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Martínez ES, Duschner N, Schaller J. A cyclic dermatosis. J Dtsch Dermatol Ges 2024. [PMID: 39092665 DOI: 10.1111/ddg.15485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 08/04/2024]
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2
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Gupta A, Saini K, Timshina D. Chronic Stevens-Johnson Syndrome Heralding a Fascinating Etiology. Dermatitis 2024. [PMID: 38985735 DOI: 10.1089/derm.2024.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Affiliation(s)
- Ankan Gupta
- Department of Dermatology, Venereology & Leprology, Christian Medical College and Hospital, Vellore, India
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3
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Ghafari-Saravi A, Greiling TM. Recurrent bullous erythema multiforme due to oral contraceptive therapy. Int J Womens Dermatol 2024; 10:e142. [PMID: 38572265 PMCID: PMC10986911 DOI: 10.1097/jw9.0000000000000142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/01/2024] [Indexed: 04/05/2024] Open
Affiliation(s)
| | - Teri M. Greiling
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
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4
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Sober S, Bradford R, Henrie B, Pradeau S, Guillard H, Laurora I, Glasier A. Evaluation of consumer self-selection of a proposed over-the-counter, progestin-only daily oral contraceptive. Contraception 2024; 133:110401. [PMID: 38431260 DOI: 10.1016/j.contraception.2024.110401] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES In an effort to switch a norgestrel 0.075 mg progestin-only pill (Opill) from prescription to over-the-counter, we conducted this study to assess whether consumers can use the drug facts label alone to guide appropriate self-selection. STUDY DESIGN Two studies assessed self-selection: (1) an all-comers, actual-use study evaluating self-selection before purchasing and using norgestrel 0.075 mg and (2) the Targeted Breast Cancer Self-Selection Study evaluating theoretical self-selection among participants with a history of breast cancer. RESULTS In the actual-use study, based on the label, 1670/1772 participants (94%) were appropriate for use of norgestrel 0.075 mg; 102 (6%) were not appropriate. Of the 102, 66 (65%) correctly did not select and 36 (35%) responded it was okay for them to use norgestrel 0.075 mg. Of the 36 participants who incorrectly self-selected, one had a history of breast cancer and thus might have been adversely affected had they taken norgestrel 0.075 mg. In the Targeted Breast Cancer Self-Selection Study (N = 206), 97% of participants correctly stated norgestrel 0.075 mg was not appropriate for them. CONCLUSIONS The proposed over-the-counter label enables 98% of potential users to self-select norgestrel 0.075 mg appropriately. Only 2% of potential purchasers may have bought and started to use norgestrel 0.075 mg inappropriately. For two-thirds of these, the potential benefits of their use of the method outweighed any theoretical risks. Adverse clinical consequences of norgestrel 0.075 mg use are unlikely even in those rare cases when the drug facts label was not followed. IMPLICATIONS The balance of the risk of inappropriate selection to the benefit of taking an over-the-counter progestin-only pill appears to be very much in favor of an overall benefit in terms of unintended pregnancy prevention.
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Affiliation(s)
- Stephanie Sober
- HRA Pharma, A Perrigo Company, Global Women's Health, Châtillon, France.
| | | | | | - Sabrina Pradeau
- HRA Pharma, A Perrigo Company, Global Women's Health, Châtillon, France
| | - Hélène Guillard
- HRA Pharma, A Perrigo Company, Global Women's Health, Châtillon, France
| | - Irene Laurora
- HRA Pharma, A Perrigo Company, Global Women's Health, Châtillon, France
| | - Anna Glasier
- Department of Obstetrics and Gynaecology, University of Edinburgh, Queen's Medical Research Institute, Scotland
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5
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Alonso Bello CD, González Guzmán OP, Moncayo Coello CV, Rojo Gutiérrez MI, Castrejón Vázquez MI. Diagnostic tests for progestogen hypersensitivity. FRONTIERS IN ALLERGY 2024; 5:1384140. [PMID: 38720769 PMCID: PMC11076683 DOI: 10.3389/falgy.2024.1384140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024] Open
Abstract
Progesterone is an endogenous hormone, produced by the adrenal cortex, the gonads and in women, its source is the corpus luteum. Progesterone is produced in the late phase of the menstrual cycle, when implantation of the zygote does not occur, the corpus luteum involutes and the release of progesterone is suppressed, thus initiating menstruation. Progestogen Hypersensitivity were initially identified as hormone allergy and were related to endogenous reactions to hormones and alteration of ovarian function. Skin manifestations such as dermatitis or urticaria were initially reported and described as progesterone autoimmune dermatitis, although the immune-mediated mechanism was not clear. Currently there is no standardization for in vivo or in vitro tests for Progestogen Hypersensitivity diagnosis. In this review, we will address the different diagnostic methods of this disease.
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Affiliation(s)
| | - Otto Pavel González Guzmán
- Spine Rehabilitation Service and Osteoporosis Clinic, Instituto Nacional de Rehabilitación, Mexico City, Mexico
| | | | | | - María Isabel Castrejón Vázquez
- Clinical Immunology and Allergy Service, Centro Médico Nacional 20 de Noviembre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
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6
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Sandru F, Dumitrascu MC, Petca A, Petca RC, Roman AM. Progesterone Hypersensitivity in Assisted Reproductive Technologies: Implications for Safety and Efficacy. J Pers Med 2024; 14:79. [PMID: 38248780 PMCID: PMC10817690 DOI: 10.3390/jpm14010079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
The global rise in the age of childbirth, influenced by changing sociodemographic patterns, has had a notable impact on fertility rates. Simultaneously, assisted reproductive techniques (ARTs) have become increasingly prevalent due to advancements in reproductive medicine. The paper explores the intersection between the surge in ARTs and the rising number of iatrogenic autoimmune progesterone dermatitis (APD). Autoimmune progesterone dermatitis, commonly known as progesterone hypersensitivity, manifests itself as a mucocutaneous hypersensitivity syndrome. It is characterized by a wide range of dermatological symptoms, with urticaria and maculopapular rashes being the most prominent signs. Concurrently, systemic symptoms, such as fever, angioedema, and, in severe instances, anaphylaxis, may ensue. This dermatologic condition poses a significant challenge to women of childbearing age. This intricate syndrome frequently manifests itself in conjunction with menstruation or pregnancy as a reaction to physiological fluctuations in endogenous progesterone. However, given that exposure to exogenous progesterone is an integral component of various modern therapies, secondary APD has also been described. Our findings unveil a heightened likelihood of developing secondary progesterone hypersensitivity in ART patients that is attributed to the administration of exogenous progesterone through intramuscular, intravaginal, and oral routes. The study also explores available therapeutic interventions for facilitating viable pregnancies in individuals grappling with autoimmune progesterone dermatitis within the context of ARTs. This comprehensive analysis contributes valuable insights into the intricate relationship between reproductive technologies, dermatological challenges, and successful pregnancy outcomes.
