Skin reactions to inhaled corticosteroids

Pharmacogenomic test that predicts response to inhaled corticosteroids in adults with asthma likely to be cost-saving

AIM

To identify the clinical and economic circumstances under which a pharmacogenomic test that predicts response to inhaled corticosteroids might be a cost-effective option for individuals with asthma.

MATERIALS & METHODS

We synthesized published data on clinical and economic outcomes to project 10-year costs, quality-adjusted life-years and cost-effectiveness of pharmacogenomic testing for inhaled corticosteroid response. We assumed the pharmacogenomic test cost was $500 with a sensitivity and specificity of 84 and 98%, respectively. These were varied in sensitivity analyses.

RESULTS

Both strategies, pharmacogenomic testing for inhaled corticosteroid response and no testing conferred 7.1 quality-adjusted life-years. Compared with no testing, pharmacogenomic testing costs less.

CONCLUSION

Pharmacogenomic testing for asthma is cost-saving and noninferior in improving health. Original submitted 19 November 2014; Revision submitted 23 February 2015.

Delayed hypersensitivity to corticosteroids in a series of 315 patients: clinical data and patch test results

BACKGROUND

Corticosteroids may cause immediate or delayed hypersensitivity. In 1989, based on structural and clinical characteristics, we put forward a classification of corticosteroids into four cross-reacting groups, namely group A, B, C, and D, the latter later subdivided into two subgroups, i.e. D1 and D2. The constituents on the D-ring of the corticosteroid-molecule are considered to have a central role for binding to skin proteins and for cross-reactions patterns; however, halogenation of the molecules is also interfering.

OBJECTIVE

To study the clinical data and analyse simultaneous positive reactions obtained in a large group of corticosteroid-allergic patients.

METHODS

Patch tests were performed with the baseline series, to which hydrocortisone butyrate and prednisolone caproate were added, as well as with the corticosteroids to which the patients had been exposed. Three hundred and forty subjects with a presumed or proven corticosteroid allergy were further investigated with an extended series containing 72 molecules.

RESULTS

Out of 11 596 patients investigated, 315 subjects reacted positively to at least 1 corticosteroid-molecule, with most of them presenting with multiple positive reactions.

CONCLUSION

A prevalence of corticosteroid allergy of 2.7% was found. Despite validity of the ABCD (sub)classification in many cases, possible adjustments may have to be considered.

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.

Delayed hypersensitivity reactions to corticosteroids

BACKGROUND

Corticosteroids (CS) are widely used in the treatment of asthma, allergic disorders and other immunological diseases due to their anti-inflammatory and immunosuppressive properties. Physicians seldom suspect them of causing allergic reactions. However, more and more cases of hypersensitivity reactions to CS have been described. Reports of delayed allergic reactions to CS in patients with asthma or allergic rhinitis are scarce.

MATERIAL AND METHODS

We report the case of a 44-year-old woman with a history of mild persistent asthma and intermittent allergic rhinitis, treated with inhaled beclomethasone and salbutamol, who developed a delayed mucocutaneous and respiratory reaction after substitution of beclomethasone with budesonide.

CONCLUSIONS

The interest of this case lies in the rarity of allergic reactions from inhaled CS in patients with asthma and/or rhinitis. These reactions therefore represent a diagnostic and therapeutic challenge.

Overview of the pharmacogenetics of asthma treatment

Asthma affects approximately 300 million individuals worldwide. Medications comprise a substantial portion of asthma expenditures. Despite the availability of three primary therapeutic classes of medications, there are a significant number of nonresponders to therapy. Available data, as well as previous pharmacogenetic studies, suggest that genetics may contribute as much as 60-80% to the interindividual variability in treatment response. In this methodologic review, after providing a broad overview of the asthma pharmacogenetics literature to date, we describe the application of a novel family-based screening algorithm to the analysis of pharmacogenetic data and highlight our approach to identifying and verifying loci influencing asthma treatment response. This approach seeks to address issues related to multiple comparisons, statistical power, population stratification, and failure to replicate from which previous population-based or case-control pharmacogenetic association studies may suffer. Identification of such replicable loci is the next step towards the goal of 'individualized therapy' for asthma.

Corticosteroid allergy in asthma

BACKGROUND

Glucocorticosteroids form the basis of therapy for asthma and other allergic diseases. However, they frequently cause delayed contact allergy and occasionally immediate allergy. The purpose of this study was to investigate the occurrence of corticosteroid allergy among patients with asthma and with some complaints caused by inhaled corticosteroids.

METHODS

Patch tests with corticosteroids were performed in 51 asthma patients with side-effects from inhalant corticosteroids and in 50 symptom-free asthma patients using the Finn Chamber system. The corticosteroids and their vehicles were: betamethasone-17-valerate 1% in petrolatum, hydrocortisone-17-butyrate (Hc-17-B) 1% in ethanol, tixocortol-21-pivalate 1% in petrolatum, budesonide 0.1% in petrolatum, beclomethasone dipropionate 0.1 and 0.5% in petrolatum and as inhalant powder 200 microg, and fluticasone propionate 0.1 and 0.5% in petrolatum and as inhalant powder 250 microg. The results were read twice, on D4-5 and again on D10.

RESULTS

Two patients in the symptomatic group reacted to corticosteroids in patch tests, one to betamethasone-17-valerate, Hc-17-B and budesonide, and the other to budesonide and Hc-17-B. The first patient suffered from widespread eczematous dermatitis when using beclomethasone. Fluticasone caused oropharyngeal irritation, hoarseness and shortness of breath. The second patient experienced a severe rash after the fourth budesonide inhalation. She had used various topical corticosteroids for her atopic dermatitis without any side-effects. None of the symptom-free patients showed positive results.

CONCLUSIONS

Delayed allergy to corticosteroids occurs occasionally in asthma, perhaps in the same frequency as in dermatitis. A positive patch test reaction usually means clinical allergy, i.e. the patient cannot use that particular steroid. Cross allergy between corticosteroids is common. However, such patients usually tolerate some other common corticosteroids.

Adverse skin reactions to inhaled corticosteroids

Inhaled corticosteroids are considered to be the therapy of choice in the treatment of asthma and allergic rhinitis. However, various cutaneous adverse reactions have been described and are probably present in approximately half of patients. Some of these reactions are related to the daily dosage of steroids or the duration of treatment, for example: thinning of the skin, easy bruising, acne or peri-oral dermatitis, mucocutaneous infection and, especially, candidiasis. Other cutaneous side effects are independent of the dose, such as allergic reactions and a few other rare side effects. Adverse effects could be prevented by monitoring the daily dosage and the family history of the patients, and by following advice provided on the use of inhaled corticosteroids. Specific treatments for infection, acne or allergy can cure these side effects. However, cutaneous side effects can become unpleasant for the patient and temporarily withdrawing therapy has proven to be extremely effective.