Contact allergy to topical budesonide A. Peris-Tortajada, Valencia, Spain
A. Giner, C. Perez, D. Hernandez,
Allergic contact reactions to cs are not usual; however, >30 moleculesgiving rise to this condition have beenreported.’ Contactallergy to Bs wasfirst repotted in 1980 in Belgium’ concerning a patient receiving topical treatment for psoriasis. In our country, Bs is only available in aerosol for topically treating rhinitis and bronchial asthma.We describea contact reaction to Bs manifestedasperinasaldermatitis and endonasal intolerance. Although local adverse reactions to cs (atrophy, Can&a infection, bleeding, etc.) are wellknown, contact allergy induced by nasal or bronchial application has only been reported in two caseswith tixocortol pivalate3and Bs.~ CASE REPORT A 46-year-old woman, suffering from endogenous chronic rhinitis and intrinsic asthma,developed,in December 1988, dermatitis on the nose and upper lip. She was treated successfully with a commercial cream containing 1% hydrocottisone. In that time, she daily used salbutamol and beclomethasonedipropionate (aerosol) to control asthmaand occasionally oral antihistaminics for her rhinitis. She also used, sometimes,a commercial nasal spray (Rhinocott; Draco AB, Lund, Sweden)containing Bs. She had previously toleratedtheseproducts. Subsequentlyto the onset of the dermatitis, the patient herself stoppedthe use of the nasal spray. In April 1989, a relapse of her rhinitis was retreated with Rhinocort spray. After the third application, shedeveloped perinasal dermatitis and worsening of her rhinitis. An allergic-contact reaction was suspected,and after the agent wasremoved,shewas submittedto our department3 months later for patch testing. An open skin test with the commercial product (Rhinocort) demonstratedan erythematousedematousreaction 48 hours later. Two seriesof tests were carried out: the Europeanstandard seriesand a secondtest including the suspectedagent and the components,individually (supplied by IFESA S.A., Spain), and a battery of 10 cs: tixocortol pivalate, 1%; hydrocortisone, 2.5% ethanol; halcinonide, 0.1%; triamcinolone acetonide, 5%. I%, and 0.1% petrolatum; fluo-
and A. Basomba
I
I Abbreviations used cs: Corticosteroids Bs: Budesonide
TABLE I. Patch test results with Rhinocort and the components individually Hours
Rhinocort (budesonide, 0.2%) Budesonide 1% 0.5% 0.25% 0.025% Sorbitol trioleate* Freont
48
96
120
+++
nr
N
-
+++ +++ +++ ++ -
+++ +++ +++ ++ -
nr, Not read. *Surface-active agent. Wropellent agent.
cinolone acetonide, 5%. I%, and 0.25% petrolatum; Auocortolone, 0.2%; prednisolone, 1%; dexamethasone,1%; betamethasone, 1%; and beclomethasone dipropionate, 0.05%. RESULTS
The Europeanstandardseriesdemonstratedpositive reactions against nickel and cobalt salts. All tested concentrationsof Bs were strongly positive, with an intense vesicular reaction at 96 hours
and even at 120 hours. The other componentsof the commercial product (sorbitol ttioleate and Freon) elicited negative results (Table I). No positive reactions were found with the other cs
that were tested. From the Allergy Division of Hospital La Fe, Valencia, Spain. Reprint requests: Dra. A. Perk-Tortajada, Hospital La Fe. S. Alergia, Avda. Campanar 21, 46009 Valencia, Spain. 1/1/26605
DISCUSSION
Clinical diagnosis and patch testing (regarding cs) are not always easy to perform5 for a number of rea597
598
Perk-Tortajada
J. ALLERGY
et al.
sons: (1) Because of its anti-inflammatory effect, the sensitization to cs may only be expressed by the failure of the treatment. (2) Epicutaneous tests with cs are standardized neither for concentration nor for vehicle. High concentrations may mask a positive reaction, whereas concentrations too low may elicit false negative reactions. (3) Furthermore, the bioavailability of a .cs is higher in a commercial preparation, with vehicles enhancing penetration, than in a dilution in petrolatum for patch testing. Patch testing performed with Bs in petrolatum (from 0.025% to 0.1%) proved to be useful for the diagnosis of contact allergy in our patient. Cs, structurally closely related, may have crosssensitivity. Coopman and Dooms-Goossen@ proposed a structural classification of cs. According to this proposal, Bs (butyraldehyde of prednisolone acetonide) would be placed in class B cs (with a C,,.,,-cis-diol or ketal chain structure), closely related to halcinonide , amcinonide , triamcinolone , and fluocinolone acetonide. The most used steroids, and specially those closely related to Bs, were tested with negative results; it was not possible in this patient to determine any
CLIN. IMMUNOL. FEBRUARY 1991
steroid cross-reaction, as in the case described by Meding and Dahlberg.4 This is, to our knowledge, the first case reported in the literature about allergy to Bs used in aerosol. As a practical consequence, clinical symptomatology in our patient (specially worsening of rhinitis) emphasize that contact allergy must be suspected in patients treated with cs in aerosol when there is nasal intolerance, even if there is not dermatitis. REFERENCES I.
Boujnah-Khouadja A, Brondle I, Reuter G, FoussereauJ. Allergy to two new cortioid molecules. Contact Dermatitis
1984;11:83-7. 2. Van Hecke E, Temmerman L. Contact allergy to the cortico-
steroid, budesonide.Contact Dermatitis 1980:6:509. 3. Camarasa JG, Malet A, Serra-Baldrich E, Lluch M. Con-
tact allergy to tixocortol pivalate. Contact Dermatitis 1988;19: 147-8. 4. Meding B, Dahlberg E. Contact allergy to budesonidein a nasal
spray. Contact Dermatitis 1986;14:253-4. 5. Dooms-GoossensA. Identification of undetectedcortlcosteroid
allergy. Contact Dermatitis 1988;18:124-5. 6. Coopman S, Dooms-GoossensA. Cross-reactionsin topical
corticosteroid contact dermatitis. Contact Dermatitis 1988;19: 145-6.
AVAILABLE NOW! The FIVE-YEAR (1981-1985) CUMULATIVE INDEX TO THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY can he purchased from the Publisher for $42.00. This comprehensive, 156~page reference guide is a current presentation of all topics included in the JOURNAL from January 1981 to December 1985 (volumes 67-
76)-the past 10 volumes. It incorporatescomplete referencesto over 672 original articles, abstracts,casereports, letters, editorials, and CME articles. It features 1,525 Subject Headings, under which there are 5,3 16 references.Each subject entry lists the complete article title, author(s), volume, page, and year of publication. It also includes 4,780 Author Entries, listing contributors, along with their respectivetitles, author-to-authorrefexraI, volume, page, and publication date. To purchase, call or write: Mosby-Year Book, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, or telephone FREE l-800-325-4177, Journal FulfiBment, ext. 4351 (in Missouri call collect at 314-872-8370, Journal Fulfillment, ext. 4351). Please referencebook code number 2605-6 when placing your order. PREPAYMENT REQUIRED. Make checkspayable to Mosby-Year Book, Inc. (All paymentsmust be in US funds drawn on a US bank.) Price: $42.00 in the US, $44.75 international (price includes mailing charges).
A. Giner, C. Perez, D. Hernandez,
Allergic contact reactions to cs are not usual; however, >30 moleculesgiving rise to this condition have beenreported.’ Contactallergy to Bs wasfirst repotted in 1980 in Belgium’ concerning a patient receiving topical treatment for psoriasis. In our country, Bs is only available in aerosol for topically treating rhinitis and bronchial asthma.We describea contact reaction to Bs manifestedasperinasaldermatitis and endonasal intolerance. Although local adverse reactions to cs (atrophy, Can&a infection, bleeding, etc.) are wellknown, contact allergy induced by nasal or bronchial application has only been reported in two caseswith tixocortol pivalate3and Bs.~ CASE REPORT A 46-year-old woman, suffering from endogenous chronic rhinitis and intrinsic asthma,developed,in December 1988, dermatitis on the nose and upper lip. She was treated successfully with a commercial cream containing 1% hydrocottisone. In that time, she daily used salbutamol and beclomethasonedipropionate (aerosol) to control asthmaand occasionally oral antihistaminics for her rhinitis. She also used, sometimes,a commercial nasal spray (Rhinocott; Draco AB, Lund, Sweden)containing Bs. She had previously toleratedtheseproducts. Subsequentlyto the onset of the dermatitis, the patient herself stoppedthe use of the nasal spray. In April 1989, a relapse of her rhinitis was retreated with Rhinocort spray. After the third application, shedeveloped perinasal dermatitis and worsening of her rhinitis. An allergic-contact reaction was suspected,and after the agent wasremoved,shewas submittedto our department3 months later for patch testing. An open skin test with the commercial product (Rhinocort) demonstratedan erythematousedematousreaction 48 hours later. Two seriesof tests were carried out: the Europeanstandard seriesand a secondtest including the suspectedagent and the components,individually (supplied by IFESA S.A., Spain), and a battery of 10 cs: tixocortol pivalate, 1%; hydrocortisone, 2.5% ethanol; halcinonide, 0.1%; triamcinolone acetonide, 5%. I%, and 0.1% petrolatum; fluo-
and A. Basomba
I
I Abbreviations used cs: Corticosteroids Bs: Budesonide
TABLE I. Patch test results with Rhinocort and the components individually Hours
Rhinocort (budesonide, 0.2%) Budesonide 1% 0.5% 0.25% 0.025% Sorbitol trioleate* Freont
48
96
120
+++
nr
N
-
+++ +++ +++ ++ -
+++ +++ +++ ++ -
nr, Not read. *Surface-active agent. Wropellent agent.
cinolone acetonide, 5%. I%, and 0.25% petrolatum; Auocortolone, 0.2%; prednisolone, 1%; dexamethasone,1%; betamethasone, 1%; and beclomethasone dipropionate, 0.05%. RESULTS
The Europeanstandardseriesdemonstratedpositive reactions against nickel and cobalt salts. All tested concentrationsof Bs were strongly positive, with an intense vesicular reaction at 96 hours
and even at 120 hours. The other componentsof the commercial product (sorbitol ttioleate and Freon) elicited negative results (Table I). No positive reactions were found with the other cs
that were tested. From the Allergy Division of Hospital La Fe, Valencia, Spain. Reprint requests: Dra. A. Perk-Tortajada, Hospital La Fe. S. Alergia, Avda. Campanar 21, 46009 Valencia, Spain. 1/1/26605
DISCUSSION
Clinical diagnosis and patch testing (regarding cs) are not always easy to perform5 for a number of rea597
598
Perk-Tortajada
J. ALLERGY
et al.
sons: (1) Because of its anti-inflammatory effect, the sensitization to cs may only be expressed by the failure of the treatment. (2) Epicutaneous tests with cs are standardized neither for concentration nor for vehicle. High concentrations may mask a positive reaction, whereas concentrations too low may elicit false negative reactions. (3) Furthermore, the bioavailability of a .cs is higher in a commercial preparation, with vehicles enhancing penetration, than in a dilution in petrolatum for patch testing. Patch testing performed with Bs in petrolatum (from 0.025% to 0.1%) proved to be useful for the diagnosis of contact allergy in our patient. Cs, structurally closely related, may have crosssensitivity. Coopman and Dooms-Goossen@ proposed a structural classification of cs. According to this proposal, Bs (butyraldehyde of prednisolone acetonide) would be placed in class B cs (with a C,,.,,-cis-diol or ketal chain structure), closely related to halcinonide , amcinonide , triamcinolone , and fluocinolone acetonide. The most used steroids, and specially those closely related to Bs, were tested with negative results; it was not possible in this patient to determine any
CLIN. IMMUNOL. FEBRUARY 1991
steroid cross-reaction, as in the case described by Meding and Dahlberg.4 This is, to our knowledge, the first case reported in the literature about allergy to Bs used in aerosol. As a practical consequence, clinical symptomatology in our patient (specially worsening of rhinitis) emphasize that contact allergy must be suspected in patients treated with cs in aerosol when there is nasal intolerance, even if there is not dermatitis. REFERENCES I.
Boujnah-Khouadja A, Brondle I, Reuter G, FoussereauJ. Allergy to two new cortioid molecules. Contact Dermatitis
1984;11:83-7. 2. Van Hecke E, Temmerman L. Contact allergy to the cortico-
steroid, budesonide.Contact Dermatitis 1980:6:509. 3. Camarasa JG, Malet A, Serra-Baldrich E, Lluch M. Con-
tact allergy to tixocortol pivalate. Contact Dermatitis 1988;19: 147-8. 4. Meding B, Dahlberg E. Contact allergy to budesonidein a nasal
spray. Contact Dermatitis 1986;14:253-4. 5. Dooms-GoossensA. Identification of undetectedcortlcosteroid
allergy. Contact Dermatitis 1988;18:124-5. 6. Coopman S, Dooms-GoossensA. Cross-reactionsin topical
corticosteroid contact dermatitis. Contact Dermatitis 1988;19: 145-6.
AVAILABLE NOW! The FIVE-YEAR (1981-1985) CUMULATIVE INDEX TO THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY can he purchased from the Publisher for $42.00. This comprehensive, 156~page reference guide is a current presentation of all topics included in the JOURNAL from January 1981 to December 1985 (volumes 67-
76)-the past 10 volumes. It incorporatescomplete referencesto over 672 original articles, abstracts,casereports, letters, editorials, and CME articles. It features 1,525 Subject Headings, under which there are 5,3 16 references.Each subject entry lists the complete article title, author(s), volume, page, and year of publication. It also includes 4,780 Author Entries, listing contributors, along with their respectivetitles, author-to-authorrefexraI, volume, page, and publication date. To purchase, call or write: Mosby-Year Book, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, or telephone FREE l-800-325-4177, Journal FulfiBment, ext. 4351 (in Missouri call collect at 314-872-8370, Journal Fulfillment, ext. 4351). Please referencebook code number 2605-6 when placing your order. PREPAYMENT REQUIRED. Make checkspayable to Mosby-Year Book, Inc. (All paymentsmust be in US funds drawn on a US bank.) Price: $42.00 in the US, $44.75 international (price includes mailing charges).
