Can people be allergic to steroids (corticosteroids)?

Can People Be Allergic to Steroids?

Yes, people can develop true allergic reactions to corticosteroids, though this is rare, occurring in approximately 0.3-0.5% of the general population. 1, 2 However, these reactions are more common in high-risk groups, particularly patients who receive multiple or repeated doses of corticosteroids. 1, 2

Types of Steroid Hypersensitivity

Steroid allergic reactions fall into two distinct categories:

Type I (IgE-Mediated) Reactions

• Immediate reactions occur within 1 hour of drug administration and can include anaphylaxis 1, 2
• These are the rarest form, with anaphylaxis occurring in only 0.3-0.5% of cases 1, 2
• Can be life-threatening and require immediate recognition 3, 4

Type IV (T Cell-Mediated) Reactions

• Delayed reactions manifest more than 1 hour after drug administration and are the more common presentation 1, 2
• Allergic contact dermatitis (ACD) is the most frequently reported delayed reaction, typically following topical corticosteroid application 2, 5
• Systemic delayed reactions may present as generalized dermatitis, exanthematous eruptions, or occasionally with blistering or purpura 5
• Contact allergy incidence ranges from 9-22% in adults with chronic steroid use and up to 25% in children 5

Critical Distinction: True Allergy vs. Excipient Reactions

A crucial clinical pitfall is that most suspected steroid "allergies" are actually reactions to preservatives or excipients in the steroid preparation rather than the active corticosteroid molecule itself. 1

Excipient-Related Reactions

• Excipients such as carboxymethylcellulose and polyethylene glycol (PEG) in injectable corticosteroids can cause life-threatening anaphylaxis 1, 6, 4
• Suspect excipient allergy when patients have anaphylaxis to ≥2 structurally unrelated drugs or products that share a common excipient (e.g., injectable corticosteroids, PEG-based laxatives) 1, 6
• One documented case involved a patient sensitive to all corticosteroid preparations containing carboxymethylcellulose, as well as pure carboxymethylcellulose itself 4
• Switching to another steroid preparation without the offending excipient often resolves the problem 1

Risk Factors for Developing Steroid Hypersensitivity

Certain patient populations face elevated risk:

• Patients receiving repeated or multiple doses of corticosteroids 1, 2
• Patients with atopic dermatitis or stasis dermatitis of lower extremities (for topical corticosteroid ACD) 2
• Patients with long-standing dermatologic conditions requiring chronic steroid use 5
• Patients who fail to respond to or worsen with topical steroid therapy 5

Diagnostic Approach

When steroid hypersensitivity is suspected, a systematic evaluation is essential:

For Immediate Reactions

• Skin testing (prick and intradermal tests) with the suspected corticosteroid preparation 3, 2, 4
• Serologic tests for allergen-specific IgE 3
• Testing should include both the parent drug and individual excipients when available 1
• Normal control subjects should be tested in parallel to avoid false positives 4

For Delayed Reactions

• Patch testing with corticosteroids is the gold standard for diagnosing allergic contact dermatitis 2, 5, 7
• Testing should be performed when the patient's underlying condition is in a quiescent state 2

Comprehensive Testing Strategy

• Test multiple available corticosteroid preparations, as patients may react to specific structural groups but tolerate others 4, 7
• One case demonstrated a patient with delayed-type allergy to dexamethasone, betamethasone, and fluocortolone who tolerated deflazacort, hydrocortisone, methylprednisolone, and prednisone 7
• Include testing of excipients and preservatives in the formulation 1, 4

Management Options

Alternative Corticosteroid Selection

• Patients with documented allergy to one corticosteroid group can often tolerate corticosteroids from different structural classes 7
• Comprehensive skin testing helps identify safe alternatives 3, 4
• For excipient-related reactions, switch to preparations without the offending excipient 1

Desensitization

• Desensitization protocols exist for patients who require corticosteroids despite documented allergy 3
• This should only be performed in specialized centers with appropriate monitoring 3

Avoidance and Documentation

• Document the specific corticosteroid and/or excipient allergy clearly in the medical record 6
• Educate patients on all synonyms and related compounds to avoid 6
• Provide lists of products containing the offending agent 1

Clinical Pearls and Pitfalls

Consider steroid allergy in any patient who fails to improve or worsens with corticosteroid therapy, as this diagnosis often goes unrecognized for extended periods. 5 The incidence in patients not responding to topical steroids is surprisingly high at 9-22% in adults. 5

Do not routinely premedicate with steroids and antihistamines for suspected allergic reactions without proper evaluation, as this may mask true hypersensitivity and delay appropriate diagnosis. 1 Current recommendations advise against indiscriminate use of steroids for transfusion reactions, favoring a personalized approach based on specific symptoms. 1

Remember that provocative challenge, serologic testing, and skin testing are the most reliable diagnostic methods, though none is infallible. 3 Testing must be comprehensive and include both parent drugs and excipients to identify the true culprit. 1, 4