BI23 Erythrodermic eczematous reactions to immunoglobulins

Abstract

Abstract Intravenous immunoglobulins (IVIg) have been used in clinical practice for more than 50 years. They are used for dermatological indications such as dermatomyositis, pemphigus and Kawasaki disease. Although this is regarded as a safe treatment modality, it can produce adverse reactions in the skin. We report two patients with IVIg-induced skin changes. A 71-year-old man with no preceding skin disease was under neurology care for the treatment of chronic inflammatory demyelinating neuropathy (CIDP) with IVIg. He presented with an erythrodermic eczematous rash and was symptomatic with pain and pruritus. The rash started on the hands and had spread to the rest of the body 3 days after completion of his third course of IVIg. He was treated with topical clobetasol propionate. His skin settled over the course of a few weeks. The patient was keen to resume IVIg for CIDP; unfortunately, he developed a more severe and rapid reaction on retrial and IVIg had to be stopped. An 82-year-old man was given IVIg for CIDP. He denied any previous skin conditions or atopy. He received a 5-day course of IVIg followed by intravenous methylprednisolone 1 g once daily for 6 days. Four weeks later, he developed pompholyx on the palms and thereafter a widespread eczematous rash over the arms, abdomen, back and face. He was treated with topical clobetasol propionate to the trunk and limbs and clobetasone butyrate to the face. His rash and symptoms settled with topical treatment. Eczematous immunoglobulin reactions are often under-recognized. Reactions preferentially affect middle-aged men and those being treated for neurological disease. The clinical presentation is peculiar and distinctive, almost always involving the palmoplantar aspects with a dyshydrotic element. The reaction pattern starts within a few days to weeks of exposure to immunoglobulins and can become erythrodermic. Histology shows a spongiotic dermatitis and is not diagnostic. Immunoglobulin-associated eczema can persist even after the discontinuation of immunoglobulins. Recommended treatment depends on severity. If mild, continuing immunoglobulins with topical steroids should be considered. If the reaction persists or worsens, up to two switches of the immunoglobulin brand can be considered. In severe or persistent cases, methotrexate may be beneficial. The mechanism of an IVIg-induced skin reaction is not fully understood. The diagnosis of eczematous IVIg reaction is clinical, with a high index of suspicion required. The care of these patients requires collaboration between dermatologists and the physician prescribing the immunoglobulin, who may be unfamiliar with this adverse event.