Symmetrical drug- related intertriginous and flexural exanthema, commonly 
known as “baboon syndrome” due to its typical involvement of the gluteal area, is 
an erythematous symmetrical rash associated with systemic drug administration

La Placa M.

Orioni G

Raschi E

Starace MVR

Tengattini V

Velez-Pelaez MC

English

Archivio istituzionale della ricerca - Alma Mater Studiorum Università di Bologna

Clin Case Rep. 2024;12:e8877.    | 1 of 3https://doi.org/10.1002/ccr3.8877wileyonlinelibrary.com/journal/ccr31  |  INTRODUCTIONSymmetrical drug- related intertriginous and flexural ex-anthema (SDRIFE) is characterized by a maculopapular erythematous rash that typically occurs on the gluteal re-gion and skin folds in a symmetrical distribution follow-ing systemic exposure to a drug.1A 57- year- old woman presented with a 7- day history of erythematous and pruritic cutaneous rash. Upon exam-ination, erythematous symmetrical patches were observed exclusively in the armpits, submammary fold, groins, and gluteal region (Figure  1). Her medical history revealed stage four breast cancer diagnosed since 2013 with hepatic metastases, and was undergoing chemotherapeutic treat-ment with doxorubicin for 2 months. She denied any al-lergies to medications, and the rash began approximately 1 week after the last cycle of chemotherapy. Routine labo-ratory tests revealed leukocytosis.A 31- year- old healthy woman presented with the sudden appearance of a purplish rash on her glutes and groins (Figure  2). Upon further questioning, the patient reported being under treatment with amoxicillin 1 g for pharyngodynia.2  |  DISCUSSIONBoth patients were diagnosed with SDRIFE, and causa-tive drugs were discontinued. Prescription of topical steroids and antihistamines resulted in complete reso-lution within 10 days. After oncologic consultation, doxurobicin was discontinued and treatment with gemcitabine was started. After 6 months, the patient is still under treatment without side effects or adverse reactions.Diagnostic criteria for SDRIFE are2:1. Exposure to a systemically administered drug, either initially or upon repeated dosing.2. Presence of sharply demarcated erythema in the glu-teal area and/or V- shaped erythema in the inguinal/perigenital area.Received: 29 January 2024 | Revised: 10 March 2024 | Accepted: 16 April 2024DOI: 10.1002/ccr3.8877  C A S E  I M A G ESymmetrical cutaneous rash in two womenGionathan Orioni1,2 |   Maria Camila Velez- Pelaez1 |   Michela V. R. Starace1,2 |   Vera Tengattini1  |   Emanuel Raschi2,3 |   Michelangelo La Placa1,2This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.© 2024 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.1Dermatology Unit, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Bologna, Italy2Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy3Pharmacology, University of Bologna, Bologna, ItalyCorrespondenceMichelangelo La Placa, Dermatology Unit, IRCCS Azienda Ospedaliero- Universitaria di Bologna, via Massarenti 1, Bologna 40138, Italy.Email: michelangelo.laplaca@unibo.itKey Clinical MessageSymmetrical drug- related intertriginous and flexural exanthema, commonly known as “baboon syndrome” due to its typical involvement of the gluteal area, is an erythematous symmetrical rash associated with systemic drug administration.K E Y W O R D Sbaboon syndrome, doxorubicin, drug reaction, SDRIFE, systemic contact dermatitis2 of 3 |   ORIONI et al.3. Involvement of at least one other intertriginous/flex-ural location.4. Symmetry of the affected areas.5. Absence of systemic symptoms and signs.The rash typically develops 1–2 weeks after initiating the offending medication and resolves upon discontinu-ation.3,4 It is often referred to as “baboon syndrome” due to its resemblance to the red buttocks of certain apes.5 The characteristic cutaneous eruptions in specific sites, such as axillae and groin, without systemic symptoms or mucosal involvement, remains difficult to explain. Our patients were both seen at the end of May, which is a relatively hot and humid season in Italy, thus body temperature and friction may have favored the site's in-volvement. In the past, SDRIFE was considered a form of systemic contact dermatitis (type IV delayed- type hy-persensitivity reaction) related to previous sensitization to contact allergens (e.g., nickel, mercury, or topical an-tibiotics) followed by a reaction after ingestion or injec-tion of the same allergen.2,6 A patch test gives positive reaction in about 50% of patients although it is not man-datory for the diagnosis, which is mostly clinical, after exclusion of other causes of skin rash.6 However, more recent cases, including our two patients, suggest SDRIFE can occur without prior contact allergen sensitization, associated with systemic drug administration.5 Several authors reported common causative drugs include cer-tain antibiotics (e.g., beta- lactams, sulphonamides, and macrolides), anticonvulsants (e.g., carbamazepine and phenytoin), and non- steroidal anti- inflammatory drugs.5,7,8 Doxorubicin and other anthracyclines are used to treat different hematologic malignancies and solid tumors, with relatively frequent reactions on the skin and the mucosae, including alopecia, mucosal ul-cers, papular, and macular eruptions.9 To our knowl-edge, this is the first reported case of SDRIFE during doxorubicin chemotherapy, while amoxicillin has been previously associated with SDRIFE and other cutaneous eruptions.8The diagnosis of SDRIFE is based solely on clin-ical findings, and histological confirmation is not mandatory.F I G U R E  1  Erythematous rash involving the submammary fold (A), the armpits (B, C), and the groins (D).F I G U R E  2  Purplish dermatitis on the buttocks (A) and the lateral left thigh (B). 20500904, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ccr3.8877 by CochraneItalia, Wiley Online Library on [01/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License   | 3 of 3ORIONI et al.AUTHOR CONTRIBUTIONSGionathan Orioni: Data curation; investigation; meth-odology; validation; writing – original draft. Maria Camila Velez- Pelaez: Data curation; supervision; validation; visualization. Michela V. R. Starace: Supervision; validation. Vera Tengattini: Validation; visualization. Emanuel Raschi: Supervision; validation. Michelangelo La Placa: Conceptualization; data cura-tion; funding acquisition; investigation; writing – original draft; writing – review and editing.FUNDING INFORMATIONNone.CONFLICT OF INTEREST STATEMENTThe authors declare no conflicts of interest with any fi-nancial organizations related to the material discussed in the manuscript.DATA AVAILABILITY STATEMENTData available on request from the authors.CONSENTWritten informed consent was obtained from the patient to publish this report in accordance with the journal's pa-tient consent policy.ORCIDVera Tengattini   https://orcid.org/0000-0003-0700-0268 Michelangelo La Placa   https://orcid.org/0000-0002-6894-3350 REFERENCES 1. Lima Miranda O, Martins J, Almeida Â, et  al. Symmetrical drug- related intertriginous and flexural exanthema (baboon syndrome). Eur J Case Rev Intern Med. 2021;8(12):003029. 2. Aquino M, Rosner G. Systemic contact dermatitis. Clin Rev Allergy Immunol. 2019;56(1):9-18. 3. Tan SC, Tan JW. Symmetrical drug- related intertriginous and flexural exanthema. Curr Opin Allergy Clin Immunol. 2011;11(4):313-318. 4. Magnolo N, Metze D, Ständer S. Pustulobullous variant of SDRIFE (symmetrical drug- related intertriginous and flexural exanthema). J Dtsch Dermatol Ges. 2017;15(6):657-659. 5. Miyahara A, Kawashima H, Okubo Y, Hoshika A. A new pro-posal for a clinical- oriented subclassification of baboon syn-drome and a review of baboon syndrome. Asian Pac J Allergy Immunol. 2011;29(2):150-160. 6. Nespoulous L, Matei I, Charissoux A, Bédane C, Assikar S. Symmetrical drug- related intertriginous and flexural exan-thema (SDRIFE) associated with pristinamycin, secnidazole, and nefopam, with a review of the literature. Contact Derm. 2018;79(6):378-380. 7. Huynh T. Symmetrical drug- related intertriginous and flexural exanthema from radio contrast media: a series of 3 cases. JAAD Case Rep. 2015;1(3):147-149. 8. Alpagat G, Baccioglu A, Dumanoglu B, Yalim SA, Kalpaklioglu AF. Amoxicillin/clavulanic acid- induced symmetric drug- related intertriginous and flexural exanthema. Cureus. 2023;15(1):e33849. 9. Reyes Habito CM, Roh EK. Cutaneous reactions to chemo-therapeutic drugs and targeted therapies for cancer. Part I. Conventional chemotherapeutic drugs. J Am Acad Dermatol. 2014;71(2):203-214.How to cite this article: Orioni G, Velez- Pelaez MC, Starace MVR, Tengattini V, Raschi E, La Placa M. Symmetrical cutaneous rash in two women. Clin Case Rep. 2024;12:e8877. doi:10.1002/ccr3.8877 20500904, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/ccr3.8877 by CochraneItalia, Wiley Online Library on [01/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Symmetrical cutaneous rash in two women.

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Symmetrical cutaneous rash in two women.

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