Q:

7/25/2013
I have a 67 yo female with known Solumedrol allergy with resultant generalized macular rash that occurred into her course of Medrol dose pak two times. One month ago, she had cataract surgery and used three eye drops, one which was Pred Forte and had a resultant generalized macular rash within 24 hours, which was pruritic. (The other two eye drops she's had in the past and had no reactions.) She had no other systemic symptoms. She is due for her right eye cataract surgery soon. The opthalmologists want to use a topical steroid again. In particular, they would like Lotemax. Other ocular steroids are Durezol or flurometholone. I was wondering if there were any known literature about allergic reactions to ocular steroids and cross-reactiviity, since I find the oral and topical steroid articles not as helpful in this situation. Also, would doing a challenge (after SPT) so soon after this reaction be wise? Thank you!

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, hopefully, you, in consultation with the ophthalmologist, will be able to choose a drop least likely to cross-react with methylprednisolone and prednisone both of which are in class-1 However, as noted in the references, oftentimes cross-reactivity occurs regardless of the choice. Unfortunately judging from its name, Lotemax (loteprednol), although not mentioned in either list, appears to be in class-1. Therefore flurometholone may be more suitable. You could also consider patch testing to both agents to further refine the choice. On the other hand, in answer to your question, I don't think a skin prick test would be of help since the reactions you describe don't appear to be Ige mediated. I also would not consider a challenge since the only valid challenge would be to use the drops intra-ocularly

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)

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

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology