Y. Hashimoto, Y. Aragane, A. Kawada
Jul 1, 2006
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Influential Citations
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Journal
The Journal of Dermatology
Abstract
Dear Editor, Topical β-adrenergic receptor antagonists (βblockers) have been widely used for treatment of open-angle glaucoma. They reduce the secretion and increase the absorption of aqueous humor and are hence useful in long-term treatment. To date, there are a few reports of allergic contact dermatitis due to β-blockers. Herein, we present a case with periorbital contact dermatitis due to a β-blocker contained in an eye-drop preparation. In this case, the patient was not sensitized to preservatives in the product and also not to anti-glaucoma eye-drop products other than β-blockers. A 55-year-old Japanese woman had been suffering from pruritic eruptions surrounding both eyelids from February of 2004. She had conducted daily application of ophthalmic preparations (latanoprost [a prostaglandin [PG]-F2α derivative], bunazosinHCl [α1-adrenergic receptor antagonist], and levobunolol-HCl [β-adrenergic receptor antagonist]) for her chronic glaucoma. At the first visit in May 2004, she presented erythematous plaques with scales surrounding both eyelids and periorbital areas. Contact dermatitis was suspected, and patch tests were performed with ophthalmic preparations on the patient’s back. These included Detantol (0.01% bunazosin-HCl, benzalkonium chloride, glycerin, boric acid), Xalatan (2% latanoprost, benzalkonium chloride, sodium hydrogenphosphate, disodium hydrogenphosphate), Mirol (0.5% levobunolol-HCl, dipotassium hydrogenphosphate, polyvinyl alcohol, sodium pyrosulfate, sodium edetate, benzalkonium chloride), benzalkonium chloride (diluted at 0.1% and 0.01% in distilled water), and physiological saline (Table 1). Based on the International Contact Dermatitis Research Group (ICDRG) criteria, the patch test reactions were judged. Both at 48 and 72 h after the application, only levobunolol-HCl (as is) gave a positive reaction (Table 1). To determine a causative agent in the levobunolol preparation, patch tests were performed with levobunolol-HCl (10%, 1%, 0.1%), sodium pyrosulfate (10%, 1%), sodium edetate (10%, 1%) and benzalkonium chloride (0.1%, 0.01%), all of which were dispersed in white petrolatum. Pure substances were kindly provided from the manufacturer (see Table 1). Fortyeight hours later, 10% levobunolol-HCl gave a positive reaction (in the ICDRG classification, +?), and 72 h after the application, 10% and 1% levobunololHCl resulted in + and +? reaction, respectively. Based on these findings, the levobunolol preparation was withdrawn, followed by rapid healing within a week. Herein, we report a case of periorbital contact dermatitis due to the topical application of levobunolol. It was originally synthesized for its cardiovascular activity, but it has been introduced in recent years for the treatment of increased intraocular pressure and open angle glaucoma. It was initially found to be safe, effective and comfortable in most patients. There are a few reports describing contact dermatitis due to levobunolol, but the problem is actually rare. Burning or irritation sensations may occur in the users, which result in discontinuation of use in less than 7% of patients, although the reports from ophthalmologists did not determine if the problem was allergic or not. In addition, allergic contact dermatitis by eye drops is, in many instances, due to preservatives, in particular benzalkonium chloride, sodium ethylene diamine tetra acetate (EDTA), and thimerosal, despite the fact that there are many case reports of allergic contact dermatitis due to β-blockers in ophthalmic preparations. In the present case, the patient had no history of oral intake of β-blockers or of allergies due to other medicines. We have not found any