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Worldwide, there are 3 major standard series of patch tests, the European, North American and Japanese, together presenting 32 allergens, the differences between them being the result of regional variation in allergen distribution as well as differences in dermatological opinion. We propose a "minimal" international standard series of 20 allergens, together with an "extended" international standard series of 14 allergens. [ABSTRACT FROM AUTHOR]

Epiquick (EPI) is a new ready to use patch test system with a set of 5 Finn Chambers on scanpor tape (FCS), filled with a standardized volume of the test material in pet. A multicenter trial comparing this system with the conventional one was performed. It was concluded that EPI is a suitable system for patch testing and yields comparable results to self-filled FCS. Major advantages are standardization of the filling volume and saving of time in the application procedure.

The frequency of contact allergy to topical corticosteroids has certainly been underestimated in the literature. Preliminary studies have been performed in which all the patients seen in a contact allergy unit were routinely tested with tixocortol pivalate, a corticosteroid to which one would assume they had never been previously exposed as this substance was not commercially available. This substance elicited positive reactions in patients previously sensitized to other corticosteroids and particularly to hydrocortisone and hydrocortisone acetate. This article reports on the survey which was designed to obtain information on the frequency of positive reactions in a large patient population to tixocortol pivalate, which has been available commercially for non-dermatological purposes.

A letter to the editor is presented which discusses the case study of a 59-year-old man who developed urticaria and swelling of the tongue and throat after eating the macadamia nuts.

Reactive perforating collagenosis (RPC) in adults commonly manifests in patients with diabetes mellitus. Pruritus and consequent induced scratching have been identified as the bases for the evolution of this skin disease. We present the unusual case of a 55-year-old female diabetic with characteristic umbilicated skin lesions and a long history of scabies. Histology from a crusty nodule revealed transepidermal elimination of collagen. Following antiscabietic treatment, two courses of oral doxycycline demonstrated beneficial effects in controlling the perforating skin disorder. [ABSTRACT FROM AUTHOR]

Inhaled corticosteroids may cause various adverse effects ranging from irritation to severe anaphylactic reactions and systemic contact dermatitis. We report a 43-year-old woman who developed sore throat, swelling of the lips and oral cavity and dysphagia, 2 weeks after the use of budesonide spray (Budefat®) for treatment of bronchial asthma. The symptoms occurred with a delay of 3–4 h after the treatment ×2 daily. There were no immediate reactions on prick and intracutaneous testing with the commercial product used by the patient. However, marked pruritic infiltration developed within 24 h, progressing to coalescing eczematous lesions over the following 2 days. In addition, severe oedema of the right upper eyelid was observed. On patch testing, budesonide was strongly positive at day 2 and 3 in a concentration ranging from 1% to 10 p.p.m. (in petrolatum). Other corticosteroids of group A, B, C and D were completely negative. Repeated open application tests with amcinonide and triamcinolone acetonide cream on the ventral aspect of the upper arm were negative. Bronchial exposure to alternative sprays containing beclomethasone dipropionate (group D), fluticasone-17- propionate (D) and dexamethasone-21-isonicotinate (C) was well tolerated. In conclusion, this case is instructive, because the symptoms which developed after a short period of corticosteroid inhalation suggested a type I allergy. Testing proved a severe type IV contact allergy restricted to budesonide (group B), without cross-reactions to major corticosteroids of other groups. [ABSTRACT FROM AUTHOR]

A 5-year retrospective study of the frequency of sensitization to the 25 allergens of the European standard series (ESS) was conducted in 10 centres in 8 European countries. Included were the results of 26 210 patients. The range in sensitivities differed moderately between the centres. Combining results of different centres and drawing conclusions on incidences can be done only with great care. The information on the ranking of the allergens and their sensitization incidence in the clinics are useful for decisions on the future composition of the standard series. The ESS is still a valid screening tool, and no substances should be deleted. [ABSTRACT FROM AUTHOR]

Since January 2001, the European Surveillance System on Contact Allergies (ESSCA), supported by European Union funding (contract QLK4-CT-2001-00343), has started to collect patch-test data. This comprises a standardized clinical history and the patch-test results using the European standard series, from 17 centres in 9 European countries listed above. In 2002 and 2003, 10 511 patients' test results have been pooled and analysed. The anamnestic data partly reflect the subspecialties of some centres. The most common allergen was nickel sulfate (17.3%); however, large international variations were observed. The prevalence of contact allergy to Myroxylon pereirae resin (balsam of Peru) (5.8%) is coming close to the frequency found with the fragrance mix (6.4%). Regarding contact allergy to chromium compounds, different frequencies were noted in the 2 centres focused on occupational dermatitis (2.3% in the FIOH versus 7.4% in the Nofer Institute). These most likely reflect the beneficial effect of addition of ferrous sulfate in one, but not the other country. As differences may partly be due to different patch-test reading, standardization may need to be refined further. By providing post-marketing surveillance in the field of contact allergy, ESSCA will meet its objective of increased consumer safety across Europe. [ABSTRACT FROM AUTHOR]