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Affiliation(s)
- Florica Sandru
- Department of Dermatovenerology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Dermatology Department, “Elias” University Emergency Hospital, 011461 Bucharest, Romania;
| | - Mihai Cristian Dumitrascu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Obstetrics and Gynecology, University Emergency Hospital of Bucharest, 050098 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Obstetrics and Gynecology, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Razvan-Cosmin Petca
- Department of Urology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Urology, “Prof. Dr. Th. Burghele” Clinical Hospital, 050659 Bucharest, Romania
| | - Alexandra-Maria Roman
- Dermatology Department, “Elias” University Emergency Hospital, 011461 Bucharest, Romania;
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7
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Chiarella SE, Buchheit KM, Foer D. Progestogen Hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3606-3613.e2. [PMID: 37579875 PMCID: PMC10841326 DOI: 10.1016/j.jaip.2023.07.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/16/2023]
Abstract
Progestogen hypersensitivity (PH) is a heterogeneous disease characterized by diverse cutaneous manifestations, bronchospasm, and/or anaphylaxis. Possible triggers include ovarian progesterone and exogenous progestogens. The timing of symptoms is critical to diagnose PH: during the luteal phase of the menstrual cycle for the endogenous form and after exposure to progestins for exogenous PH. Diagnostic modalities such as progesterone skin testing have low sensitivity and specificity for PH. When exogenous PH is suspected, the allergist should consider a progestogen challenge. Treatment strategies should be tailored for each patient, including symptom-directed therapies, ovulation suppression, and progesterone desensitization. Future studies should explore the mechanisms of PH, validation of diagnostic criteria, and standardization of treatment strategies.
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Affiliation(s)
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
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8
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Brás-Cruz R, David F, Morais Ferreira R, Rosário C. Progesterone hypersensitivity: a cyclical history. BMJ Case Rep 2023; 16:e256353. [PMID: 37996147 PMCID: PMC10668137 DOI: 10.1136/bcr-2023-256353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
Hypersensitivity reaction to progesterone is rare, with less than 200 cases reported. It occurs mainly in women in their third decade of life and can have a heterogeneous presentation (cutaneous and/or systemic), with temporal relation to serum levels of progesterone. Diagnosis is based on history and physical examination, supported by skin tests. We describe the case of a woman in her late 20s with pruritic erythema on the chest that manifested in the luteal phase of the menstrual cycle, with spontaneous resolution in less than 5 days, without secondary scarring. The histological diagnosis was non-specific, with evidence of interface dermatitis, but positive skin tests supported the diagnosis of autoimmune progesterone dermatitis. It is intended to alert to the manifestations of a pathology that is rare and difficult to diagnose but with a great impact on daily life.
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Affiliation(s)
- Rute Brás-Cruz
- Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Filipa David
- Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
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9
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Dhaliwal G, Batra J, Ankireddypalli AR, Gorle S, Kanugula AK, Kaur J. Progesterone Hypersensitivity Induced by Exogenous Progesterone Exposure. Cureus 2023; 15:e44776. [PMID: 37680259 PMCID: PMC10481886 DOI: 10.7759/cureus.44776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/09/2023] Open
Abstract
Progesterone hypersensitivity (PH) is a rare hypersensitivity reaction to either endogenous or exogenous progesterone. There are around 200 reported cases of progesterone hypersensitivity in the medical literature. We present the case of a 31-year-old female who presented with cyclical urticaria and angioedema after exogenous progesterone exposure. Her symptoms would begin a few days before her menstrual cycle began and resolve after menstruation. She only had partial recovery of her symptoms with antihistamines, steroids, montelukast, and omalizumab. She needed treatment with oral contraceptives and had a resolution of symptoms, but subsequently developed a recurrence again. Given the rarity of this condition, the diagnosis is often delayed. This diagnosis should be considered for women of reproductive age who present with cyclic hypersensitivity or allergic symptoms.
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Affiliation(s)
| | - Jaskaran Batra
- Internal Medicine, University of Pittsburgh Medical Center (UPMC), McKeesport, USA
| | | | - Swathi Gorle
- Internal Medicine, Wellstar Spalding Regional Medical Center, Griffin, USA
| | | | - Jasleen Kaur
- Endocrinology, Diabetes and Metabolism, HealthPartners, Minneapolis, USA
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10
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Patel DH, Fine LM, Bernstein JA. A focused report on progestogen hypersensitivity. Expert Rev Clin Immunol 2023; 19:357-363. [PMID: 36800518 DOI: 10.1080/1744666x.2023.2182292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Progestogen Hypersensitivity (PH) is caused by increased sensitivity to either exogenous or endogenous progestogens. It is characterized by recurrent cutaneous eruptions including erythema multiforme, eczema, urticaria, and angioedema, which may be associated with systemic symptoms including asthma and anaphylaxis. AREAS COVERED Symptoms may be persistent or cyclical, coinciding with progestogen levels. With increased use of oral contraceptives and hormonal treatments for fertility, the prevalence of PH is expected to continuously increase. Several proposed immunological mechanisms, diagnostics, and treatment modalities have been proposed. Most treatments focus on suppressing ovulation and progesterone secretion or inducing tolerance through progesterone desensitization. EXPERT OPINION Although there has been increased recognition both clinically and in the medical literature, there is still a general lack of knowledge of PH and its clinical features in the medical community. An improved understanding of the underlying pathophysiology as well as more available commercial testis, such as ELISA that accurately measures specific IgE to progesterone, are expected to broaden and improve opportunities for disease recognition and symptom control. It is essential for physicians across specialties to recognize how to diagnose PH and either manage this condition or refer these patients to a specialist with experience treating PH.
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Affiliation(s)
- Diti H Patel
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Lauren M Fine
- Department of Medical Education, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Jonathan A Bernstein
- Department of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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11
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Ji HH, Tan C. Cyclic Targetoid Rash With Menstruation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2742-2743. [PMID: 35970708 DOI: 10.1016/j.jaip.2022.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Hui-Hui Ji
- Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Dermatology, Nanjing Hospital of Chinese Medicine, Nanjing, China
| | - Cheng Tan
- Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.
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12
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Huang Y, Ye S, Bao X, Yang R, Huang J. Whole course of treatment of autoimmune progesterone dermatitis that had spontaneously resolved during pregnancy: A case report and review of the literature. Front Immunol 2022; 13:939083. [PMID: 36159858 PMCID: PMC9490548 DOI: 10.3389/fimmu.2022.939083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/04/2022] [Indexed: 11/22/2022] Open
Abstract
Anaphylaxis due to autoimmune progesterone dermatitis is a rare but severe allergic disease in women. The clinical manifestations of APD are diverse, and a proper understanding of the disease can help even diagnose and treat it. A case of autoimmune progesterone dermatitis related in our department is reported as follows. She developed a rash with severe pruritus that was highly consistent with her menstrual cycle without any trigger 10 years ago. Laboratory tests were unremarkable. But all the symptoms disappeared during her pregnancy and resurfaced after the miscarriage. Two years ago, after a positive progesterone intradermal test confirmed the diagnosis of PH, she was given mifepristone, contraceptives(OCPs), and skin embedding treatment, and her symptoms improved.
