title: Severe adverse cutaneous reaction to insulin due to cresol sensitivity.
abstract: We present the case of an 80-year-old lady known to be sensitive to chlorocresol (4-chloro-3-methyl phenol) who developed severe erythrodermic exfoliative dermatitis with atypical features 2 weeks after commencing subcutaneous insulin. All medications except insulin were stopped, without major improvement. It was noted that the insulin contained m-cresol (m-methyl phenol) so a parabens-based insulin was substituted. There was a significant improvement in her clinical condition within 72 hr. Further patch and intradermal testing to the insulin and m-cresol was planned, but she developed a nosocomial infection and died. We hypothesize that the adverse cutaneous reaction was a systemic manifestation of cresol sensitivity, given the rapid clinical resolution on changing insulins and the previously demonstrated sensitivity to chlorocresol, particularly as cross-reactivity between different low molecular weight methyl phenols is documented. Local injection site reactions and systemic side-effects including nausea, diarrhoea and vomiting have previously been reported with cresol-containing insulins, although to our knowledge, this is the first reported case of a severe cutaneous reaction. It is important to be aware of m-cresol as a potential allergen, as it is contained in most commercially available insulins.
authors.affiliation: Birmingham Skin Centre, Sandwell and West Birmingham NHS Trust, Birmingham B18, UK. sfr@blueyonder.co.uk
authors.forename: S F
authors.initials: SF
authors.lastname: Rajpar
authors.forename: I S
authors.initials: IS
authors.lastname: Foulds
authors.forename: A
authors.initials: A
authors.lastname: Abdullah
authors.forename: M
authors.initials: M
authors.lastname: Maheshwari
mesh_terms: D000369:Aged, 80 and over; D003408:Cresols / Q000008:administration & dosage / Q000009:adverse effects* / Q000032:analysis*; D003875:Drug Eruptions / Q000209:etiology*; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000737:chemistry*; D007279:Injections, Subcutaneous; D007328:Insulin / Q000008:administration & dosage / Q000009:adverse effects / Q000737:chemistry*
chemical_list: D003408:Cresols; D007004:Hypoglycemic Agents; D007328:Insulin; C032538:4-cresol