Search

Hand eczema is a very common skin disease, which can be induced by different causes. Although many interventions ranging from topical corticosteroids and UV therapy to oral cyclosporine and retinoids are available, the treatment of hand eczema can be very difficult and frustrating. The objective of our study was to assess the external evidence of different treatment modalities for hand eczema. Electronic databases (Cochrane, MEDLINE, Embase, Pascal, Jicst-Eplus, Amed) were systematically searched for clinical trials on therapy for hand eczema. Additionally, four general medical journals (BMJ, JAMA, Lancet, NEJM) and 17 specialists dermatological journals were hand searched from 1977 to August 2004. A total of 100 studies were found and 31 identified as randomised clinical trials (RCTs) dealing with different interventions. Due to the poor quality of most of these RCTs, they are inadequate as a guide to clinical practice. There is a need for high-quality RCTs on therapy for hand eczema regarding established as well as new treatment options taking different subgroups of hand eczema into consideration.

In recent years quality of life has been studied in a growing number of different dermatological diseases. Internationally validated questionnaires such the RAND-36 (identical to the SF-36) do not contain enough questions which are relevant for skin diseases. There is no publication on quality of life issues in occupational skin diseases, and only one short report gives data on quality of life in hand eczema. The widely used skin specific instrument DLQI has only 2 questions that indirectly refer to employment issues. A quality of life questionnaire on occupational skin diseases (mostly hand eczema) should ideally include questions on work-related impairment of both physical functioning and interaction with colleagues.

Background and Objective: By means of a 2-week intensive multidisciplinary training & treatment course in small groups (ISBP), young adults with atopic dermatitis may be able to achieve better self-management of their disease and reduce their number of doctor visits., Methods: Patients aged 18-35 with moderate to severe atopic dermatitis (SCORAD > 20) were randomized in a treatment (ISBP) group of n = 31 and a control group of n = 20. Follow-up was 9 months. The outcome was assessed using validated primary and secondary parameters, both specific for atopic dermatitis and more general., Results: Participants in the ISBP scored significantly better at follow-up in the Marburger atopic dermatitis-specific questionnaire and the self-care parameter, needed less time for medical consultations, and used more emollients without corticosteroids. Absence from work/sick leave was less at 10 weeks follow-up, but equal at 9 months., Conclusions: The ISBP program can be judged successful because both the patients and their doctors perceive their interactions as more efficient, less time time-consuming and more satisfying.

Pathophysiological variability affects the results of patch testing. In addition, even a minimal degree of test-imprecision due to this variability has a number of important statistical consequences for the analysis and interpretation of any patch test data set. One such statistical phenomenon that is often overlooked is the dependence of the positive predictive value (i.e., the predictive value of a positive patch test) on sensitivity and specificity, the impact of which is heavily dependent on the proportion of truly allergic subjects that are studied. A 2nd important issue is the fact that patch testing is performed in series, which means multiple tests. If we assume, for example, a patch test series of only 10 allergens, then it can be demonstrated that there is a random probability of over 40%) to find, simply by chance, for at least 1 allergen, a statistically significant difference between 2 groups of patients. Comparison of the results of series between patients calls for statistical adjustments in order to prevent erroneously positive differences and/or associations.

Occupational contact dermatitis (OCD) ranks first of all occupational diseases in many countries. The incidence rate is believed to be around 0.5-1.9 cases per 1000 full-time workers per year. Epidemiological studies play an important role in observing disease trends, analysing risk factors, and monitoring the effect of preventive measures. In this review article the lack of truly epidemiologic data on OCD and the difficulties of those studies are illustrated. The following issues are highlighted: case ascertainment and bias, the distribution of allergic and irritant contact dermatitis in the working population, the interrelationship between exogenous (allergens, irritants) and endogenous factors, the prognosis, the social and economic impact, and the need for intervention studies.

Persons with atopic dermatitis run a considerable risk of developing hand eczema when exposed to occupational agents that are a burden to the skin. This also pertains to those with a history of skin atopy in childhood. This review presents estimates of the risk of developing hand eczema and examines the evidence for an effect modification by skin atopy on exposure. Skin atopy at least doubles the effects of irritant exposure and, thus, doubles the risk in occupations where hand eczema is a common problem. On the basis of this evidence, guidelines for occupational counseling can be given. Further development of a scale indicating the degree of atopic skin diathesis should facilitate the targeting of this counseling toward specific high-risk groups.

Background: The pathogenetic role of house dust mite in atopic dermatitis remains controversial. Recent studies have shown that intensive epicutaneous contact of house dust mite allergen with premanipulated skin may induce dermatitis. It is, however, uncertain whether such conditions are met during natural contact with house dust mite. In the past, allergen inhalation has been suggested to induce exacerbation of atopic dermatitis. The aim of this study was to investigate whether dermatitis could be induced in patients with atopic dermatitis by inhalation of house dust mite., Methods: Twenty patients with atopic dermatitis underwent bronchial provocations with house dust mite. Challenge tests were performed with four concentrations of a standardized house dust mite extract in a double-blind, randomized, placebo-controlled fashion. Spirometry was performed, and FEV1 was measured before and after each challenge dose. Changes in severity or localization of itching or erythema were recorded., Results: In nine of 20 patients with atopic dermatitis bronchial challenge with house dust mite induced unequivocal skin symptoms after 1.5 to 17 hours. Pruritic erythematous lesions on noninvolved sites together with exacerbations of existing lesions were seen in three patients. Three patients had an exacerbation only, and three other patients had new lesions only. In eight of nine patients with house dust mite inhalation-induced dermatitis, skin symptoms were preceded by an early bronchial reaction. All patients with house dust mite-induced dermatitis had a history of asthma, and as a group they had a higher mean blood total IgE level compared with the "negative skin responders." One patient had pruritic erythema on the placebo challenge day, without a preceding bronchoconstrictive reaction. The number of patients who had a skin response on the house dust mite challenge day was significantly higher than the number of patients who had a skin response on the placebo day (p = 0.011 [Prescott's test])., Conclusions: The respiratory route may be relevant in the induction and exacerbation of dermatitis in a subset of patients with atopic dermatitis who have early bronchial reactions after house dust mite inhalation, a history of asthma, and an elevated blood total IgE level. Furthermore, these findings suggest a possible causal relationship between bronchial reactions and skin reactions.

From 15 May to 15 December 1994, 2943 patients suspected of having contact dermatitis (1955 women, 988 men) were patch tested with methyldibromoglutaronitrile 0.3%, 0.1% and 0.05% pet. 119 patients (4.0%; women 4.1%, men 3.8%) proved to be allergic. 71% of the reactions were considered to be relevant. In 2/3 of the patients, causative products were cosmetics, in 1/3 moistened toilet tissues. Testing with methyldibromoglutaronitrile at lower concentrations (0.05% and 0.1%) and with commercial allergens (Euxyl K 400 and methyldibromoglutaronitrile, both containing methyldibromoglutaronitrile 0.1%), resulted in a number of false-negative reactions. All preservatives in the European standard series had lower scores than the 4% positive reactions to methyldibromoglutaronitrile (formaldehyde 2.0%, MCI/MI (Kathon CG) 3.2%, parabens 1.0%, quaternium-15 1.3%). It is concluded that methyldibromoglutaronitrile (present in the commercial preservative Euxyl K 400) is an important contact allergen in the Netherlands in cosmetics and moistened toilet tissues. It should be added to cosmetics series and to proctological series. The optimal test concentration is unknow, but may be 0.3% pet. The concentration of 0.1% methyldibromoglutaronitrile in the currently available commercial allergens appears to be too low, resulting in a number of false-negative reactions.

Chloracne is an acneiform skin eruption that is still the most sensitive indicator of systemic poisoning caused by chemicals belonging to the group of chlorinated polycyclic aromatic hydrocarbons. Generally these chemicals are known as dioxins, dibenzofuranes, and PCBs. The cause of chloracne is probably interference of these chemicals with vitamin A metabolism in the skin, resulting in disturbances of the epithelial tissues of the pilosebaceous duct. A study of workers in a factory where chloracne is endemic is described. The product manufactured, pentachlorophenol, a wood preservative, was found to be contaminated with dioxins (congeners of TCDD) and dibenzofuranes. Blood levels of these chemicals in affected workers are given, along with supporting evidence of disturbances in vitamin A (retinoid) metabolism as demonstrated in skin biopsies.

In four patients, three women aged 45, 29 and 52 years and a man aged 45 years, allergic contact dermatitis due to 'tea tree' oil was diagnosed. The case of the man was published before. 'Tea tree' oils are essential oils distilled from the leaves of myrtaceous trees and shrubs occurring in Australia and South-East Asia. The 'tea tree' oil available in the Netherlands is distilled from the Melaleuca alternifolia and mainly contains eucalyptol. Eucalyptol is probably the most important allergen.

