Comparison Between Corticosteroid and Topical Steroids in the DRESS

DRESS - Setting of Corticosteroid Treatment.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare and severe multiorgan adverse drug reaction occurring within 2 to 6-8 weeks after a new drug intake. DRESS syndrome is defined by the combination of clinical manifestations, cutaneous, visceral and biological disturbances. Its prognosis is directly linked to severity of visceral involvement, with a mortality evaluated above 10%.

Considering curative treatment, there is no consensus. Until now, no controlled trial has been performed. Systemic steroids are mainly used in first intention, in particular for management of visceral involvements, whatever their severity. From clinical practice, topical steroids are often used and could be helpful in the therapeutic management of DRESS.

We propose to evaluate systemic steroids versus very potent topical steroids in a multicentric randomized controlled trial including defined moderate DRESS, ie the non-inferiority of very potent topical steroids in terms of remission of visceral involvement at Day30 and the superiority of very potent topical steroids in terms of delay to remission of skin involvement.

Inclusion Criteria:

• patient age ≥ 18 years

• signing informed consent form

• DRESS diagnosis with at least 4 criteria a, b, c, d

  1. Skin rash occurring at least 10 days and not more than two months after continuous drug intake (or within less than 10 days in case of rechallenge)
  2. Fever ≥ 38 ° at the time of examination or fever ≥ 38.5 ° peak in the last 72 hours (amendment 2 : ANSM + CPP : 08/04/14)
  3. at least one visceral compatible :

• lymphadenopathy on at least two different sites measuring at least 1 cm in diameter

• transaminases > 2 upper limit of normal (ULN) or alkaline phosphatise > 3 ULN

• lung involvement defined by hypoxemia (capillary oximetry ≤ 95%) and/or interstitial lung disease on chest radiography or scanner, in absence of other lung disease

• myocarditis, pericarditis (ECG clinical suspicion and confirmed by echocardiography)

• renal impairment defined as creatinine increase above the normal laboratory value associated with leucocyturia > 1000 / mm3 or proteinuria, a Na / K ratio >1 and Urine Cyto-bacteriology (EBCU) sterile in the absence of preexisting renal disease d) At least one of the following haematological abnormalities:

• eosinophilia ≥ 0.7 g/l or > 10 % absolute

• lymphocytosis ≥ 5*10^9 /l

• presence of atypical blood lymphocytes

• Patient with moderate DRESS : defined by at least one reached as follows :

• pulmonary: interstitial pneumonia with oxygen partial pressure in arterial blood (PaO2) 60-75 mmHg without dyspnoea at rest

• Hepatic: transaminases ≥ 4 ULN and < 15 ULN and/or PAL ≥5 ULN and V factor 50% (amendment 2 : ANSM + CPP : 08/04/14)

• renal :

• acute renal failure and organic sharp increase in the 48 hours preceding the inclusion of more of 26.4 micromol/l creatinine

• and / or increase of 1.5 times the normal creatinine value

• and / or decrease of oliguria of less than 0.5 ml/kg/h followed by a 6 hours

• cord: pancytopenia (7≤Hb≤10 gr/dl and/or 50<p<100 G/L, 0.5<PNN≤1.5G/l)

• AND absence of cardiac, neurological or gastrointestinal (gut, pancreas) threatening

• Drug withdrawal

• Patient with health insurance (or entitled beneficiary)

• Patient accepting the constraints of the test

Exclusion Criteria:

• uncontrolled sepsis

• unability to discontinue the medication(s) due

• known hypersensitivity to systemic or topical corticosteroids

• hepatitis B or C known, (active HIV status known suppressed by amendment 5 : ANSM16/04/2015 and CPP 07/04/2015)

• (Patient already treated by corticosteroid :

  • More than 48 hours
  • Less than 48 hours to following conditions :

• Patients receiving more than 1 mg/kg/day of prednisone per os

• Patients receiving methylprednisolone pulse up to 1mg/kg prednisone equivalent

• (Patients receiving more than 30 grams per day level 3 topical steroid or more than 10 grams per day level 4 topical steroid --> suppressed by amendment 3 : ANSM 28/05/14 CPP : 10/06/14)

• (Patient undergoing immunosuppressive therapy for another disease suppressed by amendment 5 : ANSM16/04/2015 and CPP 07/04/2015)

• Participation in another drug biomedical research

• Primitive bacterial infections, fungal or parasitic

• Severe rosacea cont-indicating the use of corticosteroid

• Presence of at least one ulcerated lesion (more than 10cm2)

• Severe dermatitis perioral cont-indicating the use of corticosteroid

• Severe acne contra-indicating the use of a corticosteroid

• Pregnant or nursing women