Vitamin skin reactions

The cephalosporins are contraindicated in patients with known allergies or intolerances to any of the cephalosporins. Because the penicillins and cephalosporins have a common chemical structure, cross-allergies occur with these drugs. Thus before initiating therapy with a cephalosporin, careful inquiry should be made concerning previous hypersensitivity reactions to the other drugs. Because a secondary vitamin K deficiency can develop with cephalosporin use, the cephalosporins are contraindicated in patients with hemophilia. Cefaclor is also contraindicated in any patient with previous drug-related joint and skin reactions. 

The English-language literature on adverse skin reactions associated with intramuscular or subcutaneous phytomenadione has been reviewed (8). Vitamin K is generally well tolerated subcutaneously or intramuscularly. However, erythematous eczematous plaques have been well documented. Of 39 skin reactions due to... 

Skin reactions to vitamin K are rare, only about 40 cases having been reported. 

Balato N, Cuccurullo FM, Patruno C, Ayala F. Adverse skin reactions to vitamin Kl report of 2 cases. Contact Dermatitis 1998 38(6) 341-2. 

Barnes HM, Sarkany 1. Adverse skin reaction from vitamin Kl. Br J Dermatol 1976 95(6) 653-6. 

Bullen AW, Miller JP, Cunliffe WJ, Losowsky MS. Skin reactions caused by vitamin K in patients with liver disease. Br J Dermatol 1978 98(5) 561-5. 

In the case of dermal exposure, the contaminated area must be washed with plenty of water and soap. Topical application of vitamin E preparations may help to reduce the severity of skin reactions. The affected eye must be irrigated with lukewarm water for at least 10 min. The contaminated clothing is removed and the airway cleared. In the case of ingestion, gastric lavage is avoided as solvents present in cyfluthrin formulations may increase the risk of aspiration pneumonia. Atropine (adults and children >12 years 0.6-1.2mgkg children <12 years 0.02 mg kg by IV infusion) may be useful to... 

Hypersensitivity reactions include morbilliform rash in 2—5% of patients and occasionally more serious skin reactions, including Stevens-Johnson syndrome. Systemic lupus erythematosus and potentially fatal hepatic necrosis have been reported rarely. Hematological reactions include neutropenia and leucopenia, or more rarely, red-cell aplasia, agranulocytosis, and thrombocytopenia Lymphadenopathy is associated with reduced immunoglobulin A (IgA) production. Hypoprothrombinemia and hemorrhage have occurred in the newborns of mothers who received phenytoin during pregnancy vitamin K is effective treatment or prophylaxis. 

Another possible explanation of the observed reactions are the additives in pharmaceutical preparations. Thus Lagerholm et al. (1958) reported a case of hypersensitivity to benzyl alcohol added as a preservative to vitamin B 2 preparations, resulting in urticaria after injection, Hovding (1968), however, was not able to demonstrate a positive skin reaction either with benzyl alcohol or with cobalt chloride. However, skin tests with commercial brands of cyanocobalamin and hydroxocobalamin as well as with purified cyanocabalamin and hydroxocobalamin were positive. Malten (1975) reports a flare reaction in a woman due to the third injection of 250 pg vitamin B12. Prick and patch tests, however, remained negative. A recent short review of reactions after administration of vitamin Bj2 preparations was published by Meuwissen (1978). An extensive review covering the literature up to 1975 was presented by Faivre et al. (1975). The authors conclude that, despite the widespread use of vitamin B12 preparations, cases of accidents after vitamin Bi2 administration are very rare, but nevertheless are a potential risk. Therefore, skin and immunologic tests should be made prior to administration and especially parenteral application of the vitamin. The authors do not make an explicit statement as to a definite allergic mechanism of the observed phenomena. 

Cases of allergic reactions to ascorbic acid are very rare. Early observations reported rubelliform, morbilliform, and scarlatiniform exanthemas, urticaria, and edema after vitamin C use (Widenbauer 1936a,b). Positive skin reactions were reported by Rust (1954) in seven cases and by Panzani (1961) in one case. In this latter case, the skin test was a passive transfer test (Prausnitz-Kiistner) but the data presented are too scarce to demonstrate a definite immunological etiology of the observed reactions. The same holds for three cases of respiratory and cutaneous allergy reported recently by Vassal (1975). 

Side effects of vitamin K are reported to be rare (Hellriegel and Reuter 1975 Reuter and Hellriegel 1979), examples being cases of Kemicterus in the newborn due to a high dose of vitamin K (20 mg intramuscularly) and skin reactions. 