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Affiliation(s)
- Yepei Huang
- Fourth Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Sha Ye
- Fourth Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoyan Bao
- Fourth Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Ru Yang
- The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou, China
| | - Jian Huang
- Hangzhou Women’s Hospital, Hangzhou, China
- *Correspondence: Jian Huang,
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13
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Endogenous Progesterone Dermatitis: Successful Suppression and Desensitization. Ann Allergy Asthma Immunol 2022; 129:671-673. [PMID: 36084865 DOI: 10.1016/j.anai.2022.08.994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 11/20/2022]
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Amin M, Liao CD, Simpson RL. Toxic epidermal necrolysis caused by etonogestrel implantation: A rare presentation. JAAD Case Rep 2022; 26:6-8. [PMID: 35815235 PMCID: PMC9256836 DOI: 10.1016/j.jdcr.2022.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Minorvi Amin
- New York Institute of Technology, College of Osteopathic Medicine, Glen Head, New York
| | - Christopher D Liao
- Division of Plastic and Reconstructive Surgery, Nassau University Medical Center, East Meadow, New York
| | - Roger L Simpson
- Division of Plastic and Reconstructive Surgery, Nassau University Medical Center, East Meadow, New York
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15
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Harnett C, Drumm C, Meah N, Eustace K. Athena Speciality Certificate Examination Case for cyclical angioedema in a young female. Clin Exp Dermatol 2022; 47:1603-1604. [PMID: 35404512 DOI: 10.1111/ced.15195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/07/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Clare Harnett
- Department of Dermatology, St. Helen's and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Claire Drumm
- Department of Dermatology, Connolly Hospital, Dublin, Ireland
| | - Nekma Meah
- Department of Dermatology, St. Helen's and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Karen Eustace
- Department of Dermatology, St. Helen's and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
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16
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Irshad S, Haider MS, Master MF, Asif N, Khalil A. Autoimmune Progesterone Dermatitis. Cureus 2021; 13:e19217. [PMID: 34877200 PMCID: PMC8642151 DOI: 10.7759/cureus.19217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/17/2022] Open
Abstract
The condition autoimmune progesterone dermatitis (APD) is an immune disorder, observed among women, primarily due to progesterone surge during menstrual cycle. Here, we present a case of a 29-year-old female with recurrent severe skin eruptions associated with her menstrual cycle that commenced a few years ago. She presented with blistered skin lesion of the body and also blisters in oropharyngeal mucosa leading to a variety of symptoms ranging from pruritus to difficulty in swallowing. Recognition of this process is important as it can result in significant debility among women. Our patient was treated with steroids and antihistamines to provide symptomatic relief and was encouraged to resume her oral contraceptive pill, which is a more definitive therapy.
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Affiliation(s)
- Shahmeen Irshad
- Internal Medicine, Richmond University Medical Center, New York, USA
| | - Muhammad S Haider
- Internal Medicine, Richmond University Medical Center, New York, USA
| | - Madiha F Master
- Medicine, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | - Nasir Asif
- Medicine, Rutgers University, Newark, USA
| | - Ambreen Khalil
- Internal Medicine, Richmond University Medical Center, New York, USA
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Chen TL, Yip HT, Wang JH, Chang CH, Huang C, Hsu CY, Chang CH. Risk of chronic spontaneous urticaria in reproductive-aged women with abnormal uterine bleeding: A population-based cohort study. J Dermatol 2021; 48:1754-1762. [PMID: 34462945 DOI: 10.1111/1346-8138.16109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/20/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022]
Abstract
Women with abnormal uterine bleeding (AUB) have been reported to develop chronic spontaneous urticaria (CSU). Nevertheless, whether or not AUB women have an increased risk of CSU has not been examined in large-scale epidemiologic studies. This study aimed to investigate the risk of CSU among reproductive-aged women with AUB. A total of 79 595 patients and 79 107 propensity-score matched controls were recruited from Taiwan's National Health Insurance Research Database to conduct a nationwide cohort study. The Cox proportional-hazard regression model was applied to examine the adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for CSU in relation to AUB. We found that women with AUB had a higher risk for CSU (aHR = 1.83; 95% CI, 1.76-1.90) than women without AUB. Subgroup analyses revealed that AUB with an abnormal bleeding frequency (aHR = 1.70; 95% CI, 1.60-1.79), irregular bleeding (aHR = 1.80; 95% CI, 1.71-1.89), and intermenstrual bleeding (aHR = 1.65; 95% CI, 1.49-1.83) were associated with an increased risk of CSU compared with those without abnormalities. The Kaplan-Meier analysis revealed that the cumulative incidence of developing CSU was consistently higher in the AUB cohort than in the non-AUB cohort during the entire follow-up period (log-rank test, p < 0.001). In conclusion, reproductive-aged women with AUB were found to have a higher risk of developing CSU. This study emphasizes the importance of enquiring CSU patients about menstrual problems in clinical practice. Further consultation with obstetrician-gynecologists may be beneficial.
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Affiliation(s)
- Tai-Li Chen
- Department of Medical Education, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Hei-Tung Yip
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Chi-Han Chang
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Ci Huang
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Chung-Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Chung-Hsing Chang
- Department of Dermatology, Skin Institute, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan.,Doctoral Degree Program in Translational Medicine, Tzu Chi University and Academia Sinica, College of Medicine, Tzu Chi University, Hualien, Taiwan
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Abstract
ABSTRACT Autoimmune progesterone dermatitis (AIPD) is a cyclical, cutaneous reaction to endogenous progesterone that occurs throughout the menstrual cycle. The cutaneous manifestations of AIPD vary greatly from patient to patient, ranging anywhere from urticaria to erythema multiforme to anaphylaxis. As such, recognition, diagnosis, and management of this condition are difficult for clinicians. In the present article, we conducted a systematic review of 112 articles and 132 individual cases to summarize the clinical features and presentation of AIPD while also summarizing the successes and failures of different treatment plans. Despite the great variety in clinical presentations, it is clear from the data that ovulation-suppressing medical therapies and surgery have the greatest success in treating AIPD, whereas more commonly used therapies such as antihistamines and systemic corticosteroids frequently fail in providing any relief. Further research is necessary to determine the exact pathogenesis of AIPD and allow for more targeted treatment.
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Nguyen SMT, Rupprecht CP, Haque A, Pattanaik D, Yusin J, Krishnaswamy G. Mechanisms Governing Anaphylaxis: Inflammatory Cells, Mediators, Endothelial Gap Junctions and Beyond. Int J Mol Sci 2021; 22:ijms22157785. [PMID: 34360549 PMCID: PMC8346007 DOI: 10.3390/ijms22157785] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is a severe, acute, life-threatening multisystem allergic reaction resulting from the release of a plethora of mediators from mast cells culminating in serious respiratory, cardiovascular and mucocutaneous manifestations that can be fatal. Medications, foods, latex, exercise, hormones (progesterone), and clonal mast cell disorders may be responsible. More recently, novel syndromes such as delayed reactions to red meat and hereditary alpha tryptasemia have been described. Anaphylaxis manifests as sudden onset urticaria, pruritus, flushing, erythema, angioedema (lips, tongue, airways, periphery), myocardial dysfunction (hypovolemia, distributive or mixed shock and arrhythmias), rhinitis, wheezing and stridor. Vomiting, diarrhea, scrotal edema, uterine cramps, vaginal bleeding, urinary incontinence, dizziness, seizures, confusion, and syncope may occur. The traditional (or classical) pathway is mediated via T cells, Th2 cytokines (such as IL-4 and 5), B cell production of IgE and subsequent crosslinking of the high affinity IgE receptor (FcεRI) on mast cells and basophils by IgE-antigen complexes, culminating in mast cell and basophil degranulation. Degranulation results in the release of preformed mediators (histamine, heparin, tryptase, chymase, carboxypeptidase, cathepsin G and tumor necrosis factor alpha (TNF-α), and of de novo synthesized ones such as lipid mediators (cysteinyl leukotrienes), platelet activating factor (PAF), cytokines and growth factors such as vascular endothelial growth factor (VEGF). Of these, histamine, tryptase, cathepsin G, TNF-α, LTC4, PAF and VEGF can increase vascular permeability. Recent data suggest that mast cell-derived histamine and PAF can activate nitric oxide production from endothelium and set into motion a signaling cascade that leads to dilatation of blood vessels and dysfunction of the endothelial barrier. The latter, characterized by the opening of adherens junctions, leads to increased capillary permeability and fluid extravasation. These changes contribute to airway edema, hypovolemia, and distributive shock, with potentially fatal consequences. In this review, besides mechanisms (endotypes) underlying IgE-mediated anaphylaxis, we also provide a brief overview of IgG-, complement-, contact system-, cytokine- and mast cell-mediated reactions that can result in phenotypes resembling IgE-mediated anaphylaxis. Such classifications can lead the way to precision medicine approaches to the management of this complex disease.
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Affiliation(s)
| | | | - Aaisha Haque
- The Bill Hefner VA Medical Center, Salisbury, NC 27106, USA;
| | - Debendra Pattanaik
- Division of Allergy and Immunology, UT Memphis College of Medicine, Memphis, TN 38103, USA;
| | - Joseph Yusin
- The Division of Allergy and Immunology, Greater Los Angeles VA Medical Center, Los Angeles, CA 90011, USA;
| | - Guha Krishnaswamy
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27106, USA;
- The Bill Hefner VA Medical Center, Salisbury, NC 27106, USA;
- Correspondence:
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20
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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21
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Geros H, Maor D, Higgins C, Bala HR, Nixon R. Intradermal testing for autoimmune progesterone dermatitis: should we be basing the diagnosis on it? Clin Exp Dermatol 2021; 46:906-909. [PMID: 33811662 DOI: 10.1111/ced.14664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 11/28/2022]
Abstract
Autoimmune progesterone dermatitis (APD) is a rare skin disorder with varying presentations, resulting from hypersensitivity to endogenous progesterone during the luteal phase of the menstrual cycle. The diagnosis has been traditionally confirmed with intradermal progesterone testing (IPT) or intramuscular challenge with progesterone or its derivatives. We present a case of a 31-year-old woman with suspected APD who underwent IPT to progesterone. The patient's cyclical symptoms, positive skin reaction and symptoms following IPT were sufficient to make a diagnosis of APD. However, we also tested 10 healthy female controls without symptoms of APD, and found that 9 of these also developed positive skin reactions to intradermal progesterone at 15 min, 24 and 48 h, albeit to a lesser extent. Therefore, these results raise doubts about the validity of using IPT to make a diagnosis of APD. Further research on appropriate testing is needed.
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Affiliation(s)
- H Geros
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - D Maor
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - C Higgins
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - H R Bala
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
| | - R Nixon
- Occupational Dermatology Research and Education Centre, Melbourne, Vic., Australia
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22
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Hormonal Effects on Urticaria and Angioedema Conditions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2209-2219. [PMID: 33895364 DOI: 10.1016/j.jaip.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/02/2021] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
Women appear to be more frequently affected with urticaria and angioedema. Sex hormones are believed to have an important mechanistic role in regulating pathways involved in these conditions. This effect is likely nonspecific for chronic spontaneous urticaria (CSU) or many forms of angioedema (AE), because many other chronic diseases such as asthma are also affected by sex hormones. The role of sex hormones has been better elucidated for hereditary AE, because they have been shown to have multiple effects including upregulation of FXII, an important activator of the kallikrein pathway. However, their role in the underlying pathogenesis for CSU is less clear. Autoimmunity is clearly linked to CSU, which is more common in women. This suggests that sex hormones could act as adjuvants in activating or upregulating autoimmune pathways. The purpose of this review is to discuss in detail the role of sex hormones in CSU and AE and how a better understanding of the impact hormones has on these conditions might lead to new treatment advancements with better clinical outcomes.
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23
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Georgopoulou A, Papadopoulou E, Moyseos M, Zagalioti SC, Hatzis C, Karanasios D, Tryfon S. Diffuse Alveolar Hemorrhage after Receiving Oral Levonorgerstrel for Emergency Contraception: A Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 14:11795476211005821. [PMID: 34211306 PMCID: PMC8218619 DOI: 10.1177/11795476211005821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/09/2021] [Indexed: 01/22/2023]
Abstract
Introduction: Drug-induced diffuse alveolar hemorrhage (DAH) has been associated with the
administration of various medications, among which levonorgestrel (LN) has
not been reported until now. Case Presentation: This case study describes a 42-year-old woman who presented with hemoptysis,
hypoxemia, and radiological depiction of ground glass opacities, 3 days
after she had received emergency contraceptive medication containing
levonorgestrel. Emergent bronchoscopy was performed, and BAL was diagnostic
of diffuse alveolar hemorrhage (DAH). A thorough diagnostic approach was
followed, in order to detect the underlying pathological condition that
induced DAH. The absence of other identifiable pathological conditions in
this patient raised suspicion of LN’s potential causative role. Conclusion: DAH has not been reported as an adverse effect of LN until now. However, LN
has been found to exert immunomodulatory effects and to present potential
for manifestations of vasculitis as well as severe hypersensitivity
reactions. These mechanisms may have been implicated in the development of
DAH in our patient, who presented no other pathological conditions.
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Affiliation(s)
- Athina Georgopoulou
- Pulmonary Department of NHS, General Hospital "George Papanikolaou," Thessaloniki, Greece
| | - Efthymia Papadopoulou
- Pulmonary Department of NHS, General Hospital "George Papanikolaou," Thessaloniki, Greece
| | - Marianna Moyseos
- Pulmonary Department of NHS, General Hospital "George Papanikolaou," Thessaloniki, Greece
| | | | | | | | - Stavros Tryfon
- Pulmonary Department of NHS, General Hospital "George Papanikolaou," Thessaloniki, Greece
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24
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Klangsin S, Suwanrath C, Wattanakumtornkul S. A case report of eosinophilia associated with an etonogestrel implant. Contraception 2021; 104:442-443. [PMID: 33753062 DOI: 10.1016/j.contraception.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Abstract
Progestogen hypersensitivity is a rare adverse effect of endogenous and exogenous progestogens. Etonogestrel implant is very effective for contraception; however, a few progestogen hypersensitivity cases have been reported. Here, we present a case of delayed-type progestogen hypersensitivity with marked eosinophilia against etonogestrel that resolved after implant removal.
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Affiliation(s)
- Satit Klangsin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Saranya Wattanakumtornkul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
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25
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Aghazadeh N, Chattha AJ, Hartz MF, Davis DMR. Autoimmune progesterone dermatitis in the adolescent population. Pediatr Dermatol 2021; 38:380-384. [PMID: 33368681 DOI: 10.1111/pde.14423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/21/2020] [Accepted: 09/26/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE Autoimmune progesterone dermatitis (APD) is a rare autoimmune hypersensitivity reaction that occurs cyclically at the peak of endogenous progesterone production during the menstrual cycle in women. No study characterizing APD in the adolescent population is found; it appears likely to be underdiagnosed and undertreated. METHODS A retrospective, single-center, review of all adolescent and pediatric patients (<20 years old at onset) with documented diagnosis of APD. RESULTS Seventeen adolescent APD patients were included (mean age at diagnosis: 14.4 ± 2 years, mean interval of 13.6 ± 11.1 months between symptom onset and diagnosis). Twelve patients presented with urticaria, two with fixed drug eruption. Erythema multiforme, eczema, and recurrent aphthous stomatitis were present in one patient each. Exposure to exogenous progestin was present in two patients prior to disease onset. Progesterone skin test was performed in six patients with positive results in two. Fourteen patients received antihistamines and/or a topical corticosteroid. Combined oral contraceptives (COCs) were given to eleven patients, in seven via continuous daily dosing. Gonadotropin-releasing hormone agonist (GnRHa) was used in five, progesterone desensitization in four, omalizumab in two, and danazol in one patient. CONCLUSIONS Adolescent APD is associated with a significant delay in diagnosis. The most common manifestation is urticaria. Exogenous exposure to progestins is uncommon in adolescent APD. Continuous COC, GnRHa, and progesterone desensitization have been used to control symptoms. Large, multicenter studies are required to better define, diagnose, and treat this under recognized condition among adolescent patients.
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Affiliation(s)
| | - Asma J Chattha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Martha F Hartz
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dawn Marie R Davis
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA.,Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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26
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Al-Amad SH. Ulcerative Stomatitis as the Sole Manifestation of Progesterone Hypersensitivity. Oman Med J 2020; 35:e202-e2020. [PMID: 33274071 PMCID: PMC7700113 DOI: 10.5001/omj.2020.96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 02/01/2020] [Indexed: 11/03/2022] Open
Abstract
Oral mucosal involvement of autoimmune progesterone dermatitis is exceedingly rare. This report presents a woman with very painful ulcerative stomatitis that recurred with every menstrual period, in the absence of other clinical manifestations. Ulcers were eventually controlled with oral tamoxifen treatment for three months. Subsequent follow-up visits showed complete resolution of her oral ulcerative lesions. The non-specific nature of her oral ulcers resulted in multiple medical and dental consultations and a delay in reaching the final diagnosis. Clinicians should be aware of the possibility of progesterone hypersensitivity when painful oral ulcerative lesions appear concurrently with each progesterone surge.
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Affiliation(s)
- Suhail H Al-Amad
- College of Dental Medicine University of Sharjah Consultant Oral Medicine, University Hospital Sharjah, Sharjah, UAE
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27
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A Systematic Review and Meta-analysis of the Adverse Effects of Levonorgestrel Emergency Oral Contraceptive. Clin Drug Investig 2020; 40:395-420. [PMID: 32162237 DOI: 10.1007/s40261-020-00901-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The levonorgestrel oral emergency contraceptive is well tolerated and effective, however its use is still limited, mainly due to safety concerns. OBJECTIVE This systematic review and meta-analysis aimed to summarize current evidence regarding the adverse events, and their prevalence, reported during the use of oral levonorgestrel emergency contraceptives. METHODS Four electronic databases and the US FDA Adverse Event Reporting System (FAERS) Public Dashboard were searched. Studies that reported or investigated safety outcomes or adverse reactions during the use of levonorgestrel as an emergency oral contraceptive were included. Data on study design, demographics of levonorgestrel and the control cohort, and reported adverse effects were extracted. RESULTS A total of 47 articles were included in this systematic review, from which it was shown that most of the adverse reactions were common and not serious. Uncommon adverse reactions identified included anorexia, ectopic pregnancy, exanthema, chloasma, miscarriage, and weight gain. Multiple serious adverse events, including convulsion, ectopic pregnancy, febrile neutropenia, stroke, abdominal hernia, anaphylaxis, cancer, ovarian cyst rupture, serious infections, and suicidal ideation, were reported. In addition, the prevalence of adverse events after a levonorgestrel 0.75 mg two-dose regimen and a levonorgestrel 1.5 mg single-dose regimen were not statistically different (p > 0.05). CONCLUSIONS The most common adverse effects of levonorgestrel were not serious. This systematic review shows that data regarding the adverse reactions of repeated use of levonorgestrel are scarce. Studies on the multiple uses of levonorgestrel emergency contraception are still required to ensure its safety.
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28
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Foer D, Tran LK, Wickner P, Castells M, Marquis KA, Buchheit KM. Challenges in skin testing for progestogen hypersensitivity. Ann Allergy Asthma Immunol 2020; 126:100-102. [PMID: 32911056 DOI: 10.1016/j.anai.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/26/2020] [Accepted: 09/02/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Lena K Tran
- Brigham and Women's Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mariana Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kathleen A Marquis
- Brigham and Women's Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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29
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Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: General Concepts. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:S3-S15. [PMID: 32791249 DOI: 10.1016/j.jaip.2020.08.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 01/19/2023]
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30
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Jensen‐Jarolim E, Bachmann MF, Bonini S, Jacobsen L, Jutel M, Klimek L, Mahler V, Mösges R, Moingeon P, O´Hehir RE, Palomares O, Pfaar O, Renz H, Rhyner C, Roth‐Walter F, Rudenko M, Savolainen J, Schmidt‐Weber CB, Traidl‐Hoffmann C, Kündig T. State-of-the-art in marketed adjuvants and formulations in Allergen Immunotherapy: A position paper of the European Academy of Allergy and Clinical Immunology (EAACI). Allergy 2020; 75:746-760. [PMID: 31774179 DOI: 10.1111/all.14134] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/07/2019] [Accepted: 11/10/2019] [Indexed: 02/06/2023]
Abstract
Since the introduction of allergen immunotherapy (AIT) over 100 years ago, focus has been on standardization of allergen extracts, with reliable molecular composition of allergens receiving the highest attention. While adjuvants play a major role in European AIT, they have been less well studied. In this Position Paper, we summarize current unmet needs of adjuvants in AIT citing current evidence. Four adjuvants are used in products marketed in Europe: aluminium hydroxide (Al(OH)3 ) is the most frequently used adjuvant, with microcrystalline tyrosine (MCT), monophosphoryl lipid A (MPLA) and calcium phosphate (CaP) used less frequently. Recent studies on humans, and using mouse models, have characterized in part the mechanisms of action of adjuvants on pre-existing immune responses. AIT differs from prophylactic vaccines that provoke immunity to infectious agents, as in allergy the patient is presensitized to the antigen. The intended mode of action of adjuvants is to simultaneously enhance the immunogenicity of the allergen, while precipitating the allergen at the injection site to reduce the risk of anaphylaxis. Contrasting immune effects are seen with different adjuvants. Aluminium hydroxide initially boosts Th2 responses, while the other adjuvants utilized in AIT redirect the Th2 immune response towards Th1 immunity. After varying lengths of time, each of the adjuvants supports tolerance. Further studies of the mechanisms of action of adjuvants may advise shorter treatment periods than the current three-to-five-year regimens, enhancing patient adherence. Improved lead compounds from the adjuvant pipeline are under development and are explored for their capacity to fill this unmet need.
