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In the summer people like to cool down by swimming. However, swimming may lead to annoying skin reactions, the so called swimmer's dermatoses. We present three different cases: an 8-year-old girl with skin complaints after blue-green algae, a 7-year-old boy with a late immune response after a jellyfish sting and a 40-year-old woman with contact urticaria due to latex in the bathing suit. Swimmer's dermatoses can be experienced as very irritating, but are generally harmless and in most cases recover spontaneously. Recognition is important for reassurance and correct treatment advice. Providing good information about safe swimming/bathing locations is essential for prevention.

The most common side effects of transdermal patches are mechanical reactions caused by applying or removing the transdermal patch, or by excessive perspiration under the patch. Allergic contact dermatitis (type IV allergic reaction) is the most commonly occurring hypersensitivity reaction and can be caused by the active substance or by excipients. Type I allergic reactions such as urticaria, bronchospasm and angioedema are rare and usually caused by the active substance in the patch. Allergy testing to determine the allergen is indicated following a type I allergic reaction, or after a type IV allergic reaction that requires an alternative for the patch. It is important to document hypersensitivity reactions in the electronic patient records in order to prevent a hypersensitivity reaction in the future.

Urticaria multiforme is a rare clinical variant of urticaria that occurs specifically in children.A boy aged 11 months was presented at the Emergency Department with acute onset of itching urticarial skin weals and acral oedema. This picture is consistent with the diagnosis of urticaria multiforme.The diagnosis of urticaria multiforme can be made on the basis of the clinical picture. Treatment is symptomatic and in most cases this condition resolves spontaneously within two weeks. It is often confused with erythema exsudativum multiforme, urticarial vasculitis, a serum sickness-like reaction or acute haemorrhagic oedema of infancy (AHOI syndrome). As each of these clinical presentations involves specific treatment and prognosis, it is important to be able to distinguish between them.

Early clinical development of paclitaxel was complicated by life-threatening hypersensitivity reactions (HSRs) manifested by hypotension, dyspnoea, angiooedema and urticaria. Prolongation of paclitaxel infusion time and empiric pretreatment with steroids, H1-antagonists and H 2-antagonists were introduced based on similar regimens that had proven useful in preventing reactions to radiographic contrast media. This regimen has led to a reduction in incidence of HSRs and successful retreatment of patients with prior HSRs to paclitaxel. However, the actual benefit of an H2-antagonist, such as ranitidine, in the premedication regimen is questionable and may even increase HSRs. On the basis of two case reports and review of literature data, the use of ranitidine in prophylaxis of HSRs should be revised and carefully evaluated in clinical practice. Randomized controlled clinical trials need to be performed to address the benefit of H 2-antagonists in preventing HSRs.

A 2-year-old boy showed itchy papules and wheals, which were diagnosed as papular urticaria. Papular urticaria are a hypersensitivity reaction after insect bites. The condition can relapse even without the presence of insects or new bites. Topical steroids or antihistamines diminish the symptoms in some cases.

To determine the percentage of proven allergy for local anaesthetics (LA) in patients who were tested because of a clinical suspicion of LA allergy.Retrospective multicentre case series.All patients from two hospitals who were seen from 2004 through 2013 for a possible allergy to local anaesthetics. Their records were analyzed for the probable type of allergic reaction and allergy tests were performed. Distinction was made between skin prick tests (SPT), intradermal tests (IDT), subcutaneous provocation tests and epicutaneous tests (patch tests).53 patients were included. The most common symptoms were dizziness (n = 14) and collapse (n = 12). Urticaria, oedema and/or erythema were seen in 25 patients, whilst 2 patients had a drop in blood pressure. In 4 patients an IgE-mediated allergy was proven by means of provocation testing. SPT and IDT were not predictive. In 1 patient a delayed-type allergy was established by patch testing.IgE-mediated and delayed-type allergic reactions are rarely caused by LA. IgE-mediated reactions can be proven by provocation testing. Patch testing is used when a delayed type reaction is suspected.

Angio-oedema and urticaria can be symptoms of both allergic (IgE-mediated) and non-allergic drug hypersensitivity reactions. Non-allergic drug reactions, that may have a similar clinical presentation as allergic drug reactions, are not caused by an IgE-mediated immune mechanism. Because of unfamiliarity with non-allergic drug reactions and the unclear time course between drug use and reactions, the relationship with the responsible drug is often not recognized, leading to unnecessary patient risks. In the present article three patients with angio-oedema and urticaria as side effects of frequently used drugs (ACE-inhibitors, NSAIDs and betalactams) are presented and discussed. Patient A was a 69-year-old man with ACE-inhibitor induced angio-oedema. Patient B was a 40-year-old woman with urticaria and angio-oedema after ingestion of a NSAID caused by a non-allergic drug reaction. Patient C was a 54-year-old woman who developed an anaphylactic shock because of a type I allergy to betalactams.

Two boys and a girl, aged 8, 7 and 4 years old respectively, attended the outpatient clinic suffering from urticaria. The oldest boy was diagnosed with chronic urticaria and angio-oedema, whereas the youngest boy was diagnosed with chronic urticaria only. The little girl had a history of constitutional eczema, and presented with a common cold complicated by acute urticaria. All three patients responded well to treatment with antihistamines. Urticaria is usually not caused by an allergy. The major cause of acute urticaria in childhood is viral infection. Further investigation is not usually necessary. In the majority of cases, chronic urticaria is idiopathic, and maintenance treatment with antihistamines is indicated.

A 35-year-old man presented with fever and severe urticaria after visiting Uganda. His symptoms were caused by acute invasive schistosomiasis, also known as Katayama fever.

