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Background: Allergic contact dermatitis (ACD) is associated with increased production of cytokines. The patch test is the “gold-standard” diagnostic method, but it poses a risk of false results. Objective: To evaluate a novel laboratory technique, the Luminex LiquiChip, which simultaneously measures blood levels of multiple cytokines, as a diagnostic tool in patients with chrome-induced ACD. Methods: The study group included 20 patients with ACD and relevant patch test results for potassium dichromate and 19 patients with ACD for nickel or fragrance as control. Peripheral blood mononuclear cells (PBMCs) were cultured in the presence and absence of potassium dichromate. The Luminex LiquiChip was used to measure levels of the following cytokines: granulocyte-macrophage colony-stimulating factor, interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, interferon-γ, and tumor necrosis factor (TNF)-α. Results: Potassium dichromate-stimulated PBMCs secreted significantly higher amounts of all cytokines except TNF-α than nonstimulated PBMCs. PBMCs from patients with ACD to chromium secreted significantly higher amounts of all cytokines tested, except IL-4, compared to PBMCs from patients with ACD to nickel or fragrance. Conclusions: Potassium dichromate stimulates the production of both Th1- and Th2-type cytokines in patients with chrome allergy. The Luminex LiquiChip is a promising in vitro method and may serve as a diagnostic tool for ACD.

Background: The clinical diagnosis of papular eruptions is common but poorly characterized in the literature and the etiology is often unknown. Objective: To characterize the entity of idiopathic papular dermatitis in the spectrum of chronic papular eruptions. Methods: The cohort consisted of patients who presented at a tertiary medical center in 2005–2014 with a papular eruption of at least 4 months’ duration. Findings on histological analysis and thorough clinical investigation, performed in all cases, were collected. The patients completed a questionnaire on disease course and outcome. Results: Sixty-five patients were included. Sixteen patients showed morphological changes over time and were excluded. Investigations in the remaining 49 patients with a consistent papular morphology yielded a well-defined diagnosis in 23 (46%). Twenty-six patients (54%; 14 male) were diagnosed with idiopathic papular dermatitis. Their mean age at onset was 61.6 ± 14.4 years and the mean duration of disease 3.11 ± 2.726 years. In 60%, the rash resolved with conservative treatment during follow-up (mean 4.35 ± 2.53 years). Conclusions: Chronic papular eruptions encompass a wide range of skin diseases. In more than half of the cases, the etiopathogenesis remains unclear. On the basis of our results, we propose a diagnostic algorithm for idiopathic papular dermatitis.

Background/objectives Childhood allergic contact dermatitis is recognized as a significant clinical problem. The objective was to evaluate the rate of positive patch tests in Israeli children with clinically suspected allergic contact dermatitis, identify possible sex and age differences, compare results with those in Israeli adults, and review pediatric studies in the literature. Methods The study sample included 343 children and adolescents (197 female, 146 male; 1-18 years of age, mean age 11.8 years) with clinically suspected allergic contact dermatitis who underwent patch testing with a standard pediatric series of 23 allergens at a tertiary medical center from 1999 to 2012. Data on clinical characteristics and test results were collected retrospectively from the medical files. Results Ninety-eight subjects (28.6%) (75 girls [38.1%], 23 boys [15.8%]) had at least one positive reaction. The most frequent reactions were to nickel sulfate, followed by potassium dichromate and cobalt chloride. Nickel sulfate sensitivity was more common in girls, especially those younger than 3 years and older than 12 years. The prevalence of contact sensitization was similar in subjects with and without atopic dermatitis (50% and 51%, respectively). Conclusion Nickel is the most common allergen in Israeli children, especially girls. Patch testing should be performed in children with clinically suspected allergic contact dermatitis regardless of atopic background.

Background Allergic contact cheilitis may appear after exposure to different substances, including dental materials, toothpastes, cosmetics, foods and medications. Objective To compare the rate of toothpaste allergy between patients with and without cheilitis and to examine the yield of our proposed toothpaste patch test kit for use in patients with cheilitis. Methods A patch test kit containing 11 substances used in toothpastes was formed. The study sample consisted of 44 patients, 24 with cheilitis (study group) and 20 with contact dermatitis but without cheilitis (control group). Results Eleven patients in the study group (45%) were found to be allergic to toothpaste, compared to only one patient (5%) in the control group (p Conclusion The rate of toothpaste allergy among patients with cheilitis might be higher than previously reported. Patch-testing with our toothpaste series is recommended in the evaluation of cheilitis.

Previous studies have shown that the prevalence of specific allergens varies by geographic area, population, age and sex. The objective of the present study was to determine the relative frequency of positive reactions to different sensitizers in Israeli patients with clinically suspected contact dermatitis (CD) and to identify possible sex and age differences. A total of 943 consecutive patients were tested for CD using the European standard patch test series. The most frequent allergen was nickel sulfate followed by potassium dichromate and fragrance mix. Positive reactions to nickel sulfate were more common among women, especially those in the younger age group (younger than 40 years). Positive reactions to balsam of Peru were more common among men, especially those in the older age group (40 years or older). This study presents the result of the standard patch test in Israel with stratification according to age and sex. The findings of the present study, combined with reports on geographic/population differences in the prevalence of specific allergens in CD, indicate the need for further investigations to identify prominent local allergens for better adaptation of the standard patch test to local needs.

Sapir Medical Center,Meir Hospital, Kfar Saba, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelBackground: Allergic contact dermatitis induced by the occupational use of products containingessential oils has not been studied comprehensively.Objectives: The aim of the present report was to describe the characteristics, diagnosis, and outcomeof 5 patients with occupational contact dermatitis because of essential oils attending our outpatientdermatology clinics over a 2-year period.Patients: These patients are added to the 11 cases reported thus far in the literature.Results: The research shows that for proper diagnosis, patch tests with the standard series and thefragrance series should be performed, in addition to tests with the specific oils to which the patientswere exposed.Conclusions: Patients should be instructed to avoid the allergens identified. Sensitization to essentialoils has important implications for the occupational future of affected individuals.Key words: contact dermatitis; essential oils; occupational.

Exposure to formaldehyde is common from both consumer products and industry. The reliability of the patch test is essential for the diagnosis of formaldehyde allergy as it is difficult to suspect from the patient's history. The recommended formaldehyde patch test concentration has been reduced over the last decades from 4-5% to 2% and is currently 1%. The changes have not been based upon formal studies, but driven by an intention to reduce irritancy and false-positive results. The aim of the present study was prospectively to compare the outcome of simultaneous testing with formaldehyde 1% and 2% in consecutively patch-tested patients, with respect to frequency of positive patch test reactions, strength of patch test reactions to different formaldehyde test concentrations, irritancy and relevance. The study included 3734 consecutively patch tested patients. 121 gave a positive reaction to 1% and/or 2% formaldehyde in water. There was no statistically significant difference between 1 and 2% with respect to allergic reactions, but 2% gave significantly more irritant reactions. Doubtful, positive and follicular reactions at day (D) 2 frequently developed into true positive reactions at D 3 to 4. Reading at D 7 gave few additional positive cases compared to D 3/4. Problems related to relevance are discussed. Based on present knowledge, a 1% patch test concentration for formaldehyde is recommended.

Flow cytometric DNA analysis of various tumours has indicated a correlation between the degree of malignancy and ploidy; results which could have clinical significance. We analysed the ploidy of Kaposi's sarcoma (KS) tumours, and classified the results according to clinical history and histological findings. We found that patients on steroid treatment had an aneuploid pattern, and most of the patients with classic-type KS had a diploid pattern on flow cytometry.

There has been a controversy as to the origin of lupus miliaris disseminatus faciei (LMDF). It was originally thought to be associated with tuberculosis, due to its histopathological similarity. Recently, this association has been doubted, although there remain reported cases of LMDF associated with Mycobacterium tuberculosis. Three patients with the clinical and histopathological features of LMDF are described. Skin from these patients was analysed by polymerase chain reaction (PCR) using two different oligoprimers for the detection of 123 bp and 165 bp DNA fragments specific for M. tuberculosis complex. With these two PCR systems, no M. tuberculosis DNA was detected in any of the LMDF patients. It was present in all positive controls and absent in all negative controls. In this study we could not demonstrate an association between LMDF and tuberculosis.

