Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Observation Letter
89 (
); 119-121

Symmetrical drug-related intertriginous and flexural exanthema-like rash related to severe acute respiratory syndrome coronavirus 2 infection

Department of Dermatology, Hospital del Mar, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
Corresponding author: Dr. Helena Escolà, Department of Dermatology, Hospital del Mar, Barcelona, Passeig Marítim, Barcelona, Spain.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Escolà H, March-Rodriguez A, Pujol RM. Symmetrical drug-related intertriginous and flexural exanthema-like rash related to severe acute respiratory syndrome coronavirus 2 infection. Indian J Dermatol Venereol Leprol 2023;89:119-121.


Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), previously known as “drug-related baboon syndrome,” is a benign type IV hypersensitivity drug reaction characterised by symmetrical well-demarcated erythema mainly involving the gluteal/perianal area and/or V-shaped erythema of the inguinal/perigenital area.1 The cutaneous eruption tends to develop several hours to days after exposure to the offending drug. Rarely, SDRIFE-like rashes have been reported to develop in the absence of an apparently previous drug exposure.2 Recently, isolated reports of SDRIFE-like eruptions associated with either COVID-19 infection or vaccination have been described.2-7 We report a case of SDRIFE-like eruption related exclusively with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in the absence of any associated drug.

A 29-year-old woman who was not vaccinated for COVID-19, was admitted to the emergency room with fever, cough, dyspnea and a well-demarked and symmetrical rash which was mildly pruritic, that involved the groins, inner side of thighs, axillae, antecubital fossae and the lower trunk [Figure 1]. Rash appeared one day after the onset of respiratory symptoms. She denied any topical or systemic medication prior to the onset of rash. The patient was admitted to the hospital due to hypoxemia (PO2 70 mmHg) and mild bilateral pneumonia. Reverse transcription-polymerase chain reaction analysis on nasopharyngeal swab tested positive for SARS-CoV-2. Skin biopsy from the erythematous plaque on the thigh revealed focal spongiosis associated with exocytosis, some basal cell vacuolization, and superficial dermal perivascular lymphocytic infiltrate (with few eosinophils) [Figure 2]. A complete haematological and biochemical survey disclosed leucopenia (3600 cells/mm3), lymphopenia (790 cells/mm3 22%) and elevated levels of D-dimer (1600 ng/mL). Ferritin, C-reactive protein and erythrocyte sedimentation rate levels were normal. The patient required oxygen support for one week. Treatment with 6 mg per day of intravenous dexamethasone and antipyretics (paracetamol) along with triamcinolone acetonide cream 0.1% for skin lesions during 10 days was established with good clinical response and a complete resolution of skin rash.

Figure 1:: Symmetrical erythemato-edematous plaques extending from the groin to the inner side of both thighs
Figure 2:: Skin biopsy from an erythematous plaque on the thigh of a patient with coronavirus disease-2019 showing exocytosis (black arrow), focal spongiosis (red arrow) and superficial perivascular lymphocytic infiltrate (H&E, ×100)

With a proven SARS-CoV-2 infection and a classical described rash for SDRIFE with no precipitating drug, a diagnosis of SDRIFE-like rash related to SARS-CoV-2 was established.

SDRIFE is a benign cutaneous reaction that takes place after the systemic administration of drug-related allergen. Clinically, it is manifested as a flexural symmetrically distributed skin exanthema mainly involving the buttocks and flexural areas. The face, palms, soles and mucosal surfaces are typically spared. Histological features are often non-specific. Basal cell vacuolization, often associated with necrotic keratinocytes and focal spongiosis, as well as the superficial perivascular inflammatory infiltrate, are usually observed.4 Beta-lactam antibiotics followed by non-steroidal anti-inflammatory drugs, immunoglobulin, antihypertensive, chemotherapeutic and biologic agents are the most frequently incriminated drugs.8 SDRIFE diagnosis must fulfil all the following criteria 1: sharply demarcated erythema of the gluteal/perianal area and/or V-shaped erythema of the inguinal/perigenital area, involvement of at least one other intertriginous/flexural region, the symmetry of affected areas and absence of systemic symptoms and signs in association with systemic drug exposure. Our patient fulfilled the criteria.

Furthermore, cutaneous eruptions mimicking SDRIFE have rarely been reported associated with erythrovirus B19 and Group A streptococcal infections.9,10 Recently, isolated reports of SDRIFE-like rashes associated with either SARS-CoV-2 vaccination or infection have been published.2-7 The real significance of these eruptions as a skin manifestation of COVID-19 disease remains unclear since in the vast majority of cases a concomitant or previous drug treatment was recorded.2-5,7 Additionally, SDRIFE-like reactions related to Pfizer-BioNTech COVID-19 vaccine (BNT162b2; Comirnaty) with skin biopsies showing vacuolar interface dermatitis with mild eosinophilic spongiosis have also been reported.6 The clinical and evolutive features of reported cases of SDRIFE-like eruptions associated with COVID-19 are detailed in Table 1.

