INTRODUCTION

Administering medication is a crucial step in the management of a patient. It is either aimed at curing the patient, preventing a disease, or aiding in diagnosis. Unfortunately, drug actions may exceed the desired effects and cause cutaneous or mucosal accidents. These incidents, known as drug eruptions, are among the most frequent adverse effects of drugs reported to pharmacovigilance centers worldwide [1]. Drug eruptions are adverse skin reactions resulting from systemic medication administration. Although often considered synonymous with allergies, they encompass a wide variety of clinical manifestations that correspond to different pathophysiological mechanisms, which determine the diagnostic and therapeutic approach [2]. They may occur alone or in association with systemic symptoms. For a given drug, 0.1% to 1% of patients will develop a drug eruption, and 1% to 3% of these will be severe enough to require hospitalization [3].

In Europe, drug eruptions are responsible for around 20% of spontaneous reports of drug-related adverse events. They complicate 2% to 3% of hospital treatments and account for 1% of consultations and 5% of hospitalizations in dermatology [4]. Some African authors have shown interest in the subject. Reported hospital frequencies range from 0.4% to 15.3% [5,6].

The risk of drug-related incidents is high due to the widespread use of drugs for self-medication, the proliferation of illegal points of sale for pharmaceutical products (“street medicines”), treatments administered by traditional healers, and the lack of enforcement of existing regulations [7].

MATERIALS AND METHODS

This was a cross-sectional, descriptive study involving all patients who presented at the Dermatology and Venereology Unit of DUHC-B/A from January 2009 to June 2022 with drug eruptions. Data was gathered from the patients’ medical records and included demographic information, clinical presentation, the timeline of symptoms, and associated treatments. The collected data was recorded and analyzed using EpiData 3.1 and IBM SPSS Statistics 21. Ethical standards were strictly followed during the study.

RESULTS

Epidemiological Data

Between 2009 and 2022, we recorded 123 cases of drug eruptions among 8,829 patients at the Dermatology and Venereology Unit of DUHC-B/A, yielding a hospital frequency of 1.39%. The mean age of the patients was 33.9 ± 20.7 years, ranging from 1 to 90 years. Patients aged 21 to 35 years were the most represented, accounting for 29.3% (Fig. 1).

Figure 1: Distribution of the patients with drug eruptions by age group (Dermatology and Venereology Unit of DUHC-B/A, 2009 to 2022).

The study population consisted of 62 females (50.4%), resulting in a male-to-female ratio of 0.98. Patients with higher education were the most represented (31.7%), followed by those with primary education (17.1%), unschooled patients (16.3%), and those with secondary education (12.2%).

Most patients were students, apprentices, or pupils (26.0%).

Clinical Data

The majority of the patients (74%) had no previous medical history.

The drugs most frequently implicated were cotrimoxazole (13.0%), followed by paracetamol (12.2%), amoxicillin (4.9%), and artemether-lumefantrine (4.9%) (Table 1).

Table 1: Distribution of the patients with drug eruptions according to the main drug classes and implicated medications (Dermatology and Venereology Unit of DUHC-B/A, 2009 to 2022).

The practice of self-medication was not specified for 54 patients. Among those who responded, 58.0% reported self-medicating. The time between drug intake and the appearance of symptoms was 1 to 7 days in 13.0% of the patients (Table 2).

Table 2: Distribution of the patients with drug eruptions according to the time between drug intake and symptom onset (Dermatology and Venereology Unit of DUHC-B/A, 2009 to 2022).

The most commonly associated symptom was pruritus (itching), found in 61.8% of the patients (Table 3).

Table 3: Distribution of the patients with drug eruptions according to associated symptoms (Dermatology and Venereology Unit of DUHC-B/A, 2009 to 2022).

In this study, hyperpigmented macules were the most common dermatological lesions (71.7%), followed by erosions (35.0%) and scaling (33.3%) (Table 4).

Table 4: Distribution of the patients with drug eruptions according to dermatological lesions (Dermatology and Venereology Unit of DUHC-B/A, 2009 to 2022).

The lesions were most commonly found on the thighs (52.0%), chest (51.2%), and arms (46.3%) (Table 5).

Table 5: Distribution of the patients with drug eruptions according to lesion location (Dermatology and Venereology Unit of DUHC-B/A, 2009 to 2022).

Fixed drug eruption (FDE) was the most common type of drug eruption (52.0%), followed by Stevens–Johnson Syndrome (SJS) at 17.1% (Table 6).

Table 6: Distribution of the patients by type of drug eruption (Dermatology and Venereology Unit of DUHC-B/A, 2009 to 2022).

DISCUSSION

The hospital frequency of drug eruptions at the Dermatology and Venereology Unit of DUHC-B/A was 1.39%. This was lower than that found by Atadokpèdé et al. [8] in Benin in 2014 (2%) and by Konaré et al. [9] in Mali in 2012 (3.7%) but higher than that found by Chaabane et al. [10] in Tunisia in 2013, who reported a frequency of 1.08%. This relatively low frequency could be explained by the fact that most drug eruptions are benign, and in our context, patients tend to seek medical attention only when their condition becomes severe.

In this study, young individuals were the most affected, with a higher prevalence among patients aged 21 to 50 years (50.5%). The average age of the study population was 33.9 years ± 20.7 years. Chaabane et al. [10] in Tunisia in 2013 found an average age of 44 years, with a higher prevalence among individuals aged 20 to 50 years (40.67%). A study conducted by Elkhabbazi et al. [11] in Morocco in 2014 found an average age of 35.39 years, with the 20–50 age group representing 56% of the cases. This higher prevalence in younger age groups could be due to the tendency for self-medication, repeated intake of known medications that may cause drug eruptions, and the fact that this age group is the most active.

