Search

About 17% of German children and adolescents suffer from at least one of the following atopic illnesses: allergic rhinoconjunctivitis, atopic eczema or asthma. Consistent professional therapy is necessary to limit the health-related risks and improve these medical conditions. The consequences of a diagnosis often mean an additional task for the parents of diseased children, where they have to act simultaneously as an educator and therapist for their children. Structured educational programmes were developed for a few diseases such as asthma and atopic eczema in order to prepare parents and affected children to accept this important responsibility. Moreover, a structured programme for anaphylaxis is being developed. These proposals aim not only to transfer knowledge about the disease but also to effectively support self-reliant treatment and emotional coping with the disease as well as its collateral strain., (© 2015 S. Karger AG, Basel.)

The term anaphylaxis was coined by Charles Richet and Paul Portier when they tried to immunize dogs with actinia extracts, but after a repeated injection of a small amount of the toxin the dog died within 25 min. The new term rapidly spread all over the world. The discovery of the phenomenon of anaphylaxis showed that by immunization not only protection but also harmful events could be induced. For this discovery Richet received the Nobel Prize in 1913, but he still believed the condition of anaphylaxis was a lack of protection to the poisonous effect of the substance. Already earlier similar clinical phenomena had been observed but not well described. A major breakthrough in understanding the pathophysiology came through the experiments of Dale and Laidlaw who showed that the newly discovered histamine was able to induce quite similar symptoms to anaphylaxis. For decades reactions mimicking anaphylaxis but without involvement of the immune systems were called 'anaphylactoid', 'allergy-like' or 'pseudo-allergic'. Since the new definition of the World Allergy Organization (WAO) anaphylaxis is defined on the basis of clinical symptoms independent of pathomechanisms involved: one distinguishes between allergic and non-immune anaphylaxis. Epinephrine (Adrenalin) was soon recognized as treatment of choice of this dramatic condition., (© 2014 S. Karger AG, Basel.)

Hypersensitivity reactions to contrast media (CM) are frequent causes of anaphylaxis and drug exanthemas. Adverse events after CM exposure are classified into immediate (≤1 h) and non-immediate reactions (>1 h), with differing mechanisms. In the majority of patients with immediate reactions, IgE-mediated allergy cannot be demonstrated, and the underlying mechanism remains unknown. However, recent data have provided evidence for skin test positivity and/or specific IgE in some patients. T cell-mediated hypersensitivity is the responsible mechanism for the majority of non-immediate skin eruptions. These insights have consequences for diagnosis and prevention. Skin testing evolves to be a useful tool for diagnosis of CM allergy. Skin tests have been employed to confirm this hypersensitivity. Previous reactors have an increased risk to develop new reactions upon repeated exposure; however, other risk factors are poorly defined. The use of skin tests for the selection of a 'safe' CM is under investigation with promising results. In vitro tests to search for CM-specific cell activation include flow cytometric approaches, lymphocyte cultures and construction of cell lines and hybridomas. Premedication of previous reactors is common practice among radiologists; however, breakthrough reactions are a concern, and physicians should not rely on the efficacy of pharmacological premedication., (Copyright © 2012 S. Karger AG, Basel.)

Local anesthetics (LA) are common elicitors of adverse reactions and the clinical symptoms often correspond to anaphylaxis with tachycardia, hypotension and subjective feelings of weakness, heat or vertigo. The pathomechanism of immediate hypersensitivity reactions to LA is largely unknown -they are commonly regarded as 'pseudo-allergic' or 'non-immune type' anaphylaxis. Immunologically mediated reactions have rarely been observed with positive skin prick tests. Other ingredients in LA preparations have to be considered as elicitors, e.g. preservatives like benzoates or sulfites or latex contaminants in injection bottles. Practical management of patients with a history of LA reaction includes a careful allergy history, skin-prick and intradermal tests. Undiluted LA solutions may elicit false-positive intradermal test reactions. If prick and intradermal tests are negative, the procedure of subcutaneous provocation testing is applied in a placebo-controlled manner. When patients are constantly reacting to placebo, a regimen of 'reverse placebo provocation' with injection of a LA (verum) is applied while the patient is informed about receiving placebo in order to 'rule out psychosomatic involvement'. With this regimen it is possible to eliminate anxiousness and fear, and the patient has proof that he has tolerated the respective LA substance., (Copyright 2010 S. Karger AG, Basel.)

