After a few weeks of clinical practice, medical students and residents realize that patients are often different from classic disease descriptions in textbooks. One experienced physician summarized this by saying: "his asthma did not read the book." How to bridge this gap between theory and practice? Our answer was to create the free case-based curriculum of Allergy and Immunology you are reading now: AllergyCases.org, endorsed by both the American Academy of Allergy Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI).
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Clinical Notes are short reviews of allergy and immunology topics illustrated with our innovative mind maps and mnemonics. Their goal is to provide a concise review of a particular topic in order to enhance the education of fellows, residents and medical students.
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Irritant contact dermatitis to acne medication that contains benzoyl peroxide
Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology
A 25-year-old Caucasian female developed worsening symptoms of facial dermatitis during the last 3 months. She started using over-the-counter hydrocortisone cream yesterday and her symptoms are better now. This is the third episode of similar complaints in the last 3 months. She reports long term use of the acne cream Proactiv, which contains benzyl peroxide, and she also uses Eucerin lotion on her face.
Medications
Her medications include Allegra (fexofenadine), Flonase (fluticasone nasal) and levothyroxine. Proactiv and Eucerin.
Past medical history
She has a long history of allergic rhinitis and conjunctivitis.
Physical examination
The physical examination is positive for facial erythema with some eyelid eczema.
What is the most likely diagnosis?
Facial dermatitis related to Proactiv, containing benzoyl peroxide. The etiology of the dermatitis is either irritant or allergic contact dermatitis to benzoyl
peroxide. Considering that she had two prior episodes that resolved and the rash is not worsening now, the most likely explanation for her condition is irritant contact dermatitis to benzoyl peroxide.
What treatment would you suggest?
The patient was advised to use hydrocortisone at the lowest of concentration of 1%, daily, on the face, for a week. She had to stop using Proactiv immediately. She could still use Eucerin daily.
Final diagnosis
Irritant contact dermatitis to acne medication that contains benzoyl peroxide.
Benzoyl peroxide (BP) is shown to be a weak allergen. In a study of 25 guinea pigs, only 5 were sensitized in the TINA test. BP is a skin irritant. However, only 11 of 155 acne patients had clinical signs of intolerance, which settled despite continued use in 10 cases.
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After a few weeks of clinical practice, medical students and residents realize that patients are often different from classic disease descriptions in textbooks. One experienced physician summarized this by saying: "his asthma did not read the book." How to bridge this gap between theory and practice? Our answer was to create the free case-based curriculum of Allergy and Immunology you are reading now: AllergyCases.org, endorsed by both the American Academy of Allergy Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI).
