Contact allergy to hydrocortisone and thixocortol pivalate: problems in the detection of corticosteroid sensitivity

Contact allergy to corticosteroids and Malassezia furfur in seborrhoeic dermatitis patients

BACKGROUND

Seborrhoeic dermatitis (SD) is a chronic skin disease, requiring long-term treatment, which might promote sensitization. Malassezia furfur (Mf) plays an important role in seborrhoeic dermatitis. Objectives  The aim of this study was to determine the frequency of contact sensitivity in SD patients.

PATIENTS AND METHODS

A total of 100 patients and 20 healthy controls (HC) were investigated: 50 suffering from SD with no previous local corticosteroid treatment (SDN), 50 SD patients treated with local corticosteroids (SDC). Mycological examination for Mf was performed. All patients were patch tested with the baseline standard, corticosteroid series, with 12 commercial corticosteroid preparations frequently used in Croatia; and also with Mf.

RESULTS

Malassezia furfur was found in 44 (88%) SDN, 37 (74%) SDC, and in 4 (20%) HC; patch test reaction to Mf was positive in one SDN and in three SDC. Positive patch tests to standard allergens were observed in 17 (34%) SDN, 33 (66%) SDC and 2 (10%) HC. Patch tests to the corticosteroid series revealed positive reactions in 4 SDC and to commercial corticosteroids in seven patients, i.e. 2 SD and 5 SDC.

CONCLUSIONS

Patch tests to the baseline series and to both individual corticosteroid and commercial corticosteroid preparations should be performed in SD patients with persistent dermatitis, as contact-allergic reactions may complicate their dermatitis. Sensitization to Mf was found to be infrequent.

Patch testing in non-immediate drug eruptions

The present review addresses the literature regarding the sensitivity and specificity of the various diagnostic methods for evaluating non-immediate (ie, occurring more than 1 hour after drug administration) hypersensitivity reactions associated with β-lactams and other antibiotics, anticonvulsants, heparins, iodinated contrast media, etc. Such reactions include several clinical entities, which range from mild reactions, such as maculopapular rash and delayed-appearing urticaria, to severe ones, such as acute generalized exanthematous pustulosis (AGEP), Stevens-Johnson syndrome, and toxic epidermal necrolysis (TEN). Clinical and laboratory studies indicate that a cell-mediated pathogenic mechanism is often involved in maculopapular rashes. However, this mechanism has also been demonstrated in other non-immediate reactions, such as urticarial and/or angioedematous manifestations, TEN, bullous exanthems, and AGEP. Patch tests, together with delayed-reading intradermal tests, lymphocyte transformation tests, and challenges, are useful tools for evaluating non-immediate drug eruptions. Patch tests can be performed with any form of commercial drugs and are safer than intradermal tests. However, patch tests are less sensitive than intradermal tests, and their sensitivity may vary, depending on the vehicle used.

Anogenitaldermatosen - allergische und irritative Auslosefaktoren Analyse von Daten des IVDK1 und Literaturubersicht. Anogenital dermatoses - allergic and irritative causative factors Analysis of IVDK2 data and review of the literature

BACKGROUND

Anogenital dermatoses (AGD) are common and often very distressing. Clinically it is often unclear if allergic contact dermatitis or irritant dermatitis is involved. In order to optimize therapy and prophylaxis, it is essential to identify relevant allergens or irritants.

PATIENTS AND METHODS

Data of the Information Network of Departments of Dermatology (IVDK, data center in Göttingen) collected between 1999 and 2003 were analyzed. The anogenital area was involved in 1 168 patients with suspected allergic contact dermatitis. Clinical variables and patch test results were statistically compared with the remaining IVDK patch test population, the latter standardized for age and sex.

RESULTS

Allergic contact dermatitis had been suspected prior to patch testing in 39.5 %, while in 24.6 % this diagnosis was eventually confirmed. Irritant contact dermatitis was diagnosed in 11.8 %. Other diagnoses, included balanitis, lichen sclerosus et atrophicus and herpes genitalis. Positive reactions to cinchocaine (6.6 %), bufexamac (3.5 %) and benzocaine (2.4 %) were observed significantly more often among patients with anogenital dermatitis. Among those in whom co-factors were considered important (n = 422), wetness (38.4 %), occlusion (30.3 %), mechanical strain (4.7 %) and heat (3.6 %) were mentioned as irritation factors.

