamous syringometaplasia, hypersensitive reactions with fever and hepatitis, eruptive xanthomas, and nonpruritic purpura. We hereby describe a case of fixed drug eruption following use of olanzapine in a patient with mania (first episode) with alcohol dependence syndrome. The eruptions subsided after stopping olanzapine. The Naranjo score of seven indicated olanzapine to be a probable cause for the skin eruptions.

CASE REPORT

A 39-year-old man presented to the psychiatry outpatient department with a history of alcohol use in dependent pattern for the past 14 years. The reason for the current presentation was the emergence of clinical features suggestive of mania. He was diagnosed with alcohol dependence syndrome and mania (first episode) and was started on tablet valproate (up to 750 mg) and tablet olanzapine (up to 15 mg). After 10 days of starting the medicines, the patient developed erythematous rashes on upper and lower limbs as well as trunk [Figure 1a]. The patient had no prior history of allergic reactions to either of the two medications. Investigations, including hemoglobin, total platelets counts, differential leukocyte counts, liver function test, dengue serology, were carried out, all of which came out to be within normal limits. Dermatology consultation was taken, and a diagnosis of fixed drug eruptions was made, with a possible differential diagnoses of erythema nodosum and drug-induced panniculitis. Skin biopsy was not possible owing to uncooperative nature of the patient. Following improvement in the clinical condition of the patient, tablet olanzapine was tapered off and stopped while tablet valproate was continued. The rashes resolved within a week of stopping tablet olanzapine leaving behind hyperpigmented spots [Figure 1b]. The patient was maintained on tablet valproate and achieved full remission of symptoms.

Figure 1

(a) Olanzapine-induced skin eruptions. (b) Hyperpigmented marks after resolution of Olanzapine-induced skin eruptions

DISCUSSION

Olanzapine is commonly used to control mania. In this case, skin eruptions temporally correlated with the introduction of tablet olanzapine and the remission followed discontinuance of the drug. Olanzapine-induced cutaneous eruptions are an infrequently reported adverse drug reaction. There is scarce literature on olanzapine-induced skin eruptions, mostly in the form of case reports. Olanzapine-induced skin eruptions have been described previously, like pustules in a 56-year-old bipolar affective disorder patient,[1] vasculitis in an 82-year-old female diagnosed with delirium,[2] eccrine squamous syringometaplasia[3] in a 56-year-old patient of schizophrenia (a reaction that is commonly seen with chemotherapeutic agents). There have been reports on hypersensitive reactions with fever and hepatitis,[4] eruptive xanthomas,[5] and nonpruritic purpura.[6] All these cases had disappearance of lesions after discontinuation of olanzapine. While two of the above cases[26] had a reappearance of the skin lesions after reintroducing olanzapine, other authors did not report rechallenge with olanzapine.

The probability of an adverse reaction being caused by a particular drug can be calculated objectively using various scales, like Naranjo scale which assigns probability category into definite, probable, possible, or doubtful. The Naranjo score for the current patient was seven indicating olanzapine to be a probable cause for the skin eruptions. Clinicians should be aware of the potentialcutaneous eruptions associated with olanzapine. Early detection of the same would lead to timely management and hence better compliance with the psychotropic treatment. The residual hyperpigmentation may also be an important cosmetic issue and may lead to poor treatment seeking in future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.