Iodinated Contrast-Induced AGEP and ALEP: Recognition, Diagnosis, and Management

Acute generalized exanthematous pustulosis (AGEP) and acute localized exanthematous pustulosis (ALEP) are rare T-cell-mediated hypersensitivity reactions most commonly triggered by medications but increasingly recognized after exposure to iodinated contrast media (ICM). With the growing use of contrast-enhanced imaging, clinicians are more frequently faced with diagnostic and management challenges in patients with suspected ICM-induced reactions and with decisions regarding future contrast exposure. This systematic review aimed to synthesize published cases of ICM-associated AGEP and ALEP, with a particular focus on clinical recognition, diagnostic evaluation in routine practice, acute management, and implications for future imaging. The review was registered in PROSPERO (CRD420251140990). Searches of PubMed/MEDLINE, Web of Science, and the Serbian Citation Index (SCIndeks) were conducted without language or date restrictions through September 9, 2025, supplemented by backward and forward citation searching. Thirty-one publications reporting 53 patients were included. Patient age ranged from 4 to 93 years (median 56 years), and most were female (64.1%). AGEP accounted for 96.2% of cases, while ALEP was rare (3.8%). AGEP was associated with iomeprol, iodixanol, iohexol, iopromide, ioversol, iopamidol, and iobitridol. ALEP was linked to iomeprol and ioversol. Onset was typically rapid, with a median of 1 day after ICM exposure. Recurrent reactions occurred in 18.9% of patients, often with shorter latency upon re-exposure. Reported management most frequently involved topical corticosteroids, systemic corticosteroids, and antihistamines. Nearly all patients (98.1%) recovered. Clinicians should recognize ICM as potential triggers of AGEP and ALEP and pursue appropriate diagnostic evaluation and allergological assessment to guide safe future imaging.