Abstract | December 20, 2022

Mystery of dermatitis in young female

Presenting Author: Bilaval Javed, MBBS, Research assistant, Internal Medicine, University of Arzona, Tucson, AZ

Coauthors: Joy Bulger Beck, MD, Assistant professor, University of Arizona, Tucson, AZ; Ayesha Javed, MD, Assistant Professor, University of Arizona, Tucson, AZ

Learning Objectives

  1. Progesterone hypersensitivity is rare dermatitis and usually presents with a cyclical rash in a young fertile female.
  2. The rash is intermittent in nature and can be confused with contact dermatitis or eczema in patients with irregular menstrual cycles.
  3. Thorough history taking on the menstrual cycle and results of the intradermal progesterone test are mandatory for diagnosis.
  4. A multidisciplinary approach is required for successful treatment

Introduction: Progesterone hypersensitivity is a rare skin reaction to the progesterone exclusively in childbearing females. The reaction can be from exogenous progestins or from endogenous progestin causing symptoms to appear at progesterone peak, which is typically 3-10 days prior to menstrual cycle. Patients with progesterone hypersensitivity dermatitis are frequently misdiagnosed with contact dermatitis or eczematous rash, especially in women who have an irregular cycle. 

 

Case Presentation: A 36-year-old lady presented to the clinic for evaluation of intermittent pruritic maculopapular rash prominent on arms, trunk, and abdominal region for years. Her past medical history was significant for migraine, hypothyroidism, and seasonal allergies. She had itching and hives started in her teenage starting 5-6 days before her cycle followed by resolution after the end of periods. She had an extensive workup and was treated with topical steroids for eczema for years without complete relief. Her physical examination was suggestive of a maculopapular rash on her bilateral arms and abdomen. Differentials were broad including contact dermatitis, eczematous rash, and atopic dermatitis. Blood work showed hemoglobin 14.9 g/dL, white blood cells 4900/µL (eosinophils 00 K/µL), and platelets 211,000 uL. IgE was elevated 503 IU/mil (normal <100 IU/mil), Histamine release 17.1% (normal <16%) and elevated Thyroperoxidase Ab 880 IU/mL (normal < 9 IU/ml) with normal TSH.  ESR, CRP, ANA, and CMP came back normal. 

 

Final/Working Diagnosis: The patient was referred to allergy/immunology for cyclic urticaria where she underwent intradermal progesterone skin testing that came back positive confirming the diagnosis. 

 

Management/Outcome/and or Follow-up: The patient was started on oral antihistamine agents and was advised to trial an oral contraceptive pill (OCP) which is the primary treatment to suppress ovulation. The patient declined OCP given a history of migraine. She had a follow-up in 3 months and continued to have the rash while on H1 and H2 antihistamines. She was prescribed prednisone for breakthrough episodes. Other options discussed included gonadotropin-releasing hormone (GnRH) agonists or bilateral oophorectomy in the patient’s refractory to treatment. Patient opted for Omalizumab which has only 4 reported cases with successful treatment with Omalizumab. Patient has yet to follow to see the response with Omalizumab.

 

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