Table 1:: Clinical features of previous SDRIFE-like eruptions related to SARS-CoV-2
Study Age (years)/Sex Comorbidities Rash description Duration of the rash Previous treatments SDRIFE treatment Manifestations of COVID-19
Mahé et al.2 64/F Type 2 diabetes Erythematous rash 5 days Paracetamol None Bilateral pneumonia
Bevilaqua et al.7 71/F Asthma, hypothyroidism Erythematous papules converging on plaques 7 days Piperacillin/tazbactam, azithromycine,
hydroxychloroquine, oseltamivir
Oral prednisone Pneumonia, diarrhea
Chicharro et al.4 73/F Not mentioned Erythematous rash Not mentioned Hydroxychloroquine, azithromycin Systemic steroids, and broad-spectrum antibiotics Bilateral pneumonia
Bonamigo et al.5 53/F Diabetes mellitus, chronic obstructive pulmonary disease Erythematous macular rash with overlapping blisters 7 days Meropenem, polymyxin, vancomycin Oral prednisolone Bilateral pneumonia with respiratory failure
Heck et al.3 67/M Not mentioned Erythematous macular
Not mentioned Remdesivir sufentanil,
propofol, norepinephrine, pantoprazole, macrogol,
metoclopramide, enoxaparin
None Acute respiratory distress syndrome
Hai et al. (case 1)6 23/M Not mentioned Dusky-red scaly papules coalescing
into confluent plaques
1 month Second dose of Pfizer-BioNTech COVID-19 vaccine Topical clobetasol propionate None
Hai et al. (case 2)6 38/F Not mentioned Well-demarcated
erythematous scaly plaques
Not mentioned Second dose of Pfizer-BioNTech COVID-19 vaccine Oral prednisone and topical desonide None
Escolà et al. (current patient) 29/F Chronic
spontaneous urticaria
Well-demarked symmetrical erythematous plaques 10 days None Intravenous dexametasone and topical triamcinolone acetonide 0.1% Unilateral pneumonia

M: Male, F: Female, SDRIFE: Symmetrical drug-related intertriginous and flexural exanthema, SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2

A wide range of cutaneous rashes associated to COVID-19 infection have been reported. Vesicular, morbilliform and urticarial eruptions, pseudo-chilblain lesions, livedoid and retiform purpuric rashes may appear at different times in the disease evolution and are associated with different severity, duration and prognosis.11 Our observation adds SDRIFE-like pattern as another rare cutaneous manifestation of SARS-CoV-2.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship


Conflict of interest

There are no conflicts of interest.


  1. , , . Baboon syndrome resulting from systemic drugs: Is there strife between SDRIFE and allergic contact dermatitis syndrome? Contact Dermatitis. 2004;51:297-310.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , . A distinctive skin rash associated with coronavirus disease 2019? J Eur Acad Dermatol Venereol. 2020;34:e246-7.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , , . Remdesivir-induced symmetrical drug-related intertriginous and flexural exanthema (SDRIFE)? A case report with review of the literature. Eur J Clin Pharmacol. 2021;77:141-4.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , , . SDRIFE-like rash associated with COVID-19, clinicopathological correlation. Australas J Dermatol. 2021;62:88-9.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , . Bullous SDRIFE and Covid-19. Int J Dermatol. 2022;6:372-4.
    [CrossRef] [PubMed] [Google Scholar]
  6. , , , , , , , . Systemic drug-related intertriginous and flexural exanthema induced by the Pfizer-BioNTech COVID-19 vaccine: A report of 2 cases. JAAD Case Rep. 2021;18:57-60.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , , , , . SDRIFE-like rash in COVID-19 patient: drug reaction or another cutaneous manifestation of SARS-CoV-2? Int J Dermatol. 2021;60:884-5.
    [CrossRef] [PubMed] [Google Scholar]
  8. , . Symmetrical drug-related intertriginous and flexural exanthema. Curr Opin Allergy Clin Immunol. 2011;11:313-8.
    [CrossRef] [PubMed] [Google Scholar]
  9. , , , , . Human parvovirus B19 infection showing follicular purpuric papules with a baboon syndrome-like distribution. Br J Dermatol 2004:788-9.
    [CrossRef] [PubMed] [Google Scholar]
  10. , , . A case of baboon syndrome associated with group a streptococcal infection. J Dermatol. 2003;30:69-71.
    [PubMed] [Google Scholar]
  11. , , , , , , et al. Classification of the cutaneous manifestations of COVID-19: A rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol. 2020;183:71-7.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views

PDF downloads
View/Download PDF
Download Citations
Show Sections