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Affiliation(s)
- Erika Jensen‐Jarolim
- Institute of Pathophysiology & Allergy Research Center of Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
- The Interuniversity Messerli Research Institute University of Veterinary Medicine Vienna Medical University of Vienna University of Vienna Vienna Austria
| | - Martin F. Bachmann
- Institute of Immunology Inselspital University of Berne Bern Switzerland
| | - Sergio Bonini
- Institute of Translational Pharmacology Italian National Research Council Rome Italy
| | - Lars Jacobsen
- ALC, Allergy Learning & Consulting Copenhagen Denmark
| | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wrocław Poland
- ALL‐MED Medical Research Institute Wroclaw Poland
| | - Ludger Klimek
- Center of Rhinology and Allergology Wiesbaden Germany
| | - Vera Mahler
- Division of Allergology Paul‐Ehrlich‐Institut Federal Institute for Vaccines and Biomedicines Langen Germany
| | - Ralph Mösges
- CRI‐Clinical Research International Ltd Hamburg Germany
- Institute of Medical Statistics and Bioinformatics University of Cologne Cologne Germany
| | - Philippe Moingeon
- Center for Therapeutic Innovation – Immuno‐Inflammatory Disease Servier Suresnes France
| | - Robyn E. O´Hehir
- Department of Respiratory Medicine, Allergy and Clinical Immunology (Research) Central Clinical School Monash University and Alfred Hospital Melbourne Vic. Australia
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Chemistry School Complutense University of Madrid Madrid Spain
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital MarburgPhilipps‐Universität Marburg Marburg Germany
| | - Harald Renz
- Institute of Laboratory Medicine Universities of Giessen and Marburg Lung Center (UGMLC) German Center for Lung Research (DZL) Philipps Universität Marburg Marburg Germany
| | - Claudio Rhyner
- SIAF – Swiss Institute of Allergy and Asthma Research Davos Switzerland
| | - Franziska Roth‐Walter
- The Interuniversity Messerli Research Institute University of Veterinary Medicine Vienna Medical University of Vienna University of Vienna Vienna Austria
| | | | - Johannes Savolainen
- Department of Pulmonary Diseases and Clinical Allergology University of Turku and Turku University Hospital Turku Finland
| | - Carsten B. Schmidt‐Weber
- Center of Allergy and Environment (ZAUM) German Center of Lung Research (DZL) and Helmholtz I&I Initiative Technical University, and Helmholtz Center Munich Munich Germany
| | - Claudia Traidl‐Hoffmann
- Institute of Environmental Medicine (IEM) Technical University Munich and Helmholtz Center Munich Munich Germany
| | - Thomas Kündig
- Department of Dermatology University Hospital Zurich Zurich Switzerland
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Bernstein JA. Progestogen Sensitization: a Unique Female Presentation of Anaphylaxis. Curr Allergy Asthma Rep 2020; 20:4. [PMID: 31993777 DOI: 10.1007/s11882-020-0900-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Progestogen hypersensitivity (PH) is a condition which typically occurs in women in childbearing years with a spectrum of symptoms ranging from urticaria with or without angioedema, dermatitis to systemic anaphylaxis. Herein, a clinical case of PH is presented followed by a discussion on the evaluation, diagnosis, and management of PH. RECENT FINDINGS Progestogen hypersensitivity (a.k.a. "autoimmune progesterone dermatitis") symptoms are associated with exogenous progestin exposure (e.g., contraceptive medicines, in vitro fertilization therapy) or endogenous progesterone from progesterone surges during the luteal phase of the menstrual cycle and pregnancy. This condition can be difficult to recognize due to its heterogeneous clinical presentation. The mechanism of PH is believed to be primarily IgE-mediated; however, less commonly other immune responses may be involved. There is now a useful progesterone specific IgE immunoassay to assist in diagnosis and well-defined treatment algorithms that can be used to successfully manage PH. The epidemiology of PH is still poorly elucidated but is likely to be encountered by clinicians and especially allergists given the extensive use of oral contraceptives and increased use of supra-physiologic doses of progesterone required to support pregnancy in IVF. Including PH in the differential diagnosis of women presenting with cyclic hypersensitivity will accelerate diagnosis and successful management of this condition.
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Affiliation(s)
- Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML #563, Cincinnati, OH, USA.
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Bhardwaj N, Jindal R, Chauhan P. Autoimmune progesterone dermatitis presenting as fixed drug eruption. BMJ Case Rep 2019; 12:12/11/e231873. [DOI: 10.1136/bcr-2019-231873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Autoimmune progesterone dermatitis (APD) is a rare disorder that presents as recurrent cyclical cutaneous eruptions during the premenstrual period when progesterone level is elevated. It does not have a specific cutaneous manifestation of its own and presents with a multitude of common cutaneous conditions, thus making it a diagnostic challenge. We describe the case of a young woman who presented with a hyperpigmented patch on her left thigh, over which she developed recurrent erythema, pain and itching, starting 2 days before her menstrual cycle and resolving within 2 days after menstruation. Intradermal progesterone sensitivity test was positive. Histopathology of hyperpigmented patch showed features of fixed drug eruption. A diagnosis of APD presenting as fixed drug eruption was made. She was treated with oral contraceptive pills with significant improvement. This case has been reported because of its rarity and to highlight the clinical implications this condition can pose if diagnosis is not sought timely.
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Zachary C, Fackler N, Juhasz M, Pham C, Mesinkovska NA. Catamenial dermatoses associated with autoimmune, inflammatory, and systemic diseases: A systematic review ,. Int J Womens Dermatol 2019; 5:361-367. [PMID: 31909158 PMCID: PMC6938828 DOI: 10.1016/j.ijwd.2019.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/08/2019] [Accepted: 09/26/2019] [Indexed: 11/29/2022] Open
Abstract
Background Sex hormones are important in female sexual physiology, growth, and homeostasis. Through skin receptors, sex hormones contribute to the dermatologic pathology known as catamenial dermatoses. Objective This study aims to summarize the literature on catamenial dermatoses and menses-induced exacerbations of chronic dermatoses. Methods This systematic review used the PRISMA method. PubMed was searched using the terms “menses” and “skin” in July 2018, and an assessment was conducted of the relevant literature on skin diseases related to non-pathologic menstruation, such as polycystic ovarian syndrome. Pathology associated with androgenetic acne was excluded from the study. Results A total of 102 studies with 1269 female patients were included. The most commonly reported primary catamenial dermatoses were autoimmune progesterone dermatitis and autoimmune estrogen dermatitis. The most commonly reported chronic skin disorders exacerbated by menses were psoriasis, Behcet’s disease, and eczematous dermatoses. Conclusion Physicians should be aware of the nature of catamenial dermatoses and their presentation with normal sexual physiology. Patients with chronic dermatoses should be appropriately counseled on menstruation-related exacerbations. Further research needs to be conducted to determine the interplay between immune regulation and sex hormones in catamenial dermatoses and to elucidate effective therapies.
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Affiliation(s)
- Cameron Zachary
- Georgetown University, School of Medicine, Washington, D.C., United States.,University of California, Irvine, Department of Dermatology, Irvine, CA, United States
| | - Nathan Fackler
- Georgetown University, School of Medicine, Washington, D.C., United States.,University of California, Irvine, Department of Dermatology, Irvine, CA, United States
| | - Margit Juhasz
- University of California, Irvine, Department of Dermatology, Irvine, CA, United States
| | - Christine Pham
- University of California, Irvine, Department of Dermatology, Irvine, CA, United States.,University of California, Irvine, School of Medicine, Irvine, CA, United States
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Carter MC, Akin C, Castells MC, Scott EP, Lieberman P. Idiopathic anaphylaxis yardstick: Practical recommendations for clinical practice. Ann Allergy Asthma Immunol 2019; 124:16-27. [PMID: 31513910 DOI: 10.1016/j.anai.2019.08.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/20/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is considered idiopathic when there is no known trigger. The signs and symptoms of idiopathic anaphylaxis (IA) are identical to those of anaphylaxis because of a known cause and can include cutaneous, circulatory, respiratory, gastrointestinal, and neurologic symptoms. Idiopathic anaphylaxis can be a frustrating disease for patients and health care providers. Episodes are unpredictable, and differential diagnosis is challenging. Current anaphylaxis guidelines have little specific guidance regarding differential diagnosis and long-term management of IA. Therefore, the objective of the Idiopathic Anaphylaxis Yardstick is to use published data and the authors' combined clinical experience to provide practical recommendations for the diagnosis and management of patients with IA.
