Q:

5/16/2013
If a patient is patch test positive to tixocortol pivalate, what topical steroid can be used?

A:

Thank you for your inquiry.

There are a number of excellent references that discuss the issue of cross-reactivity between topical corticosteroids. I have copied for you below two classifications regarding the cross-reactivity of corticosteroids and the source of these are also given. In addition, the scientific underpinnings thought to account for the cross-reactivity is found in the abstract by Coopman, et al., from the British Journal of Dermatology. The sources that I have copied for you below are in good part based upon Coopman’s classification.

An excellent article discussing the issue of cross-reactivity of topical corticosteroids, which has a concise discussion of Coopman’s study is found in Medscape. This article is available to you free of charge. The section is a little too lengthy to copy here, but you will find it very helpful.

Using this information, you should have no trouble in selecting a topical corticosteroid that is least likely to cross-react with tixocortol pivalate. However, as noted in the references, oftentimes cross-reactivity occurs regardless of the choice.

Thank you again for your inquiry and we hope this response is helpful to you.

Br J Dermatol. 1989 Jul;121(1):27-34.
Identification of cross-reaction patterns in allergic contact dermatitis from topical corticosteroids.
Coopman S, Degreef H, Dooms-Goossens A.
Abstract
Contact allergy to topical corticosteroids occurs more frequently than previously supposed. Cross-allergic phenomena are common. On the basis of a review of the literature and our own patch test data on 15 patients, we conclude that positive patchtests to corticosteroids occur approximately six to seven times more frequently in well-defined groups of structurally-related substances than between corticosteroids of different groups. An analogous substitution pattern on the steroid D-ring or the carbon side chain (C20, C21) seems to have a significant influence on the association of positive patchtest results. This is not the case for other structural variables, such as the presence of a double bond in the steroid A-ring or fluoride substitutions on the B-ring. The effect of other factors such as concomitant sensitization and steroid metabolism in the skin on the development of a corticosteroid polyallergy are analyzed, and the specificity and sensitivity of cross-allergy phenomena are evaluated. These are important in the selection of a topical steroid in the future treatment of a corticosteroid sensitive patient.

SOURCE: DermNet NZ When patch tests show allergy to a specific topical steroid, it is likely that the patient will also be allergic to others.

• Budesonide may result in allergy to fluocinolone, triamcinolone, hydrocortisone-17-butyrate, methylprednisolone aceponate and prednicarbate.

• Tixocortol-21-pivalate may result in allergy to hydrocortisone (acetate), prednisolone, diflucortolone, methylprednisolone, hydrocortisone-17-butyrate, methylprednisolone aceponate and prednicarbate.

• Hydrocortisone-17-butyrate allergy may result in allergy to methylprednisolone aceponate, prednicarbate, alclomethasone dipropionate, budesonide and hydrocortisone (acetate).

Cross-reactions patterns of corticosteroids (Lepoittevin JP, Driegh J, Dooms-Goossens A. Studies in patients with corticosteroids contact allergy: understanding cross-reactivity among different steroids. Arch Dermatol 1995; 131(1):91-2) Source: Auckland Allergy Clinic.

Most steroid allergic patients react to several different steroids demonstrating that concomitant sensitization and / or cross-reactions occur. It is hypothesized that cross-reactions occur in certain groups of steroids. It is found that molecules of the same group have similar spatial structures to explain the cross-reaction observed (8).

Classification of corticosteroids by the function of their allergenicity (8)

• Group A: Hydrocortisone and tixocortol Type
• Prednisone
• Prednisolone acetate (Pred mild & Pred forte eye drops)
• Methylprednisolone aceponate (Advantan)
• Meprednisone
• Cortisone, Cortisone acetate
• Hydrocortisone (-HC, Egocort, Cortaid, Skincalm)
• Tixocortol pivalate
• Group B: Triamcinalone acetonide Type
• Triamcinalone alcohol
• Triamcinalone acetonide (Aristocort)
• Budesonide (Pulmicort, Butacort & Entocort),
• Amcinonide, desonide
• Halcinonide
• Fluocinonide (Metosyn)
• Fluocinolone acetonide (Synalar)
• Group C: Betamethasone Type
• Betamethasone sodium phosphate
• Dexamethasone, dexamethasone sodium phosphate
• Fluocortolone
• Group D: Hydrocortisone-17-butyrate & Clobetasone 17 butyrate Type
• Hydrocortisone butyrate) (Locoid)
• Hydrocortisone-17-valerate
• Clobetasol propionate (Dermol, Dermovate)
• Aclometasone dipropionate
• Betamethasone 17 valerate (Betnovate, Beta)
• Betamethasone dipropionate ( Diprosone)
• Clobetasone 17 butyrate (Eumovate)
• Fluocortolone pivalate (Ultraproct)
• Mometasone Furorate (Elocon)
• Fluticasone propionate (cutivate)
Medscape

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology