Can medication trigger Sweet’s syndrome?
Yes, in 12% of cases Sweet’s syndrome is triggered by medication, and this is known as drug-induced Sweet’s syndrome (Adamska et al, 2017). Most of the time it isn’t drug-induced, and some of the medications that on rare occasions can trigger Sweet’s syndrome may even be used as effective treatments, e.g. doxycycline.
How will I know if my Sweet’s syndrome has been triggered by medication?
In at least 88% of patients with Sweet’s syndrome their condition isn’t triggered by medication, but drug-induced Sweet’s syndrome should be considered if your condition developed within a few weeks of a medication being started.
What will happen if my doctor thinks I have drug-induced Sweet’s syndrome?
Unfortunately, there’s no special test to tell you whether or not your Sweet’s syndrome has been triggered by medication. However, if it’s suspected that your Sweet’s syndrome is drug-induced, your doctor will:
- Stop the medication that’s possibly causing your Sweet’s syndrome. Your Sweet’s syndrome should then start to settle down, but you may still need treatment.
- Re-introduce the medication (rechallenge) to see if your Sweet’s syndrome flares-up again. Sometimes, your doctor will decide that this isn’t necessary or safe.
Why does medication trigger Sweet’s syndrome in some people?
Drug-induced Sweet’s syndrome can be a hypersensitivity reaction to medication or potentially occur for other reasons, e.g. a treatment causing hormonal changes. Read more here.
What medications have been reported to have triggered Sweet’s syndrome?
Medications that have been reported to trigger Sweet’s syndrome include:
Aminosalicylate anti-inflammatory drugs.
- Mesalazine/mesalamine (Shabtaie et al, 2018).
- Sulfasalazine (Romdhane et al, 2016).
- Acetaminophen-codeine (paracetamol and codeine phosphate) (Bradley et al, 2017).
- Paracetamol (Sweet’s syndrome-like) (Culla et al, 2014).
- Amoxicillin (possibly) (Volpe, 2016).
- Clindamycin (Cruz-Velasquez et al, 2016).
- Doxycycline (Ibid).
- Minocycline (Cohen, 2007).
- Ofloxacin (Ibid).
- Trimethoprim/sulfamethoxazole (Cohen, 2007; Gkrouzman et al, 2018; Sutton et al, 2018).
- Quinupristin/dalfopristin (Cohen, 2007).
- Piperacillin/tazobactam (Cruz- Velasquez et al, 2016).
- Carbamazepine (Cohen, 2007).
- Diazepam (Cohen, 2007).
- Gabapentin (Rojas-Pérez-Ezquerra et al, 2017).
- Fluconazole (Adler et al, 2017).
- Hydralazine (Cohen, 2007).
- Chloroquine (Cruz-Velasquez et al, 2016).
- Lithium (Xenophontos et al, 2016).
- Azacitidine (Tiwari et al, 2017).
- Bortezomib (Llamas-Velasco et al, 2015). Also, atypical bortezomib-induced neutrophilic dermatosis (Sweet’s syndrome-like) in a 76-year-old man receiving chemotherapy for IgG kappa multiple myeloma (Lescoat et al, 2018). Sweet’s syndrome or a Sweet’s syndrome-like condition can occur during treatment, typically during the first or second cycle, possibly due to an imbalance of proinflammatory cytokines – molecular messengers that promote inflammation – leading to the migration of white blood cells called neutrophils toward the skin (Lescoat et al, 2018).
- Dabrafenib and trametinib (histiocytoid Sweet’s syndrome triggered by therapy for metastatic melanoma) (Morgado-Carrasco et al, 2018).
- Decitabine (Kasirye et al, 2011: 134).
- Imatinib mesylate (Cohen, 2007).
- Ipilimumab (Adler et al, 2018; Gormley et al, 2014).
- Lenalidomide (Cohen, 2007).
- Obinutuzumab (Sweet’s syndrome-like) (Korman et al, 2016).