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Affiliation(s)
| | - Cem Akin
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mariana C Castells
- Department of Medicine, Division of Rheumatology, Immunology, and Allergy, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Phil Lieberman
- Departments of Medicine and Pediatrics, Divisions of Allergy and Immunology, University of Tennessee, Memphis, Tennessee.
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Chamorro-Pareja N, Carrillo-Martin I, Haehn DA, Gonzalez-Estrada A. Documented exogenous progesterone hypersensitivity related to the use of combined oral contraceptive. BMJ Case Rep 2019; 12:12/9/e230416. [DOI: 10.1136/bcr-2019-230416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ghosh D, Bernstein JA. Development of a progesterone-specific IgE assay for diagnosing patients with suspected progestogen hypersensitivity. Ann Allergy Asthma Immunol 2019; 122:616-622. [PMID: 30953782 DOI: 10.1016/j.anai.2019.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/17/2019] [Accepted: 03/29/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Progesterone hypersensitivity (PH) manifests as a spectrum of allergic symptoms during the luteal phase of the menstrual cycle. Confirming progesterone-specific immunoglobulin E (IgE; sIgE) by skin testing is unreliable because of irritant responses. OBJECTIVE To develop a progesterone sIgE assay to assist in diagnosing PH. METHODS A progesterone-bovine serum albumin (BSA) conjugate was characterized and used to analyze sera collected from women in our center with suspected PH in a 1-batch enzyme-linked immunosorbent assay (ELISA) to establish high, low and negative cut-points. Sera collected from healthy nonatopic female subjects and from women with classical PH symptoms were included as negative and positive controls, respectively. Values exceeding the average negative control (OD + 3× the standard deviation) were considered positive. These cut-points were subsequently used to establish positive and negative results for serum from women with suspected PH received from other centers. A subset of high positive sera was used for ELISA-inhibition and in a beta-hexosaminidase mediator release assay to evaluate the specificity and functional relevance of progesterone-specific serum IgE, respectively. The numbers of true negative, false negative, true positive, and false positive samples were determined. RESULTS The direct progesterone sIgE ELISA results ranged from high positive to low positive and negative compared with healthy nonatopic control sera. Enzyme-linked immunosorbent assay inhibition and beta-hexosaminidase mediator release confirmed specificity and functional relevance of progesterone-sIgE, respectively. The sensitivity, specificity positive predictive values and negative predictive values were found to be 82%, 100%, 86%, and 100%, respectively, using the mediator release assay results as the gold standard. CONCLUSION This assay has a good specificity and positive predictive value for screening women with suspected PH for progesterone sIgE.
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Affiliation(s)
- Debajyoti Ghosh
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati, Cincinnati, OH
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati, Cincinnati, OH.
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Carrasco-Zuber JE, Álvarez-Véliz S, Moll-Manzur C, González-Bombardiere S. Autoimmune progesterone dermatitis manifesting as generalized fixed drug eruption. An Bras Dermatol 2019; 93:874-877. [PMID: 30484533 PMCID: PMC6256208 DOI: 10.1590/abd1806-4841.20187290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 12/15/2017] [Indexed: 11/22/2022] Open
Abstract
Autoimmune progesterone dermatitis is an uncommon, poorly recognized and under-diagnosed catamenial dermatosis associated with hypersensitivity reactions to progestagens. Most cases manifest as urticaria, eczema or erythema multiforme-like. A 26-year-old woman developed violaceous plaques on the groin and abdomen, 4 days after a spontaneous abortion resolved with uterine curettage. The lesions recurred once monthly at the same sites, mimicking a fixed drug eruption. Although the histopathology was compatible with fixed drug eruption, positive intradermal testing and symptomatic improvement after using oral contraceptive pills gave us a clue to the diagnosis.
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Affiliation(s)
| | - Sergio Álvarez-Véliz
- Department of Dermatology, Facultad de Medicina, Pontificia
Universidad Católica de Chile, Santiago, Chile
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Respuesta de la dermatitis autoinmune por progesterona al acetato de ulipristal. ACTAS DERMO-SIFILIOGRAFICAS 2019; 110:78-81. [DOI: 10.1016/j.ad.2017.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 11/03/2017] [Accepted: 11/10/2017] [Indexed: 11/20/2022] Open
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Senila S, Ungureanu L, Candrea E, Danescu S, Vasilovici A, Cosgarea R, Dionisie V. Progesterone hypersensitivity: Case report with favorable evolution. Exp Ther Med 2018; 17:1125-1127. [PMID: 30679983 PMCID: PMC6327669 DOI: 10.3892/etm.2018.7055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/14/2018] [Indexed: 11/07/2022] Open
Abstract
Progesterone hypersensitivity or autoimmune progesterone dermatitis is characterized by heterogeneous skin eruptions that cyclically aggravate during the second half of the menstrual cycle, corresponding to a rise in the progesterone level. Clinical presentation is highly variable and includes all urticaria manifestations with or without angioedema, vesiculobullous, eczematous, purpuric or target-like lesions on the skin and mucous membrane. Both endogenous progesterone as well as exogenous progestogens may represent an initial trigger. We report a case of progesterone hypersensitivity in a 27-year old woman with favorable evolution only on topical therapy, the positive clinical outcome being maintained during a subsequent pregnancy and postpartum period.
