eMedicine Specialties > Allergy and Immunology > Allergy Pathogenesis

Hypersensitivity Reactions, Delayed: Treatment & Medication

Author: Walter Duane Hinshaw, DO, Clinical Associate Professor, Consulting Staff, Family Medicine, University of North Texas Health Science Center at Fort Worth, Baylor University Medical Center at Garland
Coauthor(s): Gregory Paul Neyman, MD, Resident, Family Practice, Family Practice Resident Physician, Covenant Medical Center; Stephen Mark Olmstead, DO, Division of Allergy and Immunology, Assistant Clinical Professor, Department of Internal Medicine, University of Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: Jun 2, 2009

Treatment

Medical Care

Medical treatment is specific for the disease entity. Some common examples follow.

  • Contact dermatitis: The treatment of contact dermatitis varies depending on the severity of the disease. The best advice is to avoid the offending antigen. Pharmaceutical treatment varies, including over-the-counter corticosteroid preparations, prescription corticosteroid preparations, injectable corticosteroids, oral corticosteroids, and Burow solution.
  • Tuberculin hypersensitivity skin reactions: Treatment is rarely needed because this response is usually short-lived and self-limited. Topical corticosteroid preparations can be applied as needed. On rare occasions, the reaction to a delayed hypersensitivity skin test may be extreme and result in axillary lymphadenopathy and fever. Such reactions are self-limited and may be treated with an antipyretic medication such as aspirin or ibuprofen.
  • Granulomatous diseases: Treatment varies greatly depending on the specific disease. Refer to the appropriate eMedicine article for a full discussion (eg, see Sarcoidosis or Crohn Disease).

Consultations

Whether or not to consult a specialist and which specialist to consult also depend on the specific disease and its severity.

  • Contact dermatitis: Most cases of contact dermatitis can be managed in an outpatient setting by a primary care physician. However, for severe cases, immediate consultation with a physician board-certified in allergy and immunology and/or dermatology is warranted.
  • Tuberculin hypersensitivity skin reactions: If the Mantoux reaction is positive, patients may require consultation with a pulmonologist or an infectious disease specialist. A primary care physician trained in assessing the significance of a positive Mantoux reaction can also effectively treat these patients.
  • Granulomatous diseases: Depending on the specific disease entity, an infectious disease specialist (eg, TB, fungal disease, schistosomiasis), pulmonologist (eg, TB, sarcoidosis), gastroenterologist (eg, granulomatous hepatitis, Crohn disease), and/or an allergist/clinical immunologist may need to be consulted.

Activity

As tolerated

Medication

Medical treatment differs greatly depending on the specific disease entity. Only a few medications are discussed. In addition to drugs mentioned below, a drug that may augment cell-mediated immunity is cimetidine, which is an H2 receptor blocker that acts as a reverse antagonist and may augment cell-mediated immunity.6

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Modify the body's immune response to diverse stimuli.


Triamcinolone (Aristocort)

Helps treat inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability.

Adult

Topical: Apply a thin film bid/tid until a favorable response is obtained; not for use >3 consecutive wk
Alternatively, 40-80 mg IM once
Strength of dose should be individualized for patient

Pediatric

Administer as in adults; not for use >2 consecutive wk

Documented hypersensitivity; fungal, viral, or bacterial skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use in patients with decreased skin circulation; avoid using on face, neck, axillae, and groin; prolonged use, applications over large areas, and use of potent steroids and occlusive dressings may cause systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria


Mometasone (Elocon)

May depress formation, release, and activity of endogenous chemical mediators of inflammation.

Adult

Apply sparingly to affected areas bid; do not use occlusive dressing; usually, do not use >2 consecutive wk

Pediatric

Not recommended but frequently used for short periods

Documented hypersensitivity; fungal, viral, or tubercular skin lesions; herpes simplex or zoster infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If used over large or denuded areas of body, for prolonged periods, with occlusive dressings, or in infants, adverse systemic effects may result


Prednisone (Deltasone, Orasone, Meticorten, Sterapred)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Adult

5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve

Pediatric

4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur

More on Hypersensitivity Reactions, Delayed

Overview: Hypersensitivity Reactions, Delayed
Differential Diagnoses & Workup: Hypersensitivity Reactions, Delayed
Treatment & Medication: Hypersensitivity Reactions, Delayed
Follow-up: Hypersensitivity Reactions, Delayed
References
Further Reading
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References

  1. Olivier C. [Intradermal tuberculin test]. Arch Pediatr. Jun 2000;7 Suppl 3:559s-564s. [Medline].

  2. Facktor MA, Bernstein RA, Fireman P. Hypersensitivity to tetanus toxoid. J Allergy Clin Immunol. Jul 1973;52(1):1-12. [Medline].

  3. Chadha VK. Tuberculin test. Indian J Pediatr. Jan 2001;68(1):53-8. [Medline].

  4. Rigouts L. Clinical practice : Diagnosis of childhood tuberculosis. Eur J Pediatr. Apr 25 2009;[Medline].

  5. Wilson JD. Skin testing in the assessment of cell-mediated immunity. N Z Med J. Jan 26 1977;85(580):41-4. [Medline].

  6. Jorizzo JL, Sams WM, Jegasothy BV, Olansky AJ. Cimetidine as an immunomodulator: chronic mucocutaneous candidiasis as a model. Ann Intern Med. Feb 1980;92(2 Pt 1):192-5. [Medline].

