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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 28-30

Risperidone-induced skin rash in an elderly female


Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Date of Web Publication16-Aug-2019

Correspondence Address:
Dr. Avinash de Sousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz (West), Mumbai - 400 054, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_7_19

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  Abstract 


Skin reactions have been reported with various antipsychotic drugs in scientific literature. It is important that clinicians be watchful of skin reactions in the elderly with antipsychotic medication, which can be an uncommon occurrence. It has been documented that the elderly are more prone to skin reactions with various forms of medication. We herewith report a case of skin reaction with risperidone in an elderly female patient.

Keywords: Antipsychotics, elderly, risperidone, skin reaction


How to cite this article:
Shah M, Karia S, Merchant H, Shah N, Sousa Ad. Risperidone-induced skin rash in an elderly female. J Geriatr Ment Health 2019;6:28-30

How to cite this URL:
Shah M, Karia S, Merchant H, Shah N, Sousa Ad. Risperidone-induced skin rash in an elderly female. J Geriatr Ment Health [serial online] 2019 [cited 2019 Dec 12];6:28-30. Available from: http://www.jgmh.org/text.asp?2019/6/1/28/264506




  Introduction Top


Psychotropic drugs such as atypical antipsychotics have been used widely in the elderly in the management of late-onset schizophrenia and behavioral issues related to dementia.[1] It is prudent that when antipsychotics are used in the elderly, the dose should be low and one must monitor stringently for side effects.[2] It is well known that skin reactions with various psychotropic drugs show a higher prevalence in the elderly.[3] Risperidone has been used in the elderly in the management of late-onset schizophrenia[4] and agitation and behavioral symptoms of dementia.[5] Risperidone has been reported to cause drug rashes and cutaneous eruptions, which can be generalized cutaneous rashes, urticaria, and even more severe lesions such as angioedema, acute exanthematous lesions, toxic epidermal necrolysis, and Steven–Johnsons syndrome, which may need emergency medical attention.[6],[7] We report herewith a case of a 64-year-old female patient who developed skin reactions with risperidone.


  Case Report Top


A 64-year-old married Hindi-speaking Muslim homemaker, educated up to the 5th standard in an Urdu medium school, presented to our outpatient department with complaints of low mood, disturbed sleep, inability to speak for 2–3 h a day, and multiple somatic complaints for the past 1 year. She was apparently alright a year back, when she was diagnosed as having multidrug-resistant tuberculosis (MDR-TB) and was started on Category II anti-Koch's treatment for 1 year which she complied with and completed properly. This treatment was completed 3 months before visiting the psychiatry department for the first time. According to her spouse, after the diagnosis of MDR-TB, she started having low mood most of the day, showed a decreased interest in routine household activities, had easy fatigue, and needed rest many times a day between household chores. She had increased irritability even when the spouse just spoke to her and preferred to sit alone, had crying spells, had decreased appetite, and underwent a weight loss of 8–10 kg. She also had disturbed sleep at night, while she had a rumination of thoughts about her illness and her future. She sometimes had death wishes which were passive in nature.

She sometimes complained of an inability to speak; though she wanted to speak, she was not able to speak. This lasted for 2–3 h a day after which she would be completely alright. These episodes of difficulty in speaking would occur 10–20 times a week. She had complaints of breathlessness on walking for some distance, knee pain, tingling, and numbness in legs; jaw pain, sweating and heat intolerance, and continuous light headache. She also had complaints of 3–4 episodes of clenching of her teeth, deviation of mouth and tongue, up-rolling of eyeballs, and tightening of the limbs. There was no history of head injury, tongue bite, urine or stool incontinence, loss of consciousness, and frothing from the mouth. There was no history of other psychiatric complaints, head injury, or epilepsy. On clinical evaluation, these were diagnosed as conversion episodes due to the stress that the patient was undergoing. There was no history of cognitive decline on clinical evaluation/mental status examination – no formal testing was done.

On mental status examination, the patient conveyed mood as being sad and expressed ideas of hopelessness, worthlessness, and passive death wishes. She was diagnosed as major depressive disorder with moderate severity and was started on oral desvenlafaxine 50 mg twice a day and clonazepam 0.5 mg at night. All her routine blood investigations were within normal limits. Electroencephalography and neuroimaging studies in the form of magnetic resonance imaging did not reveal any abnormality. After a week on follow-up, she reported improvement in depressive features but increased aggression and agitation toward her family members. There were no symptoms to suggest a mood switch or mania/hypomania. In view of aggression, she was started on oral risperidone 1 mg at night and clonazepam was increased to 1 mg. Poststarting this dosage, within 72 h, she presented with complaints of maculopapular rashes all over the body and itching over rashes along with stiffness of wrist and fingers. Injectable promethazine 50 mg was given immediately for stiffness of limbs which relieved her completely.

A dermatology opinion was taken; she was diagnosed as drug-induced reaction secondary to risperidone as there was temporal relationship of rashes over body and risperidone. She was prescribed prednisolone 20 mg once a day for 5 days and cetirizine 10 mg at night which led to subsiding of the rashes. She was then continued on desvenlafaxine and clonazepam. She was requested regarding restarting risperidone at a lower dose and observing, but she and her spouse refused considering the skin rash that occurred. A Naranjo algorithm scale was applied and a score of +4 was obtained that did indicate a relationship between risperidone and the skin rash. The patient consented for the case report to be published but refused to be photographed for the rash as she had an old tattoo on her hand which would serve as a means for people to recognize her.


