Drug-elicited systemic allergic (contact) dermatitis - update and possible pathomechanisms

Differential diagnosis of contact dermatitis: A practical-approach review by the EADV Task Force on contact dermatitis

The diagnosis of eczema ('dermatitis') is mostly clinical and depends on the clinical history and exploratory objective findings (primary lesions, patterns). Contact dermatitis remains as an important condition in the group of eczematous disorders, with important socioeconomic and occupational relevance. Although irritant and allergic contact dermatitis have a different pathogenesis, both are characterized by a rather typical morphology, are triggered by external factors and tend to occur primarily in the area of contact with the exogenous agent. In addition, allergic and irritant dermatitis may also co-exist. The importance of diagnosing contact dermatitis, especially when allergic in nature, is both due to the possibility of avoiding the trigger, and due to its role in aggravating other skin conditions. Nevertheless, the heterogeneity of clinical presentations in daily practice may pose an important challenge for the suspicion and correct diagnosis of contact dermatitis. Furthermore, other conditions, with different pathogenesis and treatment, may clinically simulate contact dermatitis. The Task Force aims to conduct a review of the unifying clinical features of contact dermatitis and characterize its main clinical phenotypes, and its simulators, in order to contribute to an early suspicion or recognition of contact dermatitis and enable a correct differential diagnosis.

Kleine Ursache – große Wirkung: Spättyp-Hauttests mit Medikamenten als Auslöser von disseminierten Rezidivexanthemen

Es werden zwei Patienten vorgestellt, die wegen eines streuenden allergischen Kontakt- bzw. Arzneimittelexanthems auf Budesonid bzw. Antibiotika abgeklärt wurden. Bei beiden trat innerhalb einiger Stunden nach Anlegen eines Epikutantests mit Budesonid bzw. Intradermaltesten mit Amoxicillin eine stark positive Hauttestreaktion sowie ein Exanthem auf. Beim ersten Patienten lag eine Sensibilisierung auf die kreuzreagierenden Moleküle Budesonid und Amcinonid, bei der zweiten Patientin eine ausgeprägte Überempfindlichkeit auf Aminopenizilline vor. Aufflammphänomene (Flare-ups) sind v. a. aus der Kontaktallergologie bekannt, können aber auch bei der Abklärung von allergischen Arzneimittelexanthemen auftreten. Systemische Reaktionen vom verzögerten Typ auf Spättyp-Hauttests mit Medikamenten sind relativ selten, können aber eine erhebliche Morbidität bewirken. Verschiedene Formen von Aufflammphänomenen in der Allergologie werden diskutiert.

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.

Allergic Contact Dermatitis From Topical Drugs: An Overview

ABSTRACT

Allergic contact dermatitis from topical drugs is frequent and is seen in 10% to 17% of patients patch tested for suspected contact dermatitis. More than 360 drugs have been implicated as contact allergens, of which-generally-antibiotics, corticosteroids, local anesthetics, and nonsteroidal anti-inflammatory drugs are the most frequent culprits. This article provides an overview of allergic contact dermatitis to topical drugs, discussing their prevalence of sensitization, predisposing factors, clinical manifestations (both typical and atypical), the drugs described as allergens, cross-reactivity and coreactivity, and diagnostic procedures.

Contact Dermatitis: Classifications and Management

Contact dermatitis (CD) is a common inflammatory skin disease caused by exposure to contact allergens and irritants. It is also the most common reason of occupational dermatitis and contributes greatly to hand dermatitis and facial dermatitis. Besides the two major forms of contact dermatitis: allergic contact dermatitis and irritant contact dermatitis, other subtypes of CD have been recognized including immediate skin reactions, photoinduced contact dermatitis, systemic contact dermatitis, and non-eczematous contact dermatitis. CD is a great imitator which can mimic many kinds of skin diseases, such as atopic dermatitis, lichen planus, and angioedema. For the diagnosis of CD, a complete medical history, including occupational history, is very important. It can give a clue of CD and provide a list of suspected substances. Besides the well-known diagnostic test, patch testing, there are many other diagnostic tests can be used to help diagnosis of CD and identify the causative allergens, including photopatch test, skin tests for detecting of immediate contact reactions, serum allergen-specific IgE test, and qualitative and quantitative testing of allergen in the suspected materials patients exposed to and challenge test. Before the treatment, the suspected irritants or allergens should be avoided completely. This includes both the removal of the patient from the environment that contains those substances and the promotion of the metabolism and expulsion of the allergens that have been absorbed by the body. In addition, it is also important to restore the skin barrier and reduce skin inflammation through multiple treatments, such as emollients, topical corticosteroids, and antihistamines, as well as systemic corticosteroids and immunosuppressants. Early and appropriate treatments are important to prevent further deterioration and persistence of the skin condition.

Drug Allergy and Cutaneous Adverse Reactions

Allergy or hypersensitivity to drugs often affects the skin and sometimes also mucosa. While immediate type reactions show a rather homogeneous pattern, delayed type reactions reveal a high variability. In both cases it may not always be easy to differentiate drug reactions from non-drug-induced skin conditions. Furthermore, the different types of cutaneous adverse reactions may be difficult to distinguish in the beginning. This accounts predominately for delayed hypersensitivity reactions that can occur after a variety of medications and present with manifold lesions. Most of these cutaneous adverse reactions are mild, but some are severe with high morbidity and mortality. In the clinical setting, it is important to recognize the signs that point to a more severe condition early on in order to initiate appropriate management. In addition, it is crucial to identify the potentially culprit medication on the basis of a detailed medication history and by evaluating the relevant exposure times of certain drugs that differ substantially between the various reaction types. After the acute stage of the adverse reaction is managed successfully, further allergologic testing may be undertaken to confirm the offending drug.

Update: methodological principles and scientific methods to be taken into account when establishing Reference Points for Action (RPAs) for non-allowed pharmacologically active substances present in food of animal origin

EFSA was asked by the European Commission to update the Scientific Opinion on methodological principles and scientific methods to be taken into account when establishing Reference Points for Action (RPAs) for non‐allowed pharmacologically active substances in food of animal origin. This guidance document presents a simple and pragmatic approach which takes into account both analytical and toxicological considerations. The RPA shall be based on the reasonably achievable lowest residue concentration that can unequivocally be determined by official control laboratories, i.e. the reasonably achievable lowest decision limit (CCα). The aim is to check whether this concentration is low enough to adequately protect the consumers of food commodities that contain that substance. The proposed step‐wise approach applies toxicological screening values (TSVs), based on genotoxic potential, pharmacological activity, as well as other effects of the substance. The highest dietary exposure corresponding to the reasonably achievable lowest CCα for the substance has to be estimated and compared with the TSV. Where equal to or lower than the TSV, the reasonably achievable lowest CCα can be accepted as the RPA. If higher, the sensitivity of the analytical method needs to be improved. In the case where no further analytical improvements are feasible within a short to medium time frame, a substance‐specific risk assessment should be considered. This also applies when the potential adverse effects do not allow use of the decision tree, as for high potency carcinogens, inorganic substances or compounds with allergenic effects or causing blood dyscrasias. The CONTAM Panel concluded that RPAs should be food matrix independent. RPAs cannot be applied to non‐edible matrices, which are also monitored for non‐allowed pharmacologically active substances.

Injection site reactions after subcutaneous oligonucleotide therapy

Oligonucleotides (ONs) are short fragments of nucleic acids, currently being investigated as therapeutic agents. When administered subcutaneously (sc), ONs cause a specific local reaction originating around the injection site, such as erythema, itching, discomfort and pain, including more severe manifestations such as ulceration or necrosis. These injection site reactions (ISRs) are common, but rather poorly described in the literature. With this review, we aim to provide an overview on the extent of the problem of ISRs, based on reported incidence. A structured literature search was performed to identify reported incidence and clinical features of ISRs which yielded 70 manuscripts that contained information regarding ISRs. The data from literature was combined with data on file available at our institution. All sc administered ONs described in the literature lead to the occurrence of ISRs. The percentage of trial subjects that developed ISRs ranged from 22 to 100% depending on ON. The majority of ONs caused ISRs in more than 70% of the trial subjects. The severity of the observed reactions varied between different ONs. Occurrence rate as well as severity of ISRs increases with higher doses. For chemistry and target of the compounds, no clear association regarding ISR incidence or severity was identified. All ONs developed to date are associated with ISRs. Overcoming the problem of ISRs might add greatly to the potential success of sc-administered ONs. Knowledge of these skin reactions and their specific immunostimulatory properties should be increased in order to obtain ONs that are more suitable for long-term use and clinically applicable in a broader patient population.

