From the Guidelines
Skin hypersensitivity reactions to chemotherapeutic agents should be managed with desensitization when the implicated drug is the preferred therapy, as stated in Consensus-based Statement 28 1.
Management of Skin Hypersensitivity Reactions
When a patient experiences an immediate hypersensitivity reaction to a chemotherapeutic agent, the primary goal is to ensure the patient can safely receive the preferred treatment.
- Desensitization protocols can be used to allow patients to receive first-line chemotherapy treatments, and these protocols typically involve dose doubling every 15-20 minutes over several hours 1.
- Candidates for drug desensitization include those with type I hypersensitivity reactions (mast cell–mediated/IgE-dependent), including anaphylaxis.
- Desensitization should be performed when there is no reasonable alternative, such as with first-line cancer treatments.
Approach to Care
The approach to care after a presumed hypersensitivity reaction to a chemotherapeutic agent includes:
- Desensitization
- Skin testing and risk stratification
- Risk stratification without skin testing and challenge Each approach has its advantages and disadvantages, and the choice of approach depends on the individual patient's situation.
- For patients with nonimmediate reactions or a history of reactions inconsistent with chemotherapeutic hypersensitivity, a slowed infusion rate, graded dose escalation, and/or premedications without desensitization may be used, as suggested in Consensus-based Statement 29 1.
Patient Evaluation and Management
A thorough clinical evaluation is essential to determine the best course of action for patients with hypersensitivity reactions to chemotherapeutic agents.
- Patients without a convincing clinical history of a hypersensitivity reaction do not require desensitization and typically respond well to readministration of the chemotherapeutic agent.
- For patients with mild symptoms, pre-medications such as H1-antihistamines and a slowed infusion rate may be used without the need for desensitization.
- Identifying and avoiding triggers is crucial for long-term management, and keeping a diary of exposures and reactions can help pinpoint specific causes.
From the FDA Drug Label
Allergic Reactions anaphylactoid or hypersensitivity reactions, anaphylaxis, angioedema Dermatologic acne, acneiform eruptions, allergic dermatitis, alopecia, angioedema, angioneurotic edema, atrophy and thinning of skin, dry scaly skin, ecchymoses and petechiae (bruising), erythema, facial edema, hirsutism, impaired wound healing, increased sweating, Karposi’s sarcoma, lupus erythematosus-like lesions, perineal irritation, purpura, rash, striae, subcutaneous fat atrophy, suppression of reactions to skin tests, striae, telangiectasis, thin fragile skin, thinning scalp hair, urticaria
Skin hypersensitivity reactions to prednisone have been reported, including allergic dermatitis, angioedema, urticaria, and rash. These reactions can be severe and may include anaphylactoid or hypersensitivity reactions and anaphylaxis 2.
From the Research
Skin Hypersensitivity Reactions
- Skin hypersensitivity reactions can be caused by various substances, including corticosteroids 3, 4, 5, 6.
- These reactions can be immediate or delayed, and can occur through different modes of administration, such as topical, oral, or parenteral 3, 4, 5, 6.
Diagnosis of Skin Hypersensitivity Reactions
- Diagnosis of skin hypersensitivity reactions can be challenging, as the symptoms may be similar to the underlying disease being treated 3, 4, 5, 6.
- Diagnostic tools, such as prick and intradermal skin tests, patch tests, and oral graded challenge, can help confirm the suspected culprit agent and identify an alternative tolerated corticosteroid 3, 4, 5, 6.
Prevalence of Skin Hypersensitivity Reactions
- The prevalence of skin hypersensitivity reactions to corticosteroids is estimated to be rare, with an estimated 0.3-0.5% of patients experiencing type I IgE-mediated allergy, including anaphylaxis 4.
- Allergic contact dermatitis is the most commonly reported non-immediate hypersensitivity reaction, usually following topical corticosteroid application 4.