Alternative glucocorticoids for use in cases of adverse reaction to systemic glucocorticoids: a study on 10 patients

Advancing the understanding of allergic contact dermatitis: from pathophysiology to novel therapeutic approaches

Allergic contact dermatitis (ACD) is a common inflammatory skin disease that, especially when the condition becomes chronic, has a high impact on the quality of life and represents a significant disease burden. ACD represents a type IV delayed-type hypersensitivity reaction that is triggered by contact with an allergen in previously sensitized individuals through the activation of allergen-specific T cells. In the acute phase, it is characterized by eczematous dermatitis, which presents with erythema, edema, vesicles, scaling, and intense itch. Non-eczematous clinical forms are also described (lichenoid, bullous, and lymphomatosis). Lichenification is the most common clinical picture in the chronic phase if the culprit allergen is not found or eliminated. ACD can be associated with both occupational and non-occupational exposure to allergens, representing approximately 90% of occupational skin disorders along with irritant contact dermatitis. Patch testing with suspected allergens is required for a diagnosis. Metals, especially nickel, fragrance mix, isothiazolinones, and para-phenylenediamine, are the most commonly positive allergens in patients patch tested for suspected ACD. The treatment goal is to avoid contact with the culprit agent and use topical and/or systemic corticosteroid therapy.

Recommendation to update the British Society for Cutaneous Allergy corticosteroid series

BACKGROUND

Patch testing is an important investigation when dermatitis is unresponsive to, or worsened by, topical corticosteroid treatment. There is a balance to be struck between testing too many allergens, which is expensive, time consuming and risks causing sensitization, and testing too few, which risks missing the diagnosis. The current British Society for Cutaneous Allergy (BSCA) corticosteroid series comprises eight allergens and was last updated in February 2007.

AIM

To review and update the BSCA corticosteroid series.

METHODS

We retrospectively analysed data from 16 patch test centres in the UK and Ireland for all patients who were patch tested to a corticosteroid series between August 2017 and July 2019. We recorded the allergens tested, the number and percentage tested to a corticosteroid series and the number of positive results for each allergen. We identified the allergens that test positive in ≥ 0.1% of selectively tested patients.

RESULTS

Overall, 3531 patients were tested to a corticosteroid series in the 16 centres. The number of allergens tested ranged from 7 to 18 (mean 10). The proportion of patch test patients who were tested to a corticosteroid series ranged from 1% to 99%. Six allergens in the 2017 BSCA series tested positive in ≥ 0.1% of patients. Nine allergens not in the BSCA corticosteroid series tested positive in ≥ 0.1% of patients.

CONCLUSION

This audit demonstrates the importance of regular review of recommended series and the significant variations in practice. The new BSCA corticosteroid series that we recommend contains 13 haptens, with the addition of the patient's own steroid creams as appropriate.

Immediate and delayed hypersensitivity reactions to corticosteroids - prevalence, diagnosis and treatment

BACKGROUND

Corticosteroids, which are anti-inflammatory and immunosuppressive agents used for the treatment of various diseases including allergic disorders, can induce immediate and delayed hypersensitivity reactions. Although these reactions are not common, due to the wide usage of corticosteroid medications, corticosteroid hypersensitivity reactions are clinically important.

OBJECTIVE

In this review, we summarise the prevalence, pathogenetic mechanism, clinical manifestations, risk factors, diagnostic and therapeutic approach for corticosteroid-induced hypersensitivity reactions.

METHODS

An integrative review of the literature was conducted using PubMed searches (mainly large cohort-based studies) regarding the different aspects of corticosteroid hypersensitivity.

RESULTS

Hypersensitivity reactions to corticosteroids can be immediate or delayed and can follow all modes of corticosteroid administration. Prick and intradermal skin tests are useful diagnostic tools for immediate hypersensitivity reactions, patch tests are useful for delayed hypersensitivity reactions. According to the diagnostic tests an alternative (safe) corticosteroid agent should be administered.

CONCLUSION

Physicians of all medical disciplines should be aware that corticosteroids can cause (paradoxically) immediate or delayed allergic hypersensitivity reactions. The diagnosis of such allergic reactions is challenging since it is often difficult to distinguish between hypersensitivity reactions and deterioration of the basic inflammatory disease (e.g., worsening of asthma or dermatitis). Thus, a high index of suspicion is needed in order to identify the culprit corticosteroid.

