Hydrocortisone sensitivity. An investigation into the nature of the allergen

Contact allergy in the population of patients with chronic inflammatory dermatoses and contact hypersensitivity to corticosteroids

INTRODUCTION

Clinical studies indicate that contact allergy to glucocorticosteroids (GCS) is not rare and has been increasingly reported over the past decade. Among the risk factors for developing contact hypersensitivity to topical corticosteroids, chronic inflammatory skin diseases and polyvalent contact allergy seem to be most important.

AIM

To present the structure of contact allergy in the population of patients with chronic inflammatory dermatoses (CID) and contact hypersensitivity to corticosteroids.

MATERIAL AND METHODS

Twenty-seven patients with contact allergy to GCS and chronic inflammatory dermatoses were patch tested with 28 European Baseline Series allergens and 8 corticosteroid allergens. This study group consisted of 5 patients with atopic dermatitis (AD), 15 patients with contact eczema (CE) and 7 with chronic leg eczema (CLE). Nineteen (70.4%) patients were females and 8 (29.6%) were males.

RESULTS

In the study group, the most sensitizing non-steroidal allergens were nickel sulfate (51.8%), cobalt chloride (33.3%) and balsam of Peru (29.6%). The most sensitizing corticosteroid allergens were budesonide (77.8%), betamethasone valerate and clobetasol propionate (55.5% each). A total of 77.8% of patients allergic to GCS also showed sensitivity to at least one non-steroidal allergen from the European Baseline Series.

CONCLUSIONS

The most important risk factors for developing contact allergy to corticosteroids appear to be chronic inflammatory dermatoses, long disease duration, extended on-and-off topical corticosteroid use, patients presenting two or more positive patch test results and polyvalent contact allergy to metal salts and to other non-steroidal haptens.

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.

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

BACKGROUND

Reactions to systemically administered corticosteroids are rare, despite their widespread use.

OBJECTIVES

To identify alternative glucocorticoids for emergency use in patients with adverse reactions to systemic glucocorticoids.

METHODS

Ten patients were identified as having adverse reactions after the use of systemic corticosteroids. Skin prick tests and intradermal tests to hydrocortisone (HC) and methylprednisolone (MP), and intradermal tests to betamethasone and dexamethasone, were performed in all patients, and oral challenge tests to betamethasone (n=10) and deflazacort (n=6).

RESULTS

Skin prick tests were negative in all patients, whereas intradermal tests to HC and MP were positive in eight; two patients showed only an isolated cutaneous sensitivity to MP. Intradermal tests to betamethasone and dexamethasone were negative, and oral challenge tests were negative in all patients.

CONCLUSIONS

Our results suggest the possibility of an IgE-mediated mechanism for allergic reactions to HC and MP, probably due, at least in part, to a steroid-glyoxal. We suggest that betamethasone and deflazacort could be reserved for emergency use in patients with adverse reactions to other corticosteroids.

Cross-reactivity patterns to budesonide

Allergic contact dermatitis from topical corticosteroids is not uncommon. Budesonide has been included in the European standard series as a marker for corticosteroid allergy, though little is known of its cross-reactivity with other corticosteroids. Twelve patients previously positive to budesonide on patch testing were given further patch and intradermal tests to a range of corticosteroids. Six patients previously negative to budesonide on patch testing were used as a control group. Budesonide cross-reacts with hydrocortisone-21-sodium phosphate and triamcinolone acetonide. Patients positive to budesonide should therefore avoid hydrocortisone and triamcinolone acetonide. Patch testing, unfortunately, is an inaccurate method of determining cross-reactivity patterns among corticosteroids.

Corticosteroid-induced contact dermatitis: a pragmatic approach

It is only in the past 10 years that the allergenic potential of topical corticosteroids has been fully realized. This has an important impact on the management of patients with chronic eczematous eruptions. Nonhalogenated topical steroids are more frequent sensitizers than halogenated molecules. Tixocortol pivalate and budesonide should be added to the standard series of patch test allergens. The topical steroid products that the patient has used should also be tested. If a patient has a positive reaction to tixocortol pivalate and/or budesonide then further patch testing with a commercial corticosteroid series should be undertaken.