A solid-phase protein assay (SPA) for the determination of protein concentrations in the nanogram range is described. The technique is based on biotinylation of immobilized protein on the solid phase of a microtiter plate and quantitation of the protein-biotin complexes by peroxidase-coupled avidin. Compared to the routinely used Bradford and Lowry protein detection techniques, the described SPA assay is (depending upon the protein assayed) 1000 to 10,000 times more sensitive. Moreover, the SPA assay can be suitable for protein quantitation of samples containing agents which commonly interfere with the routinely used detection techniques. The SPA assay is a valuable addition to the Bradford and the Lowry techniques. Used in combination with an antigen-specific ELISA it gives a reliable ratio of specific versus total protein.

The purpose of the study was to evaluate a self-administered questionnaire on hand dermatitis that was developed to identify persons with hand dermatitis in epidemiological studies. A total of 109 nurses were subject to dermatological examination of the hands within 1 month of returning the questionnaire. 2 types of questionnaire diagnoses were made: a 'symptom-based' diagnosis and a 'self-reported diagnosis'. These were compared to the medical diagnosis of hand dermatitis. The prevalence of hand dermatitis in the 12 months before the study, based on the medical diagnosis, was 18.3%. The prevalence according to the symptom-based diagnosis and the self-reported diagnosis was 47.7% and 17.4%, respectively. The sensitivity and specificity of the symptom-based diagnosis were 100% and 64%, respectively. It is concluded that the symptom-based diagnosis can be used as screening instrument for the detection of cases in large study populations, if followed by dermatological examination of persons with a positive diagnosis. The sensitivity and specificity of the self-reported diagnosis were 65% and 93%, respectively. It is concluded that the self-reported diagnosis can be used to obtain a rough estimate of the prevalence, although comparison of prevalence figures between study populations may be distorted due to a difference in reporting of hand dermatitis. The results of the study illustrate the size of the differences in prevalence estimates that may arise as a result of differences in the definition and method of diagnosing hand dermatitis.

Patch tests with house dust mite allergens were performed in 21 atopic dermatitis patients with a positive prick test and RAST for house dust mite. Variables in methodology of patch testing, i.e. allergen concentration, application time, and intensity of tape stripping, were studied. Tests were performed with Dermatophagoides pteronyssinus solutions containing 20X, 100X and 500X the prick test concentration and purified HDM antigen: 10 and 50 micrograms/ml P1Ag solution. The series was applied on 8X or 15X tape-stripped and clinically normal skin on the back during 24 and 48 h. Non-specific reactions due to tape stripping, fixation tape or patch test occlusion were frequently observed: after 15X tape-stripping in 3/7 (24-h application) and 6/7 (48-h application) patients, after 8X tape-stripping in 2/19 (24-h application) and 8/19 (48-h application) patients. Reactions clinically assessed as specific occurred in 6/21 (29%) atopic dermatitis patients, 4/6 occurring in the 10 patients with a serum IgE greater than 1000 kU/l. High allergen concentrations and 48 h of application increased the number of patients with specific reactions. If 15X tape-stripping had been omitted, 2/3 patients tested in this manner and showing specific test reactions would have been negative. Further conclusions regarding the value and the preferable method of patch testing with atopic allergens require an in vitro control test.

Transepidermal water loss measurements proved to be more accurate and sensitive than visual scoring in discriminating the irritating action of detergents on the skin. Further, the baseline transepidermal water loss might be a reliable indicator of an individual's susceptibility to weak irritants.

The influence of eccrine sweating on transepidermal water loss (TEWL) was investigated. TEWL was simultaneously measured on both forearms, with and without topical inactivation of the eccrine sweat glands by 0.3 ml of 0.5% aqueous scopolamine hydrobromide (HBr), applied under 1 h occlusive patches. The degree of sweat inhibition, after exercise, was measured at 2, 3 and 4 h after patch removal. In 42 out of 44 subjects, complete sweat inhibition (on exercise) was achieved only at 4 h after removal. After a 15-min rest in a room at 20 degrees C, the pre-exercise TEWL values (at 4 h) on the treated and untreated sites were not different (P greater than 0.05), in 38 out of 44 subjects. By this rest period, sweating due to slight physical, thermal or even emotional stimuli may be prevented in most subjects. In the other 6 subjects, the pre-exercise TEWL values (at 4 h) on the untreated site were 1-1.8 g/m2h higher than (P less than 0.001) on the treated site, due to emotional sweating. Thus, accurate baseline TEWL measurements may only be made after anticholinergic suppression of the sweat glands. In this way, accurate TEWL measurements may be made even outside favourable laboratory conditions, at industrial sites etc., where circumstances are far from ideal. The effect of this agent applied to a skin site previously irritated artificially by a 24-h occlusive sodium lauryl sulphate (SLS, 0.3 ml, 0.5% aq.) patch, was also investigated in 17 subjects. In all subjects, 4 h after removal, sweating (on exercise) was completely inhibited on the scopolamine-treated site, pre-irritated with SLS.(ABSTRACT TRUNCATED AT 250 WORDS)

