Localized exfoliating rash with paresthesia possibly due to clonazepam.

Abstract

10-year-old boy, presented with a history of sudden onset episodes of difficulty in walking, and climbing up on cupboards for three weeks, and was admitted for further evaluation and management. Detailed neurological evaluation did not reveal any abnormality. As he had functional motor symptoms, he was diagnosed having dissociative motor disorder, which is a form of conversion disorder. Psychosocial stressors were assessed and were primarily managed using nonpharmacological strategies. For disturbed sleep and anxiety, clonazepam 0.5 mg was administered at bedtime. He was not on any other medication including over-the-counter drugs at that time. On the sixth day after starting clonazepam, he developed skin peeling on the finger tips and a burning sensation on his palms that worsened while immersing hands in cold water. Dermatologist opinion was sought, and on examination the findings included mild scaling of the finger tips and hyperlinear lesions over the palmar aspect of fingers. On immersion of hands in water, there was exaggerated wrenched skin along with burning pain over the areas leading to withdrawal of the hands. He was previously exposed to clonazepam intermittently three weeks before for a maximum duration of two days without any dermatological problems. There was no major medical illness in the past and there was no history of allergy or drug reaction. His elder sister, who had dissociative disorder, had developed skin rashes following medications but further details were not available. Investigations including complete blood count, and liver and renal function tests were normal. Naranjo adverse drug reaction (ADR) probability scale score (Naranjo et al. 1981) suggested a probable association. Considering a possibility of clonazepam-induced localized exfoliating rash with paresthesia (“burning skin syndrome”), medication was discontinued on the same day. He was prescribed fluticasone propionate cream and elovera cream containing 10% aloe extract along with vitamin E IP 0.5% with which the lesions subsided after one week without any recurrence thereafter.