Cas e R e po r t

Levocetirizine Induced Fixed Drug Eruption: A Rare

Case Report
Gaurav Kataria1, Senior Resident, Department of ENT, Sri Guru Ram Das Institute of Medical Sciences and Research,
1

Amritsar, Punjab, India, 2Post-graduate, Department of Pathology, Government Medical College,

Aditi Saxena2,
Amritsar, Punjab, India, 3Professor, Department of Dermatology, Sri Guru Ram Das Institute of Medical
Saurabh Sharma3 Sciences and Research, Amritsar, Punjab, India

Corresponding Author: Dr. Gaurav Kataria, 8-G-10, Jawahar Nagar, Sri Ganganagar, Rajasthan,
India. Phone: +91-9463971250. E-mail: [email protected]

Abstract
Antihistamines are routinely used for allergic rhinitis, urticaria, eczema and some other allergic disorders. Levocetirizine is
piperazine derivative antihistamine with few cutaneous side effects. Fixed drug eruption (FDE) to piperazine derivatives is very
rare. FDE to levocetirizine is very rare. Clinicians should have a high index of suspicion and should be aware of the possibility
of reactions to antihistaminic drugs, which themselves are very frequently prescribed to manage drug reactions. Hence, before
prescribing antihistaminics, it is very important for every clinician to take a proper history, clinical examination and history of
any drug reactions. Here, we report a case of FDE to levocetirizine.

Keywords: Allergic rhinitis, Antihistamines, Cetirizine, Fixed drug eruption, Levocetirizine, Maculopapular

INTRODUCTION was seen. Patient was diagnosed as a case of allergic rhinitis.

Patient also gave a history of similar attacks of rhinitis in past
Antihistamines are routinely used for allergic rhinitis, urticaria, 2-3 years, and on taking levocetirizine patient got some relief.
eczema and some other allergic disorders. The newer Patient was prescribed levocetirizine 5 mg twice a day along
antihistamines have a more specific action on histamine with fluticasone nasal spray. After 2 days patient arrived at
receptors and have very few side-effects and are very useful for ENT outdoor with multiple, itchy, erythematous, edematous
both otorhinolaryngologists and dermatologists.1 Cetirizine maculopapular lesions on the back (Figure 1) and left arm and
and levocetirizine are piperazine derivative antihistamines right forearm (Figure 2). Patient gave the history of appearance
with few cutaneous side effects. Fixed drug eruption (FDE) of these lesions 4-5 h after taking the medication. Patient also
to these piperazine derivatives is very rare.2 Most adverse gave the history of similar lesions 3-4 times in the past, but no
effects of antihistamines are caused by their own binding history of any specific medicine at that time was correlated as
activities to H1-receptors, muscarinic receptors, serotonin she took a lot of medicines for every complaint from a local
receptors and cardiac ion currents. These mechanisms may doctor. Patient was referred to a dermatologist for further
cause drowsiness, impairment of cognitive function, dry eyes, management. On examination, it was found that pre-existing
dry mouth and urinary retention.3 Hypersensitive cutaneous patches are also present at these sites. A provisional diagnosis
lesions due to levocetirizine are very rare and very few cases of FDE due to levocetirizine was made, and patient was
of FDE due to levocetirizine are documented.2,4-6 Here, we advised to avoid levocetirizine and cetirizine. On the follow-up
report a case of FDE due to levocetirizine that was given to after healing of lesions, provocative test was done, and lesions
the patient for allergic rhinitis. showed the reactivation with itching and erythema. Patient
was advised to avoid levocetirizine and cetirizine in future.
CASE REPORT
DISCUSSION
A 41-year-old female presented to Department of ENT with
chief complaints of sneezing, rhinorrhea, watering from FDE is a common form of cutaneous adverse drug
eyes and nasal obstruction. On nasal examination, septum reactions whose exact etiology is unknown. They are
was centrally placed, and inferior turbinate hypertrophy supposed to be caused by epidermal CD8 T cells, which are

