TABLE OF CONTENTS
Page
1. Patient Profile 2
2. Health Assessment 2
3. Physical Examination 5
4. Diagnosis 5
5. Management 6
6. Evaluation 9
7. APN reflections and learning points 10
A 54-year old lady with hypertension presented with photosensitive rashes on 3 February 2007.
This case study will be focusing on the 1) approach to photosensitive rash and 2) management of
persisting hypertension.
HEALTH HISTORY
Chief Complains: Ms Catherine came for a follow-up appointment for hypertension and rashes
review. She complained that her left leg swells usually at about 4pm after she took the Nifdepine
LA 60mg in the morning. Her skin rashes are still persisting but have resolved slightly. They are
still very itchy but there are no new areas of rashes appearing.
Clinical History: Ms Catherine has been following up in Hougang polyclinic for high blood
pressure control. From 2 Feb 2006 to 3 Feb 2007, her clinic blood pressure readings range from
150/90mmHg to 200/105mmHg. She had tried (1) Beta Blockers: Atenolol, (2) ACE-inhibitors:
Enalapril and Valsartan, (3) Calcium channel blockers: Adalat LA and Amoldipine and (4)
Diuretics: Hydrocholrothiazide and (5) Combination drugs: Losartan/ Hydrochlorthiazide
(Hyzaar amd Hyzaar Forte). During the consult on 3 February, her blood pressure was
160/108mmHg and 170/110mmHg with antihypertensive medications. She denies having
headache, nausea, vision disturbances and neurological symptoms during consult.
It was noted that papular rashes appeared on Catherine’s upper limbs on 06 January 2007. The
rashes were papular and pruritic in nature. The distribution of rashes is in photosensitive areas,
predominantly over the neck, upper limbs, face, bridge of nose and feet. The medications she
was taking every morning once a day during that period of time were 1) Losartan/
Hydrochlorthiazide 100mg/ 25mg 2) Atenolol 50mg 3) Calcium and Vitamin D 1 tablet and 4)
Glucosamine 1500mg. Losartan/ Hydrochlorthizaide combination drug was prescribed to
Catherine since November 2006 which she had tolerated the medications with no side effects
reported. She was also prescribed Atenolol from 2004 to 2006 with no allergy reported. She was
only restarted back on Atenolol with Losartan/ Hydrochlorthiazide combination on the previous
consult prior to developing rashes. She claimed there was no changes in the topical agents that
She reported that the rashes were better during this consult. However, she is experiencing
swelling of the feet usually around 4pm after taking Nifedipine LA 60mg in the morning. The
swelling resolves usually the next morning. There is no report of shortness of breath or exertional
dyspnea.
Catherine has no history of chronic skin problems. There is also no other significant medical
history of note. She works as a factory operator dealing with packaging of batteries for more than
1 year. There is no exposure of batteries contents during the course of work. There are no
reported joint pains. Review of other systems is negative.
Current Medications:
1) Losartan/ Hydrochlorthiazaide 100mg every morning
2) Nifedipine LA 60mg every morning
3) Hydroxyzine 10mg morning and afternoon, 25mg in the evening
4) Betamethasone Valerate 0.025% cream
Drug Allergy:
Nil reported. However, from her medical notes, it has been noted that Catherine seems to
develop side effects to the following medications.
1) Enlapril – cough
2) Valsartan – headache and cough
3) Amolodipine – pedal edema
She exhibited rashes from enalapril with mild cough and pedal edema from amlodipine. She also
complained having cough and headache with Valsartan. On one of the consults that she
verbalized unhappiness with Adalat LA and hydrocholrothiazide regimen. See Table 1 for the
summary of polyclinic consults.
DIAGNOSES
Principal Diagnosis: Persistent hypertension
Probable Diagnosis: Photosensitivity Dermatitis secondary to drug allergy.
Differentials: Contact Dermatitis, Rosacea, Lupus Erythamous and Dermatomyositis
The urgency to rule out drug allergy is important in Ms Catherine’s case as drug allergy can lead
to other severe complications e.g. anaphylactic shock. In addition, her hypertension management
needs to be optimized. On 2 occasions in September and October 2006, she complained about
itch and rash. The clinical symptoms seem to coincide with addition of ACE and ARBs to the
treatment plan. However, there is a possibility that recurrent episodes of itch and rash can be
triggered from of an unknown primary irritant resulting in contact dermatitis.