Contact allergy to methyldibromo glutaronitrile (MDBGN), often combined with phenoxyethanol (PE) (e.g., Euxyl K 400®), increased throughout the 1990s in Europe. Consequently, in 2003, the European Commission banned its use in leave-on products, where its use concentration was considered too high and the non-sensitizing use concentration as yet unknown. The 2 objectives of the study are (a) to find a maximum non-eliciting concentration in a leave-on product in MDBGN/PE-sensitized patients, which could possibly also be considered safe regarding induction and (b) to find the best patch test concentration for MDBGN. We, therefore, performed a use-related test (ROAT) in patients sensitized to MDBGN/PE (n = 39) with 3 concentrations of MDBGN/PE (50, 100 and 250 p.p.m. MDBGN, respectively). A subset of these patients (n = 24) was later patch-tested with various concentrations (0.1, 0.2, 0.3 and 0.5% MDBGN, respectively). 15 patients (38%, 95% confidence interval (CI) = 23–55%) had a negative and 24 (62%; 95% CI = 45–77%) a positive overall repeated open application test (ROAT) result. 13 reacted to the lowest (50 p.p.m.), 8 to the middle (100 p.p.m.) and 3 to the highest concentration (250 p.p.m.) only. In those 13 reacting to the lowest ROAT concentration, dermatitis developed within a few days (1–7). The strength of the initial and the confirmatory patch test result, respectively, and the outcome of the ROAT were positively associated. Of the 24 patients with a use and confirmatory patch test, 15 reacted to 0.1% MDBGN, 16 to 0.2%, 17 to 0.3% and 22 to 0.5%. With the patch test concentration of 0.5%, the number of ROAT-negative patients but patch-test-positive patients increases considerably, particularly due to+ reactions. A maximum sensitivity of 94% (95% CI = 70–100%) is reached with a patch test concentration of 0.2%, and is not further improved by increasing the concentration. However, the specificity decreases dramatically from 88 (95% CI = 47–100%) with 0.2% to a mere 12.5% (95% CI = 0–53%) with 0.5%. It can be concluded (a) that for MDBGN 0.2% is very likely the best patch test concentration and (b) that 50 p.p.m. in a leave-on product can elicit contact dermatitis in sensitized persons. We were, therefore, unable to find a safe, still microbicidal, concentration for leave-on products. By contrast, with other contact allergens, dose–response use tests may be able to identify a non-eliciting concentration, which could give valuable clues to a non-inducing (i.e., safe) concentration in products. [ABSTRACT FROM AUTHOR]

Contact allergy to and allergic contact dermatitis from methyldibromo glutaronitrile (MDBGN) have frequently been reported. As there has been no agreement on which MDBGN test preparation to use, a study was initiated to help determine the optimal patch test preparation for MDBGN. 2661 consecutively patch tested patients at 11 test clinics representing 9 European countries participated. Petrolatum preparations with MDBGN at 1.0%, 0.5%, 0.3% and 0.1% were inserted in the standard series. Contact allergy rates were noted in the range 4.4–1.1% following decreasing test concentrations. Reactions not fulfilling all criteria to be classified as allergic reactions could represent either weak allergic or irritant reactions, and such reactions were noted in the range 8.2–0.5% with decreasing concentrations. A significant number of these reactions represented weak allergic reactions, as allergic reactions were obtained to higher patch test concentrations in the same individual. Morphologically irritant reactions were noted only for the highest test concentrations. In summary, the contact allergy rates and frequencies of doubtful and irritant reactions vary with the patch test concentration. The final decision on patch test concentration for MDBGN should not only rely on these factors but also include information on patch test concentrations required to diagnose individual cases with allergic contact dermatitis from MDBGN as well as results of repeated open application tests. [ABSTRACT FROM AUTHOR]