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Affiliation(s)
- Simona Senila
- Department of Dermatology, University of Medicine and Pharmacy ‘Iuliu Hatieganu’, 400006 Cluj‑Napoca, Romania
| | - Lorendana Ungureanu
- Department of Dermatology, University of Medicine and Pharmacy ‘Iuliu Hatieganu’, 400006 Cluj‑Napoca, Romania
| | - Elisabeta Candrea
- Department of Dermatology, University of Medicine and Pharmacy ‘Iuliu Hatieganu’, 400006 Cluj‑Napoca, Romania
| | - Sorina Danescu
- Department of Dermatology, University of Medicine and Pharmacy ‘Iuliu Hatieganu’, 400006 Cluj‑Napoca, Romania
| | - Alina Vasilovici
- Department of Dermatology, University of Medicine and Pharmacy ‘Iuliu Hatieganu’, 400006 Cluj‑Napoca, Romania
| | - Rodica Cosgarea
- Department of Dermatology, University of Medicine and Pharmacy ‘Iuliu Hatieganu’, 400006 Cluj‑Napoca, Romania
| | - Vlad Dionisie
- Department of Psychiatry, Clinical Hospital of Psychiatry ‘Al. Obregia’, 041914 Bucharest, Romania
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Lavery WJ, Bernstein JA. Cyclical hypersensitivity, anaphylaxis, and related hormonal reaction. Ann Allergy Asthma Immunol 2018; 122:140-147. [PMID: 30468931 DOI: 10.1016/j.anai.2018.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 11/16/2022]
Affiliation(s)
- William J Lavery
- Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan A Bernstein
- Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Foer D, Buchheit KM. Presentation and natural history of progestogen hypersensitivity. Ann Allergy Asthma Immunol 2018; 122:156-159. [PMID: 30712576 DOI: 10.1016/j.anai.2018.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/05/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To review the published medical literature on the clinical presentation, risk factors, and natural history of hypersensitivity reactions to progestogens. DATA SOURCES Through the use of PubMed, we conducted a review of allergy, dermatology, and obstetric literature for cases and case series of patients with hypersensitivity reactions to exogenous or endogenous progestogens. There are no longitudinal, prospective studies related to progestogen hypersensitivity. STUDY SELECTIONS Publications were selected that described cases that were clinically consistent with progesterone hypersensitivity and positive test results or clear symptoms with exposure to progestogens to confirm the diagnosis. RESULTS Progestogen hypersensitivity symptoms can be triggered by endogenous progesterone or exogenous progestins used for contraception or fertility treatments. Symptoms are varied and include dermatitis, urticaria, asthma, and anaphylaxis. CONCLUSION Although the medical literature on progestogen hypersensitivity is limited to case reports and small case series, significant heterogeneity exists in clinical presentation among patients.
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Affiliation(s)
- Dinah Foer
- Jeff and Penny Vinik Center for Allergic Diseases Research, Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Kathleen M Buchheit
- Jeff and Penny Vinik Center for Allergic Diseases Research, Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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Jimenez-Rodriguez TW, Garcia-Neuer M, Alenazy LA, Castells M. Anaphylaxis in the 21st century: phenotypes, endotypes, and biomarkers. J Asthma Allergy 2018; 11:121-142. [PMID: 29950872 PMCID: PMC6016596 DOI: 10.2147/jaa.s159411] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is the most serious of all allergic reactions and can be fatal. The diagnosis is frequently delayed, and misdiagnosis often occurs with asthma or urticaria. Biomarkers such as tryptase are not routinely checked, and appropriate treatment with epinephrine is not administered in a majority of cases, increasing the risk of poor outcomes. The objective of this review is to provide a better understanding of the pathophysiology of anaphylaxis with a description of phenotypes, endotypes, and biomarkers available in both the clinical and research settings. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among health care providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality.
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Affiliation(s)
- Teodorikez Wilfox Jimenez-Rodriguez
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Allergy Section, Alicante General University Hospital, Alicante, Spain
- PhD Program in Public Health, Medical and Surgical Sciences, Miguel Hernandez University, Alicante, Spain
| | - Marlene Garcia-Neuer
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leila A Alenazy
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mariana Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Application of precision medicine to the treatment of anaphylaxis. Curr Opin Allergy Clin Immunol 2018; 18:190-197. [DOI: 10.1097/aci.0000000000000435] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
PURPOSE OF REVIEW Progestogen hypersensitivity (PH) is a rare disorder which usually occurs in women of childbearing age with symptoms ranging from urticaria with or without angioedema, multiple organ involvement consistent with allergic anaphylaxis, to a spectrum of other non-evanescent skin eruptions. In this review, we present a clinical vignette of PH and discuss the clinical presentation and proposed pathomechanisms, diagnosis, and treatment of PH. RECENT FINDINGS The hypersensitivity symptoms are associated with exogenous progestin exposure (e.g., contraceptive medicines, in vitro fertilization therapy) or endogenous progesterone from progesterone surges during the luteal phase of the menstrual cycle and pregnancy. Recognition of this condition can be challenging to the clinician due to its heterogeneous clinical presentation. It has been recently proposed to use the new term "progestogen hypersensitivity" to replace "autoimmune progesterone dermatitis" due to the lack of evidence supporting an autoimmune mechanism for this disorder. In addition, diagnostic and treatment algorithms are now available that can lead to successful management of this condition. More new developments of Progesterone desensitization protocols are now available which appear to be the safest and most effective long-term treatment option for PH. With the extensive use of oral contraceptives and increased use of supra-physiologic doses of progesterone to support pregnancy in in vitro fertilization, there is likely to be a higher prevalence of PH in the future than currently recognized. Therefore, the allergist-immunologist will be required to collaborate with gynecologists and reproductive endocrinologists to diagnose and treat this condition.
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Affiliation(s)
- Rung-Chi Li
- Mid-Atlantic Permanente Medical Group, Baltimore, MD, USA
| | | | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML #563, Cincinnati, OH, 45267-0563, USA.
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Kuruvilla M, Vanijcharoenkarn K, Wan J, Pereira N, Chung P. Exogenous progesterone hypersensitivity associated with recurrent pregnancy loss. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1412-1413. [PMID: 29339132 DOI: 10.1016/j.jaip.2017.11.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Merin Kuruvilla
- Department of Allergy/Immunology, Emory University, Atlanta, Ga.
| | | | - Justin Wan
- Cornell Center for Reproductive Medicine, New York, NY
| | - Nigel Pereira
- Cornell Center for Reproductive Medicine, New York, NY
| | - Pak Chung
- Cornell Center for Reproductive Medicine, New York, NY
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Sood A, Sahu S, Karunakaran S, Joshi RK, Raman DK. Dermatological Manifestations in Patients Undergoing In Vitro Fertilisation: A Prospective Study. J Cutan Med Surg 2018; 22:280-284. [PMID: 29332425 DOI: 10.1177/1203475417752370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Changing sociodemographic patterns with an increase in the age of childbirth have affected fertility rates worldwide. With advancing reproductive medicine, assisted reproductive techniques (ARTs) are becoming common. While dermatological manifestations in normal pregnancies have been well documented, there is a paucity of data regarding cutaneous manifestations in patients undergoing ART. OBJECTIVES The objectives of our study were to estimate the incidence and types of dermatological manifestations in patients undergoing in vitro fertilisation (IVF) and to study their associations with age, type of infertility, and outcome of the procedure. METHODS A prospective cohort of 200 patients undergoing IVF in a tertiary care centre was observed for occurrence of any dermatological manifestations from initiation of the IVF protocol to the outcome of the procedure at 3 weeks after embryo transfer. RESULTS Dermatological manifestations were seen in 27% of the study group, with urticaria being the most common cutaneous finding seen in 13.5%, followed by acneform eruptions (3%). Twenty-six (96.3%) of patients who manifested with urticaria were on progesterone. No statistically significant association was found between the occurrence of dermatological manifestations and the outcome of IVF, type of infertility, history of ART, and ovum donation in our study. Association between the age of the patient and the outcome of IVF cycle was statistically significant. CONCLUSION Dermatological manifestations are seen in almost one-quarter of patients undergoing IVF, with progesterone-induced urticaria being the most common. Occurrence of cutaneous manifestations has no significant association with the outcome of IVF.
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Affiliation(s)
- Aradhana Sood
- 1 Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Suvash Sahu
- 2 Dermatologist, 12 Airforce Hospital, Gorakhpur, Uttar Pradesh, India
| | - Sandeep Karunakaran
- 3 Department of Obs & Gynae, INHS Asvini, Colaba, Mumbai, Maharashtra, India
| | - Rajneesh K Joshi
- 4 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Deep Kumar Raman
- 5 Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
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