D3.242 - SDRIFE induced by multiple systemic corticosteroids

Systemic corticosteroids are essential for the treatment of many inflammatory and immune mediated diseases. Allergic reactions to corticosteroids are uncommon and may present as immediate or delayed hypersensitivity reactions. Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a rare manifestation of delayed drug hypersensitivity, characterized by symmetrical erythema of flexural and intertriginous areas following systemic drug exposure, without extracutaneous involvement.

We studied the case of a 66-year-old male with asthma and recurrent cutaneous reactions temporally related to systemic corticosteroid exposure. The initial episode consisted of symmetrical erythematous and mildly pruritic exanthema involving axillary, inguinal and gluteal areas, with progression to palms and soles after a subsequent dose of systemic prednisone. At the time of allergology evaluation, the patient was receiving inhaled budesonide without adverse reactions.

Patch testing with a corticosteroid battery showed positive reactions to prednisolone, with negative results to other tested corticosteroids, including budesonide. Delayed intradermal tests were positive to hydrocortisone and methylprednisolone. Drug provocation tests with dexamethasone and deflazacort reproduced the cutaneous reaction, resolving over one week and followed by marked palmoplantar desquamation. Budesonide was clinically tolerated.

We present the case of a patient diagnosed with SDRIFE induced by multiple systemic corticosteroids, confirmed by patch testing, intradermal testing and drug provocation tests. In this setting, negative skin tests did not reliably exclude clinical reactivity, making drug provocation tests necessary to identify potential therapeutic alternatives. Moreover, cross-reactivity among corticosteroids was not predictable based on their chemical structure. This case highlights the importance of an individualized allergological evaluation, particularly in patients with underlying asthma who may require systemic corticosteroids.