Delayed systemic dermatitis from amylase cellulase, and protease

A 69-year-old woman was referred to us presenting generalized eczema and mild systemic symptoms after taking digestive tablets (AeroRed Eupeptico; UPSA Medica, San Sebastian, Spain) 7 days before consultation. Patch tests with the com ponents of these tablets (tested as is) were performed. Amylase, cellulase, and protease elicited a papulovesicular reaction at 48 and 96 hours. The other components, even a lipolytic enzyme, were negative. The same patch tests in 20 controls were negative. Several extracts of fungi and products related to the culture medium were tested by prick tests (read at 20 minutes and 48 hours) and patch tests (read at 48 and 96 hours) with negative results. Intradermal skin tests with Aspergillus were also negative at 20 minutes and 48 hours. Enzymes are well-known allergens in immunoglobulin E—mediated reactions, but a few cases of type IV hypersensitivity have been reported. This patient developed systemic contact-type dermatitis caused by cellulase, amylase, and protease taken orally in which a delayed allergy was confirmed by positive patch tests. We stress the efficacy of patch tests to establish the etiologic diagnostic mainly in cases of drug-induced dermatitis.