Retrospectively reflecting, in Ms Catherine’s case, which she presented with erythema, urticaria
and papules, drug-induced photosensitivity rash as the probable and the list of differentials seem
appropriate.
Drug photosensitivity
Systemic phototoxicity
Systemic photoallergy
Phototoxic contact
dermatitis Photoallergic
contact dermatitis
Photo-aggravated dermatoses
Endogenous eczema
Collagen vascular disease
Nutrional deficiencies
o Pellagra
o Hartnup disease
Dermatomyositis is a rare idiopathic disorder that includes characteristics skin manifestation and
inflammatory myopathy. These patients usually present with other symptoms like proximal
muscle weaknes, dysphonia or disphagia. Other possible symptoms include respiratory muscle
weakness, visual changes and abdominal pain. Patients diagnosed with dermatomyositis have a
6.5-fold increased risk of malignancy. This risk is further increased if the age of diagnosis is
Thus, a presentation of photosensitive rash in the primary care setting requires health history
taking and physical examination covering aspects of malignancy, joints and musculoskeletal
involvement. Family history of malignancy and collagen vascular disorders like SLE might also
give an estimate picture of the risk profile.
Hypertension Drug and Skin Rash. Thiazides, captopril and frusemide are noted to commonly
cause serious reactions. Certain anti-hypertensive drugs are associated with specific morphologic
patterns. Other anti-hypertensive drugs that are noted to cause skin rashes include: ACE
inhibitors (particularly Enalapril), calcium channel blockers (particularly Diltazem, amlodipine
and nifedipine) and beta blockers (particularly Propanolol). Hydralazine is note to be commonly
associated with drug-induced SLE (Blume, 2007).
Treatment. Besides determining the cause of the photosensitive rashes. Stopping the suspicious
causative agent to the development or aggravation of the rashes is important. From the medical
history notes, it has been noted that the physicians had immediately stopped the agent that they
thought has caused the eruptions. This conclusion is usually derived from the health history and
analyzing the onset of rashes in respect to the timing that the medication has been started.
Hypertension Management. Excluding complications and determining causes for persistent high
blood pressure is necessary approach to patient with very high blood pressure reading. An APN
should refer the patients who fall into this category and manage under the supervision of the
physician.
EVALUATION
Follow up visits for Ms Catherine was scheduled to return 2 weeks later in view of her high
blood pressure reading and her skin manifestations. The next follow up visit will include
assessing the resolution of the skin rashes and high blood pressure management. From the
National Skin Centre report, hydrochlorothiazide seems to be the most probable agent to cause
Ms Catherine’s photosensitive rash. Most literature stated that the onset of reaction is rarely less
than 1 week or more than 1 month (Riedl and Casillas, 2003). However, Catherine had started on
thiazide since 27 October 2006. The time period between the introduction of drug and the onset
of reaction is about 3 months. The polyclinic physicians knew this information in the subsequent
visit.
Assessing complications of high blood pressure, like renal and cardiac problems, stroke and
papilloedema is also part of the care. The decision to send Ms Catherine to the specialist, in view
of her present proteinuria and mild renal impairment status, should be considered in subsequent
visits if the blood pressure is still not controlled despite treatment. Signs of fluid overload, e.g.
swelling ankles, exertional dyspnea etc. will increase the suspicion of renal deterioration and
require urgent referral to the specialist.
REFERENCES
Blume. J.E. Drug eruptions. Retrieved on 10 June 2007 from http://www.
emedicine.com/derm/topic104.htm
Koler. R.A. and Montemarano, A. (2001). Dermatomyositis. American Family Physician, 64(9),
p. 1565-1572.
Kwok, C. (2000). Evaluation of a photosensitive rash. National Skin Centre Bulletin for Medical
Practitioners, 11(1). Retrieved on 14 June 2007 from
http://www.nsc.gov.sg/cgi-bin/WB_ContentGen.pl?id=283&gid=54
Riedl, M.A. and Casillas, A.M. (2003). Adverse drug reactions: types and treatment options.
American Family Physician, 68(9), p. 1781-1790.