Recurrent Bilateral Lime Disease in a Young Female- Case Report

Allergic skin diseases

Allergic Contact Dermatitis

Nickel allergy in the United States: A public health issue in need of a “nickel directive”

Anaphylaxis to 6-α-methylprednisolone in an eight-year-old child

Contact dermatitis in children is not uncommon. Most cases are misdiagnosed as endogenous eczema. Irritant contact dermatitis is probably more common than allergic contact dermatitis. Most epidemiology studies are based on referral populations in hospitals and the actual incidence in the community is unknown. The reported prevalence of contact allergy in patch test clinics varies from 24 to 66%. Common contact allergens include metals (e.g., nickel), mercurials (medicament), fragrance mix and rubber chemicals. Allergic and irritant contact dermatitis are often clinically indistinguishable from each other and an accurate diagnosis is possible only after a detailed history, physical examination and patch test. Occasionally, the location and morphology of the dermatitis may give a clue to diagnosis. Patch testing is seldom carried out in children, and dermatologists should be encouraged to perform the test where allergic contact dermatitis is suspected. There are similarities between pediatric and adult contact dermatitis and the same patch-test allergen concentrations can be used as in adults with minor modifications. Contact urticaria to natural rubber latex in children should not be overlooked. Children with atopic dermatitis and those with multiple surgical interventions are at a higher risk. Once diagnosed, strict avoidance of products containing natural rubber latex should be advised, as contact urticaria to natural rubber latex can be life threatening.

Henna tattoo: infection or allergy?

Allergic contact dermatitis (ACD), a prevalent skin disorder marked by delayed hypersensitivity reactions to specific allergens, is commonly diagnosed through patch testing. Previous studies have indicated lower rates of positive patch tests in summer months compared to winter months. To investigate whether there is a difference in the proportion of positive patch test results between summer and winter months. A retrospective study was performed on 1128 patients, with 14 individuals undergoing two tests each, resulting in a total of 1142 patch tests. The tests were conducted at a major tertiary referral center between 2016 and 2020. The data set encompassed patient demographics and comprehensive patch test results. Of the 1142 tests conducted, 808 (70.8%) yielded a positive response. The most frequently administered test series was the European standard series, conducted for 1135 (99.3%) of the tests, with 559/1135 (49.2%) showing positive results, followed by the cosmetics series (394/1120, 35.1%) and fragrances series (61/118, 51.7%). No statistically significant difference was observed in the proportion of positive patch tests between summer and winter months (313/419, 74.7% vs. 175/245, 71.4%, respectively; P-value = 0.35). There was no statistically significant difference in the rate of testing each specific series between the summer and winter months, except for the fragrances series. We found no significant difference in the positive patch test rates between the summer and winter months. Therefore, patch testing can be reliably conducted during the summer without an increased risk of false-negative results.

