A 10-day-old neonate, on exclusive breast feeds, had acute dacrocystitis appearing on day 6 of life. The neonate was managed with topical tobramycin drops, injectable cefotaxime and amikacin for two days and then switched to oral syrup amoxicillin-clavulanic acid as the eye condition improved. Two days after starting the oral antibiotic, the neonate developed macular rash involving gluteal region and symmetric maculo-papular rash involving flexures of elbow and axilla as in Fig. 1 (a & b). A diagnosis of symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) was made, based on the typical morphology and incriminating drug history. The drug was stopped, and rash improved over the next two days. Naranjo algorithm - adverse drug reaction (ADR) probability scale score was 5, and ADR was labelled as probable.

(a)

(b)

Fig.1 (a) Maculopapular rash involving flexures of elbow and axilla; (b) Macular rash in gluteal region.

SDRIFE, also called Baboon syndrome, is a benign, self-limiting symmetrical erythematous rash on the flexures after systemic exposure to a drug, regardless of prior sensitization. It is diagnosed by the following criteria: exposure to a systemically administered drug either for the first time or repeat exposure (excluding contact allergens), sharply demarcated erythema of the gluteal/perianal area and/or V-shaped erythema of the inguinal/peri genital area, involvement of at least one other intertriginous/flexural localization, symmetry of the affected areas and absence of systemic symptoms and signs. Among all the drugs known to cause this condi-tion, the most common is amoxicillin, which our patient received. The other drugs known to cause SDRIFE are pseudoephedrine, codeine, cimetidine, nystatin, fluco-nazole, monoclonal antibodies, and radio contrast media. The differential diagnosis includes conditions like allergic contact dermatitis, drug reaction with eosinophilia and systemic symptoms (DRESS), seborrheic dermatitis, inter-trigo, inverse psoriasis, granular parakeratosis, Darier disease, Hailey-Hailey disease and acute generalized exanthematous pustulosis (AGEP). Prognosis of SDRIFE is generally good and the rash disappears after discontinuation of the offending drug. SDRIFE is an uncommon rash in neonates but the characteristic morphology clinches the clinical diagnosis.