International Journal of Scientific Study | October 2014 | Vol 2 | Issue 7 228

 Kataria, et al.: Levocetirizine Induced Fixed Drug Eruption

Figure 1: Erythematous, edematous and itchy lesion on the

back of the patient

retained in the lesions forming an immunologic memory,

which gets activated on re-challenge.7 FDE can occur
with several drugs, common ones are sulfonamides, non-
steroidal anti-inflammatory drugs, antimicrobials and oral
contraceptives.8 However, FDE due to antihistaminics are
very rare. FDE reported to H1-antihistaminics are cyclizine,
diphenhydramine, phenothiazines, hydroxyzine,6 loratidine9 Figure 2: Erythematous and itchy lesions over left arm and right
and in few cases with cetirizine and levocetirizine.2,4,5,10 forearm of the patient
Cetirizine, levocetirizine and hydroxyzine have the
piperazine structure with same pharmacological actions. REFERENCES
When administered orally hydroxyzine is converted into
1. Greaves MW. Antihistamines. In: Wolverton SE, editor. Comprehensive
cetirizine. Levocetirizine is the R-enantiomer of cetirizine.5
Dermatologic Drug Therapy. 2nd Philadelphia: Saunders, Elsevier; 2007.
p. 391-400.
Most common adverse effects due to antihistaminics are 2. Cravo M, Gonçalo M, Figueiredo A. Fixed drug eruption to cetirizine
loss of appetite, nausea, vomiting and epigastric distress. with positive lesional patch tests to the three piperazine derivatives. Int J
Drug allergies like drug fever and photosensitisation are Dermatol 2007;46:760-2.
seen mainly with topical application. Hematological side 3. Assouère MN, Mazereeuw-Hautier J, Bonafé JL. Cutaneous drug eruption
effects include leucopenia; while agranulocytosis and with two antihistaminic drugs of a same chemical family: Cetirizine and
hydroxyzine. Ann Dermatol Venereol 2002;129:1295-8.
hemolytic anemia are rarer.1
4. Guptha SD, Prabhakar SM, Sacchidanand S. Fixed drug eruption due to
levocetirizine. Indian J Dermatol Venereol Leprol 2005;71:361-2.
5. Mahajan VK, Sharma NL, Sharma VC. Fixed drug eruption: A novel side-
CONCLUSION effect of levocetirizine. Int J Dermatol 2005;44:796-8.
6. Cohen HA, Barzilai A, Matalon A, Harel L, Gross S. Fixed drug eruption of the
FDE to levocetirizine is very rare but documented in penis due to hydroxyzine hydrochloride. Ann Pharmacother 1997;31:327-9.
few cases. It is a rare side-effect of levocetirizine. It was 7. Kauppinen K, Stubb S. Fixed eruptions: Causative drugs and challenge
concluded that any antihistamine can cause FDE. So, before tests. Br J Dermatol 1985;112:575-8.
prescribing antihistaminics, it is very important for every 8. Pudukadan D, Thappa DM. Adverse cutaneous drug reactions: Clinical
clinician to take a proper history, clinical examination and pattern and causative agents in a tertiary care center in South India. Indian J
Dermatol Venereol Leprol 2004;70:20-4.
history of any drug reactions. Clinicians should have a high 9. Pionetti CH, Kien MC, Alonso A. Fixed drug eruption due to loratadine.
index of suspicion and should be aware of the possibility Allergol Immunopathol (Madr) 2003;31:291-3.
of reactions to antihistamine drugs, which themselves are 10. Kränke B, Kern T. Multilocalized fixed drug eruption to the antihistamine
very frequently prescribed to manage drug reactions. cetirizine. J Allergy Clin Immunol 2000;106:988.

How to cite this article: Kataria G, Saxena A, Sharma S. Levocetirizine Induced Fixed Drug Eruption: A Rare Case Report. Int J Sci Stud
2014;2(7):228-229.

Source of Support: Nil, Conflict of Interest: None declared.

229 International Journal of Scientific Study | October 2014 | Vol 2 | Issue 7