- Abacavir (Cohen, 2007).
- Acyclovir (Cruz-Velasquez et al, 2016).
- Interferon-α (Cruz-Velasquez et al, 2016).
Colony stimulating factors.
- Granulocyte-colony stimulating factor (G-CSF). This is the most common treatment to trigger Sweet’s syndrome (Cohen, 2007).
- Granulocyte-macrophage-colony stimulating factor (GM-CSF).
- Pegfilgrastim (Ibid).
- Levonorgestrel/ethinyl estradiol (Triphasil) (Cohen, 2007).
- Levonorgestrel-releasing intrauterine system (Mirena) (Cohen, 2007).
- Furosemide (Cohen, 2007).
- Azathioprine, most commonly in those with inflammatory bowel disease (Aran Kumar et al, 2018; Salem et al, 2015). Sometimes, azathioprine-induced Sweet’s syndrome can be confused with azathioprine hypersensitivity syndrome (AHS) (Aleissa et al, 2017). This is a rare adverse reaction occurring a few days to weeks after azathioprine has been given. AHS can sometimes mimic Sweet’s syndrome, and an azathioprine rechallenge is not advised, as it may lead to a severe adverse reaction or even death. In AHS, skin biopsy is less likely to show massive papillary dermal oedema and dense dermal neutrophilic infiltrate – fluid in the dermal skin layer and lots of neutrophils (Ibid).
Inflammatory bowel disease.
- Vedolizumab (Martínez et al, 2018).
- Also, see ‘Immunosuppressants’.
Nonsteroidal anti-inflammatory drugs (NSAIDs).
- Celecoxib (Cohen, 2007; Oh et al, 2016).
- Rofecoxib (Cruz-Velasquez et al, 2016).
- Diclofenac (Cohen, 2007; Gupta et al, 2015).
- Flurbiprofen (Bodamyalızade and Özkayalar, 2017). Flurbiprofen-induced Sweet’s syndrome may be confused with flurbiprofen-induced hypersensitivity syndrome or erythema multiforme.
Platelet aggregation inhibitors.
- Ticagrelor (Ikram and Veerappan, 2016).
- Esomeprazole (Cohen, 2015).
- Omeprazole (Cohen, 2015).
- Clozapine (Cohen, 2007).
- Amoxapine (Cruz-Velasquez et al, 2016).
- Lormetazepam (Ibid).
- All-trans retinoic acid (Cohen, 2007; Tam and Ingraffea, 2015).
- 13-cis-retinoic acid (isotretinoin) (Cohen, 2007).
- Propylthiouracil (Cruz-Velasquez et al, 2016).
- Bacillus Calmette-Guerin (BCG or tuberculosis) (Carpentier et al, 2002: 82; Cruz-Velasquez et al, 2016). Two cases. One in 1986, occurring 15 days after vaccination, but the authors of the medical article that reported this didn’t control the tuberculin (Mantoux) test. One reported in 2002, occurring 10 days after vaccination.
- Hepatitis B (Enokawa et al, 2017). One case in a 69-year-old man with the autoimmune condition, systemic lupus erythematosus. Symptoms of Sweet’s syndrome started to develop 48 hours after vaccination.
- Influenza (Cruz-Velasquez et al, 2016; Hali et al, 2010, Jovanovic et al, 2005; Tan el al, 2006; Wolf et al. 2009). Four cases. One reported in 2005; in 2006, one case of bullous Sweet’s syndrome following vaccination in a HIV-infected patient; in 2009, neutrophilic dermatosis of the hands occurring 12 hours after vaccination; in 2010, one case of Sweet’s syndrome after H1N1 influenza (swine flu) vaccination.
- Smallpox (Carpentier et al, 2002: 82; Cruz-Velasquez et al, 2016). Two cases reported in 1975, occurring 3 days after vaccination.
