Feature Review:

Corticosteroid Allergy

Vincent St Aubyn Crump ? April 2006

Corticosteroids are the most widely used class of drugs in dermatology and in the emergency management of several allergic diseases, including asthma and anaphylaxis.

People with chronic eczema who require multiple prescriptions of topical steroids are at increased risk of becoming sensitized to topical steroids. This condition is increasing due to widespread use, but also heightened awareness that "the most useful anti-inflammatory preparation for treating dermatitis could itself be a cause of inflammation", and improved testing techniques. However, it is still under diagnosed, not only because of lack of awareness, but also because the manifestation is usually very subtle. Some of these subtle presentations include:

• Patient with chronic eczema getting worse over the years, & requiring more and more steroids despite avoiding all the known triggers and complying with the prescribed treatment.
• Frequent, recurrent secondarily infected eczema, improving on antibiotics and then relapsing as soon as the antibiotics is stopped. This might be due to the fact that some antibiotics also have anti-inflammatory properties.
• Some patients might notice that their eczema is actually worsened by some steroid preparations, and will "only improve on specific brands of steroids".
• Patients with eczema, on treatment with topical steroids might start developing hives, and increased itching, due to contact urticaria from the steroid. These patients might notice a significant improvement when they are put on oral antihistamines (even the non-sedating ones, which classically are of little benefit in eczema)
• Patients with eczema that can only be controlled on oral steroids, and always relapse when weaned onto topical steroids, even when this is done slowly.
• Increased redness and itching after applying their steroid creams
• Diagnosis picked on Patch Test, without any previous suspicion by the patient or their doctors. This group should be hopefully decreasing, as awareness increases.

Other presentations of corticosteroid allergy include:

• Occupational contact sensitization to topical corticosteroids may rarely occur in pharmacists (1)
• Acute eczematous reaction, with marked erythema and oedema, sometimes with even erythema multiforme-like symptoms.
• Eczematous lesions, particularly of the face, sometimes with spreading to the trunk and flexures or generalized erythema and urticaria from using inhaled steroids (2)
• Local adverse effects of nasal corticosteroids have ranged from nasal congestion, pruritus, burning, and soreness to perforation of the nasal septum (2)
• Inhalation of steroids into the lung has been reported to cause pruritus, dryness, erythema and swelling of the mouth (angioedema), a dry cough and painful swallowing from inhaled or nasal steroids (2)
• Allergic contact dermatitis to nasal spray may masquerade as infectious rhinosinusitis (3)

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