Symmetrical drug related intertriginous and flexural exanthema L24.4; L25.1

Clinical-morphological descriptive name for an acute or chronic dermatitis of different aetiology of the buttock and groin region (but also the axillary region), which used to be called Baboon ( = baboon) syndrome because it reminded of a reddened "monkey's buttocks". The recently used designation "SDRIFE" takes into account that predominantly systemically administered drugs without previous sensitization can cause this flexural dermatitis. SDRIFE typically occurs a few hours to days after application of the drugs in question.

Regardless of its nomenclature, the disease is controversial as an entity in its own right.

m>w (Häusermann P et al. 2004)

Baboon syndrome was originally described as an extensive fixed drug reaction localized on the buttocks or as localization-typical contact allergic eczema with scattered reaction or as hematogenous contact eczema. Pustular components have also been described (Magnolo N et al. 2017).

The syndrome has also been observed in connection with Peru balsam and food allergens. However, this polyetiological approach is not very satisfactory for a clearly defined entity.

With SDRIFE, the clinical symptoms are narrowed down to a drug-allergic or drug-toxic trigger. A localized T-cell-mediated reaction of the late type is being discussed, although it is unclear why this reaction behaves in a manner typical of localization. This could be a reactivation phenomenon in which a systemic reaction occurs in predisposed areas.

The extent to which there is an association with a COVID-19 infection or anti-COVID antiviral therapy (viral infection + medication) remains to be seen (Chicharro P et al. 2021; Bevilaqua M et al. 2021).

The following medications have been described in connection with SDRIFE:

• Antibiotics, especially beta-lactam antibiotics such as amoxicillin. Clindamycin is also described as triggering (Cabrera Hernandez V et al. 2019)
• Antimycotics: terbinafine (Weiss JM et al. 2001); nystatin, fluconazole (Koschitzki K et al.)
• Other medications
  • Allopurinol
  • Hydroxyurea
  • heparin
  • Itraconazole (Koschitzki K et al.)
  • X-ray contrast media
  • Immunoglobulins

buttocks, genitals, groin region, axillary region

Possibly slight acanthosis and spongiosis. Superficial, moderately epidermotropic, perivascular lymphocytic infiltrate mixed with few neutrophil granulocytes.

The (varied) diagnostic criteria proposed by Häusermann et al. include:

• Exposure to a systemic drug
• Erythematous plaques in the gluteal or perianal area
• V-shaped erythematous plaques in the groin area
• Involvement of at least one other intertriginous body site
• Symmetry of the affected areas
• Absence of systemic toxicity

Some authors now consider the term "Baboon syndrome" obsolete. With the acronym "SDRIFE " = symmetrical drug related intertriginous and flexural exanthema, a more precise description of this entity in question was attempted (Wolf R et al. 2015):

• S= symmetrical (symmetrical arrangement of skin manifestations).
• DR= drug related (see below etiopathogenesis)
• I= intertriginous (gluteal, perianal, V-shaped inguinal/thigh)
• F= flexural (involvement of at least one other flexor region)
• E= exanthema (often deep red erythema or plaques)

1. Andersen KE, Hjorth N, Menne T (1984) The baboon syndrome: systemically-induced allergic contact dermatitis. Contact Dermatitis 10: 97-100
2. Bevilaqua M et al. (2021) SDRIFE-like rash in COVID-19 patient: drug reaction or another cutaneous manifestation of SARS-CoV-2? Int J Dermatol 60: 884-885.
3. Blackmur JP et al. (2013) Baboon syndrome: an unusual complication arising from antibiotic treatment of tonsillitis and review of the literature. BMJ Case Rep doi: 10.1136/bcr-2013-201977.
4. Cabrera Hernandez V et al. (2019) Symmetrical drug-related intertriginous and flexural exanthema due to clindamycin. BMJ Case Rep 12:e230077.
5. Chicharro P et al (2021) SDRIFE-like rash associated with COVID-19, clinicopathological correlation. Australas J Dermatol 62: 88-89.
6. Erdmann SM et al (2010) Hematogenous contact dermatitis due to food. Allergo J 19: 264-271
7. Harde V et al (2011) Baboon syndrome in type IV sensitization to triamcinolone acetonide. Abstract CD 46th DDG Conference: P02/17
8. Haufe, K et al. (2013) Unusual clinical presentation of Baboon syndrome. derm 19: 197-201
9. Häusermann P et al. (2004) Baboon syndrome resulting from systemic drugs: is there strife between SDRIFE and allergic contact dermatitis syndrome? Contact Dermatitis 51:297-310.
10. Herfs H et al. (1993) "Baboon syndrome". A particular manifestation of hematogenous contact reaction. Dermatologist 44: 466-469
11. Kick G, Przybilla B (2000) Delayed prick test reaction identifies amoxicillin as elicitor of baboon syndrome. Contact Dermatitis 43: 366-367
12. Koschitzki K et al.(2024) Rare case of itraconaziol-induced SDRIFE. JDDG 22:833-836
13. Magnolo N et al.(2017) Pustulobullous variant of SDRIFE (symmetrical drug-related intertriginous andflexural exanthema).J Dtsch Dermatol Ges 15:657-659.
14. Nespoulous L et al. (Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) associated with pristinamycin, secnidazole, and nefopam, with a review of the literature. Contact Dermatitis 79:378-380.
15. Proske S et al. (2003) Severe allergic contact dermatitis with generalized spread due to bufexamac presenting as the "baboon" syndrome. Dtsch Med Wochenschr 128: 545-547
16. Weiss JM et al. (2001) Reproducible drug exanthema to terbinafine with characteristic distribution of baboon syndrome. Dermatology 52: 1104-1106
17. Wolf R et al. (2015) Baboon syndrome and toxic erythema of chemotherapy: Fold (intertriginous) dermatoses. Clin Dermatol 33:462-465.
18. Ziemer M (2014) Cutaneous drug reactions of the late type. Pathogenesis, clinic and histology. Dermatologist 65: 397-408