Systemic hydrocortisone/cortisol induces allergic skin reactions in presensitized subjects

Etanercept treatment for pediatric toxic epidermal necrolysis induced by deflazacort: a case report and literature review

Toxic epidermal necrolysis (TEN) is a life-threatening mucocutaneous disorder commonly caused by drugs. TEN is often treated with corticosteroids, intravenous immunoglobulin (IVIG), or cyclosporine; however, the efficacy of these treatments is controversial. Etanercept (a TNF-α antagonist) was proven to decrease skin-healing time in a randomized clinical trial. Herein, we report the case of a 44-month-old boy who developed TEN due to deflazacort as the probable culprit drug and was successfully treated with etanercept. The patient presented to the emergency department complaining of erythematous maculopapular rashes and vesicles all over the face and body, with vesicles on the hands, feet, and trunk. Symptoms started 4 days before presentation, with edema of the upper lip, which progressed to erythematous macules over the body. He was started on deflazacort for nephrotic syndrome 21 days before the visit. Approximately 20% of the body surface area (BSA) was covered by vesicular lesions. Under the diagnosis of Steven Johnson syndrome/TEN, deflazacort was discontinued, and intravenous dexamethasone (1.5 mg/kg/day), a 5-day course of IVIG (0.4 mg/kg/day), and cyclosporine (3 mg/kg/day) were administered. The lesions seemed to be stationary for 3 days, but on the 6th day of hospitalization, when IVIG was discontinued, the vesicular lesions progressed to approximately 60% of the BSA. Etanercept 0.8 mg/kg was administered subcutaneously. Lesions stopped progressing, and bullous lesions started epithelialization. However, on the 15th day, around 30% of the BSA was still involved; thus, a second dose of etanercept was administered. No acute or sub-acute complications were observed. In conclusion, the use of etanercept in children with TEN that is not controlled with conventional therapy is both effective and safe.

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.

The Oxygen Saturation in the Retinal Vessels of Patients with Diabetes Mellitus - The Search for Determinants

INTRODUCTION

Oxygen saturation in retinal vessels can be non-invasively measured by a new method. It is known that oxygen extraction is lowered in diabetic retinopathy. In the cross-sectional study presented here, it has been investigated whether diabetes-specific changes and typical accompanying diseases could influence the measurements in oximetry.

METHODS

During a time span of seven months, 237 diabetics were included who came to our clinic for an intravitreal injection, who met the inclusion criteria, who showed no exclusion criteria and gave written consent. 203 eyes of 203 patients were evaluated. The oxygen saturation (SO₂) was measured in digitally stored fundus images taken with a fundus camera (Zeiss 450 FF). In its illumination beam, a filter was inserted with two transmission maxima at 584 nm and 610 nm (bandwidth 10 nm). With the program "Oximetry" (Imedos Systems, Jena, Germany), the venous and the arterial SO₂ were measured. The values were stored in a spreadsheet. Diabetes related data, clinical parameters and accompanying diseases were documented in the predefined scheme.

RESULTS

In the whole patient sample, the venous oxygen saturation (vSO₂) was 69 ± 12%, the arterial saturation (aSO₂) 99 ± 5% and the arteriovenous difference 31 ± 9%. A statistically significant association could not be found between the measurement values of oximetry and age, duration of diabetes and HbA_1c (Kruskal-Wallis ANOVA: p > 0.05). The differences in oximetry values between units of analysis (UOA) e.g. hypertension and non units of analysis (NOA) were analysed. Descriptive testing showed significant differences in vSO₂% in the following units of analysis: allergies n = 47: UOA vs. NUOA: 64 vs. 69 (t test: p < 0.02); sartan therapy n = 46: UOA vs. NUOA: 64 vs. 70 (p = 0.003); state after intravitreal injections n = 144: 68 vs. 71 (p = 0.02). Oxygen extraction from the retinal capillaries was improved in patients who had injections with VEGF inhibitors. An improvement in oxygen extraction is also seen in patients with allergies and hypertension in comparison to those without these units of analysis.

CONCLUSION

The clinically observed improvement in the retinal state situation after intravitreal injections with VEGF inhibitors may be seen in association with the improved oxygen extraction. It seems reasonable to study whether a switch to sartans in the therapy of hypertension may improve retinal function.

Eczematous Drug Eruptions

Eczematous drug eruptions are a heterogenous group of skin reactions that resemble eczema both clinically and histologically. We reviewed the literature and cataloged the systemically administered medications that cause these eruptions, along with their characteristic clinical presentations. We identified three primary pathophysiologic etiologies: (1) cutaneous immunomodulation, (2) skin dehydration, and (3) delayed hypersensitivity. Notably, eczematous eruptions caused by altered immunity in the skin may be increasing in incidence as some responsible drugs, in particular biologic therapies (such as tumor necrosis factor-α and interleukin-17 inhibitors) and targeted cancer treatments (including immune checkpoint inhibitors and epidermal growth factor receptor inhibitors), become more commonly employed in clinical practice. Other notable causes of eczematous eruptions include antiviral agents for hepatitis C virus and cardiovascular medications in elderly individuals, and notable subtypes of eczematous reactions include systemic contact dermatitis and photoallergic reactions, which are also discussed. The diagnostic gold standard is drug rechallenge and most reactions may be treated effectively with emollients, topical corticosteroids, and oral antihistamines.

S3 Guidelines: Epicutaneous patch testing with contact allergens and drugs - Short version, Part 2

Epicutaneous patch testing is the diagnostic standard for the detection of allergic contact dermatitis. The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology and allergology as well as other medical specialties involved in establishing the indication for patch testing and its execution in patients with contact dermatitis and other forms of delayed-type hypersensitivity. The target audience also includes other health care providers and insurance funds. Based on a systematic literature search and a formal consensus process (S3), the guidelines were developed by dermatologists in collaboration with pediatricians, occupational medicine physicians, nursing staff as well as patient representatives. The systematic methodological approach and appraisal of evidence upon which the recommendations are based are outlined in a separate method report that also contains evidence tables. The guidelines address general aspects of patch testing as well as medicolegal issues. The recommendations given relate to topics such as the indication for patch testing, informed patient consent, as well as the choice of test substances, test chambers and test site, duration of exposure, reading times and interpretation of test reactions. Furthermore, recommendations are provided with respect to endogenous and exogenous factors, specific patient groups (children, pregnant women, immunosuppressed individuals) as well as possible risks and adverse events associated with patch testing using contact allergens.

Systemic contact dermatitis to corticosteroids

BACKGROUND

Although unexpected and paradoxical, allergic hypersensitivity to corticosteroids is a common finding, delayed-type reactions being much more frequently encountered than the immediate-type ones. Although the skin is the main sensitization and elicitation route, other routes, amongst them systemic administration of corticosteroids may exceptionally be involved.

OBJECTIVE

To determine the frequency, clinical presentation and cross-reactivity patterns for allergic reactions following systemic administration of corticosteroids amongst patients with identified and investigated 'contact allergy' to corticosteroids.

METHODS

We reviewed clinical data, patch test results and sensitization sources in patients who reacted positively to corticosteroids tested in the K.U. Leuven Dermatology department during an 18-year period.

RESULTS

Sixteen subjects (out of 315 with CS delayed-type hypersensitivity) presented with allergic manifestations due to systemic administration of corticosteroids. Most patients reacted to molecules from the three groups of the recently reappraised classification.

CONCLUSION

The reactions observed seem to be in most cases 'systemic contact dermatitis' due to oral or parenteral re-exposure of sensitized individuals with the respective corticosteroids previously applied topically. Moreover, most patients seem to be able to react to any corticosteroid molecules and therefore need a systematic individualized evaluation of their sensitization/tolerance profile.

Hypersensitivity reactions to corticosteroids

PURPOSE OF REVIEW

To describe the clinical entities, underlying mechanisms and diagnostic approach of hypersensitivity reactions to corticosteroids, emphasizing new data concerning hypersensitivity reactions to systemically administered corticosteroids.

