University of Southern Denmark Systemic allergic dermatitis after patch testing with cinchocaine (dibucaine) and topical corticosteroids Alves da Silva, Catarina; Paulsen, Evy Published in: Contact Dermatitis DOI: 10.1111/cod.13290 Publication date: 2019 Document version: Accepted manuscript Citation for pulished version (APA): Alves da Silva, C., & Paulsen, E. (2019). Systemic allergic dermatitis after patch testing with cinchocaine (dibucaine) and topical corticosteroids. Contact Dermatitis, 81(4), 301-303. https://doi.org/10.1111/cod.13290 Go to publication entry in University of Southern Denmark's Research Portal Terms of use This work is brought to you by the University of Southern Denmark. Unless otherwise specified it has been shared according to the terms for self-archiving. If no other license is stated, these terms apply: • You may download this work for personal use only. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying this open access version If you believe that this document breaches copyright please contact us providing details and we will investigate your claim. Please direct all enquiries to [email protected] Download date: 27. Sep. 2021 Systemic allergic dermatitis after patch testing with dibucaine and topical corticosteroids Catarina Alves da Silva1 Evy Paulsen1 1) Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, Odense C, Denmark Correspondence Catarina A. Silva Department of Dermatology and Allergy Centre Odense University Hospital University of Southern Denmark DK-5000 Odense C Denmark Email: [email protected] Telephone number: +45 6541 2705 Key words: case report; dibucaine; corticosteroids; drug hypersensitivity; mometasone furoate; ; patch test; systemic allergic dermatitis; phenylephrine Conflict of interests: none declared. This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which Accepted Article may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/cod.13290 This article is protected by copyright. All rights reserved. Systemic allergic dermatitis arises if an individual sensitised via the skin is exposed to the same allergen or a cross reacting allergen by a different route1. It is rarely elicited by cutaneous contact with an allergen2, although transepidermal rechallenge has been reported3. We report a case of systemic allergic dermatitis caused by patch testing. Case report A 69-year-old woman was referred to our department for suspected phenylephrine contact allergy. She had developed periorbital pruritic erythema and oedema one day after being examined for cataract. Her past medical history included hypertension and cerebral aneurysm. In connection with childbirth 44 years ago, the patient had used several anti-hemorrhoid ointments. More recently, the patient had applied fluocinolone acetonide gel for eczema in the ear. The patient was tested with the baseline series, including TRUE TEST panel 1-3 (AllergeEaze, Smartpractice, Arizona), an ophthalmic series (Chemotechnique Diagnostics, Vellinge, Sweden) as well as phenylephrine and Metaoxedrin (eyedrops containing phenylephrine) tested “as is” under occlusion. Readings performed at day (D) 3 showed positive patch test reactions to both phenylephrine and Metaoxedrin, as well as some allergens of the baseline series: caine mix, (benzocaine, tetracine hydrochloride and dibucaine hydrochloride), methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI), tixocortol-21-pivalate, budenoside, hydrocortisone - 17- butyrate and MI. Therefore she was additionally tested with a series of topical corticosteroids and of topical anesthetics, respectively. The results are shown in table 1. The patient was prescribed at D8 of the first test mometasone furoate cream for the patch test reactions and discharged. Two days later, the patient presented again due to pruritus and erythematous exanthema of the back and arms. She denied exposure to the sun or application of topical products in the affected areas. The presentation was interpreted as dermatitis and mometasone furoate cream was advised. Three days after the emergency consultation, eczema involved the antecubital fossae, anterior and posterior axillar folds, wrist, inner side of both thighs and anal fold (Fig. 1). Treatment with systemic prednisolone was not an attractive option due to the positive reaction to tixocortol pivalate and hence possible cross-reactivity, and mometasone furoate cream was prescribed once again, as well as zinc ointment. Three weeks later eczema had resolved and the patient was therefore discharged from the department of dermatology, to further follow-up with the general