Systemic allergic contact dermatitis due to phenylephrine in eyedrops, with a long-lasting allergic patch test reaction

ARTICLE

Auteur(s) : Risa Tamagawa-Mineoka¹, Norito Katoh¹, Kazuhito Yoneda², Yuko Cho², Saburo Kishimoto¹

¹Department of Dermatology, Kyoto Prefectural University of Medicine Graduate School of Medical Science, 465, Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
²Department of Ophthalmology, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto 602-8566, Japan

We read with interest the article by Nosbaum et al. [1] concerning the pathophysiology and clinical findings of allergic contact dermatitis. Allergic contact dermatitis is sometimes elicited by a topical drug, and systemic administration of a drug to which an individual has been sensitized may cause systemic allergic contact dermatitis. Here, we report the first case of systemic allergic contact dermatitis that spread over the face, neck and chest due to phenylephrine in eyedrops and was associated with a long-lasting allergic patch test reaction (LLAPTR).

The patient was a 53-year-old Japanese woman without a personal or family history of atopy who developed periocular oedema and erythema with pruritus within 24 hours after an operation for retinal detachment. From the following day, pruritic erythema, papules and vesicles spread over the face, neck and chest. We suspected allergic contact dermatitis caused by items used perioperatively, such as antiseptics or eyedrops. Systemic treatment was not administered during the operation. Her symptoms were not responsive to treatment with topical corticosteroids, but addition of systemic corticosteroids led to a significant improvement of the symptoms after two weeks.

Patch testing was performed with the baseline series of the Japanese Contact Dermatitis Society, antiseptics, local anesthetics and Cravit^®, Tarivid^®, Flumetholon^®, Rinderon^®-A and Mydrin^®-P eyedrops. The results were assessed after 48 hours, 72 hours and 7 days, based on the recommendations of the International Contact Dermatitis Research Group. A positive reaction occurred with Mydrin^®-P (as is; day 2: +++; day 3: +++; day 7: +++). To identify the precise allergens, further patch testing was carried out with ingredients provided by the manufacturer, and a positive reaction occurred with phenylephrine hydrochloride (5% pet.; day 2: +++; day 3: +++; day 7: +++). Reactivation of the initial lesions did not occur on patch testing. The positive reactions with Mydrin^®-P and phenylephrine both persisted for two months and left residual pigmentation. The patient had previously used eyedrops containing phenylephrine, but she had not shown any symptoms. Therefore, repeated use of phenylephrine in the eyedrops may have caused the sensitization. We recommended that the patient should avoid the use of medications containing phenylephrine and there has been no recurrence of her problem.

Phenylephrine hydrochloride is a sympathomimetic drug with α-receptor stimulatory activity that is frequently used as a mydriatic and decongestant in ophthalmology. Contact dermatitis due to an ophthalmic preparation usually induces inflammation in the periocular region. There have been several reports of allergic contact blepharoconjunctivitis caused by phenylephrine [2-5], but systemic allergic contact dermatitis due to ophthalmic use of this drug has not been reported. Systemic absorption of ophthalmic solutions of phenylephrine can occur [6], and therefore the dermatitis in our case might have spread to areas other than the periocular region due to systemic exposure to phenylephrine. Thus, phenylephrine in eyedrops should be considered as a possible allergen in systemic allergic contact dermatitis. As seen in our patient, three previous reports have described LLAPTR to phenylephrine that persisted for 2 to 7 months [2-4]. The mechanism of this phenomenon is unclear. However, since contact dermatitis usually resolves after a decrease in the local concentration of the allergen and/or immunoregulatory actions by regulatory cells and cytokines [1], the LLAPTR may be associated with a defect in these mechanisms or an active sensitization effect caused by patch testing.

Acknowledgements

References

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4 Akita H, Akamatsu H, Matsunaga K. Allergic contact dermatitis due to phenylephrine hydrochloride, with an unusual patch test reaction. Contact Dermatitis 2003; 49: 232-5.

5 Thomas P, Rueff F, Przybilla B. Severe allergic contact blepharoconjunctivitis from phenylephrine in eyedrops, with corresponding T-cell hyper-responsiveness in vitro. Contact Dermatitis 1998; 38: 41-3.

6 Kumar V, Schoenwald RD, Chien DS, Packer AJ, Choi WW. Systemic absorption and cardiovascular effects of phenylephrine eyedrops. Am J Ophthalmol 1985; 99: 180-4.