CONCLUSION

Because of the significantly higher frequency of sensitization to cinchocaine, benzocaine and bufexamac in patients with anogenital dermatitis, these ingredients should be used only with caution. According to the literature, ingredients of toiletries, cosmetics and contraceptives of any kind seem to cause allergic contact dermatitis rarely although there are several case reports. Comprehensive patch test including the standard series plus major sensitizers such as cinchocaine, benzocaine and bufexamac, and in particular patients' own skin care products, is recommended.

Detection of contact hypersensitivity to corticosteroids in allergic contact dermatitis patients who do not respond to topical corticosteroids

The delayed hypersensitivity development against topical corticosteroids which are used in allergic contact dermatitis (ACD) treatment is an important clinical problem. In our study, 41 ACD patients who did not show any response to topical corticosteroid treatment were patch tested with corticosteroid series and the commercial preparations of corticosteroids and their vehicles. In corticosteroid series, there were budesonide, bethametasone-17-valerate, triamcinolone acetonide, tixocortol pivalate, alclomethasone-17-21-dipropionate, clobetasole-17-propionate, dexamethasone-21-phosphate disodium and hydrocortisone-17-butyrate. We detected positive reaction to corticosteroids in 9 of our cases (22%) (5 single and 4 multiple). The sensitivity was mostly produced by tixocortol pivalate (6 patients). This was followed by triamcinolone acetonide (2 patients) budesonide (2 patients), alclomethasone dipropionate (2 patients), dexamethasone 21 phosphate disodium (2 patients) and betamethasone-17-valerate (1 patient). As a result, it should not be forgotten that the corticosteroids used to treat ACD patients may cause ACD themselves. In ACD patients who did not respond to corticosteroid treatment, routinely applying patch test with corticosteroids should be helpful in directing the treatment.

Corticosteroids

Up to 5% of dermatitis patients are allergic to corticosteroids. Because such allergy may be difficult to suspect due to the anti-inflammatory action of the corticosteroid, markers for corticosteroid allergy should be present in any standard series. Budesonide and tixocortol pivalate are two such markers, and they seem to detect a majority of corticosteroid allergy. The patch test concentration for a given corticosteroid may be crucial. A false-negative reaction may follow despite the patient being allergic, if too high a test concentration is used, because of the anti-inflammatory action of the corticosteroid. Patch test readings must be performed not only on Day 3 or Day 4 but also on a late occasion, i.e., Day 7 after test application, also because the anti-inflammatory action may suppress an allergic reaction at an early reading. Once a patient has reacted to a corticosteroid, an extended corticosteroid series should be tested, so that information may be given on which corticosteroids to use and, above all, which corticosteroids to avoid.

Tixocortol pivalate contact allergy in the GPMT: frequency and cross-reactivity

In spite of their intrinsic anti-inflammatory properties, corticosteroids can induce contact allergy. When studying the allergenic properties of corticosteroids it has to be considered that both the allergenic and anti-inflammatory effect may influence the induction phase as well as the elicitation phase and that such effects may be dose-dependent. A multiple dose guinea pig maximization test (GPMT) was therefore used to study the dose-response relationship of tixocortol pivalate. The GPMT was conducted according to OECD guideline #406, using a multiple-dose design and test results were analysed with logistic regression analysis. There was a significant tixocortol pivalate sensitization of the test animals compared to the control group (p<0.05), after both challenge and re-challenge. The challenge with 1% tixocortol pivalate gave more positive reactions than the challenge with 3%. The highest frequency of positive animals was observed when the animals were treated with low to intermediate induction concentrations and intermediate to high challenge concentrations with tixocortol pivalate in the TRUE Test. Cross-reactivity was found between tixocortol pivalate and hydrocortisone, which was expected from their close molecular resemblance, whereas no cross-reactivity was seen between tixocortol pivalate and the 3 other corticosteroids: amcinonide, budesonide, and hydrocortisone-17-butyrate.

