This review covers the most important adverse effects from systemic drugs prescribed by dermatologists. The emphasis is on major adverse effects from these drugs that are either life-threatening or more commonly may lead to significant, irreversible morbidity. In descending order of relative risk for a fatal outcome or persistent morbidity, the major adverse effects discussed are dapsone agranulocytosis, methotrexate pancytopenia, retinoid teratogenicity, corticosteroid osteonecrosis, immunosuppression carcinogenesis, methotrexate hepatotoxicity, cyclosporine nephrotoxicity, azathioprine agranulocytosis and pancytopenia, corticosteroid osteoporosis, retinoid bone toxicity, corticosteroid hypothalamic—pituitary—adrenal axis suppression, and corticosteroid growth suppression. The great majority of these adverse effects are preventable, are diagnosable at an early, reversible stage, or can be readily managed should the complication occur. Furthermore, after carefully reviewing reports on the occasional fatal outcomes from the adverse effects discussed in this review, I believe virtually all deaths could have been prevented with careful attention to definable risk factors and with proper monitoring measures. Overall, the goal of this review is to bring clinicians to a proper level of concern regarding the risks from these drugs, while allowing safe use of potentially risky systemic drugs to the benefit of patients with serious and important skin conditions.
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