CASE A 10-year-old girl presented with pink scaly plaques on her antecubital and popliteal fossae (Figure 1). In addition, she had swelling of the medial canthi of her eyelids. She reported that the dermatitis started a couple of years ago and that it was worsening despite use of over-the-counter hydrocortisone creams (which she used the most frequently), Desonate and Protopic.FIGURE 1: Plaques of allergic contact dermatitis in the antecubital fossae of a 10-year-old girl.Patch testing to our pediatric standard (Jacob, Burk, & Connelly, 2008) revealed a clinically relevant positive reaction to compositae mix. WHAT IS THE DIFFERENTIAL DIAGNOSIS? The differential diagnosis is as follows: atopic dermatitis (AD), irritant contact dermatitis, and allergic contact dermatitis (ACD). DISCUSSION Once thought to be rare in the pediatric population, ACD is now recognized as a significant problem. The incidence of ACD in children is rising perhaps due to increased exposure to sensitizing agents (Beattie, Green, Lowe, & Lewis-Jones, 2007). Several studies have demonstrated that 13%-24% of asymptomatic children will have positive patch test reactions (Barros, Baptista, Correia, & Azevedo, 1991; Bruckner, Weston, & Morelli, 2000; Mortz, Lauritsen, Bindslev-Jensen, & Andersen, 2002; Weston et al., 1986). In symptomatic children referred for testing due to suspected contact dermatitis, the incidence of positive reactions rises to approximately 41%-67% (Jacob, Brod, & Crawford, 2008). Although the relationship between AD and ACD remains controversial, it is well known that these two clinical entities can and do occur together (Klas, Corey, Storrs, Chan, & Hanifin, 1996). In fact, AD may be a predisposing risk factor to sensitization (Segurado Rodriguez, Ortiz de Frutos, & Guerra Tapia, 2004). One hypothesis to explain this association is that children with AD are more susceptible to sensitization because they have decreased skin barrier function. Loss-of-function mutations in the filaggrin gene, which predispose to AD, result in this skin barrier disruption and have also been shown to be associated with predisposition to irritant contact dermatitis (de Jongh et al., 2008). Another explanation for why children with AD could also contract ACD is that they can have prolonged exposure on damaged skin to sensitizing agents present in their emollients or steroid creams. Our clinical case illustrates this point as our atopic patient demonstrated a clinically relevant reaction to chamomile extract (compositae mix), an ingredient in the vehicle of her over-the-counter hydrocortisone and shampoo and conditioner. Notably, by instituting avoidance (of these products and this allergen) and barrier repair measures with emollients, our patient's atopic distribution and eyelid dermatitis resolved. Because an undiagnosed ACD in an atopic child will often result in a chronic dermatitis that is recalcitrant to standard therapies, it is important to also consider a concomitant diagnosis of ACD. Some clinical clues that suggest that a child with AD also has ACD are a new-onset, deteriorating, or recalcitrant dermatitis (Jacob et al., 2008). Furthermore, ACD should also be suspected in children with involvement of atypical areas such as their face, hands, eyelids, or neck folds or with the presentation of dyshidrosis (Beattie et al., 2007; Jacob et al., 2008). An excellent example of these principles is illustrated in a case report recently published in Contact Dermatitis (Jacob & Stechschulte, 2008). This case describes a 4-year-old atopic girl with worsening flexural dermatitis and eyelid dermatitis. Patch testing revealed that the child was allergic to tosylamide-formaldehyde resin 10% in petrolatum, a chemical present in her nail polish. After avoidance of the allergen, she experienced a significant improvement in her dermatitis. If ACD is suspected, it is important to refer the child for patch testing. Patch test evaluation includes not only administration of patch testing but also a careful intake history to assess the most likely allergens present in their environment (Jacob et al., 2008). Once the offending allergen is identified and strictly avoided, the children usually experience significant improvement in their dermatitis (Jacob et al., 2008). Furthermore, they may be able to discontinue the use of corticosteroids and immunosuppressive agents and experience an improvement in not only their dermatitis but also their and their family's quality of life.

Neonatal-onset multisystem inflammatory disease (NOMID) is a rare and severe autoinflammatory disease caused by mutations of the NLRP3 gene and is characterized by a skin rash, fever, arthropathy, and neurologic manifestations. We herein report a neonatal case with recurrent rash, fever, and meningitis from 12 h after birth, and NOMID was diagnosed during the neonatal period. We also reviewed the clinical characteristics and genetic mutations of previously reported Chinese neonates with NOMID. NOMID is rare in China, and there have been over 100 cases uncovered thus far, including ours. The patient we reported here was the youngest among the confirmed Chinese cases and had the de novo mutation c.1210G>C (p.V404L) in exon 4 of the NLRP3 gene, which has not been reported previously. All 25 patients manifested recurrent urticaria-like rash, and 24 were febrile. Of the 23 patients with genetic data available, all had NLRP3 mutations. The primary treatment of these patients entailed glucocorticoids and immunosuppressants; however, the IL-1 inhibitor was rarely used due to its current unavailability in China. One patient was cured by umbilical cord blood stem cell transplantation (UCBT), which provided an alternative treatment. We recommend that NOMID be considered for neonates with recurrent rash, fever, and aseptic meningitis. However, further research on underlying mechanisms and therapeutic regimens in China is necessary to provide improved management.

Efficacy of Combined Peroxisome Proliferator-Activated Receptor-α Ligand and Glucocorticoid Therapy in a Murine Model of Atopic Dermatitis

Linked articles: COVID‐19 SPECIAL FORUM. J Eur Acad Dermatol Venereol 2020; 34: e210–e216.

Contact dermatitis is an inflammatory skin disease induced by direct contact of a external agent to the skin. It can be classified into two main types: Irritant contact dermatitis and Allergic contact dermatitis. Irritant contact dermatitis represents a non-specific cutaneous response to the toxic or physical effects of environmental agents, while Allergic contact dermatitis represents a specific type IV hypersensitivity reaction to specific haptens. Both types are characterized by a highly variable clinical presentation that includes erythema, papules, vesicles, bullae, scaling and erosions in acute cases, and papules, plaques, lichenification, hyperkeratosis and fisures in the chronic. Pruritus is a very common symptom most frequently associated with Allergic contact dermatitis but also frequent in Irritant contact dermatitis. Furthermore, occasionally pruritus may be the leading or only symptom that guides the clinician to suspect the diagnosis of Contact dermatitis, as it is in the case of Allergic contact dermatitis of the anogenital region or when the process occurs in the elderly. Although the mechanisms underlying the pathogenicity of the inflammatory cutaneous response in irritant and allergic contact dermatitis has been widely studied, little is known about the mechanisms leading to pruritus. This chapter summarizes the most important aspects of contact dermatitis in these specific situations as well as the last insights into the pathogenicity of pruritus in contact dermatitis.

The genital region is uniquely susceptible to both irritant and allergic contact dermatitis (ACD) due to its delicate anatomy, moist environment, and frequent exposure to potential irritants and allergens. Factors such as friction, maceration, and overuse of hygiene products significantly compromise the skin barrier, increasing the risk of dermatitis. The region’s sensitivity is further exacerbated by physiological changes, such as reduced estrogen levels in postmenopausal women, which heighten susceptibility to external agents. A detailed clinical history plays a critical role in diagnosing genital contact dermatitis (CD). Key elements include symptom onset, triggers, hygiene habits, and exposure to products used personally or by sexual partners. This thorough exploration often identifies potential irritants and allergens overlooked in a routine examination. Irritant CD (ICD) in the genital area typically presents as burning, stinging, and erythema soon after exposure to irritants. Chronic ICD may lead to scaling and lichenification. In contrast, ACD arises from delayed hypersensitivity to allergens, presenting as pruritus, erythema, and, in severe cases, vesiculobullous eruptions. Common agents implicated in ICD include soaps, urine, sweat, and certain hygiene sprays, while ACD is often triggered by allergens such as fragrances, topical medications, preservatives, and rubber components. Patch testing is a cornerstone of diagnosing genital ACD. It identifies specific allergens responsible for the dermatitis and helps in differentiating between relevant and incidental reactions. Expanding patch test series to include additional potential allergens, such as personal care products or items used by partners, enhances diagnostic accuracy. The repeat open application test is another valuable tool, particularly when patch testing yields inconclusive results. Management of genital CD primarily involves strict avoidance of identified irritants and allergens. Patients should cease using unnecessary topical medications and adopt hypoallergenic alternatives. Education on proper genital care, including the use of fragrance-free and dye-free products, is essential. Topical corticosteroids, calcineurin inhibitors, or phosphodiesterase-4 inhibitors may be prescribed for short-term relief.

Methotrexate injection site reactions: Case report and literature review

Mitomycin C is an alkylating chemotherapeutic agent which is instilled intravesically to prevent recurrence of superficial bladder carcinomas. After several cycles of mitomycin C, our patient developed a pruritic genital dermatitis and palmar desquamation. Following exclusion of a fungal infection, we performed patch tests using the standard series, the major basic ointment ingredients, disinfectants, and mitomycin C in concentrations of 0.001 to 0.1%; the resulting diagnosis was allergic contact dermatitis due to delayed-type hypersensitivity to mitomycin C. The skin rash rapidly resolved with application of topical steroids, and the intravesical chemotherapy was changed to doxorubicin. Eczematous skin reactions are quite common side effects after intravesical instillation of mitomycin C. In the majority of cases, they are caused by delayed-type hypersensitivity reactions, presumably elicited by hematogenous spread of the allergen, and not by irritation. The sensitization most likely occurs via the bladder mucosa. In order to differentiate between allergic and toxic contact dermatitis, patch tests with the above-mentioned mitomycin C concentrations are useful. In cases of mild allergic contact dermatitis the intravesical chemotherapy might be continued with concomitant topical steroids.