Contact allergy to and allergic contact dermatitis from methyldibromo glutaronitrile(MDBGN) have frequently been reported. This study was initiated to help determine the optimal patch test preparation for MDBGN. In 51 patients with a doubtful or a positive patch test reaction to at least 1 of 4 test preparations with MDBGN in petrolatum at 1.0% w/w, 0.5%, 0.3% and 0.1%, a repeated open application test(ROAT) with moisturizers with and without MDBGN at 0.03% w/w was performed on the upper arms for 2 weeks. 18 of the 51(35.3%) patients developed a positive ROAT. In all patients, there was a positive ROAT only to the moisturizer with MDBGN( P < 0.001). A statistically significant association was also found between the patch test reactivity(PTRL) and the outcome of the ROAT( P < 0.001). If only considering those with a PTRL above 0.3%, thus with negative or doubtful test reactions to 0.1% and 0.3%, there were still statistically significantly more patients with a positive ROAT to the moisturizer with MDBGN than to the moisturizer without MDBGN. The study demonstrates that patch testing with MDBGN at 0.3% and 0.1% will miss clinically relevant patch test reactions to MDBGN. [ABSTRACT FROM AUTHOR]

Periorbital dermatitis is common and can be due to the external use of ophthalmic drugs. We evaluated patch test results of the Information Network of the Departments of Dermatology. During a 5-year period (1995–99), of a total 49 256 patch-tested patients, 1053 (2.1%) were eventually diagnosed as allergic periorbital contact dermatitis (APD) and 588 (1.2%) as non-allergic periorbital dermatitis (NAPD). Patient characteristics between APD, NAPD and other cases (OCs) differed with respect to sex (19.7% male in both periorbital groups versus 36.3% in OCs), atopic dermatitis (10.4% in APD versus 60.2% in NAPD versus 16.9% in OCs) and age, APD being substantially more often (68.2%) aged 40 and above than NAPD (52.6%). Several of the top allergens in OCs [such as fragrance mix, Myroxylon pereirae resin (balsam of Peru), lanolin alcohol and potassium dichromate] caused significantly fewer positive test reactions in both periorbital groups. In contrast, thimerosal, phenylmercuric acetate, sodium disulfite, gentamicin sulfate, phenylephrine hydrochloride and benzalkonium chloride tested positively significantly more often in APD but not in NAPD, verifying them as true ophthalmic allergens. Finally, in 42 cases (4%) of APD patients, additional allergens were identified by testing of the patients' own substances (mostly β-blockers, oxybuprocaine and dexpanthenol), supporting the necessity of testing with ophthalmic drugs as is where individual substances are not readily available. [ABSTRACT FROM AUTHOR]

Contact sensitivity to plants containing 1 or more sesquiterpene lactones (SLs) is difficult to diagnose. The mixture of SLs (SL mix) has been shown to detect only about 60% of sensitized individuals. In order to improve the diagnosis of sensitization to plants containing SLs, we have tested a mixture of frullanolides contained in Frullania dilatata and Frullania tamarisci at 3 different concentrations (0·01%, 0·033% and 0·1% in petrolatum). 8605 consecutive eczema patients in 1 North American and 15 European dermatology departments were tested with this mix, and 0·35% of positive cases to the different concentrations were found. Routine use of this mix permitted detection of only a small percentage of extra cases and did not improve the SL mix score. The frullanolide mix should therefore be restricted to investigations in particular geographical zones and/or in particular occupations. [ABSTRACT FROM AUTHOR]

Several contact allergens are tested at concentrations which might cause irritant reactions. In this study we investigated whether the reactivity to a standard irritant is useful in identifying subjects with hyperreactive skin yielding a higher rate of doubtful or irritant reactions. Sodium lauryl sulfate (SLS) 0.5% (aqua) was tested in addition to the standard series routinely for 5 years in the Department of Dermatology, Dortmund. For data analysis, we compared reactions at D3 to the standard series, the vehicle/emulsifier and preservative series and benzoyl peroxide to the reactions obtained with SLS. Proportions were standardized for age and sex. The association between reactivity to a certain allergen and SLS reactivity as a dichotomous outcome, controlled for age and sex as potential confounders, was assessed with logistic regression analysis. Results showed that of the 1600 tested patients, 668 (41.8%) had an irritant reaction to SLS which exceeded 2 + in only 41 patients. Seasonal variation was statistically significant, showing reduced SLS reactivity in summer vs. winter. Patients with irritant reactions to SLS showed significantly more erythematous reactions to the following 10 allergens of the standard series: fragrance mix, cobalt chloride, balsam of Peru (Myroxylon pereirae), lanolin alcohol, 4-phenylenediamine base (PPD), propolis, formaldehyde, N -isopropyl-N ′-phenyl-p -phenylenediamine (IPPD), benzocaine, and 4-tert -butylphenol-formaldehyde resin. No significant differences regarding strong positive allergic reactions were observed. Concerning other allergens, significantly more erythematous reactions were observed in SLS-reactive patients to benzoyl peroxide, octyl gallate, cocamidopropyl betaine, Amerchol L-101, tert -butylhydroquinone, and triethanolamine. In the SLS-reactive group of patients, the reaction index was negative for 10 allergens of the standard series compared to only 5 in the SLS non-responder group. For the first... [ABSTRACT FROM AUTHOR]

