Cross-reactions in topical corticosteroid contact dermatitis

Guinea pig maximization test assessment of hydrocortisone and tixocortol pivalate

The anti-inflammatory properties of topical corticosteroids are well documented; additionally, their sensitization potential is also known. We aimed to assess the relative sensitization potential of hydrocortisone and tixocortol pivalate in an animal assay as it relates to potential for sensitization in humans. Using the guinea pig maximization test (GPMT), animals were sensitized intradermally on d0, and again topically on d7. On d21 the animals were challenged topically with a closed patch for 24 h and readings were taken 24 h and 48 h post-challenge. A sham control group received the same induction and challenge applications excluding the test agent. Animals were subsequently rechallenged with open application; the tixocortol pivalate group was further retested at different test agent concentrations to determine threshold concentration that elicited response. Tixocortol pivalate resulted in sensitization rates of 42% (24 h) and 80% (48 h); hydrocortisone exhibited 0% (24 h) and 5% (48 h). Scores ranged from 0% (sham group) to 2.4 (48 h tixocortol pivalate). Open rechallenge also resulted in greater tixocortol pivalate sensitization rates compared to hydrocortisone, 82% verse 16% at 48 h, respectively. All tested concentrations of tixocortol pivalate induced sensitization, albeit at differing rates dependant on concentration and timepoint. We conclude that the GPMT remains largely for hazard identification, as it was originally designed, and requires further data sets regarding quantitative induction and elicitation for risk assessment of various compounds in clinical implications.

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.

Patch testing for allergic contact dermatitis in the allergist office

The identification of allergens responsible for allergic contact dermatitis (ACD) is key to the management of this disease. The patch test (PT) is the only safe, objective, scientific, and practical method for the diagnosis of ACD. There is no single PT panel that will screen all the relevant allergens in a patient's environment. It is generally thought that 20 to 30 allergens in routine screening tests can identify 50% to 70% of clinically relevant ACD. However, the usefulness of patch testing is enhanced with the number of allergens tested. Although the PT might be simple to apply, it might be difficult to read, interpret, and correlate to the patient's symptoms. A familiarity with the patient's environment, the process of the industry in that environment, and the uses of various chemicals in the industry is needed in most cases.

Skin reactions to inhaled corticosteroids

Corticosteroids intended for inhalation into the lungs or into the nose have been used since the 1970s. Only 2 attempts to assess contact allergy attributable to inhaled corticosteroids in patients with asthma and/or rhinitis have been made, and only 1 single case of contact allergy attributable to budesonide and tixocortol pivalate was found. However, several case reports of allergic mucosal and skin symptoms caused by corticosteroids applied locally to the mucosa have been published. Local adverse effects from nasal corticosteroids have ranged from nasal congestion, pruritus, burning, and soreness to perforation of the nasal septum. Inhalation of corticosteroids into the lungs has been reported to cause pruritus, dryness, erythema and oedema of the mouth, a dry cough and odynophagia. Systemic signs reported from the use of nasal corticosteroids and inhalation of corticosteroids into the lungs have been eczematous lesions, particularly on the face, sometimes with spreading to the trunk and flexures. Urticaria has also been noted.

Adverse reaction to prednisone in a patient with systemic lupus erythematosus

Oral corticosteroids are the main therapeutic choice for systemic lupus erythematosus (SLE). Adverse reactions to systemic corticosteroids rarely occur and the etiology is unclear in most cases. A 14-year-old girl with newly diagnosed SLE developed a pruritic bullous eruption while on prednisone. The patient had been treated successfully in the hospital with intravenous methylprednisolone. In preparation for discharge, the steroid preparation was changed to prednisone to which the patient reacted with a development of new crops of bullous lesions. Skin biopsy specimens of lesional areas showed a bullous eruption consistent with erythema multiforme. The patient underwent immediate and delayed hypersensitivity tests. Intradermal and patch tests to liquid prednisone were positive. The patient was discharged on oral methylprednisolone and has not had recurrence of the skin lesions. In conclusion, a case of prednisone sensitivity in a patient with SLE is presented here. An alternative preparation, methylprednisolone, was used to successfully treat her underlying condition.