Assessment of budesonide patch tests

Patch-test technique for budesonide needs improvement. 20 subjects with positive or questionable patch-test responses to budesonide were retested for 3 to 96 h (4 days [D]) with polyester patches coated with budesonide in serial doses (150 to 0.074 microg/cm2). Multiple readings were taken visually and with a laser Doppler perfusion imaging technique up to 264 h (day [D]11). Additionally, all subjects were tested with 0.1% budesonide in petrolatum in Finn Chambers for 48 h (2D) with readings taken at 72 (D3), 96 (D4) and 168 h (D7). Different dose levels and application times affected unpredictably highest assessments of reactions. No clear suppression of reactivity was observed at high doses. Time points of highest assessments of reactions varied between subjects but were generally the same for each subject with both reading methods regardless of dose levels or application times. Positive and negative subjects during the study were easily distinguished with all serial doses, regardless of assessment technique. At 2.0 microg/cm2, the lowest dose level tested on all subjects, longer applications than 24 h (1D) were required to detect all positive subjects. 48-h (2-D) applications required 2 readings, optimally at 96 (D4) and 216 h (D9). The only test technique with Finn Chambers used here did not make such distinction possible.

Patch testing with budesonide in serial dilutions: the significance of dose, occlusion time and reading time

Budesonide is advocated as a marker molecule for corticosteroid contact allergy. When patch testing corticosteroids, one must consider their sensitizing potential but also their anti-inflammatory properties, as well as the possibility of different time courses for such properties. The dose-response relationship for budesonide was therefore investigated with regard to dose, occlusion time, and reading time. 10 patients were patch tested with budesonide in ethanol in serial dilutions from 2.0% down to 0.0002% with occlusion times of 48, 24, and 5 h. Readings were on D2, D4, and D7. The 48-h occlusion picked up most positive reactors, 8/10. The D4 reading (48-h occlusion) detected most positive reactors, 8/10, and here 0.002% picked up most contact allergies. Late readings favoured high concentrations. The "edge effect" was noted for several concentrations at early readings. Due to the individual corticosteroid reactivity, the dose-response relationship and the time courses of the elicitation and the anti-inflammatory capacity, several features may be explained, i.e., that lower concentrations may detect budesonide allergy better at early readings, that patients with an "edge reaction" can have positive reactions to lower concentrations.

Skin care for patients with chronic leg ulcers

An update on skin care for patients with chronic leg ulcers

Corticosteroid contact hypersensitivity: what vehicle and concentration?

The correct concentration and vehicle for patch testing with corticosteroids is in many instances not known. The results of this study suggest that 1% in ethanol should be the initial choice, unless it can be shown that petrolatum as a vehicle is as sensitive (tixocortol pivalate and budesonide). We could find no evidence for the anti-inflammatory effects of corticosteroids inhibiting the patch test at higher concentrations. Using ethanol as the vehicle resulted in reactions developing at earlier time points than with petrolatum.

Screening for corticosteroid contact hypersensitivity

To evaluate which corticosteroids are most useful for the detection of corticosteroid contact allergy in our population, 2123 patients were patch tested with a series of 6 corticosteroids, in parallel with a standard series, and other relevant investigations. 127 patients (5.98%) were allergic to one or more corticosteroids; 96 to tixocortol pivalate, 51 to hydrocortisone butyrate, 47 to budesonide, 11 to betamethasone valerate, 11 to clobetasone butyrate and 8 to clobetasol propionate. 511 patients with negative patch tests to the limited corticosteroid series were in addition tested to a further 12 corticosteroids; only 1 of these patients reacted to a corticosteroid. A combination of tixocortol pivalate and budesonide thus detected 91.3% of corticosteroid-allergic subjects. We believe that both these allergens should be included in the standard series and that there may be a case for extending this further.

Contact allergy to imidazoles used as antimycotic agents

The present article reviews the literature (up to 1994) on contact sensitivity to imidazoles and presents the results obtained from 15 patients observed at the Contact Allergy Unit in Leuven. The frequency as well as the cross-reaction patterns described are analyzed. Although allergic contact reactions may have been missed in the past (mainly because of problems with the correct choice of vehicle for patch testing), they seem to be relatively infrequent in view of their widespread use. The imidazole derivatives most frequently reported to be allergens are miconazole, econazole, tioconazole, and isoconazole. As far as cross-reactivity is concerned, statistically significant associations were found in the patient data between miconazole, econazole, and isoconazole; between sulconazole, miconazole, and econazole; and also between isoconazole and tioconazole. Patients sensitive to phenylethyl imidazoles (except ketoconazole) needing antimycotic therapy should be advised to use ketoconazole, clotrimazole, bifonazole, or, perhaps, the new flutrimazole. Clearly, non-imidazole antifungals can also be used.

Reactions to other corticosteroids in patients with allergic contact dermatitis from hydrocortisone

It has been proposed that corticosteroid cross-reactions occur more frequently within structurally well-defined groups. To test this hypothesis we have compared the patch-test reactions to other corticosteroids in 96 patients allergic to hydrocortisone. We found that our data did not agree with the previously proposed classification. The presence of a substitution at the C6 or C9 position was the most important factor in determining whether a patient would be allergic to another corticosteroid. This information should facilitate the choice of an alternative corticosteroid in patients allergic to hydrocortisone, if facilities for patch testing to other corticosteroids are not available.

Hypersensitivity to topical corticosteroids

Contact hypersensitivity from topical corticosteroids is becoming increasingly recognized; it is present in 2-5% of the patients attending contact dermatitis clinics. The use of a corticosteroid series containing tixocortal pivalate 1% (petrolatum), to detect hypersensitivity to hydrocortisone, and other steroids 1% (ethanol), depending on local corticosteroid usage, detects the majority of cases of corticosteroid hypersensitivity. In selected cases, the use of intradermal tests further improves the diagnosis of corticosteroid hypersensitivity. Corticosteroid hypersensitivity occurs most frequently among patients with stasis dermatitis. However, corticosteroid hypersensitivity is also common in other types of dermatitis, occurring as frequently as hypersensitivity to several allergens (e.g. wool alcohols and colophony) in the European standard battery. Although hypersensitivity has mainly been reported with corticosteroids applied to the skin, reactions may also occur on mucosal surfaces, following systemic administration and with sex steroids.

Contact allergy to corticosteroids: the results of a two-centre study

We report a comparative study of the patch-test results obtained with a corticosteroid series, added to the standard series, in two centres, one in Belgium and the other in the Netherlands. The frequencies of positive reactions to the corticosteroids differed considerably between the two centres, and we suggest several reasons for this.

Contact allergy to corticosteroids

Recent evidence shows that contact allergy to topical corticosteroids is more frequent than earlier believed. This review summarizes the current knowledge of this condition, including methods for clinical diagnosis.

Contact hypersensitivity to hydrocortisone-free-alcohol in patients with allergic patch test reactions to tixocortol pivalate

It has been suggested that contact allergy to hydrocortisone alcohol is a frequent phenomenon. A recent study showed that all patients with allergic patch reactions to tixocortol pivalate reacted to intradermal hydrocortisone sodium phosphate. We studied patients with positive patch test reactions to tixocortol pivalate but negative to hydrocortisone alcohol, with penetration enhancers in hydrocortisone alcohol patch tests and oral challenges with hydrocortisone alcohol. Additionally, prick and intradermal tests with hydrocortisone sodium succinate were used. Using penetration enhancers and oral challenges enabled detection of more contact allergies to hydrocortisone alcohol compared to conventional patch testing alone. 9/12 patients with allergic reactions to tixocortol pivalate reacted to intradermal hydrocortisone sodium succinate. No immediate reactions were seen in prick or intradermal tests, suggesting that hydrocortisone contact hypersensitivity is probably not associated with immediate allergy to hydrocortisone. The present study suggests that allergic patch test reactions to tixocortol pivalate are caused by hypersensitivity to hydrocortisone alcohol itself or to one of its metabolites in the skin.

Hydrocortisone sensitivity: clinical features of fifty-nine cases

BACKGROUND

Hypersensitivity to topical steroids is becoming increasingly recognized.

OBJECTIVE

Our purpose was to establish factors associated with allergy to topical hydrocortisone.

METHODS

Data from 59 consecutive patients allergic to hydrocortisone were compared with 199 consecutive patients who were not allergic to hydrocortisone.

RESULTS

Patients with stasis dermatitis and leg ulceration were significantly more likely to be allergic to hydrocortisone. In patients with hand eczema, in whom hydrocortisone sensitivity was less common, hydrocortisone was still a common allergen, occurring as frequently as wool alcohols and colophony. In four patients with atopic eczema, hydrocortisone was the only allergen. Duration of dermatitis was not important in determining the presence of hydrocortisone allergy. However, patients allergic to hydrocortisone were more likely to have multiple allergies when compared with control subjects.

