TABLE 3.

Task force recommendations on diagnosis and culprit identification in children with DRESS.

Recommendation	Strength of recommendation
Diagnosis and differential diagnosis
1. The TF recommends to use current RegiSCAR criteria for diagnosis of DRESS in children, until specific criteria specific for this age group have been developed, but the limitations for pediatric patients should be recognized Patients with a RegiSCAR score ≥4 are recommended to be regarded as having DRESS and a severity classification to Grade 1, 2 or 3 should be made (see Table 4) Patients with a RegiSCAR score of 2–3 are recommended to be regarded as having an indeterminate form between systemic maculopapular exanthema and DRESS; named as AMBIGUOUS DRESS(see Table 4) and included in the evaluation and management protocol with close follow‐up	Strong
2. The TF recommends to perform a detailed study for differential diagnosis of infectious disorders (including primary herpes viridae infections, which are highly prevalent in children) and other disorders, such as rheumatologic diseases, cytokine storm syndromes, malignancies or other SCARs	Strong
Causality assessment
1. The TF recommends to use the Naranjo and/or World Health Organization‐Uppsala Monitoring Centre (WHO‐UMC) scales for causality assessment in the acute stage (or during retropective evaluation), but vigilance about the low sensitivity and the pitfalls of these scales is needed	Strong
Identification of responsible drug(s)
1. The TF recommends to perform in vivo skin tests for identification of culprit drug(s), co‐ or, neo‐sensitizations, and finding safe alternatives They should be performed after at least 3 to 6 months after resolution in Grade 1, 2 or 3 DRESS, in order to avoid relapse and/or false negatives from prolonged corticosteroid treatment If there is absolute need, tests can be done earlier in these cases, but recurrence risk increases In ambiguous DRESS cases with rapid resolution, in vivo tests can be performed after 6 weeks	Strong
2. The TF recommends to perform first patch tests (PT) with all suspected drugs and for choice of alternatives However, children with HIV may carry a higher risk for recurrence during patch tests	Strong
3. The TF suggests to perform intradermal tests with delayed reading (d‐IDT) with suspected drug(s), especially antibiotics, if the PTs are negative	Conditional
4. The TF recommends to perform intradermal tests with delayed reading (d‐IDT) with low suspicion and/or alternative drugs, especially antibiotics, if the PTs are negative	Strong
5. The TF suggests to perform in vitro tests, especially lymphocyte transformation test during recovery phase and ELISpot analysis during both the acute and recovery phase for identification of culprit drugs, if technically feasible	Conditional
6. The TF recommends against performing drug provocation tests (DPT) with highly suspected drug(s) and cross‐reactive medications	Strong
7. The TF suggests that very essential drugs (especially anti‐tuberculosis agents) with low probability of being the culprit and negative in skin tests, can be re‐administered in specialized centers with a very cautious protocol, after balancing the benefits and risk of recurrence*	Conditional
8. The TF recommends to perform a full diagnostic work‐up, including PT, d‐IDT and in vitro tests, in children with ambiguous DRESS who resolved rapidly without progression and/or complications, A cautious provocation test can be performed with suspected drugs if these tests are negative	Strong
9. The TF suggests to perform HLA testing in special ethnic groups for high risk medications such as carbamazepine, allopurinol and dapsone, as a supportive, but not diagnostic, tool	Conditional

^*Drug reintroduction protocols (Ref. 130, 131, 132).