Women were the most represented in our study, accounting for 50.4% of the cases, with a sex ratio of 0.98. This female predominance was also observed by Konaré et al. [9] in Mali, Kouassi et al. [12] in Côte d’Ivoire, Mrouki et al. [13] in Tunisia, Chaabane et al. [10] in Tunisia, and Elkhabbazi et al. [11] in Morocco, with sex ratios of 0.42, 0.50, 0.60, 0.82, and 0.95, respectively. The differences in pharmacokinetics, hormonal factors, and the tendency for women to consume more medications, particularly through self-medication, and to seek medical attention more frequently than men, may explain this predominance [10].

In this study, the highest level of education represented was university education (31.7%). This could be due to the fact that educated individuals are more likely to research the symptoms they experience, which may lead to more frequent self-medication in this category of people.

Most of the patients were students, apprentices, and pupils (26.0%), followed by the unemployed (23.6%). These professions correspond to the young population, which has relatively easy access to medications.

In this study, 74.0% of the patients had no prior medical history. Asthma and hypertension were present in 8.9% of patients each. Chaabane et al. [10] in Tunisia found comorbidities in 26% of cases. The role of previous medical conditions in the occurrence of drug eruptions may be explained by changes in drug pharmacokinetics during certain pathological conditions, such as renal or hepatic insufficiency, as well as the frequency of polypharmacy [10].

It was observed that 58.0% of patients practiced self-medication, although this information was not specified for all patients. Atadokpèdé et al. [8] in Benin and Konaré et al. [9] in Mali reported a self-medication prevalence of 49.2% and 51%, respectively. These percentages reflected the widespread practice of self-medication in our context, which may be attributed to poverty, limited access to healthcare, the availability of street medicines, and illiteracy.

The drugs most frequently implicated in this study were sulfonamides (13.0%), followed by analgesics (12.2%), antimalarials (10.6%), and beta-lactams (8.9%). Atadokpèdé et al. [8] in Benin found that the main drugs responsible for drug eruptions were anti-infective sulfonamides (36.03%), beta-lactams (13.24%), analgesics-NSAIDs (9.56%), and antimalarials (8.09%). In a study conducted in Morocco by Elkhabazi et al. [11], 21.84% of the implicated drugs were beta-lactams (amoxicillin/clavulanic acid, ceftazidime…), 16.09% were antituberculosis agents (isoniazid, ethambutol, pyrazinamide, rifampicin), and 14.94% were analgesics and antipyretics (acetylsalicylic acid, paracetamol). The observation is that the most frequently implicated drugs are also the most accessible in terms of cost and availability in healthcare structures, pharmacies, and markets.

The time interval between drug intake and the onset of symptoms was 1 to 7 days in 13.0% of the patients and less than 24 hours in 8.1%. Konaré et al. [9] in Mali reported that drug eruption symptoms most often appeared in the third week after drug intake, followed by the one-week period. Diatta et al. [14] in Senegal found that the time to onset of lesions was less than 24 hours in 32.5% of patients, less than one week in 22.5%, less than a month in 38%, and more than a month in 7.0%. These results show that drug eruptions often occur less than a month after drug intake. A more detailed comparison of the timing percentages is difficult because these delays were reported in general terms rather than being specific to each drug or type of drug eruption.

In this study, macules were the most common dermatological lesions (80.5%), among which 71.7% were hyperpigmented. Following macules, erosions (35.0%), and scaling (33.3%) were also common. Konaré et al. [9] in Mali observed that macules accounted for 31.7% of the lesions. The high frequency of macules across various studies may be explained by the fact that macules are the primary lesion in fixed drug eruptions, which was the most frequent type of drug eruption in this study. Macules are also commonly found as pigmentary sequelae in other types of drug eruptions.

In our study, the most common locations of lesions were the thighs (52.0%), chest (51.2%), and arms (46.3%). In the study by Konaré et al. [9], the trunk and face were the most frequently affected areas, with 45.8% and 43.5% of patients affected, respectively.

Fixed drug eruption (FDE) was the most common type of drug eruption in this study, accounting for 52.0% of the cases. This predominance was also observed by Konaré et al. [9] in Mali and by Atadokpèdé et al. [8] in Benin, with proportions of 42.6% and 70.0%, respectively. Maculopapular rash and urticaria accounted for 10.6% and 2.4%, respectively, in this study, and 9.1% and 27.3%, respectively, in the study by Mrouki et al. [13], and 4.9% each in the study by Atadokpèdé et al. [8]. They were the clinical types most frequently found by Chaabane et al. [10] at 35.59% and 19.49%. Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) accounted for 17.1% and 6.5%, respectively, in this study, 5.4% each in the study by Atadokpèdé et al. [8], and 3.3% and 13.1%, respectively, in the study by Konaré et al. [9]. Overall, more than 90% of drug eruptions are benign (erythematous eruptions, urticaria, pruritus, photosensitivity…) [11].

CONCLUSION

The frequency of drug eruptions at the Dermatology and Venereology Unit of DUHC-B/A was significant. Most patients were young adults, predominantly female. The most frequently implicated drugs were sulfonamides, antibiotics, analgesics, and antimalarials. Most drug eruptions were benign (erythematous eruptions, urticaria…). Severe forms that could threaten life, such as Stevens–Johnson syndrome and toxic epidermal necrolysis, were less common.

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