Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
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
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
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 - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
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
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
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
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor - Observation Letter
2015:81:6;611-612
doi: 10.4103/0378-6323.168346
PMID: 26515842

Valacyclovir-induced urticaria without acyclovir hypersensitivity

Satyendra K Singh, Anand Prabhu, Ajit Kumar
 Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Correspondence Address:
Satyendra K Singh
Department of Dermatology and Venereology, IMS, BHU, Varanasi - 221 005, Uttar Pradesh
India
How to cite this article:
Singh SK, Prabhu A, Kumar A. Valacyclovir-induced urticaria without acyclovir hypersensitivity. Indian J Dermatol Venereol Leprol 2015;81:611-612
Copyright: (C)2015 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

A 40-year-old male presented to the dermatology outpatient department (OPD), S. S. Hospital, Institute of Medical Sciences, BHU, with malaise, generalized pruritus, and urticarial lesions within 6 h of taking two 1000 mg tablets of valacyclovir for a recurrence of herpes labialis. He reported having recurrent episodes of herpes labialis for 8 years, with 2–3 episodes per year. Prior treatment included acyclovir 400 mg 5 times a day for 5 days during the prodromal phase, with reports of resolution within 4-5 days, even if vesiculation occurred.

One day prior to the current episode, the patient experienced burning and itching sensation on the right side of the lower lip, and took 2000 mg valacyclovir orally. Within 5 h of taking valacyclovir, he developed malaise and generalized pruritus and within the next hour, developed multiple, generalized, erythematous and raised lesions. There was no difficulty in breathing. There was no history of any other drug intake or any drug hypersensitivity.

On examination, the temp erature was 98.8°F, pulse rate 82/min, and blood pressure 138/86 mmHg. Muco-cutaneous examination revealed small, grouped vesicles on the right half of lower lip. Multiple erythematous, blanchable plaques varying from 1 × 1 to 3 × 5 cm were scattered over the neck, trunk, and limbs. A complete blood count, liver function tests, and renal function tests revealed a total leukocyte count of 12300/µL and SGOT/SGPT of 56/60 IU/L; the remainder of the parameters were within normal limits. Based on the history and physical examination, a diagnosis of recurrent herpes labialis with valacyclovir-induced urticaria was made.

Valacyclovir was discontinued. A single dose of 40 mg prednisolone along with daily fexofenadine 180 mg was prescribed. The urticarial lesions resolved within 5 h of taking prednisolone. Within a week, the labial lesions healed and no recurrence of pruritus or urticaria was noted.

Two months later, the patient again developed prodromal symptoms and signs of herpes labialis. He took oral acyclovir 400 mg 5 times a day for 5 days, after having prepared for emergency resuscitation if needed. No adverse drug reaction was noted this time.

After approximately 4 months, a new episode of herpes labialis occurred. The patient intentionally took two tablets of valacyclovir, 1000 mg orally to confirm whether he was allergic to valacyclovir, after making sure he was equipped for emergency resuscitation. Within 30 min of oral intake of valacyclovir, he developed itching and myalgia. Within 1 h he developed urticarial lesions all over the body. A single dose of prednisolone 40 mg and fexofenadine, 180 mg was given and he improved symptomatically within 2 h. Fexofenadine 180 mg daily was continued for 4 days and the subsequent dose of valacyclovir was omitted. No signs and symptoms of adverse drug reaction were noted after 5 days.

Most of the drugs have the potential to cause hypersensitivity reactions. Allergic reactions are a well-known adverse effect associated with antibiotics but there is less familiarity with allergic reactions to antiviral medications. Acyclovir has been associated with several types of adverse drug effects, most commonly dermatologic reactions. Dermatitis, pruritus, urticaria, vasculitis, peripheral edema, erythema nodosum and exanthems have been reported after oral acyclovir. Contact dermatitis and macular erythema have occurred following parenteral therapy and topical therapy has resulted in numerous reports of cutaneous reactions.[1],[2],[3],[4] Valacyclovir has also been associated with urticaria, diffuse erythema and pruritus indicative of systemic reactions.[5]

The two antiherpetic agents, acyclovir and valacyclovir, share a common 2-aminopurine nucleus, which may be the part of the molecule responsible for allergenicity [Figure - 1].[5] Because of this structural similarity, valacyclovir is contraindicated in patients with a history of hypersensitivity to acyclovir.[1] We were unable to find any previous report of isolated hypersensitivity to valacyclovir, without acyclovir hypersensitivity.

Figure 1: Chemical structure of acyclovir and valacyclovir

We present a case of recurrent herpes labialis who had taken multiple courses of acyclovir previously, without any adverse events. He developed acute urticaria after taking a single dose of valacyclovir. A trial of acyclovir subsequently did not cause any adverse event, however re-challenge with valacyclovir led to urticaria. This result is difficult to explain because of the structural similarity of these two drugs and similarity of most of the excipients in both formulations. Excipients, which were not common and present in valacyclovir alone, were crospovidone, silica colloidal anhydrous, macrogol, and carnauba wax. We were unable to find any previous reports of hypersensitivity reactions to these excipients. Therefore, the possible explanations include hypersensitivity to the added side chain in valacyclovir or hypersensitivity to the excipients used in valacyclovir.

References
1.
Carrasco L, Pastor MA, Izquierdo MJ, Fariña MC, Martín L, Fortes J, et al. Drug eruption secondary to aciclovir with recall phenomenon in a dermatome previously affected by herpes zoster. Clin Exp Dermatol 2002;27:132-4.
[Google Scholar]
2.
Schuster J, Fabri M, Eming S, Hunzelmann N. Allergic drug eruption secondary to intravenous acyclovir. Acta Derm Venereol 2008;88:196-8.
[Google Scholar]
3.
Gola M, Francalanci S, Brusi C, Lombardi P, Sertoli A. Contact sensitization to acyclovir. Contact Dermatitis 1989;20:394-5.
[Google Scholar]
4.
Vernassiere C, Barbaud A, Trechot PH, Weber-Muller F, Schmutz JL. Systemic acyclovir reaction subsequent to acyclovir contact allergy: Which systemic antiviral drug should then be used? Contact Dermatitis 2003;49:155-7.
[Google Scholar]
5.
Lammintausta K, Makela L, Kalimo K. Rapid systemic valaciclovir reaction subsequent to aciclovir contact allergy. Contact Dermatitis 2001;45:181.
[Google Scholar]

Fulltext Views
833

PDF downloads
267
Show Sections