Anaphylaxis after prednisone

Hypersensitivity reactions to corticosteroids

Hypersensitivity reactions to corticosteroids (CS) are rare in the general population, but they are not uncommon in high-risk groups such as patients who receive repeated doses of CS. Hypersensitivity reactions to steroids are broadly divided into two categories: immediate reactions, typically occurring within 1 h of drug administration, and non-immediate reactions, which manifest more than an hour after drug administration. The latter group is more common. We reviewed the literature using the search terms "hypersensitivity to steroids, adverse effects of steroids, steroid allergy, allergic contact dermatitis, corticosteroid side effects, and type I hypersensitivity" to identify studies or clinical reports of steroid hypersensitivity. We discuss the prevalence, mechanism, presentation, evaluation, and therapeutic options in corticosteroid hypersensitivity reactions. There is a paucity of literature on corticosteroid allergy, with most reports being case reports. Most reports involve non-systemic application of corticosteroids. Steroid hypersensitivity has been associated with type I IgE-mediated allergy including anaphylaxis. The overall prevalence of type I steroid hypersensitivity is estimated to be 0.3-0.5%. Allergic contact dermatitis (ACD) is the most commonly reported non-immediate hypersensitivity reaction and usually follows topical CS application. Atopic dermatitis and stasis dermatitis of the lower extremities are risk factors for the development of ACD from topical CS. Patients can also develop hypersensitivity reactions to nasal, inhaled, oral, and parenteral CS. A close and detailed evaluation is required for the clinician to confirm the presence of a true hypersensitivity reaction to the suspected drug and choose the safest alternative. Choosing an alternative CS is not only paramount to the patient's safety but also ameliorates the worry of developing an allergic, and potentially fatal, steroid hypersensitivity reaction. This evaluation becomes especially important in high-risk groups where steroids are a life-saving treatment. The assessment should be done when the patient's underlying condition is in a quiescent state.

Allergic Reactions to Inhalant Glucocorticosteroids: A Hot Topic for Pneumologists and Allergologists

Allergic contact dermatitis to topical glucocorticosteroids (GCS) is a delayed type cell-mediated hypersensitivity reaction; it is frequently observed in dermatological and allergological practice, although its incidence is likely underestimated. By contrast, allergic contact sensitization to inhalant GCS is virtually unknown to most pneumologists. Here, we review some cases of adverse reactions to inhalant GCS in terms of pathogenetic mechanisms, risk factors, epidemiology, and allergic cross-sensitivity. In fact, this particular form of sensitization to drugs that have a wide spectrum of use in pneumological practice deserves more attention than in the past.

Immunoglobulin E-mediated reactions to corticosteroids

Allergic reactions to steroids are rare, but are becoming more commonly recognized by clinicians. Although many reactions are thought to be IgE mediated, most are adverse drug reactions caused by nonallergic mechanisms, some related to additives in the steroid preparation being administered. Provocative challenge with the suspected offending agent, serologic tests for allergen-specific IgE, and skin testing are the most reliable methods for assessing hypersensitivity to steroids, although none is infallible. Therapeutic options for patients with documented steroid allergy include the use of alternative steroid preparations, desensitization, and, possibly, the use of monoclonal anti-IgE antibodies.

Corticosteroid-induced hypersensitivity reactions

OBJECTIVE

To review and present data on the prevalence, clinical manifestations, diagnostic techniques, and management options in patients with hypersensitivity reactions to corticosteroid preparations.

DATA SOURCES

All English language articles pertaining to human subjects were reviewed using the Pubmed database from 1964 to June 2002. Indexing terms used were anaphylaxis OR allergic OR anaphylactoid OR hypersensitivity AND steroid OR corticosteroid. Further cross-references were obtained after reviewing articles from the aforementioned search.

STUDY SELECTION

A total of 11,493 articles were identified with the above search terms. Only those articles, including letters and editorials, describing systemic reactions to steroids were included in the review. Excluded from our review were articles dealing with contact dermatitis to topical steroid preparations. This resulted in a total of 80 articles which were reviewed.

RESULTS

Although rare, steroid-induced hypersensitivity reactions do occur. They range from minor rashes to the more serious cardiovascular collapse. The mechanisms of steroid-induced adverse events vary from patient to patient, some being classic immunoglobulin E-mediated whereas others are pseudoallergic in nature. Skin testing and provocative challenges offer two ways to diagnose such reactions. Treatment consists of substituting the steroid with an alternative preparation which can be tolerated by the patient.

CONCLUSIONS

Although little is known about the epidemiology of steroid-induced hypersensitivity, because most data are derived from case reports, it is clear that steroid-induced hypersensitivity is a heterogeneous entity, with no single uniform mechanism. A great deal of work still needs to be done so that the pathogenesis of such adverse events can be clearly determined and effective therapeutic interventions devised.