practitioner. About 8 months later, the patient was again referred to the department of dermatology after having used mometasone furoate cream, prescribed by her general practioner, for localized facial eczema. This caused a flare of dermatitis in a larger area of her face, but no systemic reaction was described. Discussion Despite treatment, the patient showed progression of dermatitis, developing lesions in previously unaffected areas. Hence, a systemic allergic hypersensitivity reaction was suspected4. In view of the patient’s later clinical reaction to mometasone furoate cream, Accepted Article there is no doubt that she was sensitised to this corticosteroid as well, although it was chosen for treatment because it is a rare cause of contact allergy5 - 7. Systemic reactions to dibucaine (cinchocaine)8, 9 have been reported and the extreme positive reaction to dibucaine suggests that this compound, perhaps together with the numerous sensitizations to topical corticosteroids of different groups, and the application of mometason furoate cream to the patch test sites, has elicited the systemic reaction. We hypothesize that the sensitization route occurred during previous This article is protected by copyright. All rights reserved. treatments with anti-hemorrhoid ointments, which typically contains both dibucaine and hydrocortisone, and during treatment with Synalar (fluocinolone acetonide). Hypersensitivity to corticosteroids can have a wide range of presentations, including systemic allergic dermatitis10. Patients with previous contact allergy to topical corticosteroids can be at risk of developing systemic allergic dermatitis when exposed to a corticosteroid orally, intravenously, intramuscularly, intra-articular or intra-nasally11. Baeck et al have studied 315 patients with corticosteroid delayed-type hypersensitivity, demonstrating that most reactions occur due to oral or parenteral re-exposure of sensitised individuals, with the respective corticosteroids being previously applied topically12. It is unusual that a person with no skin complaints in general shows such a broad sensitization to various corticosteroid molecules, including to the rare sensitizer mometasone furoate. The case demonstrates that transepidermal absorption of small amounts of haptens under occlusion may cause a systemic reaction,. systemic allergic contact dermatitis to phenylephrine in eye drops has previously been reported13. Although it is likely that dibucaine may be the primary allergen responsible, based on the very strong patch test reaction, and the literature of systemic allergic contact dermatitis caused by local treatment with this allergen, the relative contribution of the individual allergens remains unknown. To our knowledge, no cases of systemic allergic dermatitis elicited by patch testing with any of the allergens presented here have been reported. Accepted Article This article is protected by copyright. All rights reserved. References 1. Aquino M, Rosner G. Systemic Contact Dermatitis. Clinical Reviews in Allergy & Immunology. 2019;56:9-18 2. Mussani F, Poon D, Skotnicki-Grant S. Systemic Contact Dermatitis to Topical Clioquinol/Hydrocortisone Combination Cream. Dermatitis. 2013;24:196–197 3. Jacob S, Zapolanski T. Systemic Contact Dermatitis. Dermatitis; 2008;19:9-15. 4. Faber MA, Sabato V, Ebo DG, Verheyden M, Lambert J, Aerts O. Systemic allergic dermatitis caused by prednisone derivatives in nose and eardrops. Contact Dermatitis. 2015;73:317-320 5. Wilkinson SM, Beck MH. Fluticasone propionate and mometasone furoate have a low risk of contact sensitization. Contact Dermatitis. 1996;34:365–366. 6. Seyfarth F, Elsner P, Tittelbach J, et al. Contact allergy to mometasone furoate with cross-reactivity to group B corticosteroids. Contact Dermatitis. 2008;58:180–181. 7. Donovan JC, Dekoven JG. Cross reactions to desoximetasone and mometasone furoate in a patient with multiple topical corticosteroid allergies. Dermatitis. 2006;17:147– 151. 8. Erdmann S, Sachs B, Merk F. Systemic contact dermatitis from cinchocaine. Contact Dermatitis. 2001;44:260-1 9. Marques C, Faria E, Machado A, Gonçalo, M, Gonçalo S. Allergic contact dermatitis and systemic contact dermatitis from chinchocaine. Contact Dermatitis. 1995;33:443 10. Vatti R, Ali F, Teuber S, Chang C, Gershwin ME. Hypersensitivity reactions to corticosteroids. Clinic Rev Allerg Immunol. 2014;47:26 - 37 11. Barbaud A, Waton J. Systemic Allergy to Corticosteroids: Clinical Features and Cross Reactivity. Curr Pharm Des. 2017;22:6825-6831. 12. Baeck M, Goossens A. Systemic contact dermatitis to corticosteroids. Allergy.