The muscle relaxant tetrazepam may cause severe cutaneous adverse effects. We report 4 cases of varying intensity: Stevens–Johnson syndrome, erythema–multiforme-like exanthema, maculopapular and maculo-urticarial exanthema. Patch testing with tetrazepam (10% in petrolatum) was strongly positive in the 2 patients with severe skin eruptions and weakly positive in the other 2. Oral rechallenge with tetrazepam was positive in 3 patients (1 not done). Diazepam, with a similar chemical structure to tetrazepam, was negative on patch testing and on oral challenge testing in 2 patients. Although the optimal patch test concentration of tetrazepam has still to be determined, it is a useful diagnostic tool to confirm sensitization, particularly in patients with severe bullous eruptions. [ABSTRACT FROM AUTHOR]

A 10-year multicentre analysis of the frequency of sensitivity to common preservatives collected in 16 centres in 11 countries has shown stable but persisting high levels of sensitivity to formaldehyde and 5-chloro-2-methyl-4-isothiazolin-3-one + 2-methyl-4-isothiazolin-3-one (MCI/MI). It has also revealed a significant increase in the level of reactivity to methyldibromoglutaronitrile (MDBGN) from 0.7% in 1991 to 3.5% in 2000. The current high level of sensitivity to MDBGN requires an urgent safety re-evaluation and risk assessment update along with consideration of immediate lowering of use concentrations, especially in leave-on products. [ABSTRACT FROM AUTHOR]

Analyzes the frequency of allergic sensitization to ammonium thiolactate and thiolactic acid among hairdressers. Methods used in determining the subjects' allergic reactions; Stability of the Hermal patch test material.

Background: Patch test (PT) guidelines recommend classifying PT reactions based on morphological criteria only, i.e. irrespective of context information such as substance, concentration and vehicle., Objectives: To analyse reclassification of PT reactions after revelation of context information subsequent to an initial blinded reading., Methods: One hundred and twenty-two participants (experienced dermatologists and researchers) rated 20 digital images of different PT reactions twice, first blinded, then unblinded regarding substance, concentration and vehicle. Agreement between both ratings was quantified with Cohen's kappa, and systematic differences statistically examined with tests for marginal homogeneity., Results: Mostly, ratings remained stable, e.g. in > 90% of cases of images showing typical strong or extreme positive PT reactions. Reclassification was comparatively often observed in images depicting irritant reactions. Conversely, 16 of 122 participants re-rated doubtful reactions to thiuram mix and dichromate, respectively, as 'allergic' (weak or strong positive) after knowing the substance., Conclusions: The considerable proportion of participants who choose an 'allergic' rating, despite a morphological presentation definitely not justifying this, points to a conceptual problem of the PT reading scale: the mixing up of morphological classification and interpretation. We therefore suggest amending the scale. Moreover, standardization of PT reading can be improved by continual PT training sessions.

Objective: Assessment of the value of patch testing patients' own perfumes, eau de toilette, deodorants and shaving lotions with regard to diagnosing contact allergy to fragrances, and an analysis of the spectrum of concurrent patch test reactions to single fragrance allergens., Study Design: Data of the Information Network of Departments of Dermatology (IVDK; http://www.ivdk.org) regarding patch test results with above products brought in by the patient, considered as possible cause of contact dermatitis, were retrospectively analysed. Between 1998 and 2002, 1468 patients were patch tested with 2557 single products (deodorants, n = 1094; eau de toilette, n = 598; perfume, n = 530; and pre- or after-shave, n = 325; remainder not classifiable), mostly 'as is'., Results: Positive reactions were observed in 129 patients (to 191 products). In 58 of these patients, no further patch test reactions to the fragrance mix (FM-I), Myroxylon pereirae resin (balsam of Peru) or 4-(4-hydroxy-4-methyl-pentyl)-3-cyclohexencarboxaldehyde (e.g. Lyral(R)) were found. A strong association between contact sensitivity to the above commercial allergens and positive reactions to products was observed. Some single compounds such as ylang-ylang oil, propolis and especially oak moss absolute are important allergens in the 'perfume-positive' subgroup, but less in a subgroup positive to own deodorants., Discussion: Patch testing this scope of products, brought in by the patient, can be regarded as a simple, safe and effective method to diagnose clinically relevant contact sensitization - the more so, as the composition of such products is ever-changing, and the sensitivity of established 'screening allergens' is thus insufficient.

Background: Late patch-test reactions, developing at day (D) 7 or later have been described for several allergens. Late reactions may reflect patch-test sensitization. Para-phenylenediamine (PPD) and epoxy resins (ER) are potent allergens and therefore may potentially induce patch-test sensitization. Up to now, there has been no prospective study on the frequency of late reactions in routine patch testing with these allergens., Objectives: To assess the frequency of late reactions to PPD and ER., Patients/methods: In 1748 patients PPD (PPD-base, 1% pet.) and ER [based on diglycidylether of bisphenol A (DGEBA, 1% pet.)], and in 812 patients, nickel sulphate (5% pet.) were removed from the test panel of the standard series and applied on the medial side of the upper arm. Patch-test occlusion time was 24 h in 588 (PPD and ER) and 241 patients (nickel sulphate), respectively, and 48 h in 1160 (PPD and ER) and 571 (nickel sulphate) patients, respectively. Patch tests were read on D1-3 and D2-3, respectively; additional late readings were performed on D7, D14 and D21 after patch-test application. Patients who were not able to return for all scheduled late readings were telephoned on D7, D14 or D21, and questioned about a reaction at the test sites. Patients were instructed to perform daily self-examination from D4 onwards and to return immediately to the clinic if a reaction at the upper arm became visible., Results: Data of 1428 patients (ER and PPD) and 638 patients (nickel) were evaluable. In 25 patients (1.8%), patch tests became positive not before D7, among them 21 reactions to PPD (1.5%) and four reactions to ER (0.3%). In five of seven patients, repeated patch tests with PPD disclosed patch-test sensitization as the cause of the late reaction. All late reactions, except for one, occurred in patients in whom patch tests were applied for 48 h. No late reactions were seen with nickel sulphate., Conclusions: PPD (1% pet.) elicited late reactions in 1.5% of routine patch tests, the majority of them probably being caused by patch-test sensitization. Therefore, the German Contact Dermatitis Research Group decided to remove PPD 1% pet. from the German standard series and to take efforts to optimize the patch-test conditions of PPD. One way to optimize PPD testing could be to reduce the exposure of PPD 1% to 24 h. Alternatively the patch-test concentration of PPD might be reduced.

A 50-year-old female developed extensive condylomata acuminata in the genitoanal region over a period of 12 years. She presented with multiple, verrucous lesions involving the whole genitoanal area plus the adjacent perineum and gluteal region which made it impossible to identify the anatomical structures. Proctoscopy was normal. Serology for infectious diseases was negative. Several biopsies showed no signs of malignant transformation. Tumor excision under general anaesthesia was incomplete. Therefore, adjunctive therapy with immunomodulatory agents was administered, utilizing local application of imiquimod cream (3 x weekly) for 3 months and subcutaneous injections of interferon-alpha-2a (3 million IU 3 x weekly) for 5 months. This treatment regimen resulted in complete remission of all skin lesions with only discrete superficial scarring but no significant loss of anatomical structures or functions. During a 1-year follow-up the patient showed no sign of relapse.

Background and Aim: Tea tree oil, a distillation product of the Australian tea tree (Melalence alternitolia) is increasingly used as an alternative remedy for various dermatological diseases. Tea tree oil contains several allergenic monoterpenes and sesquiterpenes. In this multicenter study it was evaluated, whether the increasing use of tea tree oil has lead to an increased frequency of sensitization in Germany and Austria which would justify its inclusion into the standard series., Patients and Method: For patch testing a standardized tea tree oil was used, dissolved 5% in diethylphtalate (DEP). Consecutive patients of 11 dermatological departments in Germany and Austria were tested. Readings were taken on day 2 and 3 according to the guidelines of the German Contact Dermatitis Research Group (DKG)., Results: 5% tea tree oil was positive in 36/3375 patients (1.1%). Sensitization frequencies showed great regional variations and ranged from 2.3% (Dortmund), 1.7% (Buxtehude), 1.1% (Essen), 0.7% (Graz), to 0% (Berlin, Vienna). 14/36 patients (38.9%) also showed a positive patch test reaction to oil of turpentine., Conclusion: Our results show that tea tree oil is an important contact allergen for some centers. It should be tested, if medical history suggests its previous use. Considering the great regional differences in frequencies of sensitization its inclusion into the standard series is not recommended yet.