Kaposi's sarcoma has been reported in patients receiving immunosuppressive therapy, most of whom are organ transplant recipients. The development of Kaposi's sarcoma after treatment with corticosteroids has been reported in only 38 patients who have not had acquired immunodeficiency syndrome or undergone organ transplantation. Cutaneous Kaposi's sarcoma developed 2 months after intraarticular steroid injections in a man with ulnar nerve entrapment. The lesions regressed spontaneously after 3 months but reappeared with visceral involvement 18 months later, shortly after initiation of a course of epidural steroid injections for treatment of low back pain. The cutaneous lesions and some visceral lesions rapidly regressed after cessation of treatment.

von Willebrand factor (vWF) is synthesized almost exclusively by endothelial cells and is stored there as ultra-high-molecular-weight multimers. The vWF multimers that are detected in the plasma are smaller than those stored within the endothelium. In two previous studies, comprising small series of cases with classic Kaposi's sarcoma (KS), an endothelium-derived tumor, increased levels of plasma von Willebrand factor antigen (VWF:Ag, the antigenic structure) were reported, suggesting that vWF:Ag may be a marker of endothelium proliferation.Our purpose was to investigate the quantitative as well as qualitative alterations of plasma vWF in a large series of patients with classic KS at various stages of the disease.Levels of plasma vWF:Ag were studied in 38 patients with classic KS confined to the skin at various stages of the disease and compared with a control group. Thirty-three patients had active KS (i.e., with skin lesions) and five were in remission. In five patients with active KS multimeric analysis of plasma vWF was also performed.The levels of vWF:Ag were significantly higher among KS patients than in the control group (n = 29, p0.01). Levels of vWF:Ag were also significantly higher in patients with active disease as compared with those in remission (p0.05). No correlation was found between vWF:Ag levels and the extent of KS. Analysis of the multimeric pattern of plasma vWF showed enhanced staining of all bands, particularly the intermediate and high molecular weight forms, which resemble the endothelial forms as opposed to normal circulating vWF multimers.Quantitative as well as qualitative alterations in plasma vWF were found in patients with KS, which may reflect the destruction or activation of endothelial cells within the lesions. vWF:Ag may serve as a marker of disease activity in classic KS; however, it is not a good marker for the extent of the disease.

Background The prevalence of cosmetics-related contact dermatitis is rising, owing mainly to the wider use of cosmetics by the public and the routine diagnostic use of patch tests. Objective To determine the prevalence of cosmetics allergy in Israel. Methods A questionnaire was distributed to a random sample of 360 female customers of pharmacies and beauty salons in two areas of the country. Items included general health profile, family history of atopy, occurrence of rash due to patch-test-proven cosmetics allergy, anatomic sites of the rash, subjective aspects regarding the rash, and cosmetics consumption habits. Results Patient age ranged from 15 to 89 years. Eleven subjects (3.1%) had patch-test-proven cosmetics allergic contact dermatitis. There was a correlation between proven cosmetics allergy and subjective sensitivity to facial cream (p = .03). Conclusions The 3.1% prevalence rate of cosmetics contact allergic dermatitis in a randomly selected population in Israel is similar to values reported in the literature (about 2%). The higher-than-expected rate of subjective sensitivity to facial cream among patients with proven cosmetics allergy may be explained by the wide use of facial cream, facial skin susceptibility to insult, and the relatively long duration of contact of facial cream (a leave-on product) with the skin.

Background There appear to be no published studies on the rates of positive allergic reactions to oil and cooling fluids. Objective To determine the yield of the oil and cooling fluid series from Chemotechnique Diagnostics in patients in Israel who are suspected to have occupational allergic contact dermatitis. Methods The authors reviewed the findings in 175 patients with suspected occupational contact dermatitis who worked with oil and cooling fluids and were patch-tested at two dermatologic clinics in Israel from 1999 to 2003. Results Forty-four patients (all male; mean age, 40.8 years) had 67 positive reactions to 27 of the 35 allergens (86.7% relevant). An occupational cause was established in 39 patients (88.6%). Thirty-seven of the patients with a positive reaction were also tested with the European Standard series. Of these, 22 (59%) had positive reactions to several allergens in the standard series as well. Conclusion To the best of the authors' knowledge, this is the first study of the oil and cooling fluid patch-test series in this setting. The findings indicate that this series serves as an appropriate test for evaluating occupational contact dermatitis and that its composition should not be changed, pending further studies.

The Papillon-Lefèvre syndrome is characterized by palmoplantar hyperkeratosis and juvenile periodontitis that results in the precocious loss of both the deciduous and permanent teeth. We report a patient with Papillon-Lefèvre syndrome associated with acroosteolysis, an association that has not been previously described.

Exogenous factors implicated in or suspected of precipitating connective tissue diseases are reviewed. These include environmental agents, such as ultraviolet light, drugs, chemicals, pesticides, heavy metals, infectious viruses, and bacteria. The possible roles of occupational exposures and the environmental factors early in life are discussed as well.

The reproducibility of the patch test is of great importance to its diagnostic utility. The objective of this study was to quantitatively and qualitatively compare the reproducibility of patch test reactions between the manufacturer-loaded TRUE Test (TT) panel and the investigator-loaded IQ Chamber (IQC) system using the European Standard Series (ESS) (Chemotechnique Diagnostics, Malmo, Sweden). Consecutive patients were simultaneously patch tested with 21 allergens using the TT and IQC system. The concordance and discordance of the 2 methods were analysed. Testing was performed in 207 patients (85 men and 122 women) who yielded 317 positive reactions, 188 with the IQ system and 129 with the TT. A total of 204 tests were positive with both methods, showing a positive concordance rate of 64.4%, with IQC producing more positive results. A high concordance rate of positive results was achieved for Cl+ Me- isothiazolinone (81.5%), nickel sulfate (79%), formaldehyde (76.9%), and paraphenylenediamine (PPD) (72.7%); a moderate concordance was noted for quaternium 15 (66.7%), potassium dichromate (64.3%), and fragrance mix (58.1%); and a low concordance was noted for cobalt chloride (27.6%) and Balsam of Peru (18.2%). The IQC and the TT are similar in finding allergy to allergens with high concordance. The IQC system has an advantage in detecting clinically relevant reactions to allergens that have a moderate and a low concordance.

Pemphigus vulgaris is an autoimmune disease with a well-established immunological basis. Treatment is based on high dose and maintenance systemic corticosteroids. We report on a patient with a recurrence of full-blown pemphigus vulgaris after a trial of alternative hypnosis therapy to replace the corticosteroids.

Tefillin (phylacteries) are a religious article worn by observant Jewish men. Only two cases of allergic contact dermatitis from tefillin have been reported previously. We describe 7 new cases of tefillin contact dermatitis and review the literature on contact allergy caused by religious objects and practices. All our patients had contact allergy to potassium dichromate, which was the only allergen relevant to tefillin .

High frequencies of contact allergy to fragrance ingredients have been reported in recent years. Only approximately 70-80% are detected by fragrance allergens in the standard patch test series. This investigation compares the patch test reactions to fine fragrances with reactions to fragrance mix (FM), balsam of Peru (BP) (Myroxylon pereirae resin) and a fragrance series. 641 consecutive patients with eczema were patch tested with the European standard series and with selected fine fragrances. Those who were positive to 1 of the fine fragrances or the FM or BP were also tested with the fragrance series. 95 (14.8%) patients were found to have a positive patch test reaction to FM or BP; 41 (6.4%) had positive results to fragrance no. 1 and 29 (4.5%) to no. 2. 9 (9.5% of the 95 positive patients) had a positive reaction to fine fragrances and a negative reaction to all other fragrance allergens in the standard series. These findings indicate that testing with fine fragrances can add to our evaluation of fragrance-sensitive patients.

Background: We review our experience with nine patients with partial unilateral lentiginosis (PUL), a rare pigmentary disorder. Objective: Our purpose was to define the characteristics of PUL and to discuss the differential diagnosis. Methods: The records of nine patients with PUL were reviewed. A literature review on diagnosis, association with other disorders, and differential diagnosis is presented. Results: PUL is a rare benign disorder that has no known inheritance pattern and has no commonly associated abnormalities. Conclusion: Careful history and physical examination may enable the distinction between PUL, nevus spilus, and other more serious genetic disorders associated with lentiginosis.

Background: As part of our clinical experience we encountered a group of patients from a specific population with a similar peculiar pigmentation over the lower dorsal spine. Objective: We investigated these patients to see whether we could determine a common origin. Methods: Patients meeting the inclusion criteria underwent detailed history and complete physical examination; biopsy specimens from 3 patients were studied. Results: All 13 patients were full-time male students at Orthodox Jewish Talmudic seminaries (Yeshivas). The lesion consisted of an elongated, vertical, midline, hyperpigmented patch with indistinct borders, which was distributed along the skin overlying the bony protuberances of the inferior thoracic and lumbar vertebrae. It was often unrecognized by the patients. Mean body mass index was lower than that for the general population. Histologic study showed a marked diffuse hyperkeratosis and hyperplastic epidermis with diffuse hyperpigmentation. We attributed the phenomenon to friction from the rigid backrests against the cutaneous surface of the lower back generated by the characteristic swaying activity that traditionally accompanies Torah study or "davening" (praying) and termed it Davener's dermatosis. Conclusion: We believe this phenomenon represents a new form of benign friction hypermelanosis. This report highlights the importance of a thorough history in patients presenting with pigmented lesions. (J Am Acad Dermatol 2000;42:442-5.)

