Contact allergy to budesonide and perforation of the nasal septum

Allergic Contact Dermatitis From Topical Drugs: An Overview

ABSTRACT

Allergic contact dermatitis from topical drugs is frequent and is seen in 10% to 17% of patients patch tested for suspected contact dermatitis. More than 360 drugs have been implicated as contact allergens, of which-generally-antibiotics, corticosteroids, local anesthetics, and nonsteroidal anti-inflammatory drugs are the most frequent culprits. This article provides an overview of allergic contact dermatitis to topical drugs, discussing their prevalence of sensitization, predisposing factors, clinical manifestations (both typical and atypical), the drugs described as allergens, cross-reactivity and coreactivity, and diagnostic procedures.

Intranasal Steroids and the Myth of Mucosal Atrophy: A Systematic Review of Original Histological Assessments

Background

Intranasal corticosteroids (INCSs) are well established in the treatment of allergic rhinitis, chronic rhinosinusitis, and nasal polyposis. Although reversible atrophy of keratinized skin is seen with corticosteroids, the respiratory mucosa is histologically very different and but concerns remain among patients and some health-care professionals over local side effects on nasal respiratory mucosa. A systematic review and meta-analysis were performed of the available evidence for nasal mucosal atrophy as an adverse effect of INCSs in patients with sinonasal disease.

Methods

A systematic search of Embase (1974-) and Medline (1946-) databases to September 27, 2013 was performed. Inclusion criteria selected any study where the histopathology of nasal mucosa was assessed in patients with sinonasal disease using intranasally administered corticosteroids with or without a control group.

Results

Twenty-three hundred sixty-four publications were retrieved with a subsequent full text review of 149 publications for 34 articles that met the selection criteria. These articles included 11 randomized controlled trials, 5 cohorts, and 20 case series. Duration of treatment varied from 5 days to 5.5 years. “Mucosal atrophy” as an outcome was reported in 17 studies. The definition of “mucosal atrophy” was highly variable with a definition given in only 10 studies. One hundred thirty-six patients were represented in controlled studies of atrophy with only one study reporting the event in both groups with an odds ratio of “mucosal atrophy” at 0.51 (95% CI, 0.09-3.11; p = 0.47).

Conclusion

The concept of nasal mucosal atrophy is poorly defined and there is no histological evidence for deleterious effects from INCS use on human nasal mucosa.

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.

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.

Pathophysiology and progression of nasal septal perforation

OBJECTIVE

To review the prevalence, causes, and treatments of nasal septal perforation (NSP).

DATA SOURCES

A literature search was conducted in MEDLINE to identify peer-reviewed articles related to NSP using the keywords nasal septal perforation and septal perforation for articles published between January 1, 1969, and December 31, 2006, and references cited therein.

STUDY SELECTION

Articles were selected based on their direct applicability to the subject matter.

RESULTS

Causes of NSPs include piercings, exposure to industrial chemicals, illicit drug use, intranasal steroid use, surgical trauma, bilateral cautery, and possibly improper use of nasal applicators. Prevalence is poorly reported. Mechanisms of substance-induced NSP formation are not understood. Progression from epistaxis to ulceration to NSP could not be substantiated by the literature.

CONCLUSION

Depending on the patient, NSP may be viewed as desirable (nose rings), problematic (whistling, congestion), or inconsequential. Understanding the pathogenesis of NSP is important for the practicing physician required to make decisions about whether to recommend surgical correction or medical treatment. Although the etiology of NSP is overwhelmingly iatrogenic, there is an association with a number of medical diseases in addition to use of illicit drugs and/or prescription nasal sprays.

Corticosteroids

Up to 5% of dermatitis patients are allergic to corticosteroids. Because such allergy may be difficult to suspect due to the anti-inflammatory action of the corticosteroid, markers for corticosteroid allergy should be present in any standard series. Budesonide and tixocortol pivalate are two such markers, and they seem to detect a majority of corticosteroid allergy. The patch test concentration for a given corticosteroid may be crucial. A false-negative reaction may follow despite the patient being allergic, if too high a test concentration is used, because of the anti-inflammatory action of the corticosteroid. Patch test readings must be performed not only on Day 3 or Day 4 but also on a late occasion, i.e., Day 7 after test application, also because the anti-inflammatory action may suppress an allergic reaction at an early reading. Once a patient has reacted to a corticosteroid, an extended corticosteroid series should be tested, so that information may be given on which corticosteroids to use and, above all, which corticosteroids to avoid.

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.