Hydroxyisohexyl 3-cyclohexene carboxaldehyde, also known as Lyral, is a fragrance ingredient identified as the cause of contact allergic reactions in 2-3% of eczema patients undergoing patch testing. Lyral has been included in the standard patch test series in many clinics due to its importance as an allergen. It has been used without restrictions in cosmetic products, until now. In the present study, the dose-response relationship of Lyral contact allergy was studied with doses relevant for normal exposure in cosmetic products. 18 eczema patients, who previously had given a positive patch test to Lyral 5% petrolatum, were included along with 7 control subjects. All cases were tested with a serial dilution of Lyral in ethanol 6% to 6 p.p.m and subjected to a 2-week, repeated open application test with a low dose of Lyral in ethanol. In the case of no reaction, this was followed by another 2 weeks of testing with a higher dose. The test was performed at the volar aspect of the forearm. In 16 of 18 cases (89%), a positive use test developed, 11 reacting to the low and 5 to the high concentration. None reacted to the vehicle control of ethanol applied to the contralateral arm. All controls were negative to both the test solutions of Lyral and the ethanol control. The difference between the test and the control group was statistically significant (Fisher's test, P < 0.001). It is concluded that Lyral at the current usage levels is inducing sensitization in the community. The same levels were shown to elicit allergic contact dermatitis in almost all sensitized individuals. A significant reduction in usage concentrations is recommended to prevent contact allergic reactions.

Background and Objective: Sentinel lymph node excision (SLNE) and positron emission tomography (PET) were evaluated in the staging of 51 Stage I and II melanoma patients (staged according to the guidelines of the German Dermatological Society)., Patients/methods and Results: Tumor thickness ranged from 1.0 mm to 6.0 mm (median: 1.5 mm; mean: 2.07 mm). At least one sentinel lymph node (SLN) was excised in all patients; 80 SLN were excised from 69 lymphatic drainage areas. Positive SLN were detected in 6 patients (11.8%). Additional positive lymph nodes were not detected in any of these patients in the following complete lymph node dissection of the affected lymph node basin. Preoperative PET was performed in 40 patients and did not detect any of the micrometastases that were subsequently found by SLNE. During the follow up of 7-40 months (mean 21.9 months) 3 patients experienced tumor progression; 2 of 3 had a positive SLN., Conclusions: According to the current literature SLNE is recommended in primary tumors greater than 1 mm thickness. PET cannot be expected to give additional information in the staging of stage I-II patients.

History and Clinical Findings: A 75-year-old woman took aceclofenac (100 mg/day) for 15 days for long-standing arthritis. Starting with erythema of the face she developed multiple target lesions with central bullae on her neck, chest, back, including the palmoplantar region. In several areas the lesions became confluent and showed wide detachment. The mucous membranes of the eyes, mouth and genitalia also showed marked inflammation, most prominent were large erosions in the mouth. The clinical course culminated in an overall skin loss of about 15 % of the total body surface area., Diagnosis, Treatment and Course: Treatment with topical and systemic corticosteroids as well as antiseptics resulted in complete clearing of the cutaneous lesions within 4 weeks. Various analgetics, particularly the closely related diclofenac, were tolerated without any side-effects after oral intake. Re-exposition with aceclofenac was rejected due to safety reasons., Conclusion: This is the first report of a potentially life-threatening adverse cutaneous drug reaction after taking with aceclofenac.

Systemic anaplastic large-cell lymphoma (ALCL) in human immunodeficiency virus (HIV)-infected individuals showing an extensive infiltrate of neutrophils has been reported and referred to as 'neutrophil-rich' CD30+ ALCL. Secondary cutaneous involvement has been found in a subset of these cases. We report the clinicopathological features of four immunocompetent patients with primary cutaneous neutrophil-rich ALCL and present a new histological subtype with a dissolute growth pattern of CD30+ tumour cells. Four HIV-negative patients presented with rapidly growing solitary or multiple tumours located on the face. Ulceration of the lesions with purulent discharge was a typical finding. Various inflammatory dermatoses were considered clinically in all cases. The histological hallmark was a large number of neutrophils in the infiltrate that masked neoplastic CD30+ anaplastic cells. In two cases, a dissolute growth pattern of anaplastic tumour cells was observed. In two cases, a strong correlation between tumour growth and interleukin (IL)-8 cytokine pattern as well as the production of IL-8 by tumour cells was demonstrated. The diagnosis of neutrophil-rich ALCL is challenging clinically and histologically as the tumour cell compartment is masked by an extensive inflammatory infiltrate of neutrophils and other reactive cells such as histiocytes which may be mainly due to release of IL-8 by tumour cells. The term 'pyogenic' designates the typical feature of this distinct neutrophil-rich ALCL, namely abscess formation ('pyo-') by cytokines (IL-8) produced by tumour cells ('-genic'). The clinical behaviour of this type is the same as in primary cutaneous CD30+ ALCL with classical histological presentation.