It is known that patients with mastocytosis have an increased risk of anaphylaxis. This also appears to be the case with patients with evidence of a clonal mast cell disorder resulting in the monoclonal mast cell activation syndrome (MMAS) who do not express the full mastocytosis phenotype. Most patients with mastocytosis are recognized by their characteristic skin lesions. An increased level of baseline serum mast cell tryptase is also an indicator for a possible clonal mast cell disorder including mastocytosis. Other markers for mast cell clonality and for mastocytosis include abnormal immunostaining of mast cells with CD25 and CD2, clustering of mast cells in tissues, abnormal mast cell morphology, and the presence of a mutation in the proto-oncogene c-kit encoding for the mast cell growth receptor KIT. As recognition depends on an understanding of mastocytosis, and this disease should be considered in patients with recurrent anaphylaxis, we describe the features of mast cell clonality, MMAS and mastocytosis, and review recent findings., (Copyright 2010 S. Karger AG, Basel.)

Anaphylaxis is the maximal variant of an acute life-threatening immediate-type allergy. Due to its often dramatic onset and clinical course, practical knowledge in the management of these reactions is mandatory both for physicians and patients. It has to be distinguished between acute treatment modalities and general recommendations for management of patients who have suffered from an anaphylactic reaction. Acute treatment comprises general procedures like positioning, applying an intravenous catheter, call for help, comfort of the patient as well as the application of medication. The acute treatment modalities are selected depending upon the intensity of the clinical symptomatology as they are categorized in 'severity grades'. First of all it is important to diagnose anaphylaxis early and consider several differential diagnoses. This diagnosis is purely clinical and laboratory tests are of no help in the acute situation. Epinephrine is the essential antianaphylactic drug in the pharmacologic treatment. It should be first applied intramuscularly, only in very severe cases or under conditions of surgical interventions intravenous application can be tried. Furthermore, glucocorticosteroids are given in order to prevent protracted or biphasic courses of anaphylaxis; they are of little help in the acute treatment. Epinephrine autoinjectors can be used by the patient him/herself. Histamine H(1)-antagonists are valuable in mild anaphylactic reactions; they should be given intravenously if possible. The replacement of volume is crucial in antianaphylactic treatment. Crystalloids can be used in the beginning, in severe shock colloid volume substitutes have to be applied. Patients suffering from an anaphylactic episode should be observed over a period of 4-10 h according to the severity of the symptomatology. It is crucial to be aware or recognize risk patients as for example patients with severe uncontrolled asthma, or under beta-adrenergic blockade. When bronchial symptoms are in the focus, inhaled beta(2)-agonists can be tried, also for laryngeal edema. The use of combined H(1)- and H(2)-antagonists has been recommended for prophylaxis prior to application of potentially anaphylaxis-eliciting drugs (e.g. radiographic contrast media). Patients who have survived an anaphylactic reaction have to be thoroughly examined and an allergy diagnosis has to be performed with regard to the eliciting agent and the pathogenic mechanism involved. In cases of clear-cut IgE-mediated anaphylaxis, allergen-specific immunotherapy is available for some allergens and helpful as for example for insect venom anaphylaxis. Furthermore, patients should be trained with regard to the nature of anaphylaxis, the major eliciting agents and the principles of behavior and coping with the situation including the handling of epinephrine autoinjectors and the application of antianaphylactic medication. Educational programs for anaphylaxis have been developed., (Copyright 2010 S. Karger AG, Basel.)