Systemic contact dermatitis to foods: nickel, BOP, and more

Systemic contact dermatitis (SCD), a cutaneous reaction that is a direct manifestation of systemic exposure to a known allergen in a sensitized individual, has been increasingly recognized as a cause of persistent cutaneous contact dermatitis that is refractory to conventional therapies. While SCD in response to drugs has been described well in the literature, SCD to allergens in common foodstuffs is a less well-articulated phenomenon. Several foods that are universally consumed throughout the world contain potent allergens including nickel, balsam of Peru, trace metals, urushiol, and sesquiterpene lactones as well as a host of others that may cause a distinctive clinical picture. In this review article, the authors review the typical presentation and prevalence of SCD to foods, pathophysiology, the most common offensive ingestible food allergens, several appropriate diets, and effectiveness of dietary avoidance for situations in which SCD is suspected.

Long-term allergic dermatitis caused by sevoflurane: a clinical report

BACKGROUND

Allergy to volatile anaesthetics is extremely rare, but capable of damaging the professional career.

METHODS

This article presents the case of a 60-year-old surgeon who developed a skin rash on the reverse of hands, which progressively worsened and extended to distant fold areas. Blood tests were normal but for eosinophilia and risen total IgE, with normal specific globulins and skin prick tests for common allergens. After 8 years, a malfunction in the anaesthetic gas scavenging system was found, and symptoms remitted within a week following its replacement. Repeated open application test with sevoflurane led to the appearance of the same lesions in the tested areas and in distant body folds.

RESULTS

We hypothesize that the most probable mechanism for the reaction in our patient is systemic allergic contact dermatitis, which is caused by repeated systemic exposure to a hapten that reaches the skin through haematogenous transport in a sensitized patient.

CONCLUSIONS

The report aims to warn about the potential aetiological relationship between exposure to inhaled anaesthetics and allergic manifestations with cutaneous symptoms.

Systemic contact dermatitis

Systemic contact dermatitis is an inflammatory skin disease that may occur in persons with contact allergy when they are exposed to the hapten orally, transcutaneously, per rectum, intravesically, intravenously, or by inhalation. The most common causes of systemic contact dermatitis are drugs used both topically and systemically. Other causes are ubiquitously occurring haptens, such as the metals nickel, cobalt, gold, and chromate, and aromatic substances such as spices. Avoidance of the offending hapten is the most obvious treatment. For some haptens, such as nickel, diet treatment may be effective. Chelation therapy with disulfiram is another therapeutic option in nickel-allergic patients with systemic contact dermatitis. Hyposensitization therapy has been attempted with some success in systemic contact dermatitis caused by nickel and Parthenium hysterophorus.

Systemic contact dermatitis in children: how an avoidance diet can make a difference

Systemic contact dermatitis is an under-recognized skin reaction that occurs secondary to systemic (oral, intravenous, intramuscular, inhaled, or subcutaneous) exposure to a hapten in a previously sensitized individual. Medicaments are the most common cause of SCD in the adult population, but other chemicals like nickel, cobalt, balsam of Peru, and formaldehyde have been implicated as well. Few reports in children exist to date. Dietary restriction has shown to be of some benefit in managing some adult patients. We present a case series of 8 pediatric patients diagnosed with SCD from the contact dermatology clinic, who showed marked improvement of their dermatitis after adequate dietary avoidance. We review common presentations of chemicals causing SCD in children and potential dietary modifications.

A systematic approach to systemic contact dermatitis and symmetric drug-related intertriginous and flexural exanthema (SDRIFE): a closer look at these conditions and an approach to intertriginous eruptions