- Streptococcus pneumonia (Carpentier et al, 2002: 82; Cruz-Velasquez et al, 2016; Pedrosa et al, 2013). Two cases. One reported in 1990, occurring 4 days after vaccination following a splenectomy. One reported in 2013, and the first with the 13-valent conjugate vaccine.
Xanthine oxidase inhibitors.
- Allopurinol (Polimeni et al, 2015).
- X-ray contrast agents (Cruz-Velasquez et al, 2016).
Cetin, G., Sayarlioglu, H., Erhan, C., Kahraman, H., Ciralik, H. and Sayarlioglu, M. (2014) A case of neutrophilic dermatosis who develop palpable purpura during the use of montelukast. European Journal of Dermatology, Dec; 1(4): 170–171 (PMC).
Sánchez-Borges, M., Caballero-Fonseca, F., Capriles-Hulet, A. and González-Aveledo, L. (2010) Hypersensitivity Reactions to Nonsteroidal Anti-Inflammatory Drugs: An Update. Pharmaceuticals, Jan; 3(1): 10-18 (MDPI).
Adamska, U., Męcińska-Jundziłł, K., Białecka, A., Cichewicz, A., Grzanka, A., Adamski, P., Khvoryk, D. and Czajkowski, R. (2017) Sweet’s syndrome with idiopathic epididymitis. Postepy dermatologii i alergologii, Aug;34(4):363-365 (PMC).
Adler, N., Murray, W., Brady, B., McCormack, C. and Pan, Y. (2018) Sweet syndrome associated with ipilimumab in a patient with metastatic melanoma. Clinical and Experimental Dermatology, Feb 3 (PubMed).
Aleissa, M., Nicol, P., Godeau, M., Tournier, E., de Bellissen, F., Robic, M., Livideanu, C., Mazereeuw-Hautier, J. and Paul, C. (2017) Azathioprine Hypersensitivity Syndrome: Two Cases of Febrile Neutrophilic Dermatosis Induced by Azathioprine. Case Reports in Dermatology, Jan 19;9(1):6-11 (PMC).
Arun Kumar, A.U., Elsayed, M.E., Alghali, A., Ali, A.A., Mohamed, H., Hussein, W., Hackett, C., Leonard, N. and Stack, A.G. (2018) Sweet syndrome: a rare feature of ANCA-associated vasculitis or unusual consequence of azathioprine-induced treatment. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology, Nov 8;14:46 (PMC).
Cohen, P. (2015) Proton pump inhibitor-induced Sweet’s syndrome: report of acute febrile neutrophilic dermatosis in a woman with recurrent breast cancer. Dermatology Practical & Conceptual, April; 5(2):113–119 (PMC).
Cruz-Velásquez, G., Pac Sha, J., Simal Gil, E. and Gazulla, J. (2016). Aseptic meningitis and anti-β2-glycoprotein 1 antibodies in Sweet syndrome. Neurologia (Barcelona, Spain), Jul 21 (Elsevier). Article in Spanish, use translate.
Culla, T., Amayuelas, R., Diez-Canseco, M., Fernandez-Figueras, M., Giralt, C. and Vazquez, M. (2014) Neutrophilic dermatosis (Sweet’s syndrome-like) induced by paracetamol. Clinical and Translational Allergy, Jul; 4(Suppl 3): P83 (PMC).
Enokawa, M., Giovanella, L., Zardo, B., Cunha, J., Rachid Filho, A., Zeni, L., Bisognin, M., Rosseto, C. and Guimaraes, A. (2017) Sweet’s Syndrome Discharged (Caused) by Hepatitis B Vaccine. Brazilian Journal of Rheumatology, 57(suppl 1):S197 (Science Direct). Article in Portuguese, use translate.
Gkrouzman, E., Chirch, L. and Lakshminarayanan, S. (2018) Drug-Induced Sweet Syndrome in a Man With Sarcoidosis: Are There Any Common Mechanisms of Pathogenesis? Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Disease, Mar 13 (PubMed).
