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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 47-48

Allergic contact dermatitis to luliconazole: An uncommon side effect of a commonly used drug


Department of DVL, IMS and SUM Hospital, Bhubaneswar, Odisha, India

Date of Submission20-Dec-2019
Date of Decision18-Apr-2020
Date of Acceptance13-May-2020
Date of Web Publication23-Jun-2020

Correspondence Address:
Dr. Trashita Hassanandani
Department of DVL, IMS and SUM Hospital, Bhubaneswar, Odisha - 751 003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_68_19

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How to cite this article:
Hassanandani T, Panda A, Kar BR. Allergic contact dermatitis to luliconazole: An uncommon side effect of a commonly used drug. Indian J Drugs Dermatol 2020;6:47-8

How to cite this URL:
Hassanandani T, Panda A, Kar BR. Allergic contact dermatitis to luliconazole: An uncommon side effect of a commonly used drug. Indian J Drugs Dermatol [serial online] 2020 [cited 2020 Jul 4];6:47-8. Available from: http://www.ijdd.in/text.asp?2020/6/1/47/287441



Sir,

Topical antifungals are one of the most commonly prescribed medications by a dermatologist. Luliconazole is a unique imidazole antifungal with imidazole moiety incorporated into the ketene dithioacetate structure. One percent luliconazole cream was approved in Japan in 2005 and in India in 2009, and since then, it has been used for the treatment of tinea cruris, corporis, and pedis.[1] Allergic contact dermatitis to topical luliconazole (1%) has rarely been reported and can be a challenging situation with the coexisting tinea infection.[2],[3] Here, we report a case of allergic contact dermatitis to topical luliconazole cream (1%) in a female which was confirmed with a patch test.

A 48-year-old female was diagnosed with tinea corporis and was prescribed oral itraconazole (200 mg) along with topical luliconazole 1% cream (Lulimac cream 1%, Macleods Pharmaceuticals Ltd.) for twice daily application. Two days later, she developed erythema, edema, and oozing at the site of application [Figure 1]. The patient gave a history of use of luliconazole 1% cream once in the past for tinea corporis. The medication was discontinued and a patch test was performed using a Finn chamber with luliconazole 1% cream (Lulimac cream 1%, Macleods) and Indian Standard Series (ISS). The results were interpreted using the scoring system recommended by the International Contact Dermatitis Research Group. Luliconazole elicited 2+ positive patch test reaction at day 3, whereas all 20 components of the ISS had a negative reaction [Figure 2]. Since methyl paraben and benzyl alcohol (component of Balsam of Peru) were the only other ingredients in the cream and both were negative in the patch test with the ISS, it was assumed that the reaction was due to luliconazole and not the vehicle. The patient was given oral prednisolone (30 mg/day), and after subsidence of dermatitis, oral itraconazole (200 mg) and topical ciclopirox olamine 1% were continued for tinea corporis [Figure 3].
Figure 1: Clinical picture of the patient with erythema, edema, and oozing at the site of application of luliconazole

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Figure 2: Patch test done on the back, showing no reaction to 20 components of Indian Standard Series. 2+ reaction to luliconazole

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Figure 3: Subsidence of dermatitis after oral prednisolone

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Topical antifungal agents are widely used to treat superficial fungal infections, such as dermatophytoses, candidiasis, and pityriasis versicolor. According to the Intercontinental Medical Statistics Moving Annual Total October 2019 data, the total topical antifungal market is valued at Rs. 1251.58 crores out of which 37.7% is contributed by luliconazole. Contact allergy has seldom been reported after use of antifungals. Miconazole, econazole, tioconazole, and isoconazole have also been implicated depending on their availability of local prescribing habits.[4] In contrast, other azole antifungals are regarded as infrequent sensitizers. Most studies on contact allergy to topical antifungals, however, comprise sporadic case reports; systematic patch test studies based on a large clinical population are currently lacking. Luliconazole is a recently developed imidazole antifungal agent. Till date, only two reports concerning luliconazole-induced contact dermatitis have been published from Japan and none from the Indian subcontinent.[2],[3]

In the report by Tanaka et al., luliconazole showed no cross-reaction with other imidazole antifungal drugs (neticonazole, ketoconazole, miconazole, bifonazole, and clotrimazole cream) that had a β-substituted 1-phenethyl imidazole structure, which is known to be one of the important determinants of imidazole-induced allergic contact dermatitis. It was also noted that luliconazole and lanoconazole, which have the same dithioacetal chemical structure, which are not present in other imidazole agents, showed cross-reaction. Hence, the dithioacetal structure is considered to be the cause of contact sensitization by this specific molecule.[3] In addition, it was unlikely that paraben or benzyl alcohol base was the antigenic determinant, as the paraben mix and Balsam of Peru which have benzyl alcohol as one of its constituents[5] from the ISS were nonreactive.

Although rarely reported, allergic contact dermatitis to luliconazole should be considered in patients being treated for dermatophytosis who present with a flare-up of lesions in the form of erythema and oozing, especially in Indian setting where luliconazole use has increased exponentially occupying one-third of the antifungal market. Dermatologist should consider this as a possibility in a subset of patients developing paradoxical flare or eczematous dermatitis in patients of dermatophytosis on luliconazole and should promptly withhold this agent in cases of topical intolerant reaction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khanna D, Bharti S. Luliconazole for the treatment of fungal infections: An evidence-based review. Core Evid 2014;9:113-24.  Back to cited text no. 1
    
2.
Shono M. Allergic contact dermatitis from luliconazole. Contact Dermatitis 2007;56:296-7.  Back to cited text no. 2
    
3.
Tanaka T, Satoh T, Yokozeki H. Allergic contact dermatitis from luliconazole: Implication of the dithioacetal structure. Acta Derm Venereol 2007;87:271-2.  Back to cited text no. 3
    
4.
Baes H. Contact sensitivity to miconazole with ortho-chloro cross-sensitivity to other imidazoles. Contact Dermatitis 1991;24:89-93.  Back to cited text no. 4
    
5.
Jacob SE, Stechschulte S. Eyelid dermatitis associated with Balsam of Peru constituents: Benzoic acid and benzyl alcohol. Contact Dermatitis 2008;58:111-2.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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