Epicutaneous Tests Research Articles

Place du patch-test dans le diagnostic des réactions d’hypersensibilités retardées induites par les antiépileptiques

Antiepileptic drugs are widely used and are associated with numerous side effects including skin eruptions. Epicutaneous tests have been used with variable success in skin drug reactions. The purpose of this study was to evaluate the profitability of epicutaneous tests in delayed hypersensitivity reactions induced by antiepileptic drugs. We analyzed all cases of allergic skin reactions to antiepileptic drugs notified in regional pharmacovigilance center of Sfax (Tunisia) between June 1, 2014and April 30, 2016. The imputation score, determined using the French imputation method, should be at least doubtful. Patch-tests were performed in accordance with the general Europen network on Drug Allergy/European Academy of Allergy and Clinical Immunology (ENDA/EAACI) guidelines. Patch-tests were read according to the generally accepted criteria of the International contact dermatitis research group (ICDRG). In our study, 20patients were included, among which 23events were observed. The drug involved in delayed hypersensitivity reactions was carbamazepine in 11cases, phenobarbital in 10cases and valproic acid in 4cases. The clinical reactions caused by the drug were classified as maculopapular exanthema (11cases), DRESS syndrome (6cases), Stevens-Johnson syndrome (2cases), fixed drug eruption (2cases) and erythroderma (2cases). Patch-tests were positive in 19patients (95%). Cross-reactivity between antiepileptic drugs was observed in 4cases: between valproic acid and carbamazepine in 2cases between valproic acid and phenobarbital in 1case and between phenobarbital and carbamazepine in 1case. In this study, patch testing was a safe and useful method in confirming the culprit drug in delayed hypersensitivity reactions induced by antiepileptic drugs.

Epidemiología de la dermatitis de contacto: pruebas epicutáneas estándar en el Instituto Nacional de Dermatología de Colombia

IntroductionContact dermatitis is a frequent cause of consultation in Colombia, where there is a lack of information about its epidemiology and its origin. ObjectiveTo describe the clinical and epidemiological characteristics and the results of epicutaneous tests performed at the Federico Lleras Acosta Dermatology Center, Bogotá, Colombia. Materials and methodsA descriptive study and analysis was performed on the demographic and epidemiological characteristics of the patients who underwent epicutaneous tests with the standard European battery of allergens. ResultsMore than two-thirds (68%) of the patients showeded positive results in the epicutaneous tests. The most common allergen was nickel, followed by Peruvian balm, and fragrances. The age groups between 20 to 29 and 50 to 59 years were the most affected. The most common occupation and outside work activity were household tasks. The most affected areas of the body were hands (27.4%). Erythematous desquamative plaques were observed in 52% of those affected, and current relevance was found in 80% of the patients studied. ConclusionsWomen were more affected than men. Nickel, fragrances, and preservatives were the predominant allergens, which is consistent with that reported in the international literature. There were no positive results to allergens such as budesonide, which shows the need to develop multicentre studies in Colombia that would help include new allergens and discard others.

Prevalence of sensitization to inhalant allergens in the immunology department from Hospital de Especialidades Pediátricas María, Honduras, 2016

Allergic diseases are a public health problem; estimates indicate that between 30% and 40% of the world population is affected by some allergy. Knowing the prevalence of allergen sensitization allows for adequate diagnoses and treatments to be offered. In Honduras there are no studies available in pediatric patients. The purpose of this research was to identify the most common types of sensitization in children and their correlation with the most common allergic diseases in patients on immunotherapy at the Maria Hospital of Pediatric Specialties. Cross-sectional, descriptive, retrospective study in which medical records and databases of patients on allergic immunotherapy at the Maria Hospital of Pediatric Specialties were reviewed between January 2015 and June 2016. 215 children on immunotherapy were assessed; ages ranged from 3 to 18 years, with a mean of 10.8 years. Aeroallergen-positive epicutaneous tests were identified in 73.02%. The most common aeroallergens were Dermatophagoides farinae and Dermatophagoides pteronyssinus mix (96.74%), American cockroach 37.21%, and Aspergillus fumigatus and Homodenderum cladosporioides (16.28%). House dust mites and American cockroach were the most common causes of sensitization in patients on immunotherapy.

Appropriate Testing of Isothiazolinones in Children.

The isothiazolinones methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI) are prevalent pediatric contact sensitizers. MI allergic contact dermatitis (ACD) is underreported in the literature. The objective of the current study was to use a database of provider-reported U.S. pediatric patch test cases to evaluate the positive patch test (PPT) prevalence rates of the combined preservative test substrate MCI/MI and of MI alone. U.S. pediatric patch test providers in all 50 states who had joined the registry were invited to submit deidentified cases to the database. More than 1100 logged cases in the database were evaluated for PPTs to MCI/MI combination, MCI/MI and MI, and MI alone. Within 1 year of data collection, 96 cases with a PPT for MCI/MI, MCI/MI and MI, and MI alone were identified; 37 of these were positive to MCI/MI, with MI alone not tested or negative, and 39 were positive to MI only, with MCI/MI and MI tested. Fifteen (41%) of the MCI/MI cases were detected using an epicutaneous patch test alone and 22 cases (59%) using comprehensive patch testing. Only one case (3%) of MI alone sensitization was detected using T.R.U.E. plus a supplemental panel of tests; the remaining 38 cases (97%) were detected using comprehensive testing. Testing with only the combined MCI/MI preservative substrate may miss 51% of MI allergies. Appropriate testing of isothiazolinones is needed to clarify the true prevalence of sensitization to these allergens and the burden of pediatric ACD. Patch testing for MI alone in addition to MCI/MI combination is warranted in children with recalcitrant dermatitis.

POLYGLANDULAR AUTOIMMUNE SYNDROME ASSOCIATED WITH MULTIPLE AUTOIMMUNE CONDITIONS AND ATOPIC DERMATITIS - AN UNUSUAL MANIFESTATION OF A POLYAUTOIMMUNITY PHENOTYPE.

The polyglandular autoimmune syndrome (PAS) type III is a rare condition defined as the coexistence of autoimmune thyroid disorder with other endocrine autoimmune diseases, including type 1 diabetes, without adrenal dysfunction. PAS may associate with other non-endocrine autoimmune diseases, overlapping with the multiple autoimmune syndromes (MAS). We present a case of PAS III/ MAS type 3, including autoimmune thyroiditis, autoimmune diabetes, vitiligo, lupus erythematosus, associated with adult-onset atopic dermatitis, a combination not reported previously. A 40 years old woman, registered as nurse working in dialysis unit, previously diagnosed with vitiligo, euthyroid autoimmune thyroiditis and disseminated granuloma annulare, with personal and familial history of atopic disorders, presented in our clinic for disseminated eczematous and lichenoid cutaneous rashes. She was tested positive for antinuclear, anti-double stranded DNA and anti-histone antibodies, with inflammatory syndrome and marginal lymphopenia and she was diagnosed with systemic lupus erythematosus (SLE). Subsequently, moderate hyperglycemia, positive anti-glutamic acid decarboxylase antibodies and low C-peptide level prompted the diagnosis of autoimmune diabetes. Recurrent flexural eczematous rashes, with negative epicutaneous tests but positive specific IgE tests for common allergens fulfilled the clinical criteria for the diagnosis of atopic dermatitis. The clinical, immunological and glycemic status were controlled with low doses of oral prednisone (<0.5 mg/kg), methotrexate (10mg/week), antimalarials, metformin, emollients and photoprotection. After changing her workplace, the immunosuppressive treatment could be discontinued, and the patient maintained normal immunological and biochemical profile at 6 months follow-up.This case brings a unique perspective on the evolution, associations spectrum and the management challenges of endocrine polyautoimmunity associated with atopic diathesis.

Diclofenac-Induced Allergic Contact Dermatitis: A Series of Four Patients.

Allergic contact dermatitis is an immune-mediated antigen-specific skin reaction to an allergenic chemical that corresponds to a delayed-type hypersensitivity response (type IV reaction). Allergic contact dermatitis should be suspected when skin lesions are localized to the site of previous applications of the culprit drug. Lesions appear after re-exposure in susceptible persons, with delayed onset (more than 24 h after exposure). The gold standard for diagnosis is patch (epicutaneous) testing; identification and removal of any potential causal agents is crucial. Diclofenac sodium 1% topical gel contains active (diclofenac sodium) and inactive ingredients. It is a widely used non-steroidal anti-inflammatory drug, known to cause allergic contact dermatitis, and especially photoallergic contact reactions. We present four cases of diclofenac-sodium-induced allergic contact dermatitis, diagnosed based on clinical grounds: intensively itchy eczematous lesions on the sites of drug application after several days of treatment. No allergic history and no other drug intake were reported by the patients. The application of diclofenac sodium 1% topical gel was strictly forbidden in all cases; potent topical steroids proved to be effective in all cases within 2 weeks of therapy. Patch tests were performed in all cases with European standard battery, with patients’ own diclofenac sodium 1% topical gels and with diclofenac sodium 1% in petrolatum 3 weeks after completion of local steroid therapy. Readings were done after 48 h (Day 2) and 72 h (Day 3) and proved to be positive only to patients’ diclofenac sodium 1% topical gel and diclofenac sodium 1% in petrolatum. No sun exposure was allowed during the testing, and any other treatments were forbidden.

Pediatric Contact Dermatitis Registry Inaugural Case Data.

Little is known about the epidemiology of allergic contact dermatitis (ACD) in US children. More widespread diagnostic confirmation through epicutaneous patch testing is needed. The aim was to quantify patch test results from providers evaluating US children. The study is a retrospective analysis of deidentified patch test results of children aged 18 years or younger, entered by participating providers in the Pediatric Contact Dermatitis Registry, during the first year of data collection (2015-2016). One thousand one hundred forty-two cases from 34 US states, entered by 84 providers, were analyzed. Sixty-five percent of cases had one or more positive patch test (PPT), with 48% of cases having 1 or more relevant positive patch test (RPPT). The most common PPT allergens were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), propylene glycol (6.8%), cocamidopropyl betaine (6.4%), bacitracin (6.2%), formaldehyde (5.7%), and gold (5.7%). This US database provides multidisciplinary information on pediatric ACD, rates of PPT, and relevant RPPT reactions, validating the high rates of pediatric ACD previously reported in the literature. The registry database is the largest comprehensive collection of US-only pediatric patch test cases on which future research can be built. Continued collaboration between patients, health care providers, manufacturers, and policy makers is needed to decrease the most common allergens in pediatric consumer products.

Mucosal diseases from an allergological perspective

The oral allergy syndrome is one of the most common form of food allergy and manifests as contact urticaria of the oral mucosa after consumption of cross reacting foods. Whereas allergic contact stomatitis often occurs due to dental materials, allergic contact cheilitis is usually areaction due to topical therapeutics like herpes ointments or lip care products. As late type reactions are more frequent than immediate type reactions in the anogenital mucosa, contact dermatitis in this area should be identified via epicutaneous testing. In case of contact urticaria at the genital mucosa, asemen allergy or alatex allergy should be given due consideration as apossible cause. Angioedemas, which are mostly common histamine mediated, usually prefer skin areas with loose connective tissue such as the oral or genital mucosa. Fixed drug eruption also occurs preferentially in these areas. Bullous drug-induced skin reactions (e.g., SJS and TEN) are characterized by severe hemorrhagic, erosive affections of mucous membranes.

Middle turbinate edema as a diagnostic marker of inhalant allergy.

Middle turbinate edema could be a characteristic feature of aeroallergen sensitization. In this study we sought to determine the diagnostic characteristics of middle turbinate edema as a marker of inhalant allergy. A cross-sectional diagnostic study was performed on patients who had undergone nasal endoscopy and allergy testing. Allergy status was determined by positive serology or epicutaneous testing. Endoscopy was reviewed by blinded assessors for middle turbinate head edema. Appearance was graded as either normal, focal, multifocal, diffuse, or polypoid edema. Receiver-operator (ROC) analysis, likelihood ratio (LR), sensitivity, specificity, and positive predictive value (PPV) were determined. One hundred eighty-seven patients representing 304 nasal cavities were assessed (42% female, age 39.74 ± 14.7 years, 57% allergic). Diffuse edema (PPV 91.7%/LR = 8) and polypoid edema (PPV 88.9%/LR = 6.2) demonstrated the strongest association with inhalant allergy. Multifocal edema was used as a cut-off to represent inhalant allergy from ROC analysis, which demonstrated 94.7% specificity and 23.4% sensitivity. The PPV for multifocal was 85.1% and LR = 4.4. Middle turbinate edema is a useful nasal endoscopic feature to predict presence of inhalant allergy and, although not sensitive, has excellent PPV.

Patch Testing in the Diagnosis of Medication Allergy

In evaluation of medication allergy, the utility of drug patch testing is dependent on both the type of drug reaction and the suspected causal drug. Epicutaneous patch tests reproduce T cell-mediated delayed hypersensitivity; thus, eruptions at least partially mediated by T cells can be confirmed by positive drug patch test (DPT) responses in some patients. These include acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), fixed drug eruptions (FDE), macular drug reactions (“morbilliform” or “exanthematous” reactions), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). Currently, literature supports that specific drugs, including antiepileptics and certain antibiotics, are most likely to produce diagnostic patch test results. However, drug patch testing cannot be used reliably for all medications. We suggest that standardized international guidelines should be developed and implemented to improve the comparability of results from drug patch testing reported in literature. Furthermore, an organized, systematic research strategy should be executed in order to gain further understanding of how and when drug patch testing can be used most effectively.

Hypersensitivity reactions to implantable cardiac pacemakers and defibrillators

Nowadays, for modern electrotherapy of cardiac arrhythmias different pacemaker systems are used. Antibradycardia pacing systems (e. g. single-chamber, two-chamber, three-chamber systems, frequency-adapted pacemaker) can be distinguished from antitachycardia pacing systems like implantable or portable cardioverter defibrillators and combined antibradycardia/antitachycardia systems. Cutaneous reactions overlying apacemaker or defibrillator are often termed "pacemaker dermatitis". In terms of the differential diagnostic workup, these cutaneous reactions can have various causes. After exclusion of infection by analyzing clinical and laboratory-chemical results, "pressure dermatitis" or the often clinically asymptomatic "reticular telangiectatic erythema" (synonym "postimplantation erythema") must be considered. Histological examination of the affected skin can contribute to the diagnosis. In case of suspected contact hypersensitivity to implant material, allergological exploration should be realized. In addition to patch testing with commercially available contact allergens, product-related material metal alloy discs are often available from the pacemaker manufacturer for epicutaneous testing. Due to the lack of additional benefit compared to standardized patch testing, aclear recommendation for such metal alloy discs cannot be given. In selected cases of suspected hypersensitivity reaction, sensitization can eventually be analyzed by the lymphocyte transformation test. Positive reactions must always be critically interpreted taking into consideration the corresponding clinical signs. Depending on the cause, cutaneous reactions are occasionally self-limiting. In many cases, however, removal of the pacemaker is inevitable.

Contact dermatitis to methylisothiazolinone.

Methylisothiazolinone (MI) is a preservative found in cosmetic and industrial products. Contact dermatitis caused by either methylchloroisothiazolinone/methylisothiazolinone (MCI/MI or Kathon CG) or MI has shown increasing frequency. The latter is preferably detected through epicutaneous testing with aqueous MI 2000 ppm, which is not included in the Brazilian standard tray. We describe a series of 23 patients tested using it and our standard tray. A case with negative reaction to MCI/MI and positive to MI is emphasized.

Another Great Imitator: Allergic Contact Dermatitis Differential Diagnosis, Clues to Diagnosis, Histopathology, and Treatment

Allergic contact dermatitis (ACD) is a type IV (delayed) hypersensitivity reaction that has a wide spectrum of presentations that often imitate or overlap with other cutaneous eruptions. Differential diagnoses to consider include infections, skin lymphoma-malignancies, inflammatory dermatoses, nutritional deficiencies, and mechanical causes of tissue damage. We discuss clues to the diagnosis of ACD, such as pruritus, localization to the area of skin contact with the allergen, recurrence with repeat exposures, and supportive skin biopsy histology. Epicutaneous patch testing remains the gold standard for diagnosing ACD. Definitive treatment is contact allergen avoidance and, when indicated, dietary restriction. With these measures, most patients will improve clinically. In cases where avoidance measures and interim topical therapies fail, ultraviolet light therapy or systemic immunosuppression may be considered. Key points 1. Allergic contact dermatitis (ACD) is a type IV (delayed) hypersensitivity reaction with a range of clinical presentations. 2. Mimickers of ACD include infections, skin lymphoma-malignancies, inflammatory dermatoses, nutritional deficiencies, and mechanical causes of tissue damage. 3. Allergen avoidance, which might include dietary restriction, is the definitive treatment for ACD.

Contact Dermatitis to Personal Sporting Equipment in Youth.

Contact dermatitis to personal sporting equipment in youth is poorly studied. To review the results of patch testing 6 youth to their sporting equipment in a dermatology general private practice from 2006 to 2011. A retrospective analysis of 6 youth aged 11 to 14 who were evaluated for chronic and persistent dermatitis occurring in relation to sports equipment was conducted. All patients were subjected to epicutaneous (patch) testing, which included some or all of the following: North American Contact Dermatitis Group (NACGD) series, textile series, rubber series, corticosteroid series, and raw material from the patients' own personal equipment. All cases had 1 or more positive patch test reactions to an allergen within the aforementioned series, and 3 subjects tested positive to their personal equipment in raw form. Allergic contact dermatitis, not irritant, was deemed the relevant cause of chronic dermatitis in 4 of the 6 patients due to positive reactions to epicutaneous tests and/or personal equipment. The utility of testing to patients' own sporting equipment was shown to be of additional value and should be considered when patch testing for contact allergy to sporting equipment.

A role for vancomycin epicutaneous skin testing in the evaluation of perioperative anaphylaxis

A role for vancomycin epicutaneous skin testing in the evaluation of perioperative anaphylaxis

Evaluation of a Self-Test Device Used in Allergic Contact Dermatitis

Considering the scarcity of dermatologic resources in many parts of the world, self-testing by patients is not only of interest for internal medicine but also for dermatology. In this open, nonrandomized, multicenter diagnostic trial involving subjects with suspected contact sensitization to nickel and/or a fragrance mix, we assessed the agreement of self-testing by subjects with readings made by dermatologists. The self-test product (Nixema^TM) is based on Thin-Layer Rapid Use Epicutaneous Test (TRUE Test®) technology. One hundred and sixty-five subjects self-tested the ready-made patch-test product. The test was applied for 48 h and then read after 3 or 4 days. It was also evaluated independently by experienced dermatologists after 3 or 4 days. In the 162 evaluable subjects, the proportion of agreement for both allergens together was 89.5% [95% confidence interval (CI) 83.7-93.8], the sensitivity was 97.5 % (95% CI 86.8-99.9) and the specificity was 86.9% (95% CI 79.6-92.3). Cohen's kappa was also high at 0.749 (95% CI 0.637-0.862). Discrepancies between the subjects' readings and the dermatologists' readings were mainly due to the subjects interpreting reactions of ‘irritant' or ‘doubtful' as ‘positive'. Apart from itching and burning sensations and tape irritation, no side effects were observed. In conclusion, this study showed a high rate of agreement between the self-reading of the upper arm and the readings made by the dermatologists. The upper arm proved to be an appropriate area for self-testing. Self-testing may improve the screening for contact sensitization for patients, particularly where dermatologic health resources are scarce.

European Society of Contact Dermatitis guideline for diagnostic patch testing - recommendations on best practice.

The present guideline summarizes all aspects of patch testing for the diagnosis of contact allergy in patients suspected of suffering, or having been suffering, from allergic contact dermatitis or other delayed-type hypersensitivity skin and mucosal conditions. Sections with brief descriptions and discussions of different pertinent topics are followed by a highlighted short practical recommendation. Topics comprise, after an introduction with important definitions, materials, technique, modifications of epicutaneous testing, individual factors influencing the patch test outcome or necessitating special considerations, children, patients with occupational contact dermatitis and drug eruptions as special groups, patch testing of materials brought in by the patient, adverse effects of patch testing, and the final evaluation and patient counselling based on this judgement. Finally, short reference is made to aspects of (continuing) medical education and to electronic collection of data for epidemiological surveillance.

DERMATITE DE CONTACTO ALÉRGICA PROFISSIONAL AO MERCAPTOBENZOTIAZOL

Introdução: A dermatite de contacto alérgica ao mercaptobenzotiazol e seus derivados tem sido reconhecida de forma crescente nos países industrializados devido ao seu uso alargado na polimerização da borracha sintética. Os autores descrevem dois casos clínicos com relevante exposição profissional.Caso 1: Homem de 46 anos, trabalhador na construção civil, com uma dermatite de oito meses de evolução, pruriginosa, localizada apenas nos punhos, refratária a corticóide tópico de alta potência e anti-histamínico oral. Ao exame objetivo apresentava placas eritemato-violáceas infiltradas e pápulas eritematosas escoriadas em ambos os punhos. Os testes Prick e RAST ao latex foram negativos. Foram efetuados testes epicutâneos com a bateria padrão do Grupo Português de Estudo de Dermatite de Contacto, bateria de borrachas, bateria de colas e fragmentos da própria luva tendo-se verificado positividade ao mercaptobenzotiazol (++), mistura de mercapto (++) e à faixa elástica presente no punho das luvas, às 72h e aos 7 dias.Caso 2: Homem de 61 anos, carpinteiro, com placas eritematosas infiltradas, pruriginosas, na região geniana e extensão para região cervical posterior, com cerca de 12 meses de evolução. Foram realizados testes epicutâneos com a bateria padrão do Grupo Português de Estudo de Dermatite de Contacto, bateria de borrachas e colas, bateria de cosméticos e fragmentos da própria máscara de proteção. Verificou-se positividade para mercaptobenzotiazol (+ +), mistura mercapto (+ +) e elástico de máscara (+ +) na leitura das 72 horas e aos 7 dias.Discussão: Apesar de serem alergénios bem conhecidos, o mercaptobenzotiazol e seus derivados podem estar presentes noutras fontes de exposição à borracha como o tecido elástico no vestuário. Uma vez o trabalhador sensibilizado, pode ser causa de incapacidade quer para a profissão quer para as atividades de vida diária.

Occupational dermatoses from colophony exposure

Colophony is a resin, obtained from pine trees. It has many applications in industry as well as in products for everyday life and exposure is virtually impossible to avoid. In article, we concentrate on occupational exposure, which is frequent in workers in electronics, furniture and paper industry, production of adhesives, plastics, printing ink and synthetic rubber as well as in everyone, daily in contact with products, which contain colophony, or pine wood, like carpenters and woodworkers. Main allergens are oxidation products of abietic-type acids, but cross-reactivity with fragrances, wood resins, Balsam of Peru, wood tar and oil of turpentine is also possible. Exposure to colophony manifests itself on skin in allergic patients mainly as allergic contact dermatitis. The diagnosis is based on history of exposure, clinical presentation and epicutaneous testing. Although the only effective treatment is complete avoidance of exposure, it is difficult to avoid colophony. Consequently, prophylaxis is essential and concentrates on safe working practices, personal hygiene and protection.

Poklicne dermatoze pri izpostavljenosti kolofoniji

Colophony is a resin, obtained from pine trees. It has many applications in industry as well as in products for everyday life and exposure is virtually impossible to avoid. In article, we concentrate on occupational exposure, which is frequent in workers in electronics, furniture and paper industry, production of adhesives, plastics, printing ink and synthetic rubber as well as in everyone, daily in contact with products, which contain colophony, or pine wood, like carpenters and woodworkers. Main allergens are oxidation products of abietic-type acids, but cross-reactivity with fragrances, wood resins, Balsam of Peru, wood tar and oil of turpentine is also possible. Exposure to colophony manifests itself on skin in allergic patients mainly as allergic contact dermatitis. The diagnosis is based on history of exposure, clinical presentation and epicutaneous testing. Although the only effective treatment is complete avoidance of exposure, it is difficult to avoid colophony. Consequently, prophylaxis is essential and concentrates on safe working practices, personal hygiene and protection.