Acute Generalized Exanthematous Pustulosis Induced by Fluconazole: A Case Report

Acute generalized exanthematous pustulosis (AGEP) is a rare, severe type IV hypersensitivity reaction, most commonly triggered by antibiotics, calcium channel blockers, or antifungal agents, while fluconazole-induced AGEP is exceptionally reported. Early recognition and prompt management are essential to prevent complications. We report the case of a 21-year-old female with no personal or family history of psoriasis who developed a sudden-onset, pruritic, erythematous pustular rash six days after a single 150 mg dose of fluconazole prescribed for vaginal candidiasis. On examination, she was febrile (39°C) and asthenic, with widespread non-follicular pustules initially involving intertriginous areas and subsequently extending to the trunk and limbs. The Nikolsky sign was negative, and mucosal surfaces were spared. Laboratory investigations revealed leukocytosis (10,400/mm³) with neutrophilia (7,800/mm³), and pustular cultures were sterile. Histopathological examination showed intraepidermal pustules associated with dermal neutrophilic and eosinophilic infiltrates. The European Study of Severe Cutaneous Adverse Reactions (EuroSCAR) score was 11, confirming the diagnosis of fluconazole-induced AGEP. Rapid clinical improvement was observed following discontinuation of fluconazole and supportive treatment with antihistamines and emollients; desquamation occurred within four days, and no systemic complications were noted. Although rare, fluconazole should be considered a potential cause of AGEP, and early diagnosis with prompt withdrawal of the offending drug remains essential to ensure a favorable prognosis.