  7. Cohen DE, Brancaccio RR, Soter NA. Diagnostic tests for type IV or delayed hypersensitivity reactions. Clin Allergy Immunol. 2000;15:287-305. [Medline].

  8. Fauci AJ, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.

  9. Gifford RR, Hatfield SM, Schmidtke JR. Cimetidine-induced augmentation of human lymphocyte blastogenesis by mitogen, bacterial antigen, and alloantigen. Transplantation. Feb 1980;29(2):143-8. [Medline].

  10. Goroll AH, May LA, Mulley AG, eds. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.

  11. Hyman MH. Delayed drug hypersensitivity reactions. Ann Intern Med. May 4 2004;140(9):W35; author reply W36. [Medline].

  12. Jacysyn JF, Abrahamsohn IA, Macedo MS. Modulation of delayed-type hypersensitivity during the time course of immune response to a protein antigen. Immunology. Mar 2001;102(3):373-9. [Medline].

  13. Jelinek C. Appendix E: Diagnostic Procedures. Delayed Hypersensitivity Skin Testing. In: Allergy/Immunology Specialist Course Manual. 5th ed. US Army; 1990:E-1-11.

  14. Kusy RP. Clinical response to allergies in patients. Am J Orthod Dentofacial Orthop. May 2004;125(5):544-7. [Medline].

  15. Middleton E Jr, Reed CE, Ellis EF, et al, eds. Allergy: Principles and Practice. 5th ed. St. Louis, Mo: Mosby-Year Book; 1998.

  16. Roitt IM. Essential Immunology. 9th ed. Oxford, UK: Blackwell Scientific; 1998:Chapters 22-23.

  17. Simon MR, Salberg DJ, Crane SA. In vivo cimetidine augmentation of phytohemagglutinin-induced human lymphocyte thymidine uptake. Transplantation. May 1981;31(5):400-2. [Medline].

  18. Slavin RG, Tennenbaum JI, Becker RJ, et al. Cell transfer of delayed hypersensitivity to ragweed from atopic subjects treated with emulsified ragweed extracts. J Allergy. 1963;34:368-73.

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Further Reading

Relevant guidelines
Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC.
Centers for Disease Control and Prevention (CDC). Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC. MMWR Recomm Rep 2005 Dec 16;54(RR-15):1-47.

Guidelines for infection control in dental health-care settings-2003.
Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM. Guidelines for infection control in dental health-care settings--2003. MMWR Recomm Rep 2003 Dec 19;52(RR-17):1-61.

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Keywords

classic delayed-type hypersensitivity reaction, type IV hypersensitivity reaction, cell-mediated hypersensitivity reaction, delayed-type hypersensitivity, DTH, delayed hypersensitivity, allergic reaction, delayed allergic reaction, hypersensitivity, allergy, allergies, transplant rejection, tumor immunity, transplantation reaction, transplant reaction, transplantation rejection, contact dermatitis, allograft rejection, poison ivy, poison oak, poison sumac, tuberculin skin test reactions, granulomatous inflammation, sarcoidosis, Crohn disease, allograft rejection, graft-versus-host disease, GVHD, graft versus host disease, autoimmune hypersensitivity reaction, inflammatory response, allergic dermatitis, rash, skin rash, anergy, delayed hypersensitivity reactions

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Contributor Information and Disclosures

Author

Walter Duane Hinshaw, DO, Clinical Associate Professor, Consulting Staff, Family Medicine, University of North Texas Health Science Center at Fort Worth, Baylor University Medical Center at Garland
Disclosure: Nothing to disclose.

Coauthor(s)

Gregory Paul Neyman, MD, Resident, Family Practice, Family Practice Resident Physician, Covenant Medical Center
Disclosure: Nothing to disclose.

Stephen Mark Olmstead, DO, Division of Allergy and Immunology, Assistant Clinical Professor, Department of Internal Medicine, University of Texas Southwestern Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Richard F Lockey, MD, University Distinguished Health Professor, Professor of Medicine, Pediatrics and Public Health, Joy McCann Culverhouse Chair in Allergy and Immunology, University of South Florida College of Medicine; Director, Division of Allergy and Immunology, James A Haley Veterans' Hospital
Richard F Lockey, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American College of Chest Physicians, American College of Occupational and Environmental Medicine, American College of Physicians, American Medical Association, and Florida Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael R Simon, MD, MA, Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Adjunct Staff, Division of Allergy and Immunology, Department of Internal Medicine, William Beaumont Hospital
Michael R Simon, MD, MA is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Federation for Medical Research, Michigan Allergy and Asthma Society, Michigan State Medical Society, Royal College of Physicians and Surgeons of Canada, and Society for Experimental Biology and Medicine
Disclosure: Secretory IgA, Inc. Ownership interest Board membership

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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