Identification of undetected corticosteroid allergy

Delayed systemic allergic reactions to corticosteroids

From the limited number of reports in the literature, it would appear that various types of delayed reactions from systemically, intralesionally, and intra-articularly administered corticosteroids are rare, particularly given their widespread use. The purpose of this literature review is to summarize in table form the reported cases of generalized delayed systemic corticosteroid reactions with respect to patient presentation, methods of evaluation, and conclusions reached. In total, 24 cases of generalized delayed systemic corticosteroid reactions have been reported in the literature. Clinical presentation (timing and cutaneous manifestations) as well as evaluation of these patients has been variable; reactions reported include eczematous or exanthematous eruptions, with or without bullae or purpura. In 16 cases, the diagnoses have been supported by positive patch or intradermal testing. Overall, it appears that generalized delayed systemic reactions to corticosteroids show considerable variability and are infrequently reported. Patch and intradermal tests with standardized allergens appear to be the most useful tests currently available to support this clinical diagnosis.

Hypersensitivity to topical corticosteroids

Contact hypersensitivity from topical corticosteroids is becoming increasingly recognized; it is present in 2-5% of the patients attending contact dermatitis clinics. The use of a corticosteroid series containing tixocortal pivalate 1% (petrolatum), to detect hypersensitivity to hydrocortisone, and other steroids 1% (ethanol), depending on local corticosteroid usage, detects the majority of cases of corticosteroid hypersensitivity. In selected cases, the use of intradermal tests further improves the diagnosis of corticosteroid hypersensitivity. Corticosteroid hypersensitivity occurs most frequently among patients with stasis dermatitis. However, corticosteroid hypersensitivity is also common in other types of dermatitis, occurring as frequently as hypersensitivity to several allergens (e.g. wool alcohols and colophony) in the European standard battery. Although hypersensitivity has mainly been reported with corticosteroids applied to the skin, reactions may also occur on mucosal surfaces, following systemic administration and with sex steroids.

Contact hypersensitivity to topical corticosteroids

Topical corticosteroids are increasingly recognized as relatively common contact sensitizers. Between July 1988 and December 1991 2687 patients undergoing routine patch testing were also tested with tixocortol pivalate (TP). Over the same time period 528 patients were selected for testing with a series of 18 steroids. One-hundred and thirty-one cases (4.9%) of corticosteroid hypersensitivity were detected and 119 (90.8%) of these cases were positive to TP. Thirty-seven patients reacted to one or more steroids in the steroid series, the most frequent sensitizers being hydrocortisone, budesonide (3.6%) and hydrocortisone 17-butyrate (2.5%). Of these 37 cases, 20 (54%) reacted to more than one steroid simultaneously, but the patterns of cross-reaction were not consistent with previously suggested groupings. Screening for steroid allergy should be performed as part of standard patch testing. The value of TP as a marker of corticosteroid hypersensitivity is reinforced by this study, but no satisfactory marker was found for the 9.2% of cases not detected by TP. There remains a need for further markers of corticosteroid hypersensitivity. A prevalence of 4.9% of corticosteroid allergy amongst our patients suggests that the frequency of this finding is generally underestimated.

Contact allergy to corticosteroids: a frequently missed diagnosis?

Contact allergy to corticosteroids is more prevalent than previously recognized and often goes undetected. Nineteen patients with corticosteroid contact allergy are presented. Sixteen reacted to tixocortol pivalate and also to other corticosteroids, particularly to hydrocortisone, which could explain exacerbations of eczema in these cases. Tixocortol pivalate may be a useful marker for screening patients for contact sensitivity to several corticosteroids.

Detection of contact hypersensitivity to topical corticosteroids with hydrocortisone-17-butyrate

We showed earlier that most patients with contact dermatitis due to corticosteroids show cross-reactions when patch tested with hydrocortisone-17-butyrate (H-17-B). To test whether H-17-B could be used for detecting topical corticosteroid allergy, we screened patients undergoing routine patch testing with H-17-B. Patients with clearly allergic or doubtful/mildly irritant patch test reactions to H-17-B, and with a history suggesting topical corticosteroid allergy, were further tested with a large panel of steroid preparations. 20 out of 4039 patients (0.5%) showed definite allergic test reactions to corticosteroids. A further 165 patients with clinically suspected corticosteroid allergy were directly tested with a panel of steroid preparations; 14 patients showed positive patch test reactions. Altogether, 33 out of 34 patients with corticosteroid allergy had positive test reactions to H-17-B. Inclusion of 1.0% H-17-B in ethanol in the standard patch test series improves the diagnosis of topical corticosteroid hypersensitivity.

Allergic contact dermatitis from topical corticosteroids

22 cases of allergic contact dermatitis from topical corticosteroids were observed in Strasbourg and previously published. 7 further cases are reported here and the vehicle and concentration of corticosteroids for patch tests are discussed. A 0.1% concentration in petrolatum seemed adequate for testing the 4 molecules (triamcinolone acetonide, dexamethasone, desonide and amcinonide) responsible for the 7 new cases. In 1 case, several cross-reactions were seen. A corticosteroid screening series permits patch testing of the suspected molecule(s) in a selective way. Without this series, long delays are required to make the correct diagnosis by patch testing. We have reviewed more than 60 papers on corticosteroid allergy published up to now.

Identification of cross-reaction patterns in allergic contact dermatitis from topical corticosteroids

Contact allergy to topical corticosteroids occurs more frequently than previously supposed. Cross-allergic phenomena are common. On the basis of a review of the literature and our own patch test data on 15 patients, we conclude that positive patchtests to corticosteroids occur approximately six to seven times more frequently in well-defined groups of structurally-related substances than between corticosteroids of different groups. An analogous substitution pattern on the steroid D-ring or the carbon side chain (C20, C21) seems to have a significant influence on the association of positive patchtest results. This is not the case for other structural variables, such as the presence of a double bond in the steroid A-ring or fluoride substitutions on the B-ring. The effect of other factors such as concomitant sensitization and steroid metabolism in the skin on the development of a corticosteroid polyallergy are analysed, and the specificity and sensitivity of cross-allergy phenomena are evaluated. These are important in the selection of a topical steroid in the future treatment of a corticosteroid sensitive patient.