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Background: Tumor necrosis factor (TNF) inhibitors such as adalimumab, etanercept, and infliximab play an increasingly important role in the management of a variety of chronic inflammatory disorders. With their increasing use, a wide spectrum of dermatological adverse effects, including injection site reactions and the development of dermatitis, have been recognized. Previous studies have implicated the role of the delayed-type hypersensitivity reaction in mediation of injection site reactions to etanercept. To our knowledge, there have been no published studies on immunologic mechanism of injection site reactions to adalimumab to date., Observations: We describe 2 patients with a history of worsening injection site reactions to adalimumab. Findings from skin testing in both patients were suggestive of an immediate type I hypersensitivity reaction to adalimumab. A histamine release assay performed on peripheral blood leukocytes from both patients demonstrated significant histamine release on exposure to adalimumab. Furthermore, passive transfer of serum from one of the allergic patients to basophils from a nonatopic, healthy donor sensitized those cells to release significant amounts of histamine with exposure to adalimumab. Conclusion This study demonstrates that an IgE-mediated immediate type I hypersensitivity reaction plays a role in the mediation of worsening injection site reactions in some patients receiving adalimumab.

Background and Design: Latex allergy is a type I reaction to natural rubber latex (NRL) proteins with clinical manifestations ranging from contact urticaria to fatal anaphylaxis. Previous US studies on NRL allergy have largely been reported by allergists with little detailed information on concomitant hand eczema, contact allergy, or on outcome. The charts of all patients with latex allergy seen between 1980 and 1994 in a dermatology department are reported with results of history; prick, scratch, wear, and patch tests; latex radioallergosorbent test; and follow-up questionnaire., Results: There were 44 patients (37 female) with NRL allergy; 34 of whom had atopy. In 38 it was occupationally related, with all but two in health-related professions. Of the six nonoccupational cases, three had spina bifida. Twenty-nine had local skin reactions of urticaria and/or pruritus; seven, anaphylaxis; and eight, contact urticaria with other systemic symptoms. The diagnosis was based on a positive prick or scratch test to NRL in 37 cases, a class 2 or greater latex radioallergosorbent test in five cases, and strongly positive wear test results to an NRL glove in two cases. Thirty-six patients had hand eczema, with 26 having relevant positive patch test results that included glutaraldehyde, latex and vinyl gloves, and rubber chemicals. Follow-up revealed one patient quit work and eight changed jobs or tasks because of NRL allergy, 33 of 39 continued to have symptoms at work, and 12 had lost work time because of latex allergy symptoms., Conclusions: Latex allergy was frequently seen in health care or dental workers, which was frequently associated with systemic symptoms, hand eczema, and allergic contact dermatitis. Most continue to work, but remained symptomatic. Patients with NRL allergy should be provided information on nonlatex devices and latex avoidance in medical, dental, and occupational settings. Low-NRL allergen gloves should be worn by coworkers of health care workers with NRL allergy.

A patient had a chronic hand eczema, presumably as a manifestation of atopy. Treatment resistance appeared due to handling certain foods that produced burning and stinging in the chronically eczematous skin and not in otherwise normal skin. Selected tests for delayed hypersensitivity and for immediate hyper sensitivity on intact skin of the back produced negative results, but on chronically inflamed skin of the arm and back, application of the pertinent foods produced a wheal and flare response. On intact skin, scratch tests with the foods produced positive results. Intradermal tests with commercial antigens were negative. Avoidance of these foods, as contactants, led to resolution of the dermatitis. Reappraisal of the role of immediate-type hypersensitivity in chronic hand eczema is important.