A 57-year-old woman who had undergone a lumpectomy for infiltrating duct cell carcinoma of the right breast was found to have morphea after receiving radiation therapy. The morphea occurred at the site of the irradiated field. It is suggested that the irradiation served as a provoking factor and that the morphea might be an isomorphic response to the trauma of the irradiation.

Buschke-Ollendorff syndrome is an association of connective tissue nevi and osteopoikilosis that usually appears in the first decades of life. The nevi occur on the trunk and extremities. In a 48-year-old man with this rare syndrome the connective tissue nevus was located on the scalp and was pruritic. Histologically, involvement of the epidermis with cystic dilatation of the hair follicles and an abnormality of mucopolysaccharides were present. The nevi in this syndrome may involve an alteration in the three components of connective tissue to a variable degree.

Background:Many aspects of cutaneous surgical interventions have been perfected, employed, and then scientifically examined. Conversely, ubiquitous, indiscriminate demand for sterile conditions while performing an invasive procedure remains a field devoid of satisfactory critical appraisal.Objective:Ritual neonatal circumcision served as a prototype to assess scientifically the safety of performing a dermatologic intervention under clean, uncontaminated, but nonsterile conditions.Methods:Two hundred subjects, mostly neonates, who were unselectively referred for ritual circumcision, served as the study group. The guillotine excisional technique was employed in the community setting under clean, uncontaminated, nonsterile conditions, in line with traditional practice. Follow-up was continued until full recovery.Results:No wound infections or septic complications were observed in any of the babies at either early (24–36 hours after the procedure) or late follow-up. Many subjects had an exudative discharge at the healing site several days after the procedure. This is a common finding associated with circumcision and was found to be nonindicative of infection.Conclusions:This preliminary study suggests that strict sterile conditions are superfluous for ritual neonatal circumcision, and the effort and expense invested in maintaining an aseptic environment for this sort of intervention may not be justified. Further large-scale investigations are warranted to validate these findings and to determine if they can be extrapolated to other patient populations and other types of cutaneous surgery.

Pigmented contact dermatitis has been found to be caused by fragrances, cosmetics, washing powders, azo dyes in textiles, and rubber products in selected groups of patients. The aim of this study was to run screening patch tests in an unselected group of patients with pigmented contact dermatitis (n=29) encountered in our center over a 2-year period. The test series included the European standard, cosmetics, fragrance, Scandinavian photo, and personal products. 21 patients had a positive reaction in at least 1 of the series (total, 29 reactions): 16 - standard, 3 - cosmetics, 1 fragrance, 9 photo, and 1 - personal products; 16 (55%) had relevant results. We conclude that the highest yield for screening for pigmented contact dermatitis is achieved with the standard and photo series.

Background: Kaposi's sarcoma (KS) accounts for more than 5% of malignancies in immunosuppressed organ transplant patients (OKS). A new herpesvirus (HHV-8) was identified with high prevalence in biopsy specimens of AIDS-KS, endemic KS, and classic KS and in OKS. KS has also been associated with other underlying diseases in patients treated with corticosteroids, but this subset of KS has been reported to contain HHV-8 in only a few case reports. Objective: In this larger study, we determined the prevalence of HHV-8 in seven patients of Jewish origin in whom KS developed during immunosuppressive therapy for different primary diseases (ISKS). Methods: The study included HHV-8 DNA detection by polymerase chain reaction (PCR) coupled with Southern blot and sequence analysis as well as by in situ hybridization. Results: HHV-8 sequences were detected by PCR with confirmation by Southern blot and sequence analysis in 100% of the ISKS samples. Direct sequencing revealed several previously unknown base changes within the 208 bp region from open reading frame 26 (ORF26 208 ) of HHV-8 in ISKS. Conclusion: Ours is the largest known study describing the presence of HHV-8 in iatrogenic KS from immunosuppressed nontransplant patients and provides data of previously unknown sequence variations within the ORF26 of HHV-8 DNA. (J Am Acad Dermatol 1998;38:429-37.)

