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Painful and Pruritic Blisters on the Lower Lip

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 41-year-old woman presented with a 2-day history of burning, stinging, itchy blisters on the lower lip. She had experienced a similar eruption at the same site with spontaneous resolution 1 year previously, after she had taken a cold medication containing ibuprofen. Her medical history was otherwise unremarkable. She took no prescription medications; however, she did occasionally take over-the-counter ibuprofen. On examination, she was well-appearing and afebrile. There were tense confluent blisters in a 4-cm area on and around the lower lip (Figure 1) and no other skin or mucosal lesions.

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Bullous nonpigmenting fixed drug eruption

C. Discontinue ibuprofen

The key to the correct diagnosis in this case is the recurrence of local blisters at the same anatomical site after ibuprofen administration. A fixed drug eruption is a skin or mucosal adverse drug reaction that occurs at the same site each time the causative drug is taken.1 Common sites include the hands, feet, lips, and genitals.2,3 The lesion typically appears as solitary or multiple oval erythemas, which can evolve to become blisters (bullous fixed drug eruption). This sometimes causes residual postinflammatory hyperpigmentation; however, there sometimes may be cases without pigmentary change (nonpigmenting fixed drug eruption), as in this instance.

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Article Information

Corresponding Author: Mitsuhito Ota, MD, PhD, Department of Dermatology, Chitose City Hospital, Hokkou 2, Chitose 066-8550, Japan (ota@med.hokudai.ac.jp).

Published Online: December 13, 2019. doi:10.1001/jama.2019.17568

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank the patient for providing permission to share her information.

References
1.
Derbes  VJ.  The fixed eruption.  JAMA. 1964;190(8):765-766. doi:10.1001/jama.1964.03070210071013PubMedGoogle ScholarCrossref
2.
Brahimi  N, Routier  E, Raison-Peyron  N,  et al.  A three-year-analysis of fixed drug eruptions in hospital settings in France.  Eur J Dermatol. 2010;20(4):461-464. doi:10.1684/ejd.2010.0980PubMedGoogle Scholar
3.
Singhal  RR, Sheth  NK, Nair  PA.  Non-pigmented fixed drug eruption caused by ibuprofen.  Indian Dermatol Online J. 2019;10(3):341-343. doi:10.4103/idoj.IDOJ_200_18PubMedGoogle ScholarCrossref
4.
Apaydin  R, Bilen  N, Dökmeci  S, Bayramgürler  D, Yildirim  G.  Drug eruptions: a study including all inpatients and outpatients at a dermatology clinic of a university hospital.  J Eur Acad Dermatol Venereol. 2000;14(6):518-520. doi:10.1046/j.1468-3083.2000.00159-5.xPubMedGoogle ScholarCrossref
5.
Sehgal  VN, Srivastava  G.  Fixed drug eruption (FDE): changing scenario of incriminating drugs.  Int J Dermatol. 2006;45(8):897-908. doi:10.1111/j.1365-4632.2006.02853.xPubMedGoogle ScholarCrossref
6.
Mizukawa  Y, Shiohara  T.  Fixed drug eruption: a prototypic disorder mediated by effector memory T cells.  Curr Allergy Asthma Rep. 2009;9(1):71-77. doi:10.1007/s11882-009-0011-8PubMedGoogle ScholarCrossref
7.
Dharamsi  FM, Michener  MD, Dharamsi  JW.  Bullous fixed drug eruption masquerading as recurrent Stevens-Johnson syndrome.  J Emerg Med. 2015;48(5):551-554. doi:10.1016/j.jemermed.2014.09.049PubMedGoogle ScholarCrossref
8.
Ota  M, Tanimura  S.  Fixed drug eruption occurring in vitiliginous skin.  J Am Acad Dermatol. 2013;69(6):e302-e303. doi:10.1016/j.jaad.2013.07.039PubMedGoogle ScholarCrossref
9.
Andrade  P, Brinca  A, Gonçalo  M.  Patch testing in fixed drug eruptions—a 20-year review.  Contact Dermatitis. 2011;65(4):195-201. doi:10.1111/j.1600-0536.2011.01946.xPubMedGoogle ScholarCrossref
10.
Lipowicz  S, Sekula  P, Ingen-Housz-Oro  S,  et al.  Prognosis of generalized bullous fixed drug eruption: comparison with Stevens-Johnson syndrome and toxic epidermal necrolysis.  Br J Dermatol. 2013;168(4):726-732. doi:10.1111/bjd.12133PubMedGoogle ScholarCrossref
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