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)

Originally, "Baboon syndrome" was described as an extensive fixed drug reaction localized to the buttocks, or localization-typical contact allergic eczema with scatter reaction, or hematogenous contact dermatitis. Pustular components have also been described (Magnolo N et al. 2017).

The syndrome has also been observed in association with perubalsam and food allergens. However, this polyetiologic explanatory approach is not very satisfactory for a well-defined entity.

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

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

The following drugs have been described in association with SDRIFE:

• Antibiotics especially beta-lactam antibiotics such as amoxicillin. Clindamycin has also been described to cause SDRIFE (Cabrera Hernandez V et al. 2019).
• Antifungals: terbinafine (Weiss JM et al. 2001).
• Other drugs
  • Allopurinol
  • Hydroxyurea
  • Heparin
  • X-ray contrast media
  • Immunoglobulins

buttocks, genitals, groin region, axillary region

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. Magnolo N et al.(2017) Pustulobullous variant of SDRIFE (symmetrical drug-related intertriginous andflexural exanthema).J Dtsch Dermatol Ges 15:657-659.
13. 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.
14. 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.
15. Weiss JM et al (2001) Reproducible drug exanthema to terbinafine with characteristic distribution of baboon syndrome. Dermatologist 52: 1104-1106
16. Wolf R et al (2015) Baboon syndrome and toxic erythema of chemotherapy: Fold (intertriginous) dermatoses. Clin Dermatol 33:462-465.
17. Ziemer M (2014) Cutaneous drug reactions of late type. Pathogenesis, clinic and histology. Dermatol 65: 397-408