Systemic contact dermatitis is a condition that occurs when an individual sensitized to a contact allergen is exposed to that same allergen or a cross-reacting molecule through a systemic route. Systemic exposure to allergens can include transcutaneous, transmucosal, oral, intravenous, intramuscular, and inhalational routes. Baboon syndrome is perhaps the most recognizable form of systemic contact dermatitis, presenting with diffuse, well demarcated erythema of the buttocks, upper inner thighs, and axillae. Other forms of systemic contact dermatitis include dermatitis at sites of previous exposure to the allergen such as at a previous site of dermatitis or at sites of previous positive patch tests, dyshidrotic hand eczema, flexural dermatitis, exanthematous rash, erythroderma, and vasculitis-like lesions. The most common causes of systemic contact dermatitis consist of three groups of allergens: (i) metals including mercury, nickel, and gold; (ii) medications including aminoglycoside antibacterials, corticosteroids, and aminophylline; and (iii) plants and herbal products including the Compositae and Anacardiaceae plant families and Balsam of Peru. Baboon syndrome caused by systemic medications without a known history of previous cutaneous sensitization in the patient has been termed drug-related baboon syndrome (DRBS) or symmetric drug-related intertriginous and flexural exanthema (SDRIFE). Criteria for SDRIFE include exposure to systemic drug at first or repeated dose, erythema of the gluteal/perianal area and/or V-shaped erythema of the inguinal area, involvement of at least one other intertriginous localization, symmetry of affected areas, and absence of systemic toxicity. The most common causes are aminopenicillins, β-lactam antibacterials, and certain chemotherapeutic agents, though the list of etiologic agents continues to grow. Baboon syndrome and SDRIFE should be strongly considered in a patient presenting with a symmetric intertriginous eruption involving multiple body folds. With the knowledge of the most frequent causes of these conditions, a detailed history and review of exposures will guide the clinician in the search for the most likely etiologic agent.

Metal allergy--a review on exposures, penetration, genetics, prevalence, and clinical implications

The prevalence of metal allergy is high in the general population, and it is estimated that up to 17% of women and 3% of men are allergic to nickel and that 1-3% are allergic to cobalt and chromium. Among dermatitis patients, the prevalence of metal allergy is even higher. Metal allergy is mainly an environmental disorder although null mutations in the filaggrin gene complex were recently found to be associated with nickel allergy and dermatitis. Environmental metal exposures include jewelry, buttons, clothing fasteners, dental restorations, mobile phones, and leather. Although consumer exposure is responsible for most cases of metal allergy, the importance of occupational metal exposure remains present and should always be taken into consideration when one interprets allergic patch test reactions to metals. Traditionally, nickel, cobalt, and chromium have been the most important contact allergens. However, recently, gold and palladium have drawn much attention as the prevalence of contact allergy to these metals is high. Palladium allergy is mainly a result of cross-sensitization to nickel, whereas gold allergy is rarely clinically relevant when one takes its high prevalence into account. The epidemiology of metal allergy has recently changed in Europe as nickel allergy among ear-pierced Danish women has decreased following regulatory intervention on nickel release from consumer products. In the United States, the prevalence of nickel allergy is still increasing, which may be explained by the absence of regulation. The prevalence of chromium allergy is increasing in the United States, Singapore, and Denmark among dermatitis patients. This increase is significantly associated with leather exposure in Denmark. Metal allergy may result in allergic contact dermatitis and systemic allergic (contact) dermatitis. Furthermore, metal allergy has been associated with device failure following insertion of intracoronary stents, hip and knee prostheses, as well as other implants. This area is in need of more research.

Hand dermatitis: a focus on allergic contact dermatitis to biocides

Hand dermatitis is a common disease of the skin resulting in significantly decreased quality of life. Allergic contact dermatitis is a frequent cause of hand dermatitis. Recent studies have revealed that biocides used as preservatives are frequent allergens affecting the hands. This article reviews common biocides implicated in hand dermatitis.

Skin tolerability associated with transdermal drug delivery systems: an overview

As transdermal patches become more widely prescribed, it is important that clinicians understand: (a) the common causes of skin reactions with these medications; (b) how to minimize these reactions; and (c) how to manage the signs and symptoms. Here we review published data for skin reactions with patch medications approved within the past decade. Overall, the most common application site signs and symptoms appear to be localized redness (erythema) or itching, sometimes accompanied by swelling (edema). Typically, these are mild to moderate in severity, transient in nature, and occur in 20% to 50% of patients. Most are localized to the area of application, and resolve spontaneously within several days following patch removal. Discontinuations due to these types of event are infrequent, ranging from 1.7% to 6.8% in the 6-month trials reviewed here. Based on expert opinion, the majority of these skin reactions would be a form of irritant contact dermatitis, with infrequent cases of allergic contact dermatitis. These types of reactions usually cause minimal pain or discomfort to the patient, and are unlikely to be of medical concern. Signs and symptoms of irritant contact dermatitis may be minimized by rotation of the application site, careful removal of the patch, and appropriate use of moisturizers and topical corticosteroids. In conclusion, the potential advantages of transdermal patches usually outweigh any additional skin issues; however, further research into treatment and management strategies 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.