Intralesional triamcinolone acetonide-induced urticaria in a patient with alopecia areata

INTRODUCTION

Corticosteroids are most commonly used as first-line therapy in many skin diseases. They are potent anti-inflammatory, immunosuppressive, and are indicated in auto-immune, connective tissue, vascular, eczematous, and other miscellaneous disorders.^[1] Corticosteroids can cause both immediate or delayed hypersensitivity reactions, where delayed hypersensitivity reactions occur most commonly compared to immediate.^[1,2] We report a case of a 21-year-old male diagnosed to have alopecia areata with triamcinolone acetonide (TA)-induced immediate hypersensitivity reaction.

CASE REPORT

A 21-year-old male came to the outpatient department with complaints of patchy hair loss over the vertex area for the past 3 weeks. On examination, he had a single, well-defined, and patchy hair loss over the vertex area. He denied history of any personal or family history of atopy or any raised transient lesions or swelling of the lips or the eyes in the past. No past drug allergy was reported. Our treatment modality was to start him on intralesional steroid (ILS) for alopecia areata. After obtaining informed and written consent, intralesional TA (10 mg/mL) was injected. Within 10 minutes of injection, the patient developed itching, raised, reddish lesions over the face. However, no swelling of the lips or difficulty in breathing was evident. On examination, there were two, well-demarcated, wheals present over the right upper eyelid and left cheek of the face [Figures 1a and b]. Patient vitals were stable. Considering the possibility of a hypersensitivity reaction to steroids, we gave an intramuscular (IM) injection of chlorpheniramine maleate (CPM) over the right gluteal area. After 1 hour of observation, lesions resolved [Figures 2a and b], and we thereby concluded that the patient had developed an immediate hypersensitivity reaction to TA, and he was advised to abstain from the use of the drug.

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Figure 1:

(a) Wheals present over right upper eyelid. (b) Wheals over left cheek area of face.

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Figure 2:

(a-b) Wheals resolved after intramuscular injection of chlorpheniramine maleate.

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Corticosteroids are considered to be the most important therapy in dermatology today, both topically and systemically. Steroids are a double-edged weapon when not used in correct formulations, technique, dosage, and depth of injection, which can cause both cutaneous and systemic side effects.^[3,4] ILSs are indicated when topical corticosteroids are not efficacious and to prevent systemic side effects. In fact, ILS can cause cutaneous adverse reactions such as atrophy, telangiectasia, hypersensitivity reaction, secondary infection, and hypopigmentation.^[4] Intralesional TA is the most preferred drug for many skin diseases in India. TA is a Group B, intermediate-acting corticosteroid with a half-life of 24–36 hours. In our patient, within 10 minutes of ILS injection with TA, the patient developed urticaria-like skin lesions without any anaphylactic reaction. The Naranjo score is a standardized questionnaire used to assess the likelihood of adverse drug reaction (ADR), and the total score determines the probability category of ADR as definite (>9), probable (5–8), possible (1–4), and doubtful (0).^[5] Our patient had a Naranjo score of 4.

Although cross-reactivity among corticosteroids has been reported, several case studies demonstrate that hypersensitivity to a specific corticosteroid does not necessarily preclude the use of other agents within the same group.^[6] While the Coopman classification aids in selecting alternative corticosteroids, especially for topical use, it has limitations when applied to systemic corticosteroids. Therefore, a thorough clinical assessment and individual sensitivity must be evaluated carefully. Skin prick test (SPT) is usually done to evaluate immediate hypersensitivity reaction, and it is performed on the volar aspect of the non-dominant forearm with a topical steroid.^[1] We advised for SPT, but the patient denied consent for the same. Immediate hypersensitivity reaction is attributable to immunoglobulin E (IgE)-mediated allergy, wherein the allergen penetrates the epidermis and binds with IgE receptors on the mast cell, causing degeneration, leading to release of histamine and other vasoactive substances.^[1] Our patient’s symptoms got relieved after giving an IM injection of CPM. We were cautious enough not to give IV route of any injectable corticosteroids, as it could have aggravated the condition. We prescribed him with topical minoxidil solution and advised him to abstain from steroid use.

CONCLUSION

Immediate hypersensitivity reaction to corticosteroids is very rare, but they should be noted and kept in mind, since they carry a higher possibility of life-threatening immediate hypersensitivity reaction as compared to the delayed hypersensitivity response. We report this case for its rarity and to highlight that a detailed clinical history and test dose should be done before giving any ILS.