Cutaneous-mucosal allergic contact reaction due to topical corticosteroids

Allergic hypersensitivity to topical and systemic corticosteroids: a review

Corticosteroids, which are potent anti-inflammatory and immunomodulator agents used in the treatment of various inflammatory diseases including allergic diseases, can in some cases produce immediate or delayed hypersensitivity reactions. This review summarizes the epidemiological and clinical characteristics of such reactions, including related diagnostic issues. It also presents a detailed analysis of the proposed immunological mechanisms including underlying cross-reactions.

Delayed hypersensitivity reactions to corticosteroids

BACKGROUND

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

MATERIAL AND METHODS

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

CONCLUSIONS

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

Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis

Intranasal corticosteroids and intranasal antihistamines are efficacious topical therapies in the treatment of allergic rhinitis. This review addresses their relative roles in the management of this disease, focusing on their safety and tolerability profiles. The intranasal route of administration delivers drug directly to the target organ, thereby minimising the potential for the systemic adverse effects that may be evident with oral therapy. Furthermore, the topical route of delivery enables the use of lower doses of medication. Such therapies, predominantly available as aqueous formulations following the ban of chlorofluorocarbon propellants, have minimal local adverse effects. Intranasal application of therapy can induce sneezing in the hyper-reactive nose, and transient local irritation has been described with certain formulations. Intranasal administration of corticosteroids is associated with minor nose bleeding in a small proportion of recipients. This effect has been attributed to the vasoconstrictor activity of the corticosteroid molecules, and is considered to account for the very rare occurrence of nasal septal perforation. Nasal biopsy studies do not show any detrimental structural effects within the nasal mucosa with long-term administration of intranasal corticosteroids. Much attention has focused on the systemic safety of intranasal application. When administered at standard recommended therapeutic dosage, the intranasal antihistamines do not cause significant sedation or impairment of psychomotor function, effects that would be evident when these agents are administered orally at a therapeutically relevant dosage. The systemic bioavailability of intranasal corticosteroids varies from <1% to up to 40-50% and influences the risk of systemic adverse effects. Because the dose delivered topically is small, this is not a major consideration, and extensive studies have not identified significant effects on the hypothalamic-pituitary-adrenal axis with continued treatment. A small effect on growth has been reported in one study in children receiving a standard dosage over 1 year, however. This has not been found in prospective studies with the intranasal corticosteroids that have low systemic bioavailability and therefore the judicious choice of intranasal formulation, particularly if there is concurrent corticosteroid inhalation for asthma, is prudent. There is no evidence that such considerations are relevant to shorter-term use, such as in intermittent or seasonal disease. Intranasal therapy, which represents a major mode of drug delivery in allergic rhinitis, thus has a very favourable benefit/risk ratio and is the preferred route of administration for corticosteroids in the treatment of this disease, as well as an important option for antihistaminic therapy, particularly if rapid symptom relief is required.

Adverse skin reactions to inhaled corticosteroids

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

Allergic contact dermatitis in response to budesonide reactivated by inhalation of the allergen

BACKGROUND

Up to 5% of patients with dermatitis who are consecutively patch tested are allergic to one or more corticosteroids. However, few reports of allergic mucosal and skin symptoms in patients with asthma and rhinitis caused by inhaled corticosteroids exist.

OBJECTIVE

Our purpose was to determine whether inhalation of budesonide would result in reactivation of patch test reactions caused by budesonide.

METHODS

The study, which was randomized, double-blind, and placebo-controlled, was ethically reviewed by the Medical Faculty, University of Lund, Sweden. Fifteen nonasthmatic patients who were initially given a diagnosis of budesonide hypersensitivity on patch testing from less than 1 up to 8 years before the study were provoked with budesonide or placebo by inhalation 6 weeks after they had been patch tested with budesonide, its R and S diastereomers, and potentially cross-reacting substances. Lung function was studied by using spirometry and repeated peak expiratory flow measurements.

RESULTS

In 4 of 7 patients who inhaled budesonide, reactivation of previously positive patch test reactions was noted within 24 hours, in contrast to 0 of 8 patients who inhaled placebo (P =.026). No adverse pulmonary responses could be detected.

CONCLUSION

This study shows that allergic skin reactions may occur in patients with contact allergy to budesonide when inhaled forms of the drug are used.

Skin reactions to inhaled corticosteroids

Corticosteroids intended for inhalation into the lungs or into the nose have been used since the 1970s. Only 2 attempts to assess contact allergy attributable to inhaled corticosteroids in patients with asthma and/or rhinitis have been made, and only 1 single case of contact allergy attributable to budesonide and tixocortol pivalate was found. However, several case reports of allergic mucosal and skin symptoms caused by corticosteroids applied locally to the mucosa have been published. Local adverse effects from nasal corticosteroids have ranged from nasal congestion, pruritus, burning, and soreness to perforation of the nasal septum. Inhalation of corticosteroids into the lungs has been reported to cause pruritus, dryness, erythema and oedema of the mouth, a dry cough and odynophagia. Systemic signs reported from the use of nasal corticosteroids and inhalation of corticosteroids into the lungs have been eczematous lesions, particularly on the face, sometimes with spreading to the trunk and flexures. Urticaria has also been noted.

Skin reactions to inhaled corticosteroids. Clinical aspects, incidence, avoidance, and management

Inhaled corticosteroids are considered by many to be the therapy of choice in the treatment of asthma and allergic rhinitis. Systemic adverse effects are well known and are mainly dose dependent. Adverse cutaneous effects have also been characterized. Some of them are frequent and dose dependent, for example thinning of the skin and easy bruising. These adverse effects are probably present in about half of the patients treated with inhaled corticosteroids. The risk of these adverse effects is more important among elderly people and increases with the duration of the treatment and the daily dosage. Thinning of the skin and easy bruising are probably dependent on collagen synthesis modifications. Among rare or underestimated reactions, several adverse effects have been described such as angina bullosa hemorrhagica, acne and allergy. In this latter case, the attention should be paid to relevant clinical signs such as eczematous lesions of the face and aggravation of the nasal symptoms. Mucocutaneous infections related to inhaled corticosteroid use have also been reported, the most frequent being candidiasis. However, the frequency of symptomatic clinical infection is very rare. The risk of viral infection, especially with a herpes virus, has never been described. As cutaneous complications of corticosteroids are mainly dose dependent, these adverse effects could be prevented by attention to the daily dosage. Infection could be prevented by rising the mouth after inhalation and the use of a spacer device. If cutaneous adverse effects occur despite proper use of the inhaled corticosteroids and became unpleasant for the patient, discussion with a pneumologist or otorhinolaryngologist may be required but temporary halting therapy is rarely useful.