A follow-up study was performed of the medical and social condition of 164 patients with an occupational allergic contact dermatitis. A change of work did not always lead to an improvement of the dermatitis. A number of patients improved without changing their job. It is suggested that a change of occupation can only be advised to these patients if the causal allergen can be avoided completely by doing so and only by doing so; at the same time one must reckon with other aetiologic factors and the social situation after change of work. Moreover it is pointed out that patients who changed their occupation did hardly use the possibilities, created by the Dutch law, to obtain expert advice or to be retrained for another job at the expense of the community.

A review of the literature makes it evident that occupational dermatoses in construction and building workers probably are the most important dermatological cause of sickness and absence of work in industry. Information on the real medical and social importance of these diseases is scarce. On the one hand published data point out that many working days are lost with important financial consequences. On the other hand it has also been noted that workers, despite more or less extensive dermatological problems, sometimes try to continue their work without even consulting a physician. The available information is based on out-patient records and/or insurance files only. Further investigations by trained dermatologists and experienced industrial physicians are necessary to detect and study early cases of occupational dermatosis. Follow-up studies on the further course are also imperative. Systemic longitudinal investigations will provide a more complete picture of the real medical and social importance of occupational dermatoses in this important branch of industry.

A study was made of the comparability and reproducibility of the results of measurements of water loss, both in vitro and in vivo, using 4 ServoMed Evaporimeters (3 single-probe and 1 double-probe instrument). The optimum time for recording transepidermal water loss (TEWL) after the initial application of the probe to the skin (in vivo), and the best technique for optimizing the accuracy of measuring TEWL were determined. An evaporation device with a constant level of water loss was constructed for in vitro studies. The volar aspect of the right forearm skin of one subject was used in vivo. Both in vitro and in vivo measurements showed that there were some differences between the results of 4 of the 5 probes. The other probe was distinctly out of range. For all probes, the reproducibility of results of successive measurements was high. Stabilization of TEWL values was reached for all probes from 30-45 s after their initial application to the skin. It is recommended that TEWL be recorded for a further 30-s period, after the initial stabilization (45 s), and that this be taken as the true value. The manufacturer's recommended calibration procedure is based only on adjustments for the standard specified humidities and zero water loss. The importance of incorporating an additional calibration procedure which includes adjustments for an actual standard constant water loss is thus strongly stressed.

The rôle of different factors in the susceptibility of the skin to weak irritants was studied by means of multiple linear regression models. The skin of 37 healthy subjects was exposed to a solution of sodium lauryl sulphate of low molarity 2 x daily for 4 days. The condition of the skin was evaluated by transepidermal water loss (TEWL) measurements on the 1st day (before exposure, TEWL1) and on the 5th day of exposure (TEWL5), and by a visual scoring system. The TEWL5 value was strongly related to the TEWL1 value (R = 0.71). The influence of such factors as history of mucosal atopy, history of sensitivity to soap, dry skin, skin type, sex and age on the TEWL5 value was negligible. The baseline TEWL level (TEWL1) might be a reliable indication of an individual's susceptibility to weak irritants.

The purpose of this study was to develop a new model for the induction of chronic irritant contact dermatitis, which would reflect well the conditions of daily practice. Various weak irritant agents were tested for irritating potency on the skin and the sensitivity of transepidermal water loss (TEWL) measurements in the detection of early skin changes was also studied. 10 widely used surfactants and 1 solubilizer were applied to the skin of the forearms of healthy volunteers in aqueous solutions of 12.5 millimoles/l for 45 min twice daily for 3 weeks. The effect on the skin was evaluated daily by means of TEWL measurements and by a visual scoring system. Each solution caused an increase in TEWL value over time due to the cumulative irritating action on the epidermal barrier. This increase in TEWL was different for the various solutions, resulting in different mean TEWL values on the last day of the experiment. Thus, it was possible to rank the agents according to irritating potency. This ranking order was the same in almost every individual and remained constant during the 3 weeks. In comparison with the visual scoring system, the TEWL measurements were more sensitive in the detection of early changes in the skin.