Compound betamethasone in the treatment of pain after supraspinatus tendon repair

Objective

To investigate the effect of compound betamethasone on pain points of the supraspinatus tendon by local blocking therapy after repair surgery.

Methods

This non-randomised controlled trial included patients who underwent arthroscopic repair of supraspinatus tendon tears and who had long-term pain. At 3 months following surgery, patients were assigned to an experimental group, whose pain points were treated with compound betamethasone, or a control group who did not receive compound betamethasone. Visual analogue scale (VAS) score, Pittsburgh Sleep Quality Index (PSQI) and Constant shoulder score for pain were determined at 3, 4, 5 and 6 months following surgery and analysed retrospectively.

Results

Of 38 included patients, there were no statistically significant between-group differences in VAS score, PSQI or Constant shoulder scores at 3 months following surgery. At 4, 5 and 6 months after surgery, the VAS score and PSQI were significantly lower, and the Constant shoulder score was significantly higher, in the experimental group versus controls.

Conclusions

Using compound betamethasone to locally block pain points after supraspinatus tendon repair surgery may significantly alleviate pain, improve sleep quality, facilitate functional shoulder exercise and achieve good shoulder function.

Steroid Allergy in a Patient With Behçet's Disease

Immediate hypersensitivity reactions to systemic steroids are reported rarely in the literature. The authors present a case of Behçet's disease-associated panuveitis in a patient with skin test confirmed immunoglobulin E-mediated allergy to methylprednisolone and reported allergic reaction to prednisone. The patient tolerated prednisolone eyedrops for his anterior segment disease, as well as oral prednisolone for systemic therapy. This case demonstrates a challenge to conventional treatment, as it involves a hypersensitivity that is rarely reported. It also highlights class differences in corticosteroids with regard to immune reactivity. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:447-449.].

Multiple corticosteroids allergy in a patient with asthma: a case report

Background

Allergy towards systemic corticosteroid is rare. This case report discusses the investigations to confirm diagnosis and alternative treatments.

Case presentation

A 51-year-old asthmatic woman developed severe anaphylactic reaction following administration of systemic hydrocortisone. Skin prick, intradermal, and intravenous provocation tests confirmed allergy to triamcinolone, hydrocortisone, and dexamethasone. Skin prick tests (SPTs) were negative to all the aforementioned drugs. Intradermal test (IDT) with triamcinolone 1:10 concentration resulted in a 2-mm wheal associated with rhonchi. IDT with hydrocortisone 1:10 concentration showed an 8-mm wheal with rhonchi. IDTs to dexamethasone and carboxymethylcellulose were negative. Generalized rhonchi were observed with intravenous dexamethasone full concentration challenge.

Conclusions

Corticosteroid allergy should be suspected in asthma patients with worsening bronchospasm after its administration. Due to its rarity, such diagnosis can easily be missed, resulting in increased morbidity and mortality in patients.

Allergy against Steroids in Ocular Inflammation

Allergy to steroids is an uncommon and harmful condition that leads to a decrease in treatment options and increase in morbidity due to the suboptimal disease control. It can manifest as an immediate response or a delay manifestation. Worsening of underlying condition and not treatment response can indicate corticosteroids hypersensitivity as well. Despite its low prevalence, all clinicians should be aware of this condition and know the treatment options. This narrative review attempts to update information about corticosteroid allergy and we present a case of a patient with the diagnosis of Vogt Koyanagi Harada Syndrome with a history of steroids allergy, as an example, to integrate this information to the ocular inflammation field.

Quantitative Analysis of Twelve Active Components Combined With Chromatographic Fingerprint for Comprehensive Evaluation of Qinma Prescription by Ultra-Performance Liquid Chromatography Coupled With Diode Array Detection

