DR11.2 | Dermatologic Reactions to ART Drugs — Summary & Reflection

KEY TAKEAWAYS

Antiretroviral drugs cause a spectrum of cutaneous reactions, and grading severity drives every decision. Nevirapine (an NNRTI) is the most important offender: a common early morbilliform rash, but also the ART drug most associated with Stevens-Johnson syndrome, toxic epidermal necrolysis, and DRESS, plus hepatotoxicity. Efavirenz causes a milder rash; abacavir causes a pharmacogenomic hypersensitivity reaction linked to HLA-B*57:01 (screen before use; never rechallenge); and zidovudine causes benign nail and mucocutaneous hyperpigmentation. Separately, IRIS is an inflammatory flare of existing infection after ART starts — not a drug allergy. Severity on the SJS/TEN spectrum is defined by epidermal detachment: SJS <10% BSA, SJS-TEN overlap 10–30%, TEN >30%. Management follows the grade: a mild morbilliform rash without systemic or mucosal signs may be continued under observation with antihistamines, but any red flag (mucosa, blistering, Nikolsky+, fever, systemic upset) requires stopping the drug immediately, never rechallenging, and urgent referral; SJS/TEN needs burns-unit-level supportive care, DRESS needs drug withdrawal plus steroids, abacavir hypersensitivity needs permanent withdrawal, and IRIS is managed by continuing ART with steroids for severe flares. This decisive recognise-grade-act sequence is the essence of competency DR11.2. (Confirm drug-substitution choices and thresholds against current NACO guidance.)

REFLECT

Imagine you are the intern on call at an ART centre when a patient who started treatment a few weeks ago arrives with a rash. Reflect on how you would structure your assessment in the first few minutes: which questions about timing and which examination findings would you prioritise to decide whether this is a benign rash, a severe cutaneous adverse reaction, or IRIS? Consider, too, the human weight of the decision — telling a patient that a drug must be stopped permanently, or reassuring them that a frightening rash is safe to treat through. How would you balance the competing harms of interrupting a lifesaving regimen against the danger of continuing a drug that is beginning to harm the skin? Rehearsing this recognise-grade-act-and-communicate sequence now is what will let you act calmly and correctly when it matters.