Hellriegel KP, Reuter H (1975) Side effects of vitamins. In Meyler s side effects of drugs, 8. Excerpta Medica, Amsterdam London New York, pp 799-811 Hellriegel KP, Reuter H (1978) Vitamins. In Side effects of drugs, annual 2. Excerpta Medica, Amsterdam London New York, pp 305-309 Heydenreich G (1977) A further case of adverse skin reaction from vitamin Kj. Br J Dermatol 97 697... 

A steroid very closely related structurally to cholesterol is its 7 dehydro derivative 7 Dehydrocholesterol is formed by enzymatic oxidation of cholesterol and has a conju gated diene unit m its B ring 7 Dehydrocholesterol is present m the tissues of the skin where it is transformed to vitamin D3 by a sunlight induced photochemical reaction... 

The pharmaceutical industry employs ozone in organic reactions to produce peroxides as germicides in skin lotions, for the oxidation of intermediates for bacteriostats, and in the synthesis of steroids (qv) such as cortisone (see Disinfectants and antiseptics). Vitamin E can be prepared by ozonation of trimethyUiydroquinone. 

Retinoids are needed for cellular differentiation and skin growth. Some retinoids even exert a prophylactic effect on preneoplastic and malignant skin lesions. Fenretlnide (54) is somewhat more selective and less toxic than retinyl acetate (vitamin A acetate) for this purpose. It is synthesized by reaction of all trans-retinoic acid (53), via its acid chloride, with g-aminophe-nol to give ester 54 (13). 

Homocystinuria can be treated in some cases by the administration of pyridoxine (vitamin Bs), which is a cofactor for the cystathionine synthase reaction. Some patients respond to the administration of pharmacological doses of pyridoxine (25-100 mg daily) with a reduction of plasma homocysteine and methionine. Pyridoxine responsiveness appears to be hereditary, with sibs tending to show a concordant pattern and a milder clinical syndrome. Pyridoxine sensitivity can be documented by enzyme assay in skin fibroblasts. The precise biochemical mechanism of the pyridoxine effect is not well understood but it may not reflect a mutation resulting in diminished affinity of the enzyme for cofactor, because even high concentrations of pyridoxal phosphate do not restore mutant enzyme activity to a control level. 

The GP made a provisional diagnosis of osteomalacia and prescribed vitamin D supplements. Vitamin D measurements are not performed routinely, but the assumption is that a low result would have been obtained on the blood sample. Most of the vitamin D necessary to maintain normal calcium homeostasis is derived from endogenous synthesis by reactions in the skin (which require UV radiation from sunlight), liver and kidney. The cultural habits of Mrs Al-Ameri required her to dress in a burqah and niqab whenever she left the home, meaning that very little of her skin was exposed to daylight. 

Ultraviolet light causes a chemical change in dihydrocholesterol to produce cholecalciferol, a precursor of vitamin D. The latter conforms better to the definition of a steroid hormone than a vitamin. Indeed, the classification of vitamin D as a vitamin is an historical accident. The precursor is released from the skin and is further modified in the liver and kidney to form dihydroxycholecalciferol, which is the active form of the hormone (see Chapter 15 for the reactions). It increases calcium absorption from the... 

Vitamin C is essential for the formation of collagen, the principal structural protein in skin, bone, tendons, and ligaments, being a cofactor in the hydroxylation of the amino acids proline to 4-hydroxyproline, and of lysine to 5-hydroxylysine. These hydroxyamino acids account for up to 25% of the collagen structure. Vitamin C is also associated with some other hydroxylation reactions, e.g. the hydroxylation of tyrosine to dopa (dihydroxyphenylalanine) in the pathway to catecholamines (see Box 15.3). Deficiency leads to scurvy, a condition characterized by muscular pain, skin lesions, fragile blood vessels, bleeding gums, and tooth loss. Vitamin C also has valuable antioxidant properties (see Box 9.2), and these are exploited commercially in the food industries. 

Most adverse reactions are reversible upon discontinuation however, some have persisted after cessation of therapy. Many are similar to those described in patients taking high doses of vitamin A (dryness of the skin and mucous membranes, eg, of the lips, nasal passage, eyes). 

Calcipotriol is a vitamin D3 derivative which is used as a topical agent in the treatment of psoriasis. Although not completely elucidated its mechanism of action seems to be based on inhibition of the proliferation and stimulation of the differentiation of epidermal keratinocytes. Adverse effects include irritation of the skin but also urticarial reactions. Calcipotriol has 100 fold less vitamin D activity as its active vitamin D3 metabolite calcitriol. However, calcipotriol in overdose can cause symptoms of hypercalcemia. 

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