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Adverse cutaneous drug reaction to alendronate

We present a 60-year-old Caucasian female with postmenopausal osteoporosis who developed maculopapular skin lesions in the head and neck region 4 months after daily alendronate intake of 10 mg (Fig. 1). Spontaneous regression occurred with some residual scaling within 6 weeks after cessation of the drug. The patient’s medical history and clinical findings were otherwise unsuspicious. Histology showed a superficial perivascular spongiotic dermatitis with focal vacuolization of the basal cell layer and a mixed cellular infiltrate with few neutrophils as well as eosinophils. Comprehensive patch testing including the patient’s own cosmetics were negative. 2 products (Marie Christine make up liposomal gel, Deynique anti stress refire mask) revealed doubtful positive or irritant reactions, respectively. However, subsequent repeated open application testing with both substances applied twice daily for 7 D to the flexor aspect of the forearms near the cubital fossa was negative. The minimal erythema dose for ultraviolet (UV) A andUVBwas within normal limits. Sensitization to hazel, alder, and birch pollen as well as house dust mite allergens in a standard panel of prick tests was consistent with an atopic disposition. Patch testing (scratchchamber) with alendronate 50% in water and petrolatum showed crescendo reactions at D2 and D3 (Fig. 2). Open testing (rub, prick, scratch) was negative. Control testing (closed patch tests with alendronate 50%, 10%, and 1% in water) on 10 patients without a history of bisphosphonate medication showed weak positive skin reactions (erythema with infiltration) at 50% in 3 cases, at 10% in 4 cases, and at 1% in 1 case: doubtful reactions (erythema only) were seen in 2, 0, and 1 case at these concentrations, respectively. After 2 months of complete remission oral rechallenge with alendronate in identical dosage for 3 months resulted in an isomorphic and isotopic response in our patient. All skin lesions cleared within 2 weeks after cessation of alendronate and local treatment with a steroid ointment. Substitution with risedronate (Actonel ) 5 mg/D was well tolerated and maintained to date without any side-effects.