Hypersensitivity reactions to radiocontrast media (RCM) are unpredictable and are a concern for radiologists and cardiologists. Immediate hypersensitivity reactions manifest as anaphylaxis, and an allergic IgE-mediated mechanism has been continuously discussed for decades. Non-immediate reactions clinically are exanthemas resembling other drug-induced non-immediate hypersensitivities. During the past years, evidence is increasing that some of these reactions may be immunological. Repeated reactions after re-exposure, positive skin tests, and presence of specific IgE antibodies as well as positive basophil activation tests in some cases, and positive lymphocyte transformation or lymphocyte activation tests in others, indicate that a subgroup of both immediate and non-immediate reactions are of an allergic origin, although many questions remain unanswered. Recently reported cases highlight that pharmacological premedication is not safe to prevent RCM hypersensitivity in patients with previous severe reactions. These insights may have important consequences. A large multicenter study on the value of skin tests in RCM hypersensitivity concluded that skin testing is a useful tool for diagnosis of RCM allergy. It may have a role for the selection of a safe product in previous reactors, although confirmatory validation data is still scarce. In vitro tests to search for RCM-specific cell activation still are in development. In conclusion, recent data indicate that RCM hypersensitivity may have an allergic mechanism and that allergological testing is useful and may indicate tolerability., (Copyright 2010 S. Karger AG, Basel.)

Adverse drug reactions (ADR) are an important clinical problem. They account for about 5% of all hospital admissions and cause death in approximately 0.01% of surgical patients. The mechanisms leading to ADR beyond IgE-mediated allergy are still poorly understood. The importance of chemically reactive drug metabolites and the involvement of T-lymphocytes in many drug hypersensitivity reactions have been highlighted in recent years. ADR are diagnosed on clinical grounds and the temporal relation between drug intake and the appearance of the symptoms. Allergy tests are required in the further assessment of the reaction. By means of skin tests, in vitro tests and provocation tests information about the culprit drug, the mechanism involved and possible alternatives can be obtained., (Copyright 2002 S. Karger AG, Basel)

Background: Most treatment protocols for vitiligo require a long treatment duration and usually do not result in complete repigmentation. Therefore, cosmetically acceptable and easily to handle alternatives are warranted., Objective: To evaluate the properties of dihydroxyacetone (DHA) in a new formulation for the treatment of vitiligo on exposed areas., Methods: We treated 10 patients suffering from vitiligo affecting the face and/or hands with a newly introduced, commercially available self-bronzing cream containing DHA 5%. DHA was applied every second day., Results: The characteristic pigmentation showed very satisfactory cosmetic results in 8 out of 10 patients after 2 weeks of treatment., Conclusion: The new DHA formulation is a practical and well-accepted treatment modality., (Copyright 2001 S. Karger AG, Basel)

Background: In atopic eczema (AE), skin colonization with Staphylococcus aureus plays a possible role in the pathophysiology of the disease., Methods: Thirty-eight patients with AE were screened for their cutaneous colonization with S. aureus. The antibacterial and clinical efficacy of topical therapy with the antiseptic dye gentian violet, a potent glucocorticosteroid or a tar solution (liquor carbonis detergens) was evaluated in vivo in 21 patients with a density of >10(4) CFU/cm(2) and in vitro. Skin sites were treated twice daily for 4 days with the active drug or a corresponding control. Quantification of S. aureus was done daily during therapy as well as 3 days thereafter. The severity of the lesions was rated by a regional SCORAD., Results: In gentian-violet-treated skin, bacterial density decreased significantly in lesional (p < 0.001) and unaffected skin (p < 0. 001). Bacterial densities did not decrease during therapy with glucocorticosteroid or liquor carbonis detergens but dropped afterwards. All therapeutics reduced the severity score, reduction being greatest for the glucocorticosteroid and lowest for liquor carbonis detergens. In vitro, a high antibactericidal efficacy was demonstrated only for gentian violet., Conclusions: Antibacterial therapy with gentian violet not only reduces S. aureus dramatically, but also reduces the severity of the eczema. Reduction of S. aureus after therapy with glucocorticosteroids and LCD seems to be secondary to improvement of the skin condition.