Q:

2/4/2012
I have read extensively on Autoimmune Progesterone Dermatitis and have a patient who had a positive intradermal progesterone test. The current question is whether to treat medically or surgically. And the complicating factor is that although her skin eruptions flare for the duration of her luteal phase, there are 2 definitive peaks in her flare correlating with ovulation and just prior to the onset of menses, corresponding with the times that estrogen is highest in her cycle. Therefore, at 41 years of age, a BSO may not be the best option for her if hormone replacement therapy is not an option secondary to estrogen sensitivity in addition to her known and proven progesterone sensitivity. She may need to be medically treated with hormone suppression or receptor blockade. I would like to perform an intradermal estrogen challenge and need to learn the details of where to order the conjugated estrogen and how to administer the test. Would it be the same as her progesterone challenge?

A:

Thank you for your inquiry.

Unfortunately, autoimmune estrogen dermatitis is not a condition which allergists treat with any regularity, and the vast majority of the literature is in dermatology journals. As a rule, we are far more familiar with a similar condition, progesterone-induced anaphylaxis. My response to you therefore is based not on any personal experience in dealing with autoimmune estrogen dermatitis, but rather based on the application of principles applied to the treatment of patients with progesterone-related anaphylaxis, and a reading of the literature.

I can answer one of your questions with confidence, however - that is the inquiry regarding an estrogen skin test. You mentioned the word "challenge," but I assume that you are speaking of the skin test because you used the word "intradermal" and you previously mentioned that the patient had a positive intradermal skin test to progesterone.

Thus, assuming that you do mean a "skin test" rather than "challenge," the technique would be identical to that employed with progesterone. There is an excellent discussion of skin tests to estrogen as well as other hormones in an old but somewhat iconic article from the Journal of American Academy of Dermatology. It is by Walter Shelley, M.D., Ph.D., and colleagues, and is found in Volume 32, Issue 1, (January) 1995, Pages 25-31. This study used several estrogen preparations and gives the concentrations involved. It is readily available through academic medical libraries, and I was able to access it online through our University institution. It is also available through Science Direct and MD Consult.

Unfortunately, even with this study, the exact concentrations for testing to estrogen are not well validated in that there has not, to my knowledge, been a great deal of controls utilized, and therefore differences between irritant and truly immunologic responses have not been worked out completely for various concentrations in a large number of individuals.

There is no true estrogen preparation for skin tests per se. You would simply need to either solubilize an estrogen tablet or obtain a liquid preparation which is used for injection. The latter of course would be far easier. You could make concentrations by diluting the intramuscular injection preparation.

There are at least two preparations available. These are estradiol valerate and estradiol cypionate. For your convenience, I have copied below links to information regarding both.

Finally, just applying principles that we use in suppressing ovulation in patients who experience progesterone-induced anaphylaxis, it might be simplest to apply a few months trial of an LHRH agonist to suppress estrogen and progesterone synthesis. The hormone levels may rise initially with this therapy, but then usually go down to postmenopausal levels after two to three months. The changes are entirely reversible once the agonist is stopped. We have used this to control episodes in young women, or to consider whether or not an oophorectomy would be of value long-term. Another reason to utilize this concept is that we, to be truthful, do not know the true meaning of a positive intradermal skin test in the pathogenesis of possible estrogen-induced dermatitis. This condition does not seem to be IgE-mediated, and in fact the mechanism of production is probably unknown. Therefore interpreting a positive or negative skin test in this context cannot be done definitively.

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

http://www.paddocklabs.com/html/products/pdf/Estadiol%20Valerate%20PI(02-10).pdf

http://www.drugs.com/cdi/estradiol-cypionate.html

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology