Q:  Lamictal Rash & Seasonal Allergies

I re-started Lamictal about 2 months ago after being off it for 3 years.  During the time I was on it before I had frequent nausea/vomiting (high dose).  This time around I had done very well at 50 mgs until I developed the rash all over most of my face last week.

I've had more seasonal allergies this year than in many previous years.  In fact I had scheduled an appointment to get an allergy med the day my face progressed from "I think I might have a tiny rash" to "wow, that's a big rash".  I was having so much reaction to outside stuff that I couldn't get past a cold.

Could seasonal allergies have been the trigger here since I already had a lot of histamine in my body?  The fact that they seem paired is going to influence my decision about trying again, but this is so hard because this has given me the first good month I have had in years.

Thank you.
 

Dear Anonymous --

When we first started using lamotrigine (Lamictal) in psychiatry, we were so paranoid about this rash, I think most practitioners followed quite strictly the official position recommended by the company: if one sees a rash of any kind, one should stop the medication and never use it again.

After several years of experience with it, some mood experts began to be less cautious. I remember being surprised when I heard a well-known research team leader describe an alternative strategy, in which won a rash was seen, the dose was decreased to the previous step in the upward progression, and kept there until a rash disappeared, monitoring closely all the while. I have heard that strategies described now many times and have generally followed that approach myself. Mind you, "monitoring closely" can mean something as intensive as having the patient call me every single day and did not take any further doses until I called back and we discuss exactly what he or she observes and is experiencing. I generally do this only with patients who are capable of that kind of close follow-up. By contrast, for example, when I use this medication in a local Free Clinic, I go by the original recommendation from the company in most cases.

All that is by way of reminding you that the rash we are talking about here is potentially very dangerous, even lethal in some circumstances. Given your experience, any re-exposure to this medication should be done only with close supervision from your prescriber.

As to whether or not your allergies might have had an impact on having that rash show up, that is indeed possible. One of the groups that has studied means of lowering the rash rate, at Stanford, has recommended "dermatologic precautions" when starting lamotrigine: no new soaps or lotions or anything else knew coming in contact with your skin, if possible; no new medications, if possible; and avoiding sunburn, and an even avoiding new foods. Obviously, the goal here is to keep your immune system from getting all revved up while starting lamotrigine. Extending their logic, it does seem reasonable to conclude that seasonal allergies might reflect a "revving up" of your immune system.

Unfortunately, however, having now potentially been sensitized to this medication, any re-exposure may carry even greater risk. The fact that your rash occurred on your face also raises concern level somewhat higher. Therefore, you and your prescriber will face a tough decision about risks and benefits if you look at restarting this medication, despite your good response to it.

In any case, I hope you're able to find a workable solution. Good luck with that.

Dr. Phelps