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
When dealing with skin hypersensitivity, particularly in the context of cancer chemotherapy, it's crucial to differentiate between immediate and delayed reactions. Immediate reactions, which can range from mild cutaneous eruptions to anaphylaxis, are often mast cell–mediated and may require desensitization protocols to allow patients to safely receive first-line chemotherapy treatments 1.
- Desensitization protocols for chemotherapeutics can last several hours, with dose doubling every 15-20 minutes, and are usually performed in inpatient units or infusion centers with trained staff.
- Candidates for drug desensitization to chemotherapeutics include those with type I HSRs (mast cell–mediated/IgE-dependent) including anaphylaxis.
- Drug desensitization should be performed when there is no reasonable alternative, as with first-line cancer treatments.
Approach to Care
The approach to care after a presumed hypersensitivity reaction (HSR) to a chemotherapeutic agent includes desensitization, skin testing and risk stratification, or risk stratification without skin testing and challenge. Each approach has its advantages and disadvantages.
- For patients with nonimmediate reactions or a history of reactions inconsistent with chemotherapeutic hypersensitivity, treatment with a slowed infusion rate, graded dose escalation, and/or premedications without desensitization may be suggested, as per Consensus-based Statement 29 1.
- Patients without a convincing clinical history of an HSR do not require desensitization and typically respond well to readministration of the chemotherapeutic agent.
Considerations
It's essential to note that the cutaneous toxicity of some chemotherapeutic agents may forbid any type of skin allergy testing. Therefore, an accurate clinical history and proper evaluation are critical to improve patient outcomes despite a reported HSR to chemotherapeutics 1.
- The lack of a standardized approach to management after a presumed mast cell–mediated HSR can lead to suboptimal outcomes, including needless avoidance of first-line chemotherapeutic agents.
- An accurate clinical history and proper evaluation can significantly improve patient outcomes, allowing for the safe use of first-line chemotherapeutic agents when necessary.
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 factors, including corticosteroids and antihistamines 3, 4, 5, 6.
- Corticosteroids can induce immediate and delayed hypersensitivity reactions, which can be diagnosed using prick and intradermal skin tests for immediate reactions and patch tests for delayed reactions 3, 4.
- The prevalence of hypersensitivity reactions to corticosteroids is not common, but due to their wide usage, these reactions are clinically important 3.
- Immediate hypersensitivity reactions to corticosteroids can manifest as anaphylaxis, urticaria, and/or angioedema, and can occur through any route of administration, including intravenous, oral, and intra-articular 5.
- Diagnosis of hypersensitivity reactions to corticosteroids is based on medical history and can be confirmed by challenge testing, with skin tests being positive in most cases 5.
- Antihistamines can also cause hypersensitivity reactions, including urticaria, contact dermatitis, anaphylaxis, and fixed drug eruption, with cetirizine and hydroxyzine being commonly implicated preparations 6.
Diagnostic Approaches
- Prick and intradermal skin tests are useful diagnostic tools for immediate hypersensitivity reactions to corticosteroids 3, 4.
- Patch tests are useful for diagnosing delayed hypersensitivity reactions to corticosteroids 3, 4.
- Challenge testing can help confirm the suspected culprit agent in immediate hypersensitivity reactions and identify an alternative tolerated corticosteroid 4, 5.
- Patch testing can help identify the culprit agents in delayed hypersensitivity contact dermatitis 4.
Management and Treatment
- Alternative (safe) corticosteroid agents should be administered based on diagnostic tests 3.
- Desensitization may be required in rare cases of immediate hypersensitivity reactions to corticosteroids 5.
- Awareness of hypersensitivity reactions to antihistamines and corticosteroids is essential for reducing misdiagnosis and providing appropriate treatment 6.