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Allergic contact dermatitis to prednicarbate presenting as lupus erythematosus Contact Dermatitis 2006: 55: 247–249
Javier Sa´nchez-Pe´rez1, Silvia Pe´rez Gala1, Yolanda Delgado Jime´nez1, Javier Fraga2 and Amaro Garcı´a Diez1 1
Departments of Dermatology, and Pathology, Hospital Universitario de la Princesa, Universidad Auto´noma de Madrid, Spain
2
Key words: budesonide; corticosteroids; cross-reaction; lupus erythematosus; prednicarbate.
Introduction The frequency of contact allergic reactions to corticosteroids ranges from 0.2% to 5% in consecutive patients being patch tested because of suspected allergic contact dermatitis (1, 2). Several factors were suggested to explain this wide variation: patient selection, number and type of corticosteroids, the amount of corticosteroid degradation product reacting to arginine, and tests procedures and modes such as patch or intradermal test (2–7). Corticosteroid sensitivity has long remained underdiagnosed because its anti-inflammatory activity masks the contact allergic reaction. The lesions are generally subacute or chronic and just do not respond or can sometimes worsen with local corticosteroids (2, 3). Occasionally, contact allergy to corticosteroids may express itself as acute eczema (8), acute local oedema (9), angioedema, systemic contact dermatitis, exanthema, purpura, urticaria (10), erythema multiforme-like eruptions (11), granuloma annulare (12), and acute generalized exanthematous pustulosis (13, 14).
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Prednicarbate is a strong corticosteroid without a fluorine atom at C6a and C9a. It belongs to the group D2 (the labile ester corticosteroids) and has the structure of prednisolone with an ethyl carbonate at 17 and a propionate ester at 21. Its final metabolite is prednisolone, which retains glucocorticoid activity (15). We report a patient with allergic contact dermatitis to prednicarbate who had forehead and neck lesions clinically and histopathologically diagnosed as lupus erythematosus.
Case Report A 53-year-old atopic woman had a personal history of hay fever, conjunctivitis, and 2 years of dyshidrotic eczema that had been treated with topical corticosteroid. During the past 10 years, she had gone through self-limited outbreaks of itchy dermatitis in her face and neck. Recent outbreaks had left telangiectatic veins in these regions. The patient was admitted with itchy, confluent red macules and papules that had evolved into sharply demarcated erythematous plaques localized on her forehead and neck after having applied Peitel cream (Novag, Barcelona, Spain) 72 hr previously. Clinical lesions were diagnosed as lupus erythematosus (Fig. 1). A biopsy taken from a lesion on the forehead showed hydropic degeneration of the basal layer, oedema, and a lymphocytic infiltrate around the vessels and hair follicles (Fig. 2). Immunoglobulins (IgG, IgA, and IgM) and complement (C3, C1q) components deposited in the lesional skin were positive at the dermoepidermal junction for IgM (þþ) and C3 (þ). Laboratory features including antinuclear antibodies (ANA), antidouble-stranded DNA, and complementemia were normal or negative. Acute signs disappeared in a few weeks after avoiding the cream and treatment with Lactisona lotion (Stiefel, Madrid, Spain). Two years after, at her last follow-up visit, she still presented erythema with telangiectatic veins on her forehead and neck. Patch tests were performed with Spanish standard series, corticosteroid series (Marti Tor, Barcelona, Spain), and Peitel cream Positive reaction was observed to nickel with past relevance, budesonide 0.01% pet.,
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Fig. 1. Allergic contact dermatitis presenting as lupus erythematosus.
and Peitel cream (Novag, Barcelona, Spain) at D2 and D4, with actual relevance for the latter. A biopsy of the Peitel cream positive patch test at D4 showed a spongiotic dermatitis. A repeated open application test (ROAT) with Peitel cream was positive at 24 h with eczematous morphology in nonlesional skin. Subsequently, a patch test was performed with the individual components of Peitel cream. One of its components, prednicarbate 1% pet. and 1% alcohol was positive at D2 and D3. 20 controls with prednicarbate 1% pet. were negative.
Discussion The reported case corresponds to contact allergy to prednicarbate, clinically and histopathologically compatible with lupus erythematosus. The temporary and regional relationship between the applica-
tion of Peitel cream and the skin lesions, the positive patch test and positive ROAT in nonlesional skin, leads us to associate allergic contact dermatitis to Peitel cream and prednicarbate. Allergic contact dermatitis presenting as lupus erythematosus has been rarely reflected in the literature (16– 18). There is one published case report (16) of a patient with perioral lupus erythematosus from cinnamic aldehyde in her toothpaste. A biopsy of the cutaneous lesions showed histologic features consistent with lupus erythematosus. Another reported case (17) of allergic contact dermatitis to benzophenone involved a patient with patchy erythema of the face and neck, which may have been attributed to lupus erythematosus, rosacea diathesis, or flushing. There is an additional case of a patient with discoid lupus erythematosus and associated allergic contact dermatitis
Fig. 2. Histopathology of lupus erythematosus with hydropic degeneration of the basal layer, oedema, and lymphocytic infiltrate around the vessels.
on the eyelids (18). Finally, Deleuran et al. describe a positive patch test reaction to sensitizing substances in a woman with subacute cutaneous lupus erythematosus. She showed histologic features consistent with lupus erythematosus after 19 days, which could have been locally provoked by direct skin contact with allergens (19). In a review of the literature, we found few positive reactions to prednicarbate: less than 1% in published series (6, 20) and only some isolated cases of sensitivity to prednicarbate (9, 21, 22). In our case, we observed a positive reaction to prednicarbate and budesonide, which may indicate a primary allergic contact dermatitis and/or a crossreaction between both substances, a fact that has been already published in the literature (23). Frequently, patients with allergic contact dermatitis to corticosteroids show numerous positive reactions to various corticosteroids and other medicaments of topical use (2, 3); however, this does not seem to be the case of our reported patient.
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Address: Javier Sa´nchez-Pe´rez Servicio de Dermatologı´a Hospital Universitario de la Princesa C) Diego de Leo´n, 62 28006 Madrid Spain Tel: 91-5202433 Fax: (3491) 5202435 e-mail:
[email protected]
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