Gormley, R., Wanat, K., Elenitsas, R., Giles, J., McGettingan, S., Schucher, L. and Takeshita, J. (2014) Ipilimumab-associated Sweet syndrome in a melanoma patient. Journal of the American Academy of Dermatology, Nov;71(5):e211-3 (JAAD).
Ikram, S. and Veerappan, V. (2016) Ticagrelor-induced Sweet Syndrome: an unusual dermatologic complication after percutaneous coronary intervention. Cardiovascular Intervention and Therapeutics, May 4th (PubMed).
Jovanovic, M., Poljacki, M., Vujanovic, L. and Duran, V. (2005) Acute febrile neutrophilic dermatosis (Sweet’s syndrome) after influenza vaccination. Journal of the American Academy of Dermatology, Feb;52(2):367-9 (PubMed).
Lescoat, A., Dupuy, A., Belhomme, N., Stock, N., Sebillot, M., Decaux. O. and Jégo, P. (2018) Atypical bortezomib-induced neutrophilic dermatosis. Annals of Hematology, Oct 12 (Springer Berlin Heidelberg).
Llamas-Velasco, M., Concha-Garcon, M., Fraga, J. and Arageus, M. (2015) Histiocytoid sweet syndrome related to bortezomib: A mimicker of cutaneous infiltration by myeloma. Indian Journal of Dermatology, Venereology and Leprology, May;81:305-6 (online).
Martínez Andrés, B., Sastre Lozano, V. and Sánchez Melgarejo, J. F. (2018) Sweet syndrome after treatment with vedolizumab in a patient with Crohn’s disease. Revista espanola de enfermedades digestivas: organo oficial de la Sociedad Espanola de Patologia Digestiva, Jun 14;110 (PubMed).
Morgado-Carrasco, D., Moreno-Rivera, N., Fusta-Novell, X., Garcia-Herrara, A., Carrera, C. and Puig, S. (2018) Histiocytoid Sweet’s syndrome during combined therapy with BRAF and MEK inhibitors for metastatic melanoma. Melanoma Research, Jun;28(3):256-257 (PubMed).
Polimeni. G., Cardillo, R., Garaffo, E., Giardina, C., Macrì, R., Sirna, V., Guarneri, C. and Arcoraci, V. (2015) Allopurinol-induced Sweet’s syndrome. International Journal of Immunopathology and Pharmacology, Dec 18th (PubMed).
Rojas-Pérez-Ezquerra, P., Noguerado-Mellado, B., Sáenz de Santamaría García, M., Roa-Medellín, D., Hernández-Aragüés I. and Zubeldia Ortuño J. (2017) Sweet syndrome caused by sensitization to gabapentin. The Journal of Allergy and Clinical Immunology: In Practice, Sep 22 (PubMed).
Salem, C., Larif, S., Fathallah, N., Slim, R., Aounallah, A. and Hmouda, J. (2015) A rare case of azathioprine-induced Sweet’s syndrome in a patient with Crohn’s disease. Current Drug Safety, July (PubMed).
Sutton, E., Groff, R. and Sutton, L. M. (2018) Sweet syndrome with aseptic splenic abscesses and multiple myeloma. Cutis, May;101(5):E27-E29 (PubMed). Possibly malignancy-associated Sweet’s syndrome or drug-induced.
Tam, C. and Ingraffea, A. (2015) Case Letter: Sweet Syndrome Presenting With an Unusual Morphology. Cutis, Aug;96(21)E9-E10 (MDedge). No longer available.
Xenophontos, E., Ioannou, A., Constantinides, T. and Papanicolaou. E. (2016) Sweet syndrome on a patient with autoimmune hepatitis on azathioprine and CMV infection. Oxford Medical Case Reports, Feb; (2): 24–27 (PMC).
2012-present, Sweet’s Syndrome UK