CONCLUSION

Allergy to topical hydrocortisone is associated with stasis dermatitis and multiple positive patch test reactions.

Contact hypersensitivity to topical corticosteroids

Topical corticosteroids are increasingly recognized as relatively common contact sensitizers. Between July 1988 and December 1991 2687 patients undergoing routine patch testing were also tested with tixocortol pivalate (TP). Over the same time period 528 patients were selected for testing with a series of 18 steroids. One-hundred and thirty-one cases (4.9%) of corticosteroid hypersensitivity were detected and 119 (90.8%) of these cases were positive to TP. Thirty-seven patients reacted to one or more steroids in the steroid series, the most frequent sensitizers being hydrocortisone, budesonide (3.6%) and hydrocortisone 17-butyrate (2.5%). Of these 37 cases, 20 (54%) reacted to more than one steroid simultaneously, but the patterns of cross-reaction were not consistent with previously suggested groupings. Screening for steroid allergy should be performed as part of standard patch testing. The value of TP as a marker of corticosteroid hypersensitivity is reinforced by this study, but no satisfactory marker was found for the 9.2% of cases not detected by TP. There remains a need for further markers of corticosteroid hypersensitivity. A prevalence of 4.9% of corticosteroid allergy amongst our patients suggests that the frequency of this finding is generally underestimated.

Contact allergies to topical corticosteroids: 10 cases of contact dermatitis

Patients who noticed worsening of their skin disease after using topical corticosteroid preparations were patch tested both with the commercial preparation and the corticosteroid itself. Between 1987 and 1989, 10 cases of contact dermatitis due to topical corticosteroids were detected in this way. The corticosteroids wee amcinonide (2 patients), hydrocortisone butyrate, clobetasol propionate (2), betamethasone valerate (2), prednicarbate and fluocortolone (2). Patch tests with the commercial preparations and the corticosteroids themselves elicited reactions almost identical in time course and severity. Individual sensitivity seems to be more important for test results than test conditions. 9 of the 10 patients underwent further patch testing with a corticosteroid series. In 2 patients, a true cross-reaction between budesonide and hydrocortisone butyrate was found. All 9 patients showed further sensitivities to other corticosteroids. Most of the cross or concomitant reactions could be categorized into recently defined corticosteroid classes. To improve our understanding of corticosteroid sensitization, and to help the patient avoid reactions to other topical corticosteroids, a corticosteroid series should be patch tested in every case of corticosteroid sensitivity.

Hydrocortisone: an important cutaneous allergen

We have found a high incidence (4.8%) of allergy to hydrocortisone in patients with suspected allergic contact dermatitis. In view of this finding we would suggest that, in any condition that does not improve or that deteriorates after administration of hydrocortisone, allergy to this compound should be considered.

Contact allergy to corticosteroids: a frequently missed diagnosis?

Contact allergy to corticosteroids is more prevalent than previously recognized and often goes undetected. Nineteen patients with corticosteroid contact allergy are presented. Sixteen reacted to tixocortol pivalate and also to other corticosteroids, particularly to hydrocortisone, which could explain exacerbations of eczema in these cases. Tixocortol pivalate may be a useful marker for screening patients for contact sensitivity to several corticosteroids.

Detection of contact hypersensitivity to topical corticosteroids with hydrocortisone-17-butyrate

We showed earlier that most patients with contact dermatitis due to corticosteroids show cross-reactions when patch tested with hydrocortisone-17-butyrate (H-17-B). To test whether H-17-B could be used for detecting topical corticosteroid allergy, we screened patients undergoing routine patch testing with H-17-B. Patients with clearly allergic or doubtful/mildly irritant patch test reactions to H-17-B, and with a history suggesting topical corticosteroid allergy, were further tested with a large panel of steroid preparations. 20 out of 4039 patients (0.5%) showed definite allergic test reactions to corticosteroids. A further 165 patients with clinically suspected corticosteroid allergy were directly tested with a panel of steroid preparations; 14 patients showed positive patch test reactions. Altogether, 33 out of 34 patients with corticosteroid allergy had positive test reactions to H-17-B. Inclusion of 1.0% H-17-B in ethanol in the standard patch test series improves the diagnosis of topical corticosteroid hypersensitivity.

