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Competing Interests: Conflicts of interest None disclosed.

Objectives: Allergic reactions are rare and poorly understood complications of neuromodulation device implantation. There are currently no guidelines for management of allergic reactions to these devices and their components. Here we review the published cases of allergic reactions to implanted neuromodulatory devices and leverage the experiences of other specialties that deal with similar complications to formulate recommendations for prevention and management., Materials and Methods: A review and assessment of the literature., Results: Allergic reactions to a number of implantable devices have been observed and published. In dentistry and orthopedics, metals such as nickel are the most frequent cause of allergic reactions. In interventional cardiology, where devices closely resemble neuromodulatory devices, titanium, silicone, and polyurethanes are the most common causes of allergic reactions. In neurosurgery, allergic reactions to implantable neuromodulatory devices are rare, and we summarize 13 cases published to date. Such allergic reactions generally present as local dermatitis, erythema, and pruritus, which can be difficult to distinguish from surgical site infection. In one published case, symptoms resolved with corticosteroid treatment, but all other cases required explantation. The successful reimplantation with a modified device was reported in some cases., Conclusions: Patients should be screened for a personal history of contact allergy before implantation procedures. A multidisciplinary approach to suspected cases of postoperative allergic reactions involving collaboration between neurosurgeons and other implanting physicians, dermatologists or allergists, and device manufacturers is recommended. In cases where an allergic reaction is suspected, an infectious etiology should be ruled out first. Clinical suspicion can then be supported with the use of patch testing, interpreted by an experienced dermatologist or allergist. If patch testing supports an allergic etiology, the implanting physician and the device manufacturer can work together to modify the device for safe reimplantation., (© 2021 International Neuromodulation Society.)

Background: Reports of patch test data with an extended metal series that includes rare metals are limited., Objective: The aims of the study were to analyze and report patch testing results from an extended metal series, examine associations with sex and age, and highlight concomitant metal reactions., Methods: This study is a retrospective review of 150 patients referred for suspected metal allergy from January 1, 2007, to December 31, 2016., Results: The most common indications for evaluation referral were those having symptoms after implantation of a metal device (55.3%) and those with a history and concern of metal allergy before implantation of a metal device (22.0%). One or more positive patch test reactions were observed in 87 patients (58.0%). Metals with the highest frequencies were nickel sulfate 2.5% (26.2%), gold sodium thiosulfate 0.5% (23.0%), gold sodium thiosulfate 2.0% (20.7%), palladium chloride 2.0% (19.6%), cobalt chloride 1.0% (12.0%), and manganese chloride 2.0% (10.1%). Of the 45 metals tested, 15 caused no patch test reactions. Female patients were more likely to be sensitized to nickel, gold, and palladium (P < 0.05). Younger patients (≤40 years) had higher reaction rates to nickel, mercury, palladium, and cobalt. Concomitant reactions of the top metals (nickel, palladium, gold, and cobalt) were statistically associated bidirectionally (P < 0.05), except for cobalt and gold., Conclusions: Allergy to metals, including those not included in standard series, may be more prevalent than previously suspected. Results may help guide future testing for suspected metal allergy, although future studies are warranted.

Background: Patch test preparation for evaluation of allergic contact dermatitis is traditionally a slow process with inherent errors., Objective: A novel device, referred to as a syringer, designed to dispense 10 unique petroleum-based haptens simultaneously, significantly reduces preparation time and increases the precision of the mass dispensed per well., Methods: The syringer was custom designed and "printed" through the use of a 3-dimensional printer with a polylactic acid plastic medium., Results: The syringer dispensed 10 haptens significantly (P < 0.05) faster: 6.9 seconds on average, compared with 29.6 seconds by the traditional method. The syringer demonstrated a significantly (P < 0.05) lower average deviation of each strip's per-well mass average compared with the traditional method., Conclusions: In practice, this syringer is ideal for preparing patient-ready patch tests in quantities of 2 identical strips or more.

Background: Metal hypersensitivity reactions (MHR) as a cause of implant-related complications are highly debated and recommendations regarding pre-procedural allergy evaluation vary dramatically., Objective: To examine patients referred before or after device implantation and identify factors that could be useful to guide the value of patch testing., Methods: Patients who underwent patch testing pre- or post-device implantation between July 2006 and September 2016 were analyzed retrospectively., Results: A series of 127 patients underwent patch testing: pre-implantation (n = 40) and post-implantation (n = 87). In the pre-implant group, a history of metal allergy demonstrated high sensitivity (0.94; 95% CI: 0.83-1.00) and negative likelihood ratio (0.17; 95% CI:0.02-1.29) for diagnosing MHR. No predictive value could be ascribed to any of the clinical symptoms (eg dermatitis, pain, swelling, implant failure, and/or other symptoms) for patients referred following orthopaedic and dental post device implantation. Eight patients in the orthopaedic group and six patients in dental group with relevant patch test reactions underwent implant revisions, and seven and five patients improved, respectively., Conclusions: Pre-implant patch testing for selected individuals with a history of metal allergy can help guide implant choice. Post-implant patch testing may be helpful in some patients if other causes have been excluded, as patients with confirmed MHR benefited from revisions., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The American Contact Dermatitis Society Core Allergen series was introduced in 2013 and updated in 2017. Changes in our recommended allergens are again necessary, taking into account data from the American Contact Dermatitis Society's Contact Allergen Management Program top 100 allergens from 2018. For the updated series, we removed methyldibromoglutaronitrile and added new haptens: Lyral, Limonene, Linalool, carmine, benzyl salicylate, disperse yellow 3, jasmine, peppermint, pramoxine, shellac, and lauryl polyglucose (glucosides). These additional allergens should increase the yield of relevant positive reactions for our patients.

Background: Patch testing is the criterion standard for diagnosis of allergic contact dermatitis (ACD)., Objective: The aim of the study was to report the trends of patch testing results with the standard series at Massachusetts General Hospital from January 1, 2007, to December 31, 2016, compared with previous data from 1998 to 2006 and from 1990 to 2006 and those reported by the North American Contact Dermatitis Group., Methods: Data were collected and analyzed from retrospective chart reviews, focusing on 50 allergens in our standard series., Results: A total of 2373 patients were patch tested. One or more positive reactions were observed in 1428 patients (60.2%), and 1153 patients (48.6%) had a final primary diagnosis of ACD. Top 5 allergens were nickel (19.8%), fragrance mix I (14.6%), Myroxylon pereirae (balsam of Peru) (13.5%), neomycin (9.4%), and bacitracin (7.7%). Sensitization frequencies statistically increased over time for 3 allergens: nickel, neomycin, and propylene glycol, and decreased for 5 allergens: formaldehyde, paraben mix, thiuram mix, n-isopropyl-N-phenyl-4-phenylenediamine, and epoxy resin (P ≤ 0.001)., Conclusions: Surveillance of ACD trends is essential to detect emerging sensitizers. Patch testing is an important diagnostic tool for detection of ACD to commonly encountered and potential allergens.

This article provides an overview of the pathogenesis and risk factors associated with antiepileptic drug (AED) hypersensitivity reactions, provides prescribing guidelines that may minimize the risk of antiepileptic induced