Erythema multiforme-like allergic contact dermatitis following localized topical tocopherol application on a surgical scar: A case report and review of the literature

Allergic contact dermatitis (ACD) is a delayed hypersensitivity response (type IV) of the immune system to small-molecule haptens that come in contact with an individual’s skin. Although ACD is often localized or well-demarcated, it can also present in a generalized manner upon ingestion, autoeczematization, or diffuse allergen use. Clinicians must be rigorous in their assessment of patients’ previous exposures and diligently patch-test for potential allergens. Here, we present the case of a 28-year-old woman with an acute localized ACD reaction with subsequent generalized erythema multiforme following topical application of tocopherol, which was initially erroneously diagnosed as a type IV hypersensitivity to oral diclofenac. Tocopherol hypersensitivity was demonstrated by patch testing. Erythema-multiforme-like eruptions secondary to localized topical vitamin E application are not well known among clinicians and were, in this case, initially overlooked as a cause for the skin eruption. Allergists should be aware of tocopherol as a possible less common causal agent of erythema-multiforme-like ACD. Clinical suspicion of ACD to less common causal agents, such as tocopherol, must be maintained, especially when patients present a classical exposure timeline and generalized lesion distribution resembling target lesions or autoeczematization.