Addressing concerns in DRESS syndrome
New treatments, diagnostic tools can help solve the drug-related mystery.
U024 – High-Yield Updates in DRESS Syndrome
3:30-4:30 p.m. | Friday, March 7
Location: W315A
Drug reaction with eosinophilia and systemic symptoms, or DRESS, is a syndrome that can be accompanied by a variety of symptoms including a rash and fever, but it can also be potentially life-threatening and difficult to track down exactly which drug is responsible.
And while it is rare — the DRESS Syndrome Foundation puts the risk at about one in every 1,000 to 10,000 drug exposures — dermatologists need to be aware of the latest diagnostic clues for rendering a diagnosis of DRESS syndrome.
“This includes new data surrounding the latency period between medicine initiation and syndrome development as well as the use of the earlobe crease sign to identify potential patients with DRESS,” said Abraham Korman, MD, FAAD. “And though still in its infancy, there is also the use of augmented intelligence to differentiate DRESS from its main mimicker — a lowrisk morbilliform drug eruption.”
Dr. Korman, who is a clinical assistant professor of dermatology and director of the division of inpatient dermatology at The Ohio State University Wexler Medical Center in Columbus, will lead a discussion on these and other developments in today’s session, U024 – High-Yield Updates in DRESS Syndrome. He will be joined by Caroline Nelson, MD, FAAD, and Misha Rosenbach, MD, FAAD.
DRESS syndrome algorithm
One new tool for identifying culprit medicines in DRESS syndrome is the novel drug algorithm of drug causality for DRESS, or ADDRESS. Dr. Korman said ADDRESS is a scoring system that assigns points to the drugs a patient is using based on six different components that will be discussed in this afternoon’s session:
- latency
- pharmacokinetics
- prechallenge/rechallenge
- dechallenge
- drug risk level
- alternative causes
The total score for each medicine is determined based on these components, said Dr. Korman, and the medicine is ranked by points to ascertain its relative risk. The higher the score, the more likely the medicine is the cause (and vice versa).
“It is based on a prior, validated drug attribution algorithm called ALDEN, [which is used for] Stevens-Johnson Syndrome, as well as a systematic review that our group performed which was published in the Journal of the American Academy of Dermatology,” he said.
Dr. Korman cited an example of the ADDRESS system in use: a patient who was taking seven different medications presented with a rash. To determine which medicine caused the rash, doctors applied the algorithm to assign a score to each drug. While most of the medicines had negative scores, two — vancomycin and cefepime — had scores of six and four, respectively, pointing to one or both as the likely cause of the rash.
DRESS syndrome subtypes
There are a number of subtypes of DRESS syndrome that Dr. Korman said are important for dermatologists to be aware of, including DRESS in African American patients, DRESS in older patients, and patients with DRESS who develop pustules. Each of these groups presents its own unique set of challenges.
“It is important to recognize these because one, African American patients with DRESS have higher mortality than their white counterparts; two, older patients with DRESS have higher rates of cytopenias than their younger counterparts; and three, DRESS patients with pustules have higher rates of flaring and intertriginous involvement than those without pustules,” Dr. Korman said.
Despite those challenges, Dr. Korman said there is a lot happening in DRESS research that will shape how the syndrome is treated in the future.
“We are improving diagnostics and the subtyping of DRESS,” he said. “It’s important to note that it’s not all created equal. There are developments happening in the attribution of medicines in DRESS. This is a big issue that has not yet been solved. And in terms of management, there are new drugs being tried with exciting data along with new scoring systems that are helping us track the disease.”
