Pustular Drug Eruption to Voriconazole

A 52‐year‐old male with Crohn’s disease presented with florid pustulosis of the face and trunk. Six months prior to presentation, he received amphotericin for pulmonary aspergillosis. Amphotericin was discontinued after five months due to toxicity, and pharmacotherapy was changed to voriconazole. After four weeks of voriconazole, the acneiform eruption occurred which prompted referral to dermatology. Physical examination revealed innumerable 0.5 cm–1.5 cm pustules, cysts, and inflammatory papules concentrated predominantly over the central face, ears, and conjunctiva, but also involving the chest, shoulders, and back. The clinical differential diagnosis included suppurative folliculitis, papulonecrotic tuberculid, cutaneous Crohn’s disease, acne fulminans, and pustular drug eruption. Multiple biopsies demonstrated diffuse neutrophilic and granulomatous dermal inflammation in a predominantly follicular and perifollicular distribution. Microorganisms were not identified by either histology or culture. The histologic differential diagnosis included cutaneous Crohn’s disease and pustular drug eruption. Voriconazole was discontinued with gradual clearing of the skin lesions. Three months later, worsening of the pulmonary disease necessitated restarting voriconazole. A recurrent pustular eruption, similar to the original eruption, occurred within weeks and subsequently cleared upon discontinuation of voriconazole. To our knowledge, this represents the first reported case of a voriconazole induced pustular drug eruption.