An analysis of variance was conducted to estimate the intra- and inter-individual variations in TEWL on the forearms, by sites (8 measurement sites) and by days (10 different days), in 30 non-exposed healthy individuals. The estimated intra- and inter-individual variations, by sites, were 15.5% and 84.5%, respectively, the sum of the 2 components always being 100%. With the exclusion of the 2 most distal sites near the wrist, which had significantly higher baseline TEWL values and fluctuations in TEWL, an improvement in the intra-individual variation was obtained. Thus, of the 6 sites, the estimated intra- and inter-individual variations were 8.4% and 91.6%, respectively. This finding supports the exclusion of these most distal sites for future investigations. The estimated intra- and inter-individual variations, by days, were 20.6% and 79.4%, respectively. The low site-to-site (8.4%) and day-to-day (20.6%) intra-individual variations, as compared to the large inter-individual variations of the same (91.6% and 79.4%), indicate that baseline TEWL is a stable personal characteristic. Thus, individual susceptible to irritant contact dermatitis (ICD), due to occupational exposure, may be reliably characterized by utilizing their baseline TEWL values, for "prediction" of risk in epidemiological field studies.

Based on experiences in homes for the aged in Singapore, the following may be useful guidelines when dealing with dermatological cases in old people: Diagnosis can be difficult: common diseases come first. The clinical picture is often altered by the patient's self-medication: search for the primary disease. Expect considerable interference of your therapy by other medication. Keep therapy as simple as possible. Refrain from oral medication. Scabies is more common than usually thought and often difficult to recognize when the general standard of hygiene is high. Creams and ointments are not helpful in stasis eczema and leg ulcers. Diuretics often do not work in ankle oedema and its skin complications. Compressive bandages or elastic stockings are cheaper and safer. Antihistaminics rarely work to relieve itch, but cause considerable drowsiness. Use them only for urticaria. Many elderly have a dry skin: soap can cause itch and dermatitis.

Of 982 female clients of beauticians interviewed, 254 (25.9%) claimed to have experienced adverse reactions to cosmetics and toiletries in the preceding 5 years. Most reactions were caused by skin-care products (36.6%), followed by personal cleanliness products (29.5%), eye cosmetics (24.0%), deodorants and antiperspirants (12.6%), and facial make-up products (8.3%). 150 women were patch tested. In the European standard series, only a few positive reactions were seen to possible cosmetic allergens: fragrance mix (n = 3), wool alcohols (n = 3), formaldehyde (n = 2), balsam of Peru (n = 1), and colophony (n = 1). In the cosmetic series, only Kathon CG elicited positive patch test reactions (n = 3). Cosmetic allergy was considered to be "proven" in 3 patients (2.0%), and "possible" in 7 (4.7%). It is concluded that contact allergy is responsible for a minority (less than 10%) of all reactions to cosmetics and toiletries. The majority of reactions are due to irritation from personal cleanliness products such as soaps, shampoos, bath foams and from deodorants, or worsening of pre-existing dermatoses such as seborrhoeic dermatitis and acne.

The roles of the natural permeability of the stratum corneum to water, and the changes in that permeability effected by a single patch test, were investigated as parameters to predict the susceptibility of the skin to repeated exposures of an irritant. One site on the forearm skin of 27 non-atopic healthy subjects was exposed to a 0.5% concentration of sodium lauryl sulphate by a single occlusive 24-h patch. Another site was exposed to a twice daily 4-day repeated occlusive patch with the same irritant solution. The effects were evaluated by transepidermal water loss measurements made prior to the applications (baseline) on day 1 (BASE), following the single 24-h patch on day 2 (SINGL), and following the 4-day repeated applications on day 5 (REPET). Individuals with higher BASE had higher SINGL (R = 0.80, P less than 0.001) and higher REPET (R = 0.76, P less than 0.001). There was also a significant linear correlation between SINGL and REPET (R = 0.63, P less than 0.001). Multiple linear regression analysis of results, however, indicated that a high baseline TEWL is better indication of an individual's increased susceptibility (high REPET) to weak irritants than a high TEWL value following a single 24-h patch test. Baseline TEWL may therefore be used as a reasonably accurate preliminary "predictive" screening test for susceptibility to irritants.

The case history is presented of a patient who developed a maculopapular rash following treatment with 3 different coumarin derivatives. Apparently cross-sensitivity between coumarin derivatives may occur.