Background. Darier's disease is an acantholytic dyskeratotic genodermatosis with autosomal dominant inheritance. A predictive diagnostic marker for this disorder would be beneficial because of the relatively late onset and the large number of sporadic cases of the disease. The dermatoglyphic features of patients with Darier's disease were examined to determine whether they have a common pattern. Methods. Ink prints of fingers and palms obtained from 11 patients of both sexes with sporadic and familial Darier's disease were analyzed and compared with those of normal subjects. Results. No significant quantitative or qualitative differences were found between the dermatoglyphic features of our patients and those of a healthy population, except for punctate interruptions of the skin ridges that indicate pitting, a well-known manifestation of Darier's disease. Conclusions. These results refute the conclusions of a previous publication claiming that there is a common characteristic dermatoglyphic feature in patients with this dermatosis.

A 57-year-old woman who had undergone lumpectomy for infiltrating duct-cell carcinoma of the right breast was found to have morphea after receiving radiation therapy. Three years later she developed a vesicular eruption on the area of the morphea, which was diagnosed as bullous morphea. The histologic findings of the vesicular component were characteristic of lichen sclerosus et atrophicus. It is suggested that in some cases bullous morphea represents a secondary appearance of bullous lichen sclerosus et atrophicus on a lesion of morphea.

Summary Interferon alpha-2a, which has antineoplastic, antiviral, immunomodulatory, and antiangiogenic effects, was evaluated in a prospective study, treating 10 lesions of patients with classical Kaposi's sarcoma. Ten patients received injections of interferon alpha-2a intralesionally in a dose of 3 million units three times weekly for 4 weeks, and in a variable dose for 4 more weeks. Two of the patients had a complete response, and in one of these, distant lesions also responded. Seven had a partial response, and one did not respond. The treatment was generally well tolerated. The results of our study support the use of interferon in the therapy of classical Kaposi's sarcoma, although it would appear that to achieve maximum efficacy, a longer period of treatment is needed.

OBJECTIVE: To report smoking intolerance that occurred in two patients while they were treated with minoxidil. DATA SYNTHESIS: Minoxidil is a potent vasodilator useful in treating severe hypertension. Topical minoxidil was approved as a treatment for androgenital alopecia. Only few side effects have been reported during treatment with topical minoxidil, most of them localized skin reactions. Two of our patients developed smoking intolerance during treatment with topical minoxidil for androgenital alopecia. The relation between treatment with minoxidil and smoking intolerance was emphasized by stopping treatment and the disappearance of the smoking intolerance, and then by rechallenge in both patients. CONCLUSIONS: Topical minoxidil may cause smoking intolerance; further studies are needed to evaluation this side effect.

We present three patients with familial congenital hypertrichosis localized to the anterior cervical region, associated with peripheral sensory and motor neuropathy. This association may represent a new neurocutaneous syndrome. The association of anterior midline cutaneous lesions with an underlying malformation is discussed.

Acne fulminans is a rare form of acne characterized by ulcerative nodules and associated with systemic complications. We report the case of a 17-year-old boy with cystic acne who experienced sudden onset of acne fulminans associated with fever, weight loss, hepatosplenomegaly, and erythema nodosum migrans. To the best of our knowledge, this is the first reported case of acne fulminans manifested by hepatomegaly and erythema nodosum migrans.

Eleven newly diagnosed patients and one patient with pemphigus vulgaris who relapsed underwent endoscopy of the upper gastrointestinal tract. Three patients had blisters or erosions and two had longitudinal lines of erythema in the esophageal mucosa. In four patients histopathologic examination showed findings of pemphigus vulgaris but direct immunofluorescence was positive in all patients. This study demonstrates that the immunopathologic disturbance in pemphigus vulgaris involves the entire length of the esophagus, although only some patients have clinical or histologic involvement. To the best of our knowledge this is the first histopathologic and direct immunofluorescence study of esophageal involvement in patients with untreated pemphigus vulgaris.