  Discussion Top


The patient in our case developed a mild drug-induced rash that subsided easily with treatment. The patient refused a re-challenge with the drug, and we could not corroboratively confirm the evidence. Skin rashes with risperidone have been previously reported in literature and have been seen to be more frequent in the elderly.[8] Clinicians need to be vigilant about drug-induced rashes in the elderly when on antipsychotics. In our case, luckily, the patient did not have any other concomitant drugs that may have caused or aggravated the existing skin reaction. We also acknowledge that both desvenlafaxine[9] and clonazepam[10] may cause skin rashes, but the temporal relationship between the drug rash and initiation of risperidone made us rule in favor of a risperidone skin rash. The prevalence of dermatologic disorders in patients receiving psychotropic medications was 8.4% in a study where 50% of those who developed dermatologic symptoms had their first treatment with psychotropic medicines. These reactions were seen more often in patients receiving more than two psychotropic medications than those in monotherapy.[11] A multicenter drug safety surveillance study revealed that about 0.1% of cases had clinically relevant cutaneous adverse reactions related to a single psychotropic medication, of which 3.3% were life-threatening. These reactions were significantly less often with new generations of antidepressants (such as selective serotonin reuptake inhibitors(SSRIs) and dual-mechanism or other second-generation antidepressants) than with classical types of antidepressants (such as tricyclic and tetracyclic antidepressants). Atypical antipsychotics had the lowest rates of dermatologic side effects in this study.[12] Multiple drug use and drug–drug interactions between medical and psychotropic drugs may cause skin reactions in the elderly,[13],[14] and one must be aware of the same when treating the elderly with atypical antipsychotics. It is best that medication be started at a low dose and gradual slow increments be done based on symptomatic improvement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Byerly MJ, Weber MT, Brooks DL, Snow LR, Worley MA, Lescouflair E. Antipsychotic medications and the elderly: Effects on cognition and implications for use. Drugs Aging 2001;18:45-61.  Back to cited text no. 1
    
2.
Bloch F, Thibaud M, Dugué B, Brèque C, Rigaud AS, Kemoun G. Psychotropic drugs and falls in the elderly people: Updated literature review and meta-analysis. J Aging Health 2011;23:329-46.  Back to cited text no. 2
    
3.
Carneiro SC, Azevedo-e-Silva MC, Ramos-e-Silva M. Drug eruptions in the elderly. Clin Dermatol 2011;29:43-8.  Back to cited text no. 3
    
4.
Sable JA, Jeste DV. Antipsychotic treatment for late-life schizophrenia. Curr Psychiatry Rep 2002;4:299-306.  Back to cited text no. 4
    
5.
Deberdt WG, Dysken MW, Rappaport SA, Feldman PD, Young CA, Hay DP, et al. Comparison of olanzapine and risperidone in the treatment of psychosis and associated behavioral disturbances in patients with dementia. Am J Geriatr Psychiatry 2005;13:722-30.  Back to cited text no. 5
    
6.
Desarkar P, Nizamie SH. Risperidone-induced erythema multiforme minor. Br J Clin Pharmacol 2006;62:504-5.  Back to cited text no. 6
    
7.
Janardhana P, Nagaraj AK, Basavanna PL. Risperidone-induced skin rash. Indian J Psychiatry 2016;58:106-7.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Sidhu K, Saggu H, Lachover L, Dziuba JT. Rare case report of rash associated with risperidone long-acting injection. Prim Psychiatry 2010;17:38-40.  Back to cited text no. 8
    
9.
Alice Nichols I, Jessica Behrle A, Virginia P, Lyette Richards S, Stephanie McGrory B. Pharmacokinetics, pharmacodynamics, and safety of desvenlafaxine, a serotonin-norepinephrine reuptake inhibitor. J Bioequiv Availab 2013;5:22-30.  Back to cited text no. 9
    
10.
Shareef SM, Sai Krishna P, Tadvi NA, Naidu CD. Clonazepam induced maculopapular rash: A case report. Int J Basic Clin Pharmacol 2013;2:647-9.  Back to cited text no. 10
    
11.
Murak-Kozanecka E, Rabe-Jabłońska J. Prevalence and type of dermatologic disorders in psychiatric patients treated with psychotropic drugs. Psychiatr Pol 2004;38:491-505.  Back to cited text no. 11
    
12.
Lange-Asschenfeldt C, Grohmann R, Lange-Asschenfeldt B, Engel RR, Rüther E, Cordes J. Cutaneous adverse reactions to psychotropic drugs: Data from a multicenter surveillance program. J Clin Psychiatry 2009;70:1258-65.  Back to cited text no. 12
    
13.
Björkman IK, Fastbom J, Schmidt IK, Bernsten CB; Pharmaceutical Care of the Elderly in Europe Research (PEER) Group. Drug-drug interactions in the elderly. Ann Pharmacother 2002;36:1675-81.  Back to cited text no. 13
    
14.
Mufaddel A, Osman OT, Almugaddam F. Adverse cutaneous effects of psychotropic medications. Exp Rev Dermatol 2013;8:681-92.  Back to cited text no. 14
    




 

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