Epicutaneous Tests Research Articles

A CASE OF ANAPHYLAXIS TO SUGAMMADEX SKIN PRICK TESTING

<h3>Introduction</h3> Sugammadex is a modified gamma-cyclodextrin gaining increasingly common usage as an anesthetic medication for the rapid reversal of the neuromuscular blocking agents rocuronium and vecuronium. While considered safer than traditional reversal agents, sugammadex is becoming more widely recognized as a rare cause of peri-operative anaphylaxis. There are no standardized skin prick testing protocols or commercially available IgE assays for sugammadex, although previous literature has used an undiluted concentration of 100mg/ml for epicutaneous skin testing. <h3>Case Description</h3> A 57 year old woman with a medical history of anaphylaxis to bee sting experienced peri-operative anaphylaxis upon first time exposure to sugammadex. Despite adequate treatment, she had subsequent rebound anaphylaxis. Four months after her reaction she completed skin prick testing to sugammadex. During the first round of epicutaneous skin prick testing with a diluted concentration of 0.1mg/mL of sugammadex she experienced diffuse hives, throat closer, and hoarseness of voice requiring treatment with epinephrine, diphenhydramine, and steroids. She again had rebound of symptoms shortly thereafter, requiring transfer to the emergency department for monitoring. <h3>Discussion</h3> The evaluation of a patient with peri-operative anaphylaxis can be challenging. As the use of sugammadex increases, clinicians should be aware of its ability to cause anaphylaxis. This case demonstrates anaphylaxis in a sugammadex naive patient, both intra-operatively and then during in-office skin prick testing. The case raises awareness of the possibility for anaphylaxis at a concentration of 0.1mg/ml for epicutaneous skin testing and highlights the need for standardized skin prick testing protocols.

PREVALENCE OF ALLERGIES ON PEDIATRIC PATIENTS WITH ATOPIC DERMATITIS AND EOSINOPHILIC ESOPHAGITIS

<h3>Introduction</h3> One of the most common allergic diseases in the population is atopic dermatitis (AD), which is sometimes associated with cases of Eosinophilic Esophagitis (EoE). Both, EoE and AD are often associated with other forms of allergy spectrum diseases such as asthma, rhinitis, conjunctivitis, sensitization to foods or pollens, and others. The purpose of this study is to identify and compare the prevalence of the most common allergies and comorbidities in pediatric patients with AD and EoE in the southern region of Puerto Rico. <h3>Methods</h3> A cross-sectional record review of 138 patients from ages 1-18 years old at an allergist/immunologist outpatient clinic in Ponce, Puerto Rico, with epicutaneous and RAST IgE-specific test from December 2016 to 2021. <h3>Results</h3> In dietary allergies nuts, peanuts, soya beans and walnuts had statistical significance with prevalence in patients with EoE compared to AD. The most prevalent in patients with AD were eggs (36.0%), milk (32.8%), wheat (16.8%), and peanuts (11.2%). In the case of EoE, the most frequent food allergies were peanuts (36.4%) and soya bean (27.3%); eggs, almonds, nuts, and wheat had the same percentages of patients (18.2%). <h3>Conclusion</h3> When our data was analyzed and compared to that of the United States, atopic dermatitis showed the same trend as reported across the states. In contrast, the prevalence of sensitivities to the most common allergens was reported differently in our studies in patients with EoE. More patients may be evaluated to reassess dietary restrictions for patients with EoE in Puerto Rico.

THE "FLARE-UP PHENOMENON": NEW ONSET OF DISTANT DERMATITIS DURING PATCH TESTING

<h3>Introduction</h3> Allergic contact dermatitis is common, affecting ∼20% of adults, and is often evaluated via diagnostic patch testing.[1] In rare cases, patch testing may result in worsening of pre-existing dermatitis, but development of de novo lesions is unusual.[2] <h3>Case Description</h3> In 2018, a 46-year-old woman experienced severe, bilateral eyelid swelling with intense itching and skin cracking, along with an eczematous rash on her chest and hands. Inpatient workup revealed no infectious/rheumatologic cause, and patient was diagnosed with contact dermatitis from an unknown trigger. After a period of remission, in 2021 patient again developed bilateral eyelid rash without involvement of the hands or chest. Following treatment with topical steroids, eyelid rash resolved. Epicutaneous patch testing was performed (T.R.U.E. TEST). 36h after patch test placement, patient experienced, rapid intensification of eczematous lesions around the eyelids, as well as new onset of rash on the dorsa of her hands, which had been unaffected prior to patch testing (Figure 1). 72h read was positive to colophony and fragrance mix (+1). Systemic and topical corticosteroids were prescribed for presumed flare-up phenomenon, with subsequent resolution of periorbital and hand rash. <h3>Discussion</h3> While generally well-tolerated, diagnostic patch testing has been associated with the "flare-up" phenomenon, worsening pre-existing eczema—and, in this case, leading to the development of de novo lesions.[3] Flare-up is more common in polysensitized patients, as was seen in our case.[2] The mechanism of the "flare-up phenomenon" is poorly understood, but is believed to involve reactivation of memory T cells at previous sites of disease.[3]

35302 Assessment of the impact of Cates plot on patient comprehension of patch test predictive value

Patch testing is the gold standard to diagnose allergic contact dermatitis. It is a generally safe epicutaneous test performed by application of individual allergens in an attempt to identify an offending ingredient. Patch testing is an impactful diagnostic tool for allergic contact dermatitis; However, the outcome may be inconclusive at times. Various determinant factors that influence patch test result includes: identification of all potential allergens in the home and work environment for testing, technical accuracy of patch application, and avoidance of immunosuppressive topical therapies at the test site as well as systemic therapies during testing.

Equipamento de Proteção Individual: Causa ou Consequência? Caso Clínico

Introduction Contact dermatitis comprises 70–90% of all occupational skin diseases, leading frequently to functional disability. If contact dermatitis is suspected, the patient’s occupational history can guide the clinical suspicion as well as the allergens to be tested. Case Report A 63-year-old male electrician, who went to a Dermatology Specialist with pruritic erythematous-scaly lesions on the hands and feet, two years after the onset of symptoms. An epicutaneous test was performed, and Potassium Dichromate, Paraphenylenediamine, Lanolin Alcohols and Textile Blends were found positive. Considering the characteristics of the lesions, their distribution, occupational exposure and the results of skin patch tests, the diagnosis of Allergic Contact Dermatitis was established. Discussion It was possible to establish a relationship between the Personal Protective Equipment used by the worker and the symptoms, as well as establish the presumptive diagnosis of Occupational Dermatitis. The best approach for treatment is to identify and remove the agent, since avoiding the allergens can improve the clinical condition. Workplace analysis, as well as the development of preventive strategies are essential for Occupational Health. It is important to encourage companies to reduce/eliminate exposure to risk factors, promoting the health and safety of workers. Conclusion Contact Dermatitis is associated with a high personal and professional impacts, which can result in absenteeism, reduced productivity and disability. The Occupational Health Care Physician plays an active role in informing workers, with regards to safe working practices and the correct use of Personal Protective Equipment, so that these are used for protection instead of the source of the illness. Keywords: Dermatitis, Allergic contact, Contact Dermatitis; Occupational Dermatitis; Occupational Health.

Contact allergy mimicking trench foot infection: a case study

Hard-to-heal wounds are a major cause of morbidity and/or mortality. Multiple aetiologies can be identified and wounds can be treated according to their aetiology and macroscopic appearance. However, evidence behind the wide range of locally applied treatments is weak, without clear guidelines available to treat a variety of wound aetiologies. We present the case of a 63-year-old male with hard-to-heal wounds not responding to standard topical treatment. No clear underlying aetiology could be found. Extensive contact allergies were diagnosed after multiple topical and systemic treatments had been applied. A full recovery was observed after stopping topical agents and treating the wounds with an alternative treatment based on epicutaneous test results.

Sarcoid Granulomas Over Scars: Beyond Sarcoidosis

Sarcoid granulomas can be found in a wide range of diseases and differentiating sarcoidosis from a sarcoid-like reaction may be a challenge. We present a woman with erythematoviolaceous papulonodular lesions located on the ears where piercings were placed. A skin biopsy showing an infiltrate of sarcoid and focal tuberculoid granulomas did not exclude sarcoidosis. There was a slight increase in the level of angiotensin-converting enzyme. Systemic involvement due to sarcoidosis was excluded. Epicutaneous tests performed revealed a strong positive reaction to palladium and nickel, supporting the diagnosis of granulomatous contact dermatitis. There are only a few reports of granulomatous contact dermatitis to palladium with piercings as the source of sensitization. The formation of sarcoid granulomas can represent either a sarcoid-like reaction or a form of cutaneous sarcoidosis, and patch tests are essential in order to establish the diagnosis.

Patch testing with the Japanese baseline series 2015: A 4-year experience.

The Japanese baseline series (JBS), established in 1994, was updated in 2008 and 2015. The JBS 2015 is a modification of the thin-layer rapid-use epicutaneous (TRUE) test (SmartPractice Denmark, Hillerød, Denmark). No nationwide studies concerning the TRUE test have previously been reported. To determine the prevalence of sensitizations to JBS 2015 allergens from 2015 to 2018. We investigated JBS 2015 patch test results using the web-registered Skin Safety Care Information Network (SSCI-Net) from April 2015 to March 2019. Patch test results of 5865 patients were registered from 63 facilities. The five allergens with the highest positivity rates were gold sodium thiosulfate (GST; 25.7%), nickel sulfate (24.5%), urushiol (9.1%), p-phenylenediamine (PPD; 8.9%), and cobalt chloride (8.4%). The five allergens with the lowest positivity rates were mercaptobenzothiazole (0.8%), formaldehyde (0.9%), paraben mix (1.1%), mercapto mix (1.1%), and PPD black rubber mix (1.4%). Nickel sulfate and GST had the highest positivity rates. The JBS 2015, including a modified TRUE test, is suitable for baseline series patch testing.

Allergy Evaluation under X-Ray Exposition in Patients with Failed or Upcoming Arthroplasty

Nowadays metal implants are a major source of metal exposure. Contact allergy to nickel, cobalt and chromium is one of the most prevalent allergic reactions in humans with contact dermatitis; up to 17% of women and 3% of men. Setting up the sensitization to implant components is needed before orthopedic surgeon. Patch testing remains the gold standard for verification a for type IV reaction of metal, bone cement, or antibiotic. We assessed the records of all 22 patients, whom we followed up since orthopedic intervention or were indicated for such intervention. All patients were exposed to X-ray after placement of epicutaneous tests. X-ray exposure may have influence on positive skin test results- odds ratio 0.56 [95% confidence interval 0.16393 - 1.91031].

The American Contact Dermatitis Society Core Allergen Series

ABSTRACT Allergic contact dermatitis has been increasing in prevalence with the growing complexity of the ingredients in commercial products. The gold standard for the diagnosis of allergic contact dermatitis is patch testing. Patch testing allows for identification of relevant allergens that can then guide treatment with targeted avoidance. Although patch testing initially required clinicians to handpick suspected allergens, the development of a standard allergen panel in 1995 called the Thin-Layer Rapid Epicutaneous Test transformed the way patch testing is performed. In recent years, more comprehensive series have been developed, including the American Contact Dermatitis Society (ACDS) Core Allergen Series, which tests for 80 allergens rather than 36 allergens. The benefits of using the ACDS Series include (a) a greater likelihood of detecting relevant allergen(s), (b) a decreased need for repeat testing and subsequently fewer clinic appointments and less patient travel, and (c) an ability to update and modify the series of allergens based on consumer trends and patient data. Important/relevant allergens found in the ACDS Series but not the Thin-Layer Rapid Epicutaneous Test include many preservatives, adhesives, fragrances, and propylene glycol. We propose that patch testing with extended series of allergens be considered for first-line use when evaluating patients with suspected allergic contact dermatitis.

No Clinical or Radiographic Differences Between Cemented Cobalt-Chromium and Titanium-Niobium Nitride Mobile-Bearing Unicompartmental Knee Arthroplasty.

This study aimed to compare the clinical and radiographic outcomes of patients with positive patch tests undergoing a medial mobile-bearing titanium-niobium nitride (TiNbN) unicompartmental knee arthroplasty (UKA) to patients undergoing standard UKA (cobalt-chromium [CoCr] implants). Two successive groups of patients, amounting to a total of 246 individuals, who received Oxford (Zimmer-Biomet, Warsaw, Indiana, USA) UKA were included. The first group was composed of a series of 203 consecutive standard CoCr UKAs (Standard Group), while the second group comprised 43 consecutive hypoallergenic TiNbN UKAs (HA group). The patients of the second group had a positive epicutaneous patch test result for metals. Each patient was evaluated using the Oxford Knee Score (OKS) and Knee Society Score (KSS) a day prior to the surgery (T 0) and at two consecutive follow-ups, namely T 1 (minimum follow-up of 12months) and T 2 (minimum follow-up of 34months). Radiographic measurements were performed at the final follow-up (T 2). No statistical differences were noted between the two groups regarding demographic data (p > 0.05). No clinical or radiographic differences were found between the HA and standard groups at any follow-up (p > 0.05). A statistically significant improvement was found at any follow-up for both OKS and KSS (p < 0.05). No clinical or radiographic differences between the hypoallergenic and standard cobalt-chromium groups at any follow-up were found, with a clinically significant improvement being experienced by both groups during the entire follow-up. Level II-comparative prospective study. The online version contains supplementary material available at 10.1007/s43465-021-00486-3.

Evaluating the inclusiveness of common allergens in expanded series patch tests for children in the pediatric allergic contact dermatitis registry

Evaluating the inclusiveness of common allergens in expanded series patch tests for children in the pediatric allergic contact dermatitis registry

Type IV hypersensitivity to timolol

Type IV hypersensitivity to timolol

Allergenic components of the mRNA-1273 vaccine for COVID-19: Possible involvement of polyethylene glycol and IgG-mediated complement activation.

Following the emergency use authorization of the mRNA‐1273 vaccine on the 18th of December 2020, two mRNA vaccines are in current use for the prevention of coronavirus disease 2019 (COVID‐19). For both mRNA vaccines, the phase III pivotal trials excluded individuals with a history of allergy to vaccine components. Immediately after the initiation of vaccination in the United Kingdom, Canada, and the United States, anaphylactic reactions were reported. While the culprit trigger requires investigation, initial reports suggested the excipient polyethylene glycol 2000 (PEG‐2000)—contained in both vaccines as the PEG‐micellar carrier system—as the potential culprit. Surface PEG chains form a hydrate shell to increase stability and prevent opsonization. Allergic reactions to such PEGylated lipids can be IgE‐mediated, but may also result from complement activation‐related pseudoallergy (CARPA) that has been described in similar liposomes. In addition, mRNA‐1273 also contains tromethamine (trometamol), which has been reported to cause anaphylaxis to substances such as gadolinium‐based contrast media. Skin prick, intradermal and epicutaneous tests, in vitro sIgE assessment, evaluation of sIgG/IgM, and basophil activation tests are being used to demonstrate allergic reactions to various components of the vaccines.

Automated detection of skin reactions in epicutaneous patch testing using machine learning

Patch testing is the diagnostic gold standard to identify causes of allergic contact dermatitis (ACD); however, the paucity of specialized patch testing clinics along with the need for multiple clinic visits can be burdensome for patients and healthcare systems. Automated classification of allergic reactions from photographs offers the opportunity to reduce patient, physician, and clinic time and improve access to care.

Standard photopatch test battery? Proposal based on current epidemiology and experience in our Skin Allergy Unit.

The diagnosis of photoallergic contact dermatitis (PACD) is confirmed by photopatch testing (PPT). In Spain, the latest recommendation on which allergens to test in PPT dates from 1995. In the last 4years, we studied 455 patients with epicutaneous tests and performed PPT on 33 of those patients (7.3%). The most prevalent allergens in PPT were as follows: non-steroidal anti-inflammatory drugs (NSAIDs) (46%), fragrances (21%), and solar filters (18%). In our country, the most common photoallergens continue to be NSAIDs (ketoprofen). The increasingly common use of sunscreens has led to a growing involvement of solar filters in PACD, which can be also contained in other cosmetics. In our experience, PACD due to fragrances is nonetheless at least similar in frequency. The PPT battery must adapt to the prescription, use, and exposure habits of each country. We propose a diagnostic model to guide which allergens to test in PPT, which in our experience should also include fragrances.

Prevalence of titanium hypersensitivity in patients with titanium implants: A systematic review and meta-analysis

Background:With increase in exposure to titanium in daily life and its use in medical procedures, there is a greater chance for developing titanium hypersensitivity. Our aim and objective is to examine whether patient patients with titanium implants had a greater incidence of titanium hypersensitivity or not. Titanium is widely considered to have good biocompatibility. A passivating surface layer of TiO2 is formed when exposed to air which gives it good corrosion resistance. These properties along with its high strength, lightweight, and improvements in smelting technologies have led to its widespread use as an intraosseous and periosteal implant in dentistry and orthopedics.Materials and Methods:Only case–control studies were used for the meta-analysis. Studies with a sample size of <5 were excluded. Cutaneous and epicutaneous tests were used in the study.Results:Three studies met the inclusion criteria. Titanium hypersensitivity is more prevalent in patients with titanium implants.Conclusions:It is also used in a variety of medical devices such as pacemakers and insulin pumps. Moreover, our external exposure to titanium is increasing. It is used in aerospace, chemical, and automobile industries. It is also used in jewelry, home furnishings, and in making sports and marine equipment. Titanium implants increase the possibility of developing titanium hypersensitivity, and thus, it should be considered as a major factor in unexplained implant failure where other causes have been excluded.

Epicutaneous Patch Testing in Type IV Allergy Diagnostics: State of the Art and Best Practice Recommendations.

This chapter summarises all relevant aspects of patch testing, closely following recommendations outlined in a recent European, and a German S3 guideline on diagnostic patch testing with contact allergens and medicinal products (drugs). Patch testing is indicated in patients suspected of suffering, or having been suffering, from delayed-type hypersensitivity leading to allergic contact dermatitis or other skin and mucosal diseases. Sections of this chapter include detailed indications, reasons for possibly postponing the test, considerations on choosing haptens (contact allergens) to test, various aspects of the application of patch test allergen preparations (storage, dosing) and of testing with individual materials provided by the patients. Special aspects of patch testing in cutaneous adverse drug reactions, children, or occupational contact dermatitis are outlined. Supplemental test methods, notably the repeated open application test, are briefly described. Finally, the final evaluation in terms of assessment of clinical relevance of reactions and patient counselling are outlined.

Dermatite de Contato Alérgica aos (Meta)Acrilatos- estudo retrospetivo de sete anos num Hospital Público Português

Introduction Acrylates are salts or esters of the acrylic acid, widely used as part of cosmetic or dental products, surgical equipment, medical devices, household items, building materials and printing inks. Allergic contact dermatitis (ACD) caused by (metha)acrylates could be described in occupational settings, mainly in beauticians using acrylic manicure and, specifically, the photo-bonded long-lasting nail polish. The use of gloves, fingertips made of Polyethylene/ Ethylvinyl-alcohol, mask, safety glasses and an appropriate uniform are recommended in these cases. Materials and methods We present a retrospective study of ACD to acrylates diagnosed at an Hospital in Braga (Portugal), between January 2012 and March 2018. In all cases the epicutaneous patch tests used included the Portuguese Contact Dermatitis Research Group baseline series and an extended series of (meth)acrylates. Results A total of 39 female patients had a sensitization to (metha)acrylates, aged between 21-66 years, with personal history of atopic eczema and allergic rhinitis in 23 and 26% of cases, respectively. The most frequent presentation was hand eczema (87%). Dorsal and palms were affected in an equal percentage of cases (38%) and nail dystrophy in 8% of patients. Ectopic lesions on the face were detected in 33% of cases, mostly with the involvement of the eyelids. Occupational related exposure due to (metha)acrylates was found in 69% of cases, mostly of them beauticians/ artificial nail technicians. The most common sensitizers among the 39 allergic individuals were 2-hydroxyethyl methacrylate (HEMA; positive in 97% of cases) and ethyleneglycol dimethacrylate (positive in 69% of cases). Conclusion In our population, we highlight the high number of cases of ACD from (meth)acrylates in relation to artificial nails. Concerning to the health and safety of workers, it certainly deserves better preventive measures at the occupational level and specific regulation from the authorities concerned with the safety of consumers. HEMA was the most frequent positive allergen (above 90% of tests) and, in agreement with previous studies, can be considered a good screening allergen.

The effect of a low-nickel diet and nickel sensitization on gastroesophageal reflux disease: A pilot study.

Gastroesophageal reflux disease (GERD) is a common medical condition, frequently refractory to medical therapy. Nickel is a leading cause of allergic contact dermatitis. Although nickel is widely found in foods, the effect of nickel on GERD is unknown. This pilot study sought to evaluate the effect of a low-nickel diet on GERD and determine if epicutaneous patch testing to nickel could predict responsiveness to a low-nickel diet. This prospective, single-site pilot study recruited 20 refractory GERD patients as determined by GERD Health-Related Quality of Life (GERD-HRQL) scores. All patients had epicutaneous patch testing for nickel and were then instructed to follow a low-nickel diet for 8weeks regardless of patch test results. GERD-HRQL was recorded at baseline and following 8weeks of a low-nickel diet. Demographic and clinical data associated with GERD and nickel allergy were recorded. A Wilcoxon signed-rank test and nonparametric analysis of longitudinal data were run to determine statistical significance in pre-and post- GERD-HRQL scores in nickel patch test-positive and negative groups. Nearly all (19/20 [95%]) participants reported reduced GERD symptoms after 8weeks on a low-nickel diet. Mean total GERD-HRQL, regurgitation, and heartburn scores declined (27.05 ± 16.04, 11.45 ± 6.46, 10.85 ± 8.29). Participants with positive vs. negative patch testing to nickel responded equivalently to a low-nickel diet. A low-nickel diet improves GERD symptoms, but responsiveness to a low-nickel diet does not correlate with epicutaneous patch testing to nickel. ClinicalTrials.gov number: NCT03720756.