A patient with persistent urticaria related to the premenstrual phase of the menstrual cycle is presented. Although systemic administration of progesterone provoked the eruption, we were unable to confirm that there was an immunological reaction to endogenous progesterone or oestrogen. Mechanisms whereby progesterone can augment subclinical types I and IV hypersensitivity reactions are discussed.Case report
Summary Background Most studies investigating steroid allergy have been performed with tixocortol pivalate, hydrocortisone butyrate and budesonide. Betnovate® and Dermovate® are widely prescribed in the U.K. but little is known about the frequency of sensitization to them.
Objectives To determine the optimum method to detect contact allergy to betamethasone valerate (BV) and clobetasol propionate (CP).
Methods Seven centres tested consecutive patients attending for investigation of suspected allergic contact dermatitis to these steroids at a range of concentrations in different vehicles.
Results Of 1562 patients tested, 16 (1%) reacted to either BV or CP. Ten patients (0·7%) reacted to BV and 13 (0·8%) to CP. Two patients of a further centre were included in analysis of dilutions and vehicles. Sixteen of a total of 25 reactions (64%) were identified with a 1% dilution in ethanol.
Conclusions Consideration should be given to adding BV and CP to a standard allergy series, given that both are frequently used in the treatment of eczema and that most patients sensitized to them are not identified with currently used markers of steroid allergy. If patch tests to BV and CP are initially negative, but an allergy is suspected, the patient should be further investigated. Further studies are required to identify the ideal patch test material.
Hypersensitivity to topical corticosteroids is a common cause of allergic contact dermatitis. The development of contact allergy is dependent on individual susceptibility, exposure to the potential allergen and the ability to penetrate the epidermis and react with epidermal protein. We looked at corticosteroid binding to arginine and relative usage of corticosteroids to see if these variables explain the number of allergic reactions seen to these structurally similar chemicals. A linear relationship was found between a measure of corticosteroid binding to arginine, the log of relative corticosteroid usage and the log of the relative number of corticosteroid allergies. Using multiple regression this association was significant (P = 0.01). Statistically, these two variables accounted for 73% of the variation in the results. Our results showed that the number of corticosteroid allergic reactions was dependent on usage and the intrinsic ability of the corticosteroid to degrade and bind to arginine. While total corticosteroid usage is unlikely to change, the prescription of individual corticosteroids with a reduced potential to degrade and bind to protein, but with equal efficacy, might reduce the overall prevalence of corticosteroid hypersensitivity.
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