(135) Recurrent Rash with Sertraline and Escitalopram: A Case Report

‎Background/Significance: Selective serotonin reuptake inhibitors (SSRIs) are one of the first-line treatments ‎for anxiety and depression given their efficacy and generally favorable side effect profile. Dermatological reactions are ‎relatively rare and previously reported to be approximately 11% of adverse reactions, typically consisting of rash, ‎pruritus and urticaria (Spigset 1999). There have been several case reports of these reactions associated with ‎antidepressants, such as fluoxetine, escitalopram and sertraline. Management strategies differed among these cases, ‎with some avoiding all medications within the same class and utilizing a different medication class such as serotonin ‎norepinephrine reuptake inhibitors (SNRIs), while others found success with alternatives within the same class. The ‎time to resolution of rash varied, with studies finding resolution as early as 48 hours and as late as up to 5 weeks ‎‎(Cederberg 2004, Byrne 2017). There are a few case reports regarding cross-reactivity between SSRIs, specifically ‎between fluoxetine and sertraline, to suggest that switching classes of antidepressants should be considered ‎‎(Warnock 2002, Khairkar 2010). To our knowledge, there are no published case reports of potential cross-reactivity ‎between sertraline and escitalopram.‎

‎

Case Presentation: A 30-year-old female with a history of generalized anxiety disorder and postpartum ‎depression was started on escitalopram 10 mg, noticing a pruritic rash behind her ears within one week of initiation. ‎Escitalopram was titrated to 20 mg approximately 1 month later, at which time, she experienced a diffuse, pruritic, ‎erythematous rash. A cross titration between escitalopram and sertraline was initiated, at which her rash resolved ‎within 7 days of discontinuing escitalopram. Sertraline was ultimately titrated to 150 mg and after 3 weeks on this ‎dose, she developed a pruritic erythematous rash on her right breast that spread to her trunk and extremities. She ‎was seen by her dermatologist, who biopsied a lesion and determined it to be a drug rash. She was then cross titrated ‎to the SNRI duloxetine, ultimately up to 60 mg daily. Her rash resolved approximately 3 weeks after discontinuing ‎sertraline. She did not experience reemergence of the rash when she was last seen in clinic approximately 4 months ‎after transitioning to duloxetine. Of note, the patient denied other medication changes or changes in soaps, ‎detergents or lotions throughout this time.‎

‎

Conclusions: This case suggests a potential cross-reactivity between sertraline and escitalopram regarding risk ‎of developing adverse events, despite chemically different structures. This further supports an emerging number of ‎case reports to suggest cross-reactivity between SSRIs. Therefore, switching antidepressant classes should be ‎considered after development of a suspected SSRI-induced rash.‎

‎

References: ‎
‎1. Spigset O. Adverse reactions of selective serotonin reuptake inhibitors: reports from a spontaneous reporting ‎system. 1999 Mar;20(3):277-87.‎
‎2. Cederberg J et al. Itch and skin rash from chocolate during fluoxetine and sertraline treatment: case report. BMC ‎Psychiatry. 2004;4:36.‎
‎3. Byrne A et al. SSRI-induced severe adverse cutaneous reaction- a case report. Prog Neurol Psychiatry. 2017;21(4):9-‎‎12.‎
‎4. Khairkar et al. Possible cross-sensitivity between sertraline and paroxetine in a panic disorder patient. Indian J ‎Pharmacol. 2010 Apr;42(2):110-1.‎
‎5. Warnock CA and Azadian AG. Cross-sensitivity between paroxetine and sertraline. Ann Pharmacother. 2002 ‎Apr;36(4):631-3.‎