Severe dermatitis caused by diltiazem

Introduction

To the Editor, Skin rash which caused by drugs shows a high polymorphism, which is determined, on the one hand, by the large amount of drugs used, and on the other hand, by the presence of polymedication, particularly in seriously-ill elderly patients, that increases the possibility for interaction among them, with the attendant risk of morphological expression of medicinal rash. The spectrum of these reactions ranges from mild rash to the most severe forms, which are Stevens-Johnson's syndrome and epidermal toxic necrolysis. The term epidermal necrolysis is a neologism proposed by Lyell¹ to indicate necrosis and separation of epidermis. Blisters are merely exudates accumulating under the necrotic epidermis. The necrolysis phenomenon results from massive apoptosis of the epidermal cells, together with the degradation of the adhesion molecules between the basal cells and the basal membrane of the epidermis.² Stevens-Johnson's syndrome and epidermal toxic necrolysis are considered to be variants of the same disease, based on their similar condition (epidermal necrolysis), similar risk factors, causes and frequent progression from Stevens-Johnson's syndrome to toxic epidermal necrolysis. The main difference between these two conditions resides in the extension of the skin lesions: classified as Stevens-Johnson's syndrome when necrolysis affects less than 10% of the body surface; as superposition of both when it affects from 10 to 30%; and as toxic epidermal necrolysis when it affects over 30% of the body surface.³ We here present the case of a 66-year-old woman, with a history of depressive syndrome treated with mirtazapine and previous cholecystectomy, who in the past...