CD07 Corticosteroids: a complex case of friend and foe

Abstract Hypersensitivity reactions to corticosteroids, either immediate or delayed, represent a clinical paradox as one would not expect such reactions to compounds with anti-inflammatory and immunomodulatory effects. We present the case of a 67-year-old patient referred to our service with three episodes of a delayed hypersensitivity reaction to steroids. The first episode occurred in 2016 when the patient was treated for a chest infection with amoxicillin and 5-mg prednisolone. Following 1 day of treatment, the patient developed a widespread erythematous rash. The patient remained systemically well, and the rash resolved over 3 weeks. Subsequently, the patient tolerated penicillin with no issues. In April 2019, following a bupivacaine and triamcinolone steroid injection to the shoulder and back for pain management, the patient developed a widespread erythematous rash. The patient denied any blistering or peeling of the skin and was systemically well. This rash took ∼3 weeks to settle. In August 2019, the patient had a dexamethasone injection to her back and subsequently developed a widespread erythematous pruritic rash. On this occasion, the patient reported symptoms of nausea and headache. The patient has avoided all steroids since 2019 and has developed no rashes. The patient had a negative skin prick test to bupivacaine under the care of immunology. Patch testing results showed positivity to 10/13 compounds tested in the corticosteroid series (Table 1). The patient had a negative patch test result to tixocortol-21-pivalate (0.1%) and to hydrocortisone-21-acetate (1%). In the fragrance series, the patient tested positive to one compound, Santalum album oil (sandalwood oil) 2%. Corticosteroids are classified into four groups (A, B, C and D), with the last subdivided into D1 and D2. A further classification proposed divides corticosteroids into three groups based on their structural characteristics. Allergic reactions to corticosteroids have been reported, with an estimated prevalence of 0.1–0.3%, with contact dermatitis to corticosteroids having a higher frequency (0.5–5%). Although not life-threatening, contact allergy to corticosteroids can have significant impacts on quality of life and on treatment.Table 1Corticosteroid series patch testing resultsHapten/compound%48 h96 hBudesonide0.01+/–+++Betamethasone-17-valerate1++Triamcinolone acetonide1++Tixocortol-21-pivalate0.1Alclometasone-17,21-dipropionate1+/–Clobetasol-17-propionate1++Dexamethasone-21-phosphate disodium salt1+Hydrocortisone-17-butyrate+/–+++Desoximetasone1+++Betamethasone-17,21-dipropionate1+++Methylprednisolone aceponate1+++Corticosteroid mix2.1++++Hydrocortisone-21-acetate1