Topical corticosteroids


Widely used drugs in dermatology. Allergy to hydrocortisone has been reported for the first time in 1959.
 
There are 4 chemical/structural classes of corticosteroids.
  • A: hydrocortisone, prednisolone, tixocortol pivalate
     
  • B: acetonides (triamcinolone, desonide, budesonide)
     
  • C: betamethasone, dexamethasone, desoxymethasone, fluocortolone
     
  • D: esters: hydrocortisone-17-butyrate, betamethasone-vale rate, betamethasone-dipropionate, carbonates, carboxylates.
Incidence
0.4% to 6.4% of positive patch-tests to different topical corticosteroids in populations with contact dermatitis.
 
189/7238 patients (2.6%) in a multicentre European study.
 
Risk factors
Long term application of topical corticosteroids (leg ulcers, atopic dermatitis, psoriasis, lichen planus).
 
Clinical manifestations
The diagnosis of topical corticosteroid allergy is often difficult due to the anti-inflammatory action on cutaneous lesions and their delayed appearance.
  • Increased eczema despite well-conducted topical treatment
     
  • Eczematization of chronic dermatosis (seborrheic dermatitis, leg ulcers, psoriasis)
     
  • Reactivation of eczema following oral, parenteral or intra- articular administration of a corticosteroid.
     
  • Anaphylaxis, urticaria, angioedema following parenteral ad ministration of a corticosteroid.
Diagnostic methods
Cutaneous testing.
 
Patch-tests must be read at 48 and 96 hours, but also at day 7 or 10 (delayed reactions due to the anti-inflammatory effects of the topical corticosteroids).
 
Interpretation of the tests is often difficult due to vasoconstriction or vasodilatation effects. In dubious cases, a repeated open application test with the corticosteroid preparation or a serial dilution of patch testing may be useful.
 
Among the corticosteroids, budesonide and tixocortol pivalate give the highest positive patch-tests (1.4%); followed by hydrocortisone-17-butyrate (1%). Clobetasol propionate and betamethasone valerate have the lowest frequency.
 
Mechanisms
Delayed contact hypersensitivity.
 
Topical corticosteroids should be included in standard patch testing: budesonide, tixocortol pivalate, hydrocortisone-17-butyrate are the best candidates.
 
Management
Avoidance.
 
Cross-reactivity between corticosteroids may be found in patch testing but is not always clinically relevant.

References

  1. Pons-Guiraud A, "Allergie aux dermocorticoïdes", Objectif. Peau., 1996; 4: 433-5
  2. Dooms-Goossens A, Andersen K.E, Brandao F.M, Bruynzeel D, Burrows D, Camarasa J, Ducombs G, Frosch P, Hannuksela M, Lachapelle J.M, Lahti A, Menne T, Wahlberg J.E, Wilkinson J.D, "Corticosteroid contact allergy: an ECDRG multicentre study", Contact. Dermatitis, 1996; 33: 40-4
  3. Lepoittevin J.P, Drieghe J, Dooms-Goossens A, "Studies in patients with corticosteroid contact allergy: understanding cross-reactivity among different steroids", Arch. Derm., 1995; 131: 31-7
  4. Coopman F, Degreef H, Dooms-Goossens A, "Identification of cross-reaction patterns in contact dermatitis from topical corticosteroids", Br. J. Dermatol., 1989; 121: 27-34

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.