Recurrent Localized Erythema Scarlatiniforme Desquamativum Recidivans Induced by Iodinated Contrast Media

A 69-year-old woman was presented for consultation with suspected iodinated contrast media (ICM) hypersensitivity. She did not report any history of atopy or drug hypersensitivity. She had a history of 2 discrete reactions (1 month apart) consisting of pruritic, isolated bilateral palmar erythematous lesions, which evolved into desquamative exfoliation (Figure 1), 2 days after iohexol (Omnipaque) injections. Both reactions were treated with topical betamethasone with resolution in 3 weeks. She reported the same reaction with thumb peeling (Figure E1, available in this article's Online Repository at www.jaci-inpractice.org) 5 months later, after iodixanol (Visipaque) injection. Intradermal tests (IDT) were performed on the forearms to undiluted solutions of iodixanol (Visipaque 320 mg/mL), iohexol (Omnipaque 300 mg/mL), iomeprol (Iomeron 350 mg/mL), and iobitridol (Xenetix 350 mg/mL), according to the European Academy of Allergy and Clinical Immunology recommendations. The delayed IDT reading, 7 days after the test, was negative. Because of the recurrent localized reactions with negative IDT on the forearms, 7 months after the resolution of the symptoms, intralesional IDT on the palms were performed (Figure E2, available in this article's Online Repository at www.jaci-inpractice.org), with undiluted solutions of iodixanol, iohexol, iomeprol, and iobitridol. The patient contacted us 38 days after the intralesional IDT to relate a palmar reaction. She had presented limited peeling at the IDT site of iohexol and to a lesser extent at the iodixanol site (Figure 2). However, IDT to iomeprol and iobitridol, on the contralateral palm, remained negative. Thus, we recommended avoidance of iodixanol and iohexol and cleared iomeprol and iobitridol for future use. The clinical features of her reactions are suggestive of erythema scarlatiniforme desquamativum recidivans (ESDR), which is characterized by an erythematous rash followed by an extensive desquamation of the involved skin. Generalized or localized reactions to the hands and/or feet have been described. The causes and pathogenesis of ESDR remain uncertain. Beltraminelli et al1Beltraminelli H. Itin P. Erythema scarlatiniforme desquamativum recidivans—a forgotten disease (recurring localized scarlatiniform scaled erythema).Dermatology. 2006; 212: 211-213Crossref PubMed Scopus (7) Google Scholar reported a series of 7 patients with ESDR. Two were concomitant to an infection, 2 others were possibly consequent to ICM, but without allergy testing, and 3 had an unknown trigger. Gastaminza et al2Gastaminza G. Audicana M.T. Fernandez E. Anda M. Ansotegui I.J. Palmar exfoliative exanthema to amoxicillin.Allergy. 2000; 55: 510-511Crossref PubMed Google Scholar described 5 cases of palmar exfoliative exanthema secondary to amoxicillin. Cutaneous allergy tests (skin prick test, IDT, and patch test) on the unaffected skin were negative for all patients, as in our patient. Intralesional patch tests for amoxicillin were also performed in 2 patients with negative results. We chose to perform intralesional IDT with delayed reading, considering that palmar localization was not compatible with patch testing. The positive intralesional IDT with a negative forearm IDT suggests a mechanism similar to fixed drug eruption. The very long delay for positivity (38 days) could be explained by the thicker palmar skin, leading to a slower diffusion of the allergen. Delayed patch test reactions up to 30 days have been described in the literature, especially with metals, topical antibiotics, preservatives, surfactants, and corticosteroids. This case, to our knowledge, is the first case of ESDR induced by ICM with positive intralesional allergy tests. In some cases, ESDR can be considered as a localized drug hypersensitivity reaction. These patients should be evaluated with IDT. If IDT is negative, intralesional IDT should be considered. We thank all the practitioners who contributed to the discussion on this case via the medical French platform Advice Medica. Download .docx (.01 MB) Help with docx files Figure For Online Repository Legends Download .docx (.14 MB) Help with docx files Figure E1 Download .docx (1.46 MB) Help with docx files Figure E2