Reactions to other corticosteroids in patients with positive patch test reactions to budesonide

BACKGROUND

Corticosteroid cross-reactions have been classified into four well-defined groups. A previous study of patch test reactions to other corticosteroids in patients allergic to hydrocortisone failed to conform to these groups. It was suggested that substitution at the C6 and C9 positions of the corticosteroid was the most important determinant of a further reaction.

OBJECTIVE

Our aim was to analyze multiple positive patch tests to corticosteroids in patients sensitized to budesonide to confirm our earlier findings.

METHODS

Forty-six patients with positive patch tests to budesonide were patch-tested to 17 other topical corticosteroids. The results were examined by a generalized linear model and a chi-square test.

RESULTS

Substitution of the corticosteroid at the C6 and C9 positions significantly reduced the number of reactions. A different substitution at the C16 and C17 positions was less important, and that at the C21 position was of no significance.

CONCLUSIONS

Patients sensitized to budesonide are most likely to react to other non-C6 and non-C9 substituted corticosteroids.

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 allergies to topical corticosteroids

The patient, a 34-year-old Japanese woman who noticed worsening of her rash after using topical corticosteroid preparations on her neck, was patch tested for both commercial preparations and corticosteroids themselves. The patch test results revealed that she had a contact allergy to gold, oxytetracycline, and 2 types of corticosteroid (acetonides and esters) in 7 compounds (betamethasone valerate and dipropionate, hydrocortisone butyrate and hydrocortisone butyrate propionate, amcinonide, budesonide, and fluocinonide).

Hydrocortisone sensitivity. An investigation into the nature of the allergen

11 patients, positive to tixocortol pivalate on patch testing, were tested intradermally with a variety of hydrocortisone analogues. Substitution at the C21 position had no effect on the occurrence of positive reactions to hydrocortisone, whereas alteration of any of the carbon rings significantly reduced the number of positive reactions. We suggest that the C17 side chain is involved in protein binding and subsequent presentation of antigenic sites on the carbon rings.

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.

Screening for corticosteroid contact sensitivity. Comparison of tixocortol pivalate, hydrocortisone-17-butyrate and hydrocortisone

3 corticosteroids have so far been tried as markers for corticosteroid contact sensitivity: hydrocortisone, tixocortol pivalate and hydrocortisone-17-butyrate. The present study compared these steroids for screening in addition to a standard patch test series. Of 727 patients, 28 (3.9%) reacted to tixocortol pivalate and 10 (1.4%) to hydrocortisone-17-butyrate; hydrocortisone gave an allergic reaction in 2 of 521 (0.4%) patients. Serial dilutions suggested that tixocortol pivalate, not marketed in Finland, caused allergic reactions which could possibly be cross-reactions to hydrocortisone. In contrast to previously published data, frequent cross-reactions occurred with hydrocortisone-17-butyrate and tixocortol pivalate. All allergic reactions to other corticosteroids found by testing with tixocortol pivalate concurred with reactions to hydrocortisone-17-butyrate. The study suggests that the most effective choice for routine testing for corticosteroid contact sensitivity would be both tixocortol pivalate and hydrocortisone-17-butyrate.

Corticosteroid sensitivity and cross-sensitivity. A review of 18 cases 1967-1988

506 patients were suspected of being allergic to corticosteroid medicaments in our clinic during the 22 years from 1967 to 1988. Patch tests were performed in these patients. Scratch tests, intradermal tests, and challenge tests were also carried out in some cases. 69 patients showed positive reactions to corticosteroid products (as is). 18 were allergic to the corticosteroid itself and 44 were sensitive to vehicle components or other active ingredients. In 7 cases, the allergen could not be detected. Patients who were allergic to corticosteroids were tested for their cross-sensitivity with our corticosteroid patch test series. Cross-reactions tended to occur between members of the same corticosteroid type, and some of the combinations of different corticosteroid types cross-reacted with each other. Corticosteroid-sensitive cases have increased in number during these 22 years. Corticosteroid sensitivity is not as rare as formerly thought.

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.

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.