Antipsychotics and rashes.

Common side effects of antipsychotic medications include antidopaminergic and anti-HAM (histaminic, adrenergic, muscarinic) effects.[1] Antipsychotics’ antidopaminanergic side effects on the mesolimbic pathway are the therapeutic target; however, blockade of the nigrostriatum dopamine pathways causes extrapyramidal symptoms such as parkinsonism, akathisia, and dystonia.[2] Extrapyramidal symptoms may range from distressing (e.g., torticollis) to life threatening (e.g., glossopharyngeal spasms).[3]

Dermatological exanthems induced by antipsychotic use is uncommon but a rare side effect that can be alarming to patients and can signal systemic reactions to the medications. The rashes associated with antipsychotic use are due to drug reactions and rashes due to injection sites. Rashes due to antipsychotic use that were reported in the literature are summarized in Table 1.[4-20]

Table 1.

Reported rashes with antipsychotic treatments

Medication	Route of administration	Types of rash	Location
Olanzapine	Long acting injection[4]	Unspecified	Site of injection
	Oral[5]	Pruritic, pigmented (allergic)	Whole body, especially on her neck, neckline and shanks
	Oral[6]	Pustules, erythema, pruritus	Whole body, concentrated especially on her neck and face
	Oral[7]	Erythematous (biopsy confirmed leukocytodastic vasculitis)	Dependent areas of body
	Oral disintegrating tablet[8]	Purpuric	Generalized
Clozapine	Oral[9]	Confluent, erythematous macules	Trunk and lower extremities
	Oral[10]	Erythematous macules	Diffuse around neck and chest
	Oral[11]	Itchy urticarial	Hands and limbs and the back, particularly in the pressurized area
	Oral[12]	Papular, pruritic, erythematous, and very well circumscribed	Started on torso and spread to extremities
	Oral[13]	Erythematopustular	Unspecified
Quetiapine	Oral[14]	Psoriatic	Unspecified
Aripiprazole	Oral[15]	Morbilliform maculopapular	Anterior aspect of the chest and abdomen to the upper and lower limbs sparing the face and scalp and mucosal areas (buccal cavity)
Levosulpiride	Oral[16]	Unspecified	Unspecified
Asenapine	Oral[17]	Unspecified	Unspecified
Promazine	Oral[18]	Maculopapular, pruritic	Face, limbs and trunk
Paliperidone	Oral[19]	Pruritic	Face and extremities
Risperidone	Oral[20]	Macular erythematous	Buttocks, anogenital area, pubic-suprapubic regions, inner thighs, and groins

In the psychiatric setting, rashes are most commonly associated with the mood stabilizer lamotrigine. However, it is important to realize the other skin manifestations after antipsychotic treatments. Discontinua - tion of the offending drug is important after identification of a drug reaction. Topical and oral medications can help alleviate the pruritus and erythema; however, no longterm consequences have been noted from the rashes associated with antipsychotic use.

We hope that by highlighting these dermatological side effects of antipsychotics will help with managing these occurrences in clinical practice.