Suspected AGEP
Acute onset of numerous small non-follicular pustules on erythematous base
All Pathways
DermatologyEmergency
Acute Generalized Exanthematous Pustulosis (AGEP)
Acute Generalized Exanthematous Pustulosis (AGEP): Suspected AGEP → Recognize Clinical Features → STOP Causative Drug → Differential Diagnosis → Apply E...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Recognize Clinical Features
Characteristic AGEP presentation
- Dozens to hundreds of small (<5mm) sterile pustules
- Non-follicular distribution
- Arising on widespread edematous erythema
- Facial/intertriginous areas often first affected
- Fever >38°C common
- Burning/pruritus
- Onset: 1-11 days after drug (usually <5 days)
03Action STOP Causative Drug
Identify and discontinue culprit medication
- Most common: Aminopenicillins, quinolones, sulfonamides
- Pristinamycin, hydroxychloroquine
- Terbinafine, diltiazem
- Macrolides, cephalosporins
- Timeline: Usually within 48h of first dose (sensitized)
- Or up to 11 days (first exposure)
04Decision Differential Diagnosis
Distinguish from other pustular conditions
- Pustular psoriasis: History of psoriasis, slower evolution
- Generalized pustular psoriasis: Recurrent, psoriasis history
- Subcorneal pustular dermatosis: Chronic course
- Bacterial folliculitis: Follicular pustules
- DRESS: Fewer pustules, more organ involvement
05Action Apply EuroSCAR Validation Score
Standardized diagnostic scoring
- MORPHOLOGY: Typical pustules (+2), compatible (+1), insufficient (0)
- DISTRIBUTION: Typical (+2), compatible (+1)
- FEVER ≥38°C: Yes (+1), No (0)
- NEUTROPHILS ≥7×10⁹/L: Yes (+1), No (0)
- COURSE: Pustules resolve <15 days (+0), not compatible (-2)
- HISTOLOGY: Exocytosis + pustules (+3), compatible (+2), other (-10)
- TOTAL: ≤0=No AGEP, 1-4=Possible, 5-7=Probable, 8-12=Definite
06Action Diagnostic Workup
Laboratory and histologic evaluation
- CBC: Neutrophilia >7×10⁹/L typical, eosinophilia possible
- CMP: Usually normal, mild hepatic elevation possible
- Skin biopsy including pustule: Subcorneal/intraepidermal pustules
- Histology: Papillary edema, neutrophilic + eosinophilic infiltrate
- Pustule culture: STERILE (not infected)
07Action Mild AGEP
Limited extent, stable patient
- Outpatient management possible
- High-potency topical corticosteroids
- Emollients for desquamation phase
- Antipyretics for fever
- Close follow-up
08Action Supportive Treatment
Symptomatic care for all patients
- Topical corticosteroids (potent) for inflammation
- Antiseptic baths/cleansers
- Emollients during desquamation phase
- Antihistamines for pruritus
- Antipyretics (acetaminophen) for fever
09Action Course and Monitoring
AGEP is self-limiting
- Pustules resolve spontaneously in <15 days
- Desquamation follows (collarette scaling)
- Complete resolution typically by 2-3 weeks
- No scarring expected
- Document culprit drug
10Action Allergy Workup (After Resolution)
Patch testing to identify culprit
- Perform 6 weeks to 6 months after resolution
- Patch test sensitivity: ~58% (higher than SJS/TEN)
- Identifies causative drug for future avoidance
- Document results in medical record
- Allergy card for patient
11Outcome Resolution
Excellent prognosis
- Complete recovery expected
- Mortality <5% (rare systemic involvement)
- No long-term sequelae
- Recurrence if re-exposed to culprit
12Warning Rare Complications
Uncommon but reported
- Hepatic involvement (rare)
- Renal involvement (rare)
- Pulmonary involvement (rare)
- Secondary bacterial infection
- If systemic: Manage supportively + consult derm
13Action Moderate-Severe AGEP
Extensive involvement or systemic symptoms
- Admission may be required
- Systemic corticosteroids: Prednisone 0.5-1 mg/kg/day
- Monitor for rare internal organ involvement
- Fluid/electrolyte support if extensive skin loss
- Secondary infection surveillance
- Path rejoins step 08Shared downstream outcome
Guideline Source
EADV European Expert Consensus for AGEP Diagnosis and Management
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- EuroSCAR score requires histopathology for definitive diagnosis
- Must differentiate from pustular psoriasis
- Patch testing for drug identification done after resolution
- Rare cases may have systemic involvement
- Does not address viral/non-drug AGEP triggers
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Acute Generalized Exanthematous Pustulosis (AGEP)?
The Acute Generalized Exanthematous Pustulosis (AGEP) is a emergency clinical algorithm for Dermatology. It provides a structured decision tree to guide clinical decision-making, based on EADV European Expert Consensus for AGEP Diagnosis and Management.
What guideline is the Acute Generalized Exanthematous Pustulosis (AGEP) based on?
This algorithm is based on EADV European Expert Consensus for AGEP Diagnosis and Management (DOI: 10.1111/jdv.20232).
What are the limitations of the Acute Generalized Exanthematous Pustulosis (AGEP)?
Known limitations include: EuroSCAR score requires histopathology for definitive diagnosis; Must differentiate from pustular psoriasis; Patch testing for drug identification done after resolution; Rare cases may have systemic involvement; Does not address viral/non-drug AGEP triggers. Individual patient factors may require deviation from these recommendations.
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