In order to find sensitizers additional to the current fragrance mix (FM) a series of fragrance materials (series II) was evaluated in 6 dermatological centres in Europe. 11 of the test materials were essential oils, the remaining 7 being either mixtures of isomers or simple chemicals of frequent usage in the perfume industry. 1606 patients were consecutively tested with series II and 8% FM. Each patient was classified regarding a history of adverse reactions to scented products: certain, probable, questionable, none. Reactions to FM occurred most frequently in 11.4% of the subjects. The 6 materials with the highest reactivity after the FM were ylang-ylang oil (YY) I (2.6%), YY II (2.5%), lemongrass oil (1.6%), narcissus absolute (1.3%), jasmine absolute (1.2%) and sandalwood oil (0.9%). 48 (3.0%) of the patients reacted only to materials of series II and not to FM. 6.0% of 1606 patients gave a history of adverse reactions to fragrances which was classified as certain. This group reacted to FM only in 22.9%, to series II and FM in 15.6% and to series II only in 5.2%. 63.5% of the patients reacting to both FM and 1 of the materials of series II had some type of positive fragrance history, which was higher in comparison to those with isolated reactions to FM (46.2% of 121) or to series II, respectively, (45.8% of 48). However, this difference was not statistically significant. In conclusion, the materials of series II identified a further subset of patients with a fragrance problem, which would have been missed by the current FM as the single screening tool for patch testing.

A range of antibiotics has been shown to modify host functions apart from the antimicrobial potency. They may directly influence phagocyte and lymphocyte function, as well as chemotaxis. Effects on the generation and release of various cytokines involved in the inflammatory process have been studied both in vivo and in vitro. However, the molecular mechanisms have not been elucidated in detail. It is suggested that antibiotics can exert immunopharmacological effects on the basis of structure-activity relationships independent of their antibacterial activity. We present a collection of clinical studies and case reports dealing with the potential benefits of systemic antibiotics in the treatment of selected dermatoses which have primarily been classified as non-infectious. Generally accepted treatments such as dapsone in dermatitis herpetiformis and leukocytoclastic vasculitis or chloroquine in lupus erythematosus have not been considered. Based on existing clinical trials with a higher number of cases the following antibiotics have been shown to be effective: erythromycin in bullous pemphigoid and pityriasis rosea as well as tetracyclines in pemphigus vulgaris, bullous pemphigoid and pustulosis palmaris et plantaris. However, most reports have to be viewed critically due to the uncontrolled study design, particularly in dermatoses with a tendency to spontaneous resolution. Despite this lack of evidence-based data, it is important for the clinician to know about the potential use of antibiotics for various skin disorders as a primary treatment option or steroid-sparing therapeutic adjunct. In clinical practice the use of antibiotics depends on various factors including the severity of the disease, the patient's age, contraindications to conventional therapeutic regiments and economic considerations.

Induction of immunological tolerance to contact allergens might prevent undesired sensitization, in particular to occupational sensitizers, e.g., methacrylates (MA). Here, using a guinea pig model, we studied to which extent tolerance to one methacrylate might result in cross-tolerance to other congeners. Strong tolerance to the monomethacrylates hydroxy-ethyl MA (HEMA) and methyl MA, but not to the dimethacrylate ethylene-glycol MA (EGDMA) could be induced. The induced tolerance was stable, could not be broken by repeated sensitization attempts, and was mediated by specific suppressor cells, as demonstrated in T cell transfer experiments. In HEMA-tolerized animals, strong cross-tolerance to methacrylate congeners, including EGDMA, itself being nontolerogenic and showing the lowest cross-reactivity to HEMA, was found. Thus, oral application of contact allergens, to which skin contact cannot be avoided, e.g., in occupational settings, can induce broad cross-tolerance to related substances and might offer a promising preventive approach., (Copyright 2001 Academic Press.)