Two patients with esophageal involvement of pemphigus vulgaris are presented, who were diagnosed histopathologically and by direct immunofluorescence. In most dermatological textbooks the possibility of esophageal involvement is not mentioned. In the English medical literature 11 cases have been reported. It seems that if upper gastrointestinal endoscopy had been done on a routine basis it might have shown that esophageal involvement is more widespread than present findings indicate.

Skin disorders at ostomy sites are common and include irritant contact dermatitis from the draining fluid and/or the ostomy devices, intertrigo, and bacterial and mycotic infection (1). Allergic contact dermatitis has also been described, from a karaya seal ring (2), stoma adhesive paste (3), and rubber (4). The allergens causing contact dermatitis from ostomy bags, have been defined as epoxy resin (5–7), diaminodiphenylmethane (8) and polyisobutylene (9).

BACKGROUND Patch testing with the shoe series may be useful for the diagnosis of shoe contact dermatitis. OBJECTIVE The aim of the study was to verify the usefulness of the shoe series and the association of fungal infection with positive results in the shoe series. METHODS A total of 140 patients with suspected shoe contact dermatitis underwent patch testing with the standard series and shoe series; 41 underwent mycologic examination. RESULTS Positive results in the shoe series were noted in 58 patients (41.4%). The most common allergens were potassium dichromate (27.2%), nickel sulfate (11.9%), Kathon CG (10.9%), and 4-tert-butylphenol formaldehyde resin (8.7%). Of the 41 patients with suspected tinea pedis, 13 (32%) had positive mycologic findings and 9 (69.2%) also had a positive response to the shoe series. Of the patients with a negative result on mycologic examination, only 10 (35.7%) had a positive result in the shoe series. CONCLUSION Our study indicates that all patients with foot dermatitis should undergo patch testing with the shoe series. Positive results in the shoe series seem to be more prevalent in patients with a fungal infection.

I. McClatchie S, Bremner AD. Unusual subcutaneousswellings in African patients. East Afr Med .I 1969;46:625-33. 2. McClatchie S, Warambo MW, Bremner AD. Myospherulosis: A previouslyunreported disease? Am J Clin Pathol 1969;51 :699-704. 3. Kyriakos M. Myospherulosisof the paranasal sinuses, nose and middle ear. Am J Clin Patbol 1977;76: I J8-30. 4. De Schryver-Keckemeti K, Kyriakos M. The inductionof human myospherulosis in experimental animals. Am J Pathol 1977;87:33-46. 5. Rosai 1. The nature of myospherulosis of the upper respiratory tract. Am 1 Clin Pathol 1978;69:475-81. 6. Wheeler TM, McGavran MH. Myospherulosis-further observations. Am J Clin Pat hoi 1980;73:685-6. 7. GillespieCA, Clark WB, Finkelstein E, et al. Myospherulosis of the mastoid antrum. Auris Nasus Larynx 1990; 16:199-207. Briefcommunications 267

Allergy to chromium is relatively common, often in association with exposure to cement or in leather manufacture. However, in certain locations, there appears to be a relatively large cohort of chromium-sensitive individuals whose allergy cannot be explained by these common sources. In particular, this group include Israeli housewives with persistent hand eczema and concomitant patch test positivity to chromium. The causation of their allergy has been linked with relatively high levels of chromium contamination in household products. To provide further information in respect of the definition of safe levels for such products, we examined 17 chromium-allergic individuals to determine their threshold for reaction under closed patch test and repeated open application test (ROAT) conditions. The data derived indicated that, on normal skin, the patch test threshold was 10 ppm chromium; in the presence of an irritant (sodium lauryl sulfate) the threshold was closer to 1 ppm, 2/17 subjects giving 1+ reactions at this concentration. In the more realistic exposure conditions of the ROAT, 8/14 individuals failed to react to 50 ppm, whilst 3/15 reacted to 5 ppm. Interestingly, there was very poor correlation between patch test sensitivity and ROAT sensitivity. To ensure the large majority of chromium-allergic individuals do not suffer elicitation of their allergy, as well as to limit the development of new chromium-sensitive subjects, it is recommended that household products adhere to a previously published standard of a maximum limit of 5 ppm, with an ultimate target of 1 ppm contamination by chromium.

«Jewel-like» blisters and rosettes are terms that refer to a peculiar pattern of blister formation in which a cluster of new blisters appears around resolving lesions. This pattern is regarded as highly characteristic of chronic bullous dermatosis of childhood. Recently, we observed jewel-like blisters in a man with generalized bullous pemphigoid