D2.232 - SDRIFE related to generalized corticosteroids’ hypersensitivity: A case report

Background: Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a delayed T-cell mediated hypersensitivity (HS) reaction characterized by the appearance of a fixed, symmetrical exanthem in intertriginous areas. Objective: To report a rare case of SDRIFE with documented HS to all chemical groups of corticosteroids (CS), according to the classifications of Matura and Baeck. Case description: Woman, 70-year-old, with a medical history of fibromyalgia and degenerative vertebral pathology. Between 2020 and 2023, she experienced multiple episodes of fixed, symmetrical exanthema, accompanied by pruritus and burning, in intertriginous and flexural areas, after treatment with various non-steroidal anti-inflammatory drugs (NSAIDs) and CS used for pain control and in perioperative context. The first episode occurred 6 days after starting treatment, while subsequent ones occurred after 2 to 3 days. Given the delayed nature of the clinical manifestations and the involvement of multiple NSAIDs and CS, generalized HS to NSAIDs was considered unlikely. Oral challenges with etoricoxib, meloxicam and acetylsalicylic acid were all negative. Regarding CS-related HS investigation, patch tests performed with hydrocortisone, budesonide, prednisolone, betamethasone and triamcinolone were all negative, as well as skin prick tests. Intradermal tests were positive for prednisolone, hydrocortisone, dexamethasone and triamcinolone in the late reading (32 hours after). As methylprednisolone skin tests were negative an oral challenge was performed, which was positive 24 hours after, with an identic reaction comparing to previous episodes. Given the strong suspicion of HS to deflazacort based on the clinical history and documented patient’s profile, intradermal tests with oral deflazacort solution (22.75 mg/mL) at dilutions of 1:10000 to 1:10 were performed. These tests were considered irritative in the immediate reading for 1:10 and 1:100 dilutions, but positive in the late reading (48 hours after) for the same dilutions. Conclusion: SDRIFE due to CS is extremely rare, with only a few cases described in the literature. The pattern of cross-reactivity appears to be variable – several classifications of CS chemical groups have been proposed, but none fully explain the different patients’ profiles observed. This case is particularly unique, as it demonstrates hypersensitivity to all CS chemical groups in the same patient.