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Occupational contact urticaria caused by donepezil

A 28-year-old non-atopic nurse presented with two episodes of pruritic red wheals with surrounding erythema and associated swelling of her hands and forearms that occurred immediately after crushing donepezil (Aricept®, Pfizer, Madrid, Spain), zolpidem and omeprazole tablets at work. The cutaneous lesions resolved in approximately 6 hr without any intervention. After informed consent, skin prick tests were performed on her forearm using Aricept® (5 mg/ml), zolpidem (10 mg/ml), omeprazole (40 mg/ml) and a commercial natural rubber latex protein extract (Bial-Aristegui, Bilbao, Spain); histamine dihydrochloride (10 mg/ml) was the positive control. There was no immediate reaction to the drugs or latex. Patch tests were carried out with the European baseline series and the three involved drugs at 50% pet. (Curatest®; Lohman & Rauscher GmbH, Neuwied, Germany). Reading at 20 min showed a positive reaction to Aricept® (papules and erythema), and the patch test was removed after 2D and no reaction was noted at D2 or D4. All the other allergens tested gave negative reactions at 20 min, D2 and D4. Patch tests with Aricept® in 10 controls were negative. Subsequently, the patient underwent provocative use test with the three different drugs (crushing and handling the tablets); only Aricept® produced symptoms at 20 min. In order to exclude sensitization to an excipient, she was patch tested with Aricept® inactive ingredients (10% pet.): lactose monohydrate, corn starch, microcrystalline cellulose, hydroxypropyl cellulose, magnesium stearate, talc, polyethylene glycol, hypomellose and titanium dioxide. Negative results to all excipients were noted. Double-blind, placebo-controlled oral challenges with omeprazole and zolpidem were well tolerated. After avoiding donepezil at work, the patient experienced no further symptoms.