Para-tertiary-butylcatechol (PTBC) has been patch tested in Europe at 1% in petrolatum (pet.) and is now suspected of induction of patch test sensitization. A prospective study was initiated to obtain detailed data on this undesirable risk. A dilution series of PTBC (1%, 0.5%, 0.25%, 0.1% pet.) was used. Patch tests were read on days (D) 1-3, 7, 14 and 21 after application. Patients who were unable to return for late readings were telephoned and asked to report any reaction at the patch test sites. 40 out of 46 patients included completed the study. Patch tests were negative in 35 patients. 4 patients showed a positive patch test at later readings only (D7-D21); 2 patients reacted to a concentration as low as 0.1%. Rechallenge was performed in 2 of these patients, revealing a clearly positive reaction as early as D2 after patch test application. PTBC clearly induced patch test sensitization in 10% of the patients. It cannot be excluded that patch testing with 0.25% PTBC or with even lower concentrations might induce patch test sensitization. The optimal patch test concentration still has to be determined but may be within the range of 0.01% to 0.25% PTBC.

Irritant patch testing with sodium lauryl sulfate (SLS) will become more and more a routine test determining skin susceptibility in men. Recently, it has been shown that for practical reasons, irritant SLS patch testing can take place on the back simultaneously with a routine allergic patch test to other contact allergens. However, SLS patch testing has mostly been performed on the forearm in studying experimental skin irritation so far. The aim of this study was to determine whether there is a relationship in skin response to aqueous SLS (0.125%; 0.25%; 0.5% and 1.0%) between the forearm and the back assessed by visual scoring and measurement of transepidermal water loss (TEWL). We found a pronounced reaction of the forearm compared to the back. TEWL values as well as visual scores correlated well with SLS concentration. There was also a high correlation in visual scoring between the forearm and the back. Based on test sensitivity and specificity we suggest a 48 hrs patch test for routine screening with 0.5% SLS on the forearm evaluated by TEWL measurement or visual scoring 24 hrs after patch removal. A mild erythema (scored as < or =1) is considered to be normal. If for practical reasons, the SLS patch is placed on the back simultaneously with the allergic patch test, 0.5% SLS may be sufficient, too. TEWL measurement so far provides a reliable method and will certainly be necessary for experimental studies on irritant skin reactions, particularly when different SLS concentrations are used. After a 48 hrs patch test with SLS 0.5% TEWL measurement should be performed at 72 hrs. A value of < or =31.6 g/m(2)hr seems to follow the normal distribution.

A 46 year old woman suffering from Erdheim-Chester disease is reported for the first time in the German dermatologic literature. She showed periorbital xanthelasmas and indurated erythemas on both flanks. Histologically the skin manifestations were also a sign of the basic disease which had spread to various organs. Small granulomas with foam cells, macrophages and few giant cells were found in the corium. Immunohistochemistry demonstrated positive reactions to protein S-100 and alpha-1-Antichymotrypsin, while CD 1 a-antigen and PNA were negative. Further localizations of Erdheim-Chester disease were found in the femurs, tibiae and mandibula as well as in the right breast, retroorbital region and abdominal aorta. Infiltration of the retroperitoneal cavity led to urinary retention and nephrectomy. With systemic corticosteroid therapy, the skin lesions on the flanks regressed but recurred after discontinuance of the drug. Erdheim-Chester disease is now classified as part of the histiocytoses which is confirmed by our immunohistochemical findings. The histiocytes are probably not identical with Langerhans cells. The diagnosis is usually made by the radiologist on the basis of typical osteosclerotic symmetrical lesions of the long bones, histologically representing lipoid granulomas. Common non-osseous manifestations of the disease are in the retroperitoneal region, orbita and intracranially (partially associated with diabetes insipidus) which are often fatal. On the skin, xanthelasma and xanthoma are present in 1/6 of the cases; in some patients yellow-brown papular and widespread infiltrated lesions have been described. As regards to therapy corticosteroids chemotherapy, radiation and immunomodulating agents as well as surgery have been used with limited success.

Pyodermatitis-pyostomatitis vegetans is a rare, polymorphous inflammatory disorder of the skin and oral mucosa first described by Hallopeau in 1898. On the skin papules, pustules and reddish brown annular vegetating plaques develop, most frequently in the intertriginous areas. In the mouth, yellowish flat ulcerations arise, typically in the shape of "snail tracks". The association with inflammatory bowel disease is very common. An unusual case with a chronic relapsing course of 2 decades is presented. Gastrointestinal inflammation was absent. Prednisolone in high and medium doses suppressed most lesions. Various attempts with other drugs (dapsone, isotretinoin, azathioprine) to reduce the corticosteroid dose failed. This is the first report of the successful treatment of pyodermatitis-pyostomatitis vegetans with cyclosporin A, which proved to be highly effective in this regard. The unknown aetiopathology of pyodermatitis-pyostomatitis vegetans is discussed.