Urticaria induced by Etoxisclerol® (polidocanol)

Abstract

EditorDodecyl polyethyleneoxid ether (polidocanol), also known as laureth-9, was first reported as a local anaesthetic. Due to its spasmogenic action on veins, it is used as a sclerosant drug nowadays. The microfoam form is considered to cause less adverse reactions than the liquid form because it displaces the blood instead of mixing and diluting itself in it. 1 It is also used as an emulsifier and surfactant in cosmetics.A 50-year-old woman was treated for superficial varicose veins in her legs with polidocanol microfoam (Etoxisclerol®). Seventy-two hours after the second session of sclerosis, the woman experienced itchy skin, first located in her thighs but later extended all over her body. Physical examination revealed confluent erythematous and oedematous papules located in the areas where the veins were sclerosed. She progressively developed swelling of the eyelids and an erythematous papular, no confluent and well-demarcked eruption in trunk and upper limbs. She was treated with antihistamines and systemic corticosteroids during 2 weeks with remission of the lesions. At this time, skin biopsy of the lesions was done after interrupting treatment.Referred for evaluation, the patient showed no history of previous allergic diseases.The skin biopsy showed an oedema in papillar dermis and a lympho-histiocytic perivascular infiltrate. We performed skin prick tests (SPT) with Etoxisclerol® (polidocanol) at 2%, with an eruption of a 4 × 5 mm papule. We also skin tested five controls, with similar results in two of them. We later performed patch test with aqueous solution of Etoxisclerol® at 2% (1 : 1 and 1 : 10 dilution) and Etoxisclerol® at 2% in petrolatum (1 : 1). Twenty-four hours after patch testing, the patient suffered a new pruritic eruption. The lesions resembled the ones referred at the moment of consultation. Prurigo lesions and papules with a small vesicle on top were also found in the trunk and arms ( fig. 1). No lesions were observed where the patch test was placed. All the blood tests carried out were in normality levels.A wide variety of adverse effects have been attributed to polidocanol. Most of them are related to contact dermatitis. 2,3 Cases of anaphylaxis during accidental intravenous injection and immediate urticaria have also been reported. 4,6 Urticaria or angio-oedema after local anaesthetic administration have usually been considered to be IgE-or complement-mediated, but recent studies suggest that could also be T-cell mediated. 5 In this case, the immunological mechanism involved remains unclear. An SPT is considered positive if the difference between the mean of the weal length and width, and the negative control is at least 3 mm. 6 Positive SPT usually show tissue bound IgE and suggest an immediate hypersensitivity type, but in this case, we consider it a false positive due to an irritant skin reaction because also the controls showed the same result. In addition, although late reactions suggest a delayed type of hypersensitivity, we support the hypothesis that a retarded absorption of...

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