Allergic contact dermatitis from topical corticosteroids

22 cases of allergic contact dermatitis from topical corticosteroids were observed in Strasbourg and previously published. 7 further cases are reported here and the vehicle and concentration of corticosteroids for patch tests are discussed. A 0.1% concentration in petrolatum seemed adequate for testing the 4 molecules (triamcinolone acetonide, dexamethasone, desonide and amcinonide) responsible for the 7 new cases. In 1 case, several cross-reactions were seen. A corticosteroid screening series permits patch testing of the suspected molecule(s) in a selective way. Without this series, long delays are required to make the correct diagnosis by patch testing. We have reviewed more than 60 papers on corticosteroid allergy published up to now.

Contact dermatitis from topical imidazole antifungals: 15 new cases

Contact allergy from topical imidazole antifungals is seldom reported. 15 such cases, over a 12-year period, are reported here. Results are discussed particularly with regard to imidazole cross-reactions and to sensitization to topicals combining miconazole and hydrocortisone.

Identification of cross-reaction patterns in allergic contact dermatitis from topical corticosteroids

Contact allergy to topical corticosteroids occurs more frequently than previously supposed. Cross-allergic phenomena are common. On the basis of a review of the literature and our own patch test data on 15 patients, we conclude that positive patchtests to corticosteroids occur approximately six to seven times more frequently in well-defined groups of structurally-related substances than between corticosteroids of different groups. An analogous substitution pattern on the steroid D-ring or the carbon side chain (C20, C21) seems to have a significant influence on the association of positive patchtest results. This is not the case for other structural variables, such as the presence of a double bond in the steroid A-ring or fluoride substitutions on the B-ring. The effect of other factors such as concomitant sensitization and steroid metabolism in the skin on the development of a corticosteroid polyallergy are analysed, and the specificity and sensitivity of cross-allergy phenomena are evaluated. These are important in the selection of a topical steroid in the future treatment of a corticosteroid sensitive patient.

Epicutaneous patch testing: current trends and controversial topics

In the 20th century, epicutaneous patch testing has played an integral and central role in the assessment of allergic contact dermatitis and therefore in general dermatologic practice. After recent verification of the safety and accuracy of patch testing by the Food and Drug Administration, domestic distribution of testing materials has resumed for the first time in 5 years. Because of the importance of this procedure, it is timely to review current standards of epicutaneous patch testing with emphasis on proper use and interpretation, clinical applications, trends in allergic contact dermatitis, and selected controversial issues.

Ring-shaped positive allergic patch test reactions to allergens in liquid vehicles

In recent years, we have observed several "ring-shaped" positive allergic patch test reactions to allergens dissolved in a liquid vehicle, a more intense response at the periphery of the site of application than in the central part. The occurrence of such reactions was evaluated for formaldehyde, Kathon CG, hydrocortisone and hexamidine diisethionate. Possible explanations for such reactions include pressure and/or a capillary effect.

Topical provocation of fixed drug eruption

To determine whether topical provocation could be used for the diagnosis of fixed drug eruption (FDE) instead of systemic provocation, we applied the suspected drug at various concentrations (1-10%) in either petrolatum, 94% ethanol or dimethyl sulphoxide (DMSO) as an open test on both clinically normal skin and on previous FDE lesions in 24 patients with established FDE due to phenazone salicylate, a sulphonamide, doxycycline, trimethoprim, chlormezanone, a barbiturate, or carbamazepine. In 18 of the 24 patients, local provocation of FDE was seen at sites or previous eruption but never on clinically normal skin. With some drugs, e.g. phenazone salicylate, positive provocation of FDE was seen with all the vehicles used; with sulphamethoxazole and trimethoprim, a positive result was seen only in DMSO. To study cross-reactions to other phenazone derivatives in patients with an FDE caused by phenazone salicylate, we applied topical phenazone, aminophenazone and propyphenazone to sites of previous FDE lesions in three patients. In all three, a positive reaction was seen with phenazone, but only one patient showed positive results with aminophenazone and propyphenazone. The present study suggests that topical provocation is useful with several drugs causing FDE. Testing should always be performed on sites of previous FDE, and the sensitivity of the open topical testing can be increased in certain cases by using a vehicle which increases penetration of the drug.