RECENT FINDINGS

Reactions after topical corticosteroid administration to the skin have been known for decades, appearing as an eczematous lesion and with diagnosis by patch testing. However, new data have appeared about cutaneous symptoms after inhaled and systemically administered corticosteroids. In fact, T-cell involvement in a generalized maculopapular exanthema induced by inhaled budesonide has recently been demonstrated by lymphocyte transformation tests. Moreover, T-cell involvement has also been shown in skin biopsies from a group of patients with urticaria and maculopapular exanthema after systemically administered corticosteroids, with detection of a significant increase in the expression of interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha), and a significant decrease in interleukin-4 and GATA-3 when samples obtained during the drug provocation test reaction were compared with samples from the resolution phase. In immediate allergic reactions to corticosteroids, an immunoglobulin E (IgE) response has recently been shown by skin testing, ImmunoCAP and basophil-activation tests.

SUMMARY

Generalized cutaneous symptoms after corticosteroid administration occur with both IgE and T-cell involvement. Skin testing, in-vitro testing and drug provocation tests are useful diagnostic tools.

Hypersensitivity to topical corticosteroids in otitis externa

Over a12-monthperiod, nine patients were seen in a contact dermatitis clinic with an inflammatory dermatosis localized predominantly to the external auditory canal. Of these patients, four were found to have an allergic contact dermatitis which was exacerbating their dermatitis. All were allergic to one or more corticosteroids and topical antibiotics used in the treatment of their dermatitis. We would suggest that hypersensitivity to topical corticosteroids and other medicaments be considered in patients with otitis externa which fails to respond to 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.

Chronic urticaria associated with intra-articular methylprednisolone

Reports of allergic reactions following treatment with systemic corticosteroids are rare, despite their widespread use. A 47-year-old man developed widespread urticaria, resistant to antihistamines, coinciding with injections of local anaesthetic and methylprednisolone for cervical spondylosis. He underwent immediate and delayed hypersensitivity tests. Intradermal tests showed immediate-type sensitivity to methylprednisolone and hydrocortisone. Patch tests were positive to 21 of 26 corticosteroids tested. A diagnosis of both an immediate and a delayed-type hypersensitivity to corticosteroids was made. With avoidance of all corticosteroids he has been free from urticarial rash for 9 months and has been able to stop all medication.

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.

Dermatitis following systemic prednisolone: patch testing with prednisolone eye drops

Although positive reactions to topical corticosteroids can occur in over 1% of a patch-test population, systemic reactions to oral corticosteroids are uncommon. A 45-year-old woman who gave a clear history of the generalization of a cutaneous eruption following oral prednisolone was positive on patch testing using prednisolone eye drops.

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.

Allergic contact dermatitis due to topical application of corticosteroids: review and clinical implications

Allergy due to topically applied corticosteroids is being recognized more frequently. Testing for hypersensitivity to these agents is performed with delayed hypersensitivity patch testing. Cross-reactivity among topically administered corticosteroids is frequent and often can be predicted on the basis of additional patch testing and an established classification scheme. Herein we review allergy due to topically applied corticosteroids with regard to its prevalence, means of testing, cross-reactivity among the subclasses, risk factors, and relationship to steroids.

What is new in clinical research in contact dermatitis

The field of cutaneous allergy has enjoyed dynamic research advances in epidemiology and clinical contact dermatitis. Studies regarding outcomes analysis, validity, predictive value, and sensitivity have allowed clinicians to better understand the importance of patch test results. In the clinical arena, new and clinically relevant allergens are being discovered, such as corticosteroids, metals, preservatives, surfactants, and glues. Continued epidemiologic surveillance of new allergens will enable manufacturers to develop safer products for patients to use.

Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis

BACKGROUND

Toxic epidermal necrolysis and Stevens-Johnson syndrome are rare, life-threatening, drug-induced cutaneous reactions. We conducted a case-control study to quantify the risks associated with the use of specific drugs.

METHODS

Data were obtained through surveillance networks in France, Germany, Italy, and Portugal. Drug use before the onset of disease was compared in 245 people who were hospitalized because of toxic epidermal necrolysis or Stevens-Johnson syndrome and 1147 patients hospitalized for other reasons (controls). Crude relative risks were calculated and adjusted for confounding by multivariate methods when numbers were large enough.

RESULTS

Among drugs usually used for short periods, the risks were increased for trimethoprim-sulfamethoxazole and other sulfonamide antibiotics (crude relative risk, 172; 95 percent confidence interval, 75 to 396), chlormezanone (crude relative risk, 62; 21 to 188), aminopenicillins (multivariate relative risk, 6.7; 2.5 to 18), quinolones (multivariate relative risk, 10; 2.6 to 38), and cephalosporins (multivariate relative risk, 14; 3.2 to 59). For acetaminophen, the multivariate relative risk was 0.6 (95 percent confidence interval, 0.2 to 1.3) in France but 9.3 (3.9 to 22) in the other countries. Among drugs usually used for months or years, the increased risk was confined largely to the first two months of treatment, when crude relative risks were as follows: carbamazepine, 90 (95 percent confidence interval, 19 to infinity); phenobarbital, 45 (19 to 108); phenytoin, 53 (11 to infinity); valproic acid, 25 (4.3 to infinity); oxicam nonsteroidal antiinflammatory drugs (NSAIDs), 72 (25 to 209); allopurinol, 52 (16 to 167); and corticosteroids, 54 (23 to 124). For many drugs, including thiazide diuretics and oral hypoglycemic agents, there was no significant increase in risk.

CONCLUSIONS

The use of antibacterial sulfonamides, anticonvulsant agents, oxicam NSAIDs, allopurinol, chlormezanone, and corticosteroids is associated with large increases in the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. But for none of the drugs does the excess risk exceed five cases per million users per week.

Cutaneous-mucosal allergic contact reaction due to topical corticosteroids

We report the case of a 41-year-old nonatopic women with a previous history of eczematous reaction due to hydrocortisone who suffered worsening of her perennial rhinitis in association with perinasal dermatitis from the use of budesonide in nasal spray form, and stomatitis and pharyngitis due to budesonide in a bronchial inhaler. Patch tests with a series of 25 corticosteroids, some of them at different concentrations and in different vehicles, were positive to tixocortol pivalate, hydrocortisone, budesonide, prednisolone, hydrocortisone butyrate propionate, triamcinolone acetonide, and fluocinolone acetonide. For some of them, a 1% solution in ethanol gave a positive reaction when a 20% mixture in petrolatum did not. Like other authors, we suggest that some multiple positives may represent sensitization to several steroids independently, true cross-reactions, or both, and that ethanol is a better vehicle than petrolatum.

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.

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.

Allergy to systemic and intralesional corticosteroids

In this study, allergic reactions to systemic or intralesional corticosteroids were characterized, and skin tests utilized in the diagnosis of corticosteroid allergy. Five patients who had developed a rash when treated with systemic or intralesional hydrocortisone, methylprednisolone, prednisolone or betamethasone, were challenged with oral or intra-articular corticosteroid preparations, and skin tested. Upon provocation the patients reacted with diffuse erythema principally on the trunk or on the face. The erythema appeared within a period ranging from a few hours to 24 h and faded in 1-3 days. On patch testing, one patient reacted to prednisolone and methylprednisolone, which induced a positive response upon provocation, and two patients were positive to Pivalone. Patients who were sensitive to hydrocortisone or methylprednisolone, as judged by anamnestic data and provocations, reacted to these corticosteroids in the intradermal tests. Allergy to betamethasone could not be verified by intradermal or patch tests. A combination of intradermal and patch tests is recommended when allergy to systemic or intralesional corticosteroids is suspected. If these skin tests remain negative, provocation is the method of choice.

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.

A prospective study into the value of patch and intradermal tests in identifying topical corticosteroid allergy

We have prospectively performed patch and intradermal tests on 105 consecutive patients, attending for patch testing, to determine the optimum method of screening for corticosteroid hypersensitivity. Patch tests with Pivalone and a corticosteroid series (all 1% in ethanol) detected all the patients with steroid sensitivity. However, intradermal tests were essential to exclude false positive reactions and detect all relevant steroid allergies in any individual patient.