Allergy to topical corticosteroids

What are corticosteroids and where are they found?

Corticosteroids, also referred to as steroids or cortisone, are a group of anti-inflammatory agents used in the treatment of many conditions and diseases. There are many different types of corticosteroids with varying potencies and actions. Topical corticosteroids are used in many inflammatory rashes. They are available in a variety of forms such as creams, ointments, lotions, eye preparations and eardrops.

Topical steroids are also commonly found in combination preparations with antibacterials and antifungal agents. These prescription and non-prescription preparations are used to treat a variety of skin, eye and external ear disorders that have become inflamed and sometimes infected.

Corticosteroids or steroids are not related to the anabolic steroids that are misused by some athletes to increase performance.

What are the reactions in cases of corticosteroid allergy?

Topical corticosteroid sensitivity produces classic allergic contact dermatitis reactions. Usually this is seen as a failure to improve or a worsening of an existing dermatitis that is being treated with corticosteroids. Very rarely, corticosteroid allergy may appear as an eczematous rash in a completely different area of the body from the original dermatitis.

Very rarely, severe allergy to a topical corticosteroid is associated with allergy to oral or injected corticosteroids.

Am I allergic to topical corticosteroids?

Allergic sensitivity to topical corticosteroids is usually only picked up when an eczematous dermatitis being treated by a topical corticosteroid fails to respond to treatment or worsens. In cases of persistent or exacerbating dermatitis treated with corticosteroid preparations, corticosteroid sensitivity should be considered. However, it may also be due to irritation from or allergy to other components of the preparation. These may include lanolin, ethylenediamine, quaternium-15 and the antibacterial agent neomycin, all known to be potent sensitisers.

Corticosteroid allergy is diagnosed by performing special allergy tests, i.e. patch tests, and in some cases intradermal tests. There are many topical corticosteroid preparations available; allergy may arise to one or more of these. Positive patch test reactions to budesonide and tixocortol-21-pivalate are a good indicator of corticosteroid allergy. These 2 corticosteroids are often included in the standard panel. Further testing with other corticosteroids should be done if these 2 indicators are positive.

Patch testing may be performed using a standard corticosteroid series. In ideal conditions, a positive patch test result to both the commercial preparation and the isolated active corticosteroid agent should be achieved to confirm the diagnosis.

Patch testing with Standard Corticosteroid Series	Positive patch test reaction
Budesonide Betamethasone-12-valerate Triamcinolone acetonide Tixocortol-21-pivalate Alclomethasone-17, 21-dipropionate Clobetasol-17-propionate Dexamethasone-21-phosphate disodium salt Hydrocortisone-17-butyrate

Cross reactions

When patch tests show allergy to a specific topical steroid, it is likely that the patient will also be allergic to others.

• Budesonide may result in allergy to fluocinolone, triamcinolone, hydrocortisone-17-butyrate, methylprednisolone acetponate and prednicarbate.
• Tixocortol-21-pivalate may result in allergy to hydrocortisone (acetate), prednisolone, diflucortolone, methylprednisolone, hydrocortisone-17-butyrate, methylprednisolone aceponate and prednicarbate.
• Hydrocortisone-17-butyrate allergy may result in allergy to methylprednisolone aceponate, prednicarbate, alclomethasone dipropionate, budesonide and hydrocortisone (acetate).

Treatment of corticosteroid allergy

Confirmation of corticosteroid allergy requires the prompt removal of the causative agent and then management as for any acute dermatitis/eczema; this may include treatment with topical corticosteroids (one which you are not allergic to) emollients and treatment of any secondary bacterial infection (Staphylococcus aureus), etc.

What should I do to avoid corticosteroid allergy?

Your doctor or dermatologist should give you a list of all the names of the corticosteroids to which you are allergic. You must avoid using any preparations that contain any of the listed corticosteroids.

Many anti-inflammatory skin preparations, antibiotic creams and ointments, eye and ear preparations contain corticosteroids (hydrocortisone). If purchasing over-the-counter products alert your pharmacist to the fact that you have a contact allergy to corticosteroids and provide them with the list of the corticosteroids you are allergic to.

Always alert your doctor to the fact that you have a contact allergy to corticosteroids so that they can prescribe you suitable alternatives if necessary.

Your dermatologist may have further specific advice, particularly if you are highly sensitive to corticosteroids.

Reference

Book: Fisher's Contact Dermatitis. Ed Rietschel RL, Fowler JF. Lippincott Williams & Wilkins 2001