[Allergic contact dermatitis and systemic contact dermatitis in a patient with polysensitization to topical corticosteroids].

Although allergic contact dermatitis (ACD) due to corticosteroids is a well-known and relatively common phenomenon, the systemic administration of corticosteroids only rarely produces skin reactions (systemic contact dermatitis [SCD]). We present the case of a patient with ACD to various corticosteroids, and who subsequently developed SCD to multiple systemic corticosteroids. A 47-year-old man was seen in our outpatient clinic for a plaque of alopecia areata on the scalp. A 0.1% methylprednisolone aceponate emulsion was prescribed. Four days later, pruritic, macular, desquamative, erythematous lesions developed on the eyelids, neck, and around the plaque of alopecia. With a suspected diagnosis of corticosteroid-related ACD, 1% pimecrolimus cream was prescribed and skin patch testing was performed with True Test, using a series of corticosteroids and steroidcontaining products (Lexxema emulsion). Readings were made on days 2, 5, and 7, obtaining positive reactions to multiple corticosteroids (Table 1, Figure). Skin prick and intradermal reaction tests were performed with hydrocortisone, prednisone, methylprednisolone, prednisolone, dexamethasone, and deflazacort, giving negative results, and oral therapeutic doses were then administered. Pruriginous, erythematous lesions affecting the neck, axillas, groin, and perineum (baboon-like) developed in all cases after a period of 6 to 24 hours. The lesions did not recur on placebo challenge. The skin biopsy of one of the lesions showed spongiotic dermatitis with a superficial perivascular inflammatory infiltrate and dermal edema. A diagnosis was made of ACD and SCD due to corticosteroids, with polysensitization. A use test was performed with 0.1% mometasone furoate cream, which did not produce lesions after 10 days, and this was therefore indicated for treatment if topical corticosteroids were required. Corticosteroid-related ACD must be suspected when there is a deterioration or prolongation of a previous dermatitis or when the expected improvement does not occur. Using patch tests, Gonul and Gul1 demonstrated sensitization in 22% of patients diagnosed with ACD who did not respond to topical corticosteroids. The rates of positivity to corticosteroids in patch tests vary between 0.52% and 6%, which has led to these allergens being included in a number of standard series.2-4 In Spain, the Spanish Contact Dermatitis Research Group (GEIDC) initially introduced 1% tixocortol pivalate in petroleum jelly, subsequently adding 0.1% budesonide in petroleum jelly. In 2007, hydrocortisone-17-butyrate was also added to the True Test. In the epidemiologic study of ACD in Spain published by the GEIDC in 2001, positivity to corticosteroids was only detected in 1.01%.5 We do not know the present levels with the new corticosteroids used for screening. In a retrospective study of 1188 patients undergoing patch tests with a specific corticosteroid series, it was shown that if tixocortol pivalate alone had been used, less than 50% of the sensitizations would have been detected.6