Thread by @DrStevenTChen

Thanks, @MelBreggs for the mention, and thank you to @gopiastik for a great #tweetorial on #AGEP (acute generalized exanthematous pustulosis). I would add a couple thoughts here. Please read on!

#MedEd #FOAMEd #derm #dermatology #dermatologia #medthread PC: @dermnetnz
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https://twitter.com/MelBreggs/status/1120431493665492993

First of all, the name AGEP can be confusing, but really all it is a description (we dermatologists just like to sound #fancy). If you break it down, Acute (really quick onset) generalized (everywhere), exanthematous (rash-y), pustulosis (pustules)!
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The exam is red plaques studded with pustules (see photo). These pustules can coalesce and become "lakes of pus!" The 2nd picture doesn't have pustules b/c all of them came together, lifted off, and left the "collarette" of scale (which means there's a footprint leftover!
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Of note, the 2nd photo isn't actually of AGEP, because AGEP is indistinguishable from another diagnosis both histologically and clinically. What do you think that might be?
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AGEP & pustular psoriasis can be indistinguishable on exam & on pathology. Because of that, the most important historical question (aside from asking about drugs) is whether the pt has a history of psoriasis. If they do, then the history might help you determine what's likely.
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I would argue that a bx isn't necessary in all cases. If the exam is clear cut, you know what the pathology will look like ( microabscesses w/ PMNs).
If I may get on my soapbox: When calling a derm consult, ask for our opinion, not for a bx! I promise we'll do it if needed!
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As for drug culprits, agree with the list that @gopiastik tweeted! I'll make one mention for all you #hospitalists and inpatient folk: don't forget about the OR. Unlike other drug reactions, you DON'T need repeated exposure, so a commonly forgotten drug is the periop abx!
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And time-wise, remember that knowing how long drug dose to skin eruption is critical in identifying the drug. in AGEP, it's usually within 24-36 hours. So you don't have to look too far back to find the cause.

What labs might you check if you have a pt with AGEP?
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Since some people can have AGEP overlap with other more serious conditions, we often will advocate for checking all the above labs, but this is certainly more institutional preference. Also, if the pt looks quite well, you might get away with just topical steroids!
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If anything does seem off, the patient seems ill, systemic steroids may be indicated. Definitely consider involving your friendly @dermhospitalist to help you manage! We are happy to pitch in if we can be of service.
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So to recap:
- AGEP occurs 24-36 hours after culprit drug.
- Can just be 1 dose of drug, so don't forget about the OR.
- Consider checking CBC/diff and a comprehensive metabolic panel.
- Biopsy isn't necessarily required.
- Ask about psoriasis history.
- Call a derm to help!
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I'll end it here, as I'm wrapping up clinic myself! Hope you find this to be a helpful addition to an already great #tweetorial on the topic! Please leave any comments/questions below!
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