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.

Reactivity of tixocortol pivalate-positive patients in intradermal and oral provocation tests

Pivalone/tixocortol pivalate commonly yields positive reactions in the patch test series. The clinical relevance of these positive reactions was investigated in more detail. In the standard patch test series 5.6% (73 of 1306) of the patients were positive to corticosteroids, 5.2% to 0.1% tixocortol pivalate in ethanol (Pivalone nasal spray diluted 1:10) and 2.3% to 1% hydrocortisone butyrate in ethanol. Some of the patients were tested in parallel with Pivalone and 1% tixocortol pivalate in petrolatum. The former test reagent yielded some false-positive reactions, whereas with the latter, some allergic responses were missed. Intradermal tests with the succinate esters of hydrocortisone, methylprednisolone and prednisolone were performed with 52 patients positive to Pivalone. Of these 76.9% (40 of 52) were positive in the intradermal tests; 38 to hydrocortisone, 35 to methylprednisolone and 30 to prednisolone. Twelve patients who had been positive in the intradermal tests were challenged orally with corticosteroids and they all showed positive reactions to hydrocortisone, methylprednisolone or prednisolone. The patients developed localized reactions at the sites of previous eczema or positive skin tests or diffuse erythema or exanthema. The oral doses of hydrocortisone eliciting positive delayed skin reactions ranged from 20 to 200 mg. Reactivity to tixocortol pivalate is closely related to sensitivity to hydrocortisone, methylprednisolone and prednisolone, but high oral doses of these corticosteroids may be required to produce allergic symptoms.

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.

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.

Delayed systemic allergic reactions to corticosteroids

From the limited number of reports in the literature, it would appear that various types of delayed reactions from systemically, intralesionally, and intra-articularly administered corticosteroids are rare, particularly given their widespread use. The purpose of this literature review is to summarize in table form the reported cases of generalized delayed systemic corticosteroid reactions with respect to patient presentation, methods of evaluation, and conclusions reached. In total, 24 cases of generalized delayed systemic corticosteroid reactions have been reported in the literature. Clinical presentation (timing and cutaneous manifestations) as well as evaluation of these patients has been variable; reactions reported include eczematous or exanthematous eruptions, with or without bullae or purpura. In 16 cases, the diagnoses have been supported by positive patch or intradermal testing. Overall, it appears that generalized delayed systemic reactions to corticosteroids show considerable variability and are infrequently reported. Patch and intradermal tests with standardized allergens appear to be the most useful tests currently available to support this clinical diagnosis.

IgG antibodies and early intradermal reactions to hydrocortisone in patients with cutaneous delayed-type hypersensitivity to hydrocortisone

Seven of 25 patients with cutaneous delayed-type hypersensitivity to hydrocortisone had an immediate reaction following the intradermal injection of hydrocortisone sodium succinate. Using an ELISA method, we found that these patients had significantly increased levels of IgG antibodies to hydrocortisone when compared with normal blood donors (P < 0.005) and nickel-allergic patients (P < 0.05). We suggest that these patients are at risk of developing type III and possibly type I reactions following the systemic administration of hydrocortisone and that, if needed, an alternative systemic corticosteroid should be used, for example betamethasone or dexamethasone.

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.

In vitro evidence of delayed-type hypersensitivity to hydrocortisone

Hypersensitivity to topical hydrocortisone is becoming increasingly recognized. We present further evidence that this is mediated via a delayed-type hypersensitivity reaction. A hydrocortisone: albumin complex was able to induce a proliferative response in the peripheral blood mononuclear cells of patients allergic to hydrocortisone. Protein binding of hydrocortisone or a degradation product may be important in the development of corticosteroid allergy.

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.