A combination method of ultra-performance liquid chromatography (UPLC) coupled with diode array detection has been developed for quality evaluation of Qinma prescription (QMP), based on chromatographic fingerprint technology with the similarity analysis (SA) and the quantitative analysis of 12 components by hierarchical cluster analysis (HCA). The established method has been validated by linearity, precision, repeatability, stability and recovery tests. The UPLC fingerprints with 17 common peaks of 5 QMP samples prepared by different extraction methods including water decoction extraction, water extraction-ethanol precipitation method, ethanol reflux extraction, ethanol extraction-water precipitation method and methanol ultrasonic extraction were obtained, and the SA results indicated that similarity index was greatly influenced by the large peak. The similarity index ranged from 0.816 to 0.999 basing on 17 peaks, which has been decreased to 0.683-0.999 basing on 16 peaks without the large peak of baicalin (BA). The results of simultaneous quantification of 12 components in these 5 QMP samples proved that BA, gallic acid (GA), wogonoside (WOG) and gentiopicroside (GEN) were the major ingredients in QMP with high contents >1.44 (mg/g), indicating that ethanol reflux was the most effective extraction method. Integrating fingerprint analysis, simultaneous determination and HCA, the established method is rapid, sensitive, accurate and readily applicable. All the results indicated that the combination method can control the quality of QMP and its related traditional Chinese medicinal compounds more comprehensively and scientifically.

Anaphylactic shock with methylprednisolone, Kounis syndrome and hypersensitivity to corticosteroids: a clinical paradox

Corticosteroids are widely used for the treatment of allergic reactions but paradoxically themselves may induce acute, delayed, local or systemic allergic reactions and even anaphylaxis with Kounis syndrome. They can suppress the release of arachidonic acid from mast cell membranes, via phospholipase A2 and eicosanoid biosynthesis inhibition. Corticosteroids can promote cell apoptosis and mediate in annexin or lipocortin synthesis, substances that modulate inflammatory cell activation, adhesion molecule expression, transmigratory and phagocytic functions. Antigen-antibody reaction, hapten formation, and medication contaminants are some of the incriminated causes. Patients with atopic diathesis are particularly vulnerable. Complete and thorough previous history of drug reactions or allergies is necessary before administration of any particular medication including corticosteroids.

Anaphylaxis Induced by Intramuscular Betamethasone Disodium Phosphate: Reflections on a Clinical Case

Glucocorticoids could be responsible for allergic symptoms correlated to an Ig-E mediated hypersensitivity mechanism. We describe the case of an anaphylactic reaction in a professional nurse, occurring after an intramuscular administration of Betamethasone. After performing skin prick tests, intramuscular tests and patch tests we concluded that the patient had Ig-E mediated sensitization. She was prescribed oral Prednisone and Deflazacort and shows good tolerance of these drugs. This demonstrates that in these patients it is possible to administrate glucocorticoids without the changes in the sites indicated by Wilkinson. Nevertheless, our patient showed a negative allergy test for Dexamethasone disodium phosphate, and in those patients sensitized to fluorinated glucocorticoids, tolerance to other glucocorticoids is not so easily predictable as in patients with hypersensitivity to first generation steroids or in corticosteroid contact dermatitis, according to the four patterns of cross-reactivity proposed by Coopman and Dooms-Goossens.

Hypersensitivity reactions to corticosteroids

Hypersensitivity reactions to corticosteroids (CS) are rare in the general population, but they are not uncommon in high-risk groups such as patients who receive repeated doses of CS. Hypersensitivity reactions to steroids are broadly divided into two categories: immediate reactions, typically occurring within 1 h of drug administration, and non-immediate reactions, which manifest more than an hour after drug administration. The latter group is more common. We reviewed the literature using the search terms "hypersensitivity to steroids, adverse effects of steroids, steroid allergy, allergic contact dermatitis, corticosteroid side effects, and type I hypersensitivity" to identify studies or clinical reports of steroid hypersensitivity. We discuss the prevalence, mechanism, presentation, evaluation, and therapeutic options in corticosteroid hypersensitivity reactions. There is a paucity of literature on corticosteroid allergy, with most reports being case reports. Most reports involve non-systemic application of corticosteroids. Steroid hypersensitivity has been associated with type I IgE-mediated allergy including anaphylaxis. The overall prevalence of type I steroid hypersensitivity is estimated to be 0.3-0.5%. Allergic contact dermatitis (ACD) is the most commonly reported non-immediate hypersensitivity reaction and usually follows topical CS application. Atopic dermatitis and stasis dermatitis of the lower extremities are risk factors for the development of ACD from topical CS. Patients can also develop hypersensitivity reactions to nasal, inhaled, oral, and parenteral CS. A close and detailed evaluation is required for the clinician to confirm the presence of a true hypersensitivity reaction to the suspected drug and choose the safest alternative. Choosing an alternative CS is not only paramount to the patient's safety but also ameliorates the worry of developing an allergic, and potentially fatal, steroid hypersensitivity reaction. This evaluation becomes especially important in high-risk groups where steroids are a life-saving treatment. The assessment should be done when the patient's underlying condition is in a quiescent state.

