Corticosteroids patch testing

Glucocorticoid contact allergy is well known (SEDA-21, 158) and has to be particularly suspected in chronic conditions affecting the perianal area (17), after long-term topical medication, and in cases of failure to ameliorate dermatitis with corticosteroids. Patch tests should then be performed both with the recommended markers, budeso-nide (0.1% petrolatum) and tixocortol pivalate (1% petrolatum), and with the patient s own formulations. 

A 37-year-old woman with a 5-year history of multiple itchy nodules on the outer aspects of the upper parts of the arms at sites of previous vaccine injections had been receiving hyposensitization vaccines to treat recurrent extrinsic asthma and rhinitis for 10 years (56). Physical examination and a biopsy of one of the nodules were identical to those of the previous case. Patch tests with aluminium chloride were negative. Symptomatic relief was obtained with topical corticosteroids and oral antihistamines. The nodules persisted for at least 3 years. 

Exfoliative dermatitis with fever occurred in a 69-year-old man with ischemic heart disease treated with mex-iletine and diltiazem for three weeks the rash resolved after withdrawal of both drugs and systemic corticosteroid therapy. Patch tests with mexiletine and diltiazem were positive. In addition to this case, 39 cases of drug eruption due to diltiazem have been reported in Japan (16). 

A 70-year-old man had multiple coin-sized exudative eczematous plaques on his legs and trunk for several months (20). Various kinds of corticosteroid ointments and white petrolatum as an emollient gave him little relief. Patch tests showed that he reacted to 1 % ammoniated mercuric chloride in petrolatum and 0.05% mercuric chloride in water. He had all his dental amalgam removed, and 1 month later his eruption had subsided, leaving pigmentation. 

Reports of contact allergy to topical medicaments containing sodium metabisulfite are rare (9). In two cases, a topical corticosteroid formulation that contained sodium metabisulfite (Trimovate cream) caused contact allergy patch tests were positive with both sodium metabisulfite and Trimovate cream (10). 

Three Chinese national servicemen developed an itchy postauricular rash (3). None had a history of atopy and all three reported prior use of rubberized spectacle retainers as a curved pliable extension to the posterior ends of the earpieces of their spectacles, to stabilize them while undergoing rigorous military physical training. They were all patch-tested with the National Skin Center standard series and were positive to thiuram mix and the rubberized spectacle retainers. They were treated with topical corticosteroids and were advised to stop wearing their rubberized spectacle retainers. 

Rarely have complications from CS exposure included haemoptysis and haematemesis (Anderson et al., 1996). A case of multisystem hypersensitivity reaction characterized by delayed development of cutaneous rash, pneumonitis, hypoxaemia, hepatitis and hypereosinophilia, with rapid response to corticosteroids, was described in a man heavily exposed to CS solution spray. The authors ascribed this to a systemic allergic reaction patch testing confirmed sensitization to CS (Hill et al., 2000). The possible abuse and complications from illegal drugs should be considered where clinical suspicions exists (Hayman and Berkely, 1971). Physicians should be aware of the possible contribution from formulation constituents some may exacerbate effects known to be produced by RCAs (e.g. eye injury and skin irritation) and others may introduce additional toxicological factors (such as the development of carbon monoxide intoxication from the absorption and metabolism of dichloromethane as a formulation solvent). 

Eczematous skin lesions are characterized by their chronic evolution and their frequent spread, despite the topical administration of corticosteroids. They are caused, as was shown by Hjorth and Trolle-Lassen (1963), by parabens contained in corticosteroid ointments. Patch tests done with different types of parabens yielded positive responses. Local application of pure corticosteroids, without preservatives, brought about rapid healing. This type of allergy, falsely related to corticosteroids, was particularly studied by Shorr (1968) 1 % of his patients treated for chronic dermatitis suffered from this allergy. 

However, Sulzberger and Baer (1951) have called attention to the fact that in man, patch tests are barely affected by corticosteroids, even with treatments of long duration. 

A blood eosinophilia persists following sensitization in animals sensitized with CA (see p. 44) and varies in those sensitized with PA. In the eczematous sensitization we did not observe a continuous parallel between this blood eosinophilia and the accumulation of eosinophils in the patch test. Their number in patch tests is not influenced by corticosteroids, unlike blood eosinophilia. In passive transfer by serum the eosinophils are numerous in the patch test, whereas their number is normal in the recipient blood. 

Dooms-Goossens A, Morren M (1992) Results of routine patch testing with corticosteroid series in 2073 patients. Contact Dermatitis 26 182-191... 

Testing patients on oral corticosteroids, antihistamines or immunomodulators always creates uncertainty. It has been shown that irradiation with UVB reduces the intensity of patch-test reactions in man and testing after heavy sun exposure should therefore be avoided. 

Fischer T (1989) Occupational nickel dermatitis. In Maibach HI, Menne T (eds) Nickel and the skin immunology and toxicology. CRC Press, Boca Raton, pp 117-132 Fischer T, Rystedt I (1990) Influence of topical metal binding substances, vehicles, and corticosteroid creams on the allergic patch test reactions in metal-sensitive patients. Dermatol Clin 8 27-31... 

A mild potency, topical non-fluorinated corticosteroid with low systemic effects. Uses It has been used since 1986 for the treatment of corticosteroid-responsive dermatoses. It is ranked in Group 6 based on potency and has been classified as group D. According to the A-D grouping, patch-test reactions occur six to seven times more frequently within well-defined groups of structurally related chemicals than between corticosteroids of different groups... 

Baeck M, Chemelle J-A, Terreux R, et at. Delayed hypersensitivity to corticosteroids in a series of 315 patients clinical data eind patch test results. Contact Dermatitis. 2009 61 163-75. 

Salava A, Alanko K, Hyry H. A case of systemic allergic dermatitis caused by inhaled budesonide cross-reactivity in patch tests with the novel inhaled corticosteroid ciclesonide. Contact Dermat October 2012 67(4) 244-6. 

Immunologic Topical corticosteroids have been previously implicated in allergic contact dermatitis, but only rarely in systematic allergic reaction. Lips, nose, and eyelid angioedema and pruritic urticarial papules in face, chest, and arms of a 34 year old nonatopic woman were attributed to nasal budesonide, which was administered for common cold [32 ]. The adverse effects developed 8 h after the second administration of 256 gg of budesonide nasally (two puffs per nostril) and remitted gradually over 3-4 days and after treatment with hydroxyzine. Previously the patient had tolerated nasal budesonide without adverse effects. This case of systemic allergic reaction was confirmed by positive results in patch and intradermal test and without cross-reactivity with others corticosteroids. 

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