A 4-year-old boy was treated for an infection with a meningococcus type B. After a few days of recovery, he felt ill again on day 6. The patient had urticaria and arthralgia without arthritis. The infection parameters did not normalize or increase in severity. No abnormalities other than a lowered CH50 value were found in the extensive diagnostic tests performed. The diagnosis of immune-complex mediated complications following a meningococcal infection was made. The patient was sent home where he continued pain relief and physiotherapy treatment. After 2 months at outpatient follow-up, he showed complete recovery and the CH50 value had returned to normal. Other immune-complex mediated complications of meningococcal infection are arthritis, episcleritis, pericarditis, myocarditis and pleuritis. These occur in 6-15% of the patients with a meningococcal infection. Early recognition prevents unnecessary extensive and costly diagnostic testing as well as a longer than necessary hospital stay.

A 41-year-old patient was referred to our rheumatology ward due to a long history of urticaria, joint pain and fever. These symptoms appeared during the evening and then resolved during the night. Extensive testing in the past failed to provide a diagnosis and treatment with high-dose corticosteroids, methotrexate and colchicine was ineffective. Based on clinical criteria, including bilateral sensorineural hearing loss, we diagnosed Muckle-Wells syndrome, a rare auto-inflammatory disease considered one of the hereditary periodic fever syndromes and caused by a mutation in the CIAS1 gene. There was a remarkable response to anakinra, an interleukin-1 receptor antagonist. The favourable results suggest that interleukin-1 plays an important role in the development of this syndrome.

A patient with burning sensations, pruritus, erythema and swelling after the injection of a local anaesthetic is described. The reaction was caused by a type IV allergic reaction to sodium metabisulfite in the local anaesthetic.

In dentistry, contact with a wide range of both irritants and contact allergens pose an important occupational hazard. It is important to understand the resulting clinical skin symptoms and their causes to prevent further exposition and to avoid serious problems that may lead to an incompatibility with the dentist profession.

Despite treatment for malaria two travellers who acquired fever in Africa continued to have complaints: a 25-year-old Dutch woman and a 25-year-old Australian man. On questioning they appeared to have swum in Lake Malawi and a diagnosis of acute schistosomiasis was made, confirmed by serological tests. This syndrome, also called Katayama fever, is characterized by fever, oedema, urticaria and eosinophilia. The aetiology is not fully elucidated but it is supposed to be caused by immune complexes initiated by maturing worms and eggs. Patients who acquired fever in an endemic area must be questioned about contact with fresh water. Serological tests are important for the diagnosis. Treatment is with praziquantel but it is advised to treat only after the acute phase. During the acute manifestations corticosteroids may be necessary. Prevention is by avoiding contact with infected water. There is no vaccine. The role of artemisinin drugs in prevention is currently being studied.

In only a minority of chronic urticaria patients an underlying cause or illness can be detected. Previous studies demonstrated that detailed history taking is more important than routine laboratory investigations. To improve the process of history taking, the use of a detailed urticaria questionnaire is highly recommended. By using such a history-based diagnostic approach, the costs of laboratory investigations could be reduced from an average of 538 NLG per patient to 84 NLG per patient. The percentage of patients in whom a cause could be found increased from 29% to 53%. No severe underlying illnesses were missed by using this approach.

A 74-year-old woman had an 8-year history of spells consisting of facial flushing and swelling, itching and erythema of the hands, rhinorrhoea and gastrointestinal complaints. The ultimate diagnosis was systemic mastocytosis without urticaria pigmentosa. In the clinical decision process the treating physicians used clinical axioms to try to establish a diagnosis, but these axioms were sometimes used inappropriately. In particular, spells accompanied by flushing inappropriately elicited a possible diagnosis of phenochromocytoma. Generalised mastocytosis can occur in the absence of urticaria pigmentosa and is probably an underestimated cause of spell-like complaints.

In two homeless men aged 38 and 32 years, who suffered from itching, infestation with body lice (Pediculus humanus var. corporis, a.k.a. clothes lice) was diagnosed. This infestation is rare in the Netherlands. In 1993 and 1994 and infection with body lice was registered 41 times in 31 patients at the clinic for homeless of the Community Health Service of Utrecht. The body louse can be seen by the naked eye. Treatment is by hygienic measures, pediculicides if necessary, and by prevention. Important to recognize is that P. humanus can be the vector of trench fever (Bartonella quintana), relapsing fever and typhus.

A patient with burning sensations, pruritus, erythema and swelling after the injection of a local anaesthetic is described. The reaction was caused by a type IV allergic reaction to sodium metabisulfite in the local anaesthetic.

Fifty-two children with atopic dermatitis were investigated with the mixed-food radio-allergosorbent test (RAST) and the skin provocation test 'Skin Application Food Test' (SAFT). The mixed-food RAST is a commercially available test with multiple allergens on one disk. The disk contains 6 common food allergens: cow's milk, egg, peanut, soy, codfish and wheat. The SAFT is a system with which foods are applied to the skin in the state in which they are consumed. This test system is routinely used in our subdivision of Paediatric Dermatology in Sophia Children's Hospital. In some children, atopic dermatitis grew worse after a positive SAFT reaction. In 50% of the 38 children with food allergy a correlation was found between exacerbation/induction of atopic dermatitis and consumption or direct skin contact of foods to which the child was allergic. Due to direct skin contact of foods, atopic dermatitis can grow worse with sudden attacks of pruritus, especially on the hands and in the face. The SAFT imitates the naturally occurring symptoms, is child friendly and easy to perform. The mixed-food RAST can be used as a screening test to identify the children with atopic dermatitis and an atopic immune response to foods, so possibly food allergy. Further investigations of the sensitivity of the target organ (in atopic dermatitis: the skin) and the usefulness of the SAFT are then indicated.

A case of generalized urticarial rash due to subcutaneous administration of methylene blue for lymphangiography is presented. The urticarial lesions were coloured blue.