Anaphylaxis induced by oral methylprednisolone in a 10-year-old boy

Corticosteroids are potent anti-inflammatory and anti-allergic agents used in the treatment of various inflammatory diseases, including allergic diseases. Allergic reactions caused by corticosteroids, however, have been reported. Among these, delayed reactions to topical steroids are more common, whereas immediate reactions to systemic steroids are rare. Herein, we report the case of a 10-year old boy with methylprednisolone-induced anaphylaxis, in which the patient had a positive oral challenge test result. Physicians should be aware of the possibility of anaphylaxis or other allergic hypersensitivity in response to corticosteroids.

Methylprednisolone sodium succinate-associated macroglossia in a critically ill patient

Allergic hypersensitivity reactions are a rare adverse effect of corticosteroids. Previous reports have identified patients who developed symptoms of urticaria, dyspnea, hypotension, bronchospasm, and angioedema occurring within minutes to an hour after corticosteroid administration. A 35-year-old woman is described who developed an atypical reaction of isolated macroglossia after receiving intravenous methylprednisolone sodium succinate for myasthenic crisis. Macroglossia was identified on day 2 of therapy and worsened through day 5. On day 5, she was transitioned to prednisone 50 mg daily administered by feeding tube. Tongue swelling improved by day 7 and on day 10, the patient was extubated. The patient required reintubation due to stridor, but received a tracheostomy and was weaned off mechanical ventilation by day 15. The reaction was not confirmed with skin-prick tests, intradermal tests, or a drug rechallenge; however, she had previously received and tolerated all other drugs administered during this time. Due to the timing of administration and onset of symptoms, we feel this adverse drug reaction was likely due to administration of methylprednisolone. Applying the Naranjo adverse drug reaction probability scale to this case, a score of six was obtained, indicating a probable association between the administration of methylprednisolone and the development of macroglossia. As intravenous corticosteroids are often used in the treatment of allergic reactions, they may be overlooked as a cause of macroglossia and other allergic reactions; therefore, practitioners need to be aware of the possibility of this adverse effect secondary to corticosteroid administration. In the event of methylprednisolone sodium succinate-induced macroglossia, alternative nonesterified corticosteroids, such as dexamethasone or prednisone, should be considered if continuation of therapy is required.

Allergic hypersensitivity to topical and systemic corticosteroids: a review

Corticosteroids, which are potent anti-inflammatory and immunomodulator agents used in the treatment of various inflammatory diseases including allergic diseases, can in some cases produce immediate or delayed hypersensitivity reactions. This review summarizes the epidemiological and clinical characteristics of such reactions, including related diagnostic issues. It also presents a detailed analysis of the proposed immunological mechanisms including underlying cross-reactions.

Glucocorticoid hypersensitivity as a rare but potentially fatal side effect of paediatric asthma treatment: a case report

Introduction

Immediate-type hypersensitivity to glucocorticosteroids is rare but well known among allergists. Surprisingly, very few reports of glucocorticosteroid hypersensitivity in children exist although glucocorticosteroid treatment is particularly common in this age group.

Case presentation

We report the case of a 2-year-old boy who developed generalized urticaria, facial angio-oedema, nausea and severe dyspnoea after intravenous application of prednisolone-21-hydrogen succinate. Skin prick testing with prednisolone-21-hydrogen succinate elicited a positive result; no reactions were observed to prednisone, betamethasone or dexamethasone. While fluorescence enzyme immunoassay analysis revealed no specific IgE antibodies against prednisolone-21-hydrogen succinate, CD63-based basophil activation testing with the culprit drug prednisolone-21-hydrogen succinate was positive. In contrast, additional incubation of basophils with prednisone, betamethasone and dexamethasone did not elicit any significant response. Hence, we performed an oral provocation test with betamethasone and a titrated intravenous dexamethasone challenge. As both drugs were tolerated without any complications they were recommended for future treatment.

Conclusion

In a child with confirmed immediate-type hypersensitivity to glucocorticosteroids, it is still not possible to predict which glucocorticosteroid might be tolerated by solely relying on clinical history or results of skin and in vitro testing. Therefore, incremental glucocorticosteroid challenges under standardized clinical conditions remain necessary in order to facilitate a patient-tailored emergency treatment and to avoid severe reactions to glucocorticosteroids in these patients.

Worsening of asthma with systemic corticosteroids. A case report and review of literature

Despite widespread use for treatment of asthma and allergies, glucocorticoids may cause allergic reactions, even anaphylaxis. The incidence of adverse reactions to systemic glucocorticoids is 0.3%. The most commonly reported corticosteroids causing anaphylaxis like reactions are hydrocortisone, prednisone, and methylprednisolone. Most authors agree that allergic reactions to systemic corticosteroids are possibly immunoglobulin E mediated. We report a patient with asthma, aspirin allergy, and nasal polyps who developed bronchospasm following the administration of intravenous methylprednisolone sodium succinate during an acute asthmatic attack. We discuss the differential diagnosis of worsening asthma despite adequate treatment, and suggest corticosteroid-induced bronchospasm in our patient. Corticosteroid-induced bronchospasm should be considered when asthmatics fail to improve, or frankly deteriorate with systemic corticosteroid therapy, particularly when a history of aspirin allergy is present. TEACHING POINT: Know the differential diagnosis for worsening of asthma despite adequate treatment. Consider corticosteroid-induced bronchospasm when asthmatics fail to improve, or frankly deteriorate with systemic corticosteroid therapy. Corticosteroid-induced bronchospasm is more commonly seen in asthmatics with a history of aspirin allergy.

Systemic allergic reaction and diffuse bone pain after exposure to a preparation of betamethasone

Allergic reactions to corticosteroids are unexpected as they seem to contradict their pharmacodynamic action. Nevertheless, they are not infrequent, with an estimated incidence of up to 4% for cutaneous reactions. Systemic reactions are rarely reported, but their incidence might be underestimated. We report here an unusual allergic reaction to betamethasone presenting with diffuse bone pain, erythema, and bronchoconstriction, which was confirmed by a positive rechallenge in a double-blind procedure. This is the first case report of a systemic reaction to betamethasone confirmed by a positive rechallenge. An impurity in betamethasone diproprionate cannot be excluded. As this substance is frequently used in rheumatologic soft-tissue injections, it is important to recognize this potentially life-threatening side effect.

Immunoglobulin E-mediated reactions to corticosteroids

Allergic reactions to steroids are rare, but are becoming more commonly recognized by clinicians. Although many reactions are thought to be IgE mediated, most are adverse drug reactions caused by nonallergic mechanisms, some related to additives in the steroid preparation being administered. Provocative challenge with the suspected offending agent, serologic tests for allergen-specific IgE, and skin testing are the most reliable methods for assessing hypersensitivity to steroids, although none is infallible. Therapeutic options for patients with documented steroid allergy include the use of alternative steroid preparations, desensitization, and, possibly, the use of monoclonal anti-IgE antibodies.

Pharmacokinetics and pharmacodynamics of systemically administered glucocorticoids

Glucocorticoids have pleiotropic effects that are used to treat diverse diseases such as asthma, rheumatoid arthritis, systemic lupus erythematosus and acute kidney transplant rejection. The most commonly used systemic glucocorticoids are hydrocortisone, prednisolone, methylprednisolone and dexamethasone. These glucocorticoids have good oral bioavailability and are eliminated mainly by hepatic metabolism and renal excretion of the metabolites. Plasma concentrations follow a biexponential pattern. Two-compartment models are used after intravenous administration, but one-compartment models are sufficient after oral administration.The effects of glucocorticoids are mediated by genomic and possibly nongenomic mechanisms. Genomic mechanisms include activation of the cytosolic glucocorticoid receptor that leads to activation or repression of protein synthesis, including cytokines, chemokines, inflammatory enzymes and adhesion molecules. Thus, inflammation and immune response mechanisms may be modified. Nongenomic mechanisms might play an additional role in glucocorticoid pulse therapy. Clinical efficacy depends on glucocorticoid pharmacokinetics and pharmacodynamics. Pharmacokinetic parameters such as the elimination half-life, and pharmacodynamic parameters such as the concentration producing the half-maximal effect, determine the duration and intensity of glucocorticoid effects. The special contribution of either of these can be distinguished with pharmacokinetic/pharmacodynamic analysis. We performed simulations with a pharmacokinetic/pharmacodynamic model using T helper cell counts and endogenous cortisol as biomarkers for the effects of methylprednisolone. These simulations suggest that the clinical efficacy of low-dose glucocorticoid regimens might be increased with twice-daily glucocorticoid administration.