Systemic allergic dermatitis (systemic contact dermatitis) from pharmaceutical drugs: A review

The literature on systemic allergic dermatitis (SAD; also known as systemic contact dermatitis) is reviewed. Both topical drugs (from absorption through mucosae or skin) and systemic drugs (oral, parenteral, rectal) may be responsible for the disorder. The topical route appears to be rare with 41 culprit topical drugs found to cause SAD in 95 patients. Most reactions are caused by budesonide (especially from inhalation), bufexamac, and dibucaine. SAD from systemic drugs is infrequent with 95 culprit drugs found to cause SAD in 240 patients. The drugs most frequently implicated are mitomycin C, methylprednisolone (salt, ester), and hydrocortisone (salt). The largest group of culprit drugs consisted of corticosteroids (19%), being responsible for >30% of the reactions, of which nearly 40% were not caused by therapeutic drugs, but by drug provocation tests. The most frequent manifestations of SAD from drugs are eczematous eruptions (scattered, widespread, generalized, worsening, reactivation), maculopapular eruptions, symmetrical drug-related intertriginous and flexural exanthema (SDRIFE [baboon syndrome]) and widespread erythema or erythroderma. Therapeutic systemic drugs hardly ever cause reactivation of previously positive patch tests and infrequently of previous allergic contact dermatitis. The pathophysiology of SAD has received very little attention. Explanations for the rarity of SAD are suggested.

Occupational allergy to pharmaceutical products

PURPOSE OF REVIEW

Occupational allergy in healthcare workers is common and can lead to significant costs from both loss of productivity within the workforce as well as those associated with diagnosis and treatment. This review aims to provide an update on drugs implicated in causing occupational allergy.

RECENT FINDINGS

Drugs traditionally reported as causing occupational allergy, such as penicillin, remain problematic. However, as their use reduces and newer drugs, such as cephalosporins, are used more frequently there is a changing pattern to occupational sensitization. In some studies up to 17% of healthcare workers now appear sensitized to cephalosporins. Other drug classes also reported include proton pump inhibitors and benzodiazepines. Interestingly, drugs such as omeprazole and tetrazepam rarely cause allergy in patients but can be very sensitizing if applied topically or inhaled. Recent studies involving pharmaceutical company employees show that this problem can no longer be considered primarily related to healthcare workers.

SUMMARY

The diagnosis of occupational allergy to drugs can be complicated and has been shown to take up to 5 years from the onset of symptoms. Ultimately, workplace avoidance remains key; however, an up to date awareness of culprit drugs and the patterns of allergy seen are key to a prompt resolution of symptoms.

New Contact Allergens: 2008 to 2015

Every year, new contact allergens, chemicals reported to have caused contact allergy/ACD for the first time, are described in literature. In the journals Contact Dermatitis and Dermatitis, 172 such compounds were identified in the period 2008-2015, 119 of which induced ACD. These are presented with the following data: name, synonyms, Chemical Abstracts Service (CAS) number, patch test data, function or class, causative product, number of patients, occupation (in case of occupational ACD), additional clinical data (if applicable), and references. Approximately one third of the new allergens were ingredients of cosmetics, followed by drugs causing occupational ACD (18%), chemicals in rubber, plastics, and paints (9%), drugs causing a drug eruption (9%), as well as chemicals used in laboratories inducing occupational ACD (8%). In 40%, the dermatitis was occupationally acquired. Fifty-three other chemicals causing contact allergy as indicated by positive patch test reactions only are shown without specifics.

Recent Trends in Occupational Contact Dermatitis

Occupational contact dermatitis (OCD) remains prevalent among workers and impacts quality of life and workability. The purpose of this review is to summarize the recent advances in occupational contact dermatitis as well as potential hazardous agents in the workplaces causing OCD. The review covers new developments in the epidemiology, etiology, diagnosis, and management of occupational contact dermatitis. This article also provides updated information on the prevalence of work-related skin symptoms and on new contact allergens among working population. It is emphasized that in the context of prevention of OCD, special attention should be focused on the identified high-risk occupational groups, especially healthcare workers and hairdressers starting with the apprentices. Current approaches include working out the standards and guidelines to improve the education, knowledge, diagnosis, and management of OCD based on a multidisciplinary team of medical specialists and an employer.