peritoneal dialysis is a type of renal replacement treatment used for end - stage renal disease . in peritoneal dialysis , glucose is used as an osmotic agent in standard peritoneal dialysis solutions , but peritoneal dialysis solutions containing icodextrin are chosen due to their high osmotic effect , particularly in patients with insufficient ultrafiltration [ 1 , 2 ] . icodextrin is a glucose polymer derived from starch that can be metabolized into malt sugar . in intraperitoneal administration , icodextrin is less absorbent than glucose . icodextrin , due to its content , does not result in hyperglycemia and hyperinsulinemia , which are caused by glucose - containing solutions . solutions with icodextrin are known to mostly be well tolerated by patients [ 1 , 3 ] . the development of a rash following the use of icodextrin is very rare and defined as a case report in the literature . our objective was to present a 23-year - old female patient who developed a skin rash following the use of icodextrin . a 23-year - old female patient , who had undergone continuous ambulatory peritoneal dialysis ( 4 exchanges a day ) for 1 year for end - stage renal disease , presented at our clinic complaining about stomachache , nausea , vomiting and cloudy dialysate fluid . a physical examination of the patient revealed the following : blood pressure 130/80 mm hg , temperature 37.8c , and pulse 78/min . an examination of other systems gave normal results except for the presence of abdominal sensitivity . the laboratory analyses of the patient provided the following results : urea 110 mg / dl , creatinine 10.8 mg / dl , na 137 mmol / l , k 4.2 mmol / l , white blood cells 10,200/mm ( 85% pmnl , 10% lymphocyte , 0.2% eosinophil ) ; c - reactive protein 8.4 mg / l , and erythrocyte sedimentation rate 76 mm / h . the white blood cell count in peritoneal fluid was 2,700/mm , and the patient was hospitalized in our clinic and diagnosed with peritonitis . after taking peritoneal fluid cultures , intraperitoneal 1  1 g of ceftazidime and 1  1 g of vancomycin were empirically initiated to be administered every 96 h for peritonitis therapy . the 2.27% glucose solution , used for the night exchange , was replaced with icodextrin because ultrafiltration was insufficient on peritoneal dialysis assessment on day 4 of her hospitalization . the patient began to suffer from itching the next day after the use of icodextrin . the physical examination revealed redness and a rash , particularly on the neck and the upper extremities . the patient did not have a previous history of a known allergic reaction or a drug allergy ; thus , the dermatology department was consulted . because the patient had an allergic reaction , 20 mg of methylprednisolone and 1 ampule ( 45.5 mg ) of pheniramine were administrated intravenously . this therapy did not resolve the symptoms ; moreover , erythematous maculopapular lesions spread over her body and the lower extremities ( fig . in addition to an ongoing intravenous steroid therapy of the patient , pomade with steroids was prescribed , but the rash did not resolve despite the application of the pomade . the patient had a normal hemogram eosinophil value ( 0.2% , 20  10/l ) at her hospitalization , but the eosinophil value gradually increased to 1,000  10/l ( 13.4% ) during her follow - up . the icodextrin therapy was interrupted after the patient had expressed an increase of her itching following the use of icodextrin . the rash and the redness began to resolve 2 days after icodextrin had been ceased , and the entire rash disappeared within 1 week . her whole blood count showed that eosinophil dropped back to 400  10/l ( 5.1% ) . peritonitis regressed , and the peritoneal fluid count revealed that white blood cell count was 10/mm . icodextrin is a glucose polymer with its molecular weight being 16,600 da , and it metabolizes into glucose from malt sugar . icodextrin provides a continuous and longer osmotic gradient because it is absorbed through the peritoneal cavity more slowly than standard peritoneal dialysis solutions [ 5 , 6 ] . it has clinical benefits such as improvement of blood sugar control in diabetic patients , improvement of lipid profiles , and enhanced phosphate removal as compared to glucose - containing peritoneal dialysis solutions . icodextrin is very safe apart from possible side effects related to the skin , which is reported to be very rare . a total of 102 patients , and 80 patients receiving icodextrin for a minimum of 6 months , reported that the development rate of skin reactions was 15% . reported 3 patients with limited rashes on the hands , arms and body , and lam - po - tang et al .   reported a patient who developed severe exfoliative dermatitis 10 days after icodextrin had been initiated . in a randomized , double - blind multicenter study by finkelstein et al . , maculopapular rashes were significantly higher in the icodextrin group compared to the 4.25% dextrose solution . its construction resembles the dextran which is also used as a plasma dilator and anticoagulant and can lead to allergic reactions including anaphylaxis . the only constructional difference between icodextrin and dextran are the polymer bonds between -1,4 and -1,6 , respectively . recent studies have confirmed the immunogenicity of dextran and the formation of immunocomplexes with skin localization despite a lack of identification of the epitope for the dextran allergic reaction . recently , it has been noted that chronic exposure to dextran results in deposits on the skin and the peripheral nerves , which can lead to persistent rashes [ 6 , 13 ] . icodextin - related skin rashes usually occur on the palms and soles , but it can also develop on the body and the extremities ( as in our case ) [ 2 , 14 ] . the rash may be accompanied by flaking of the skin . icodextrine - related allergic rashes usually occur during the early period of icodextrin therapy , are self - limited and heal without leaving sequelae after the icodextrin is ceased . our patient also developed an allergic reaction that caused erythematous maculopapular rashes on the skin 1 day after the use of icodextrin ; it improved 1 week after icodextrin had been stopped . in general , icodextrin is known to be safe and well tolerated , but it should be noted that it can cause hypersensitivity reactions .
icodextrin may be used as an alternative to glucose as the osmotic agent in peritoneal dialysis with ultrafiltration failure . in general , icodextrin is known to be safe and well tolerated , but it can also cause hypersensitivity reactions such as skin rashes . 
 allergic rashes are generally defined as erythematous , itchy and maculopapular , visible over the trunk and the extremities . 
 when a rash occurs , it generally develops early in therapy , is self - limited , and resolves without sequelae after the discontinuation of icodextrin . 
 although the safety and efficacy of icodextrin peritoneal dialysis solution is well documented , clinicians should be aware of the possibility of severe adverse cutaneous reactions to it . 
 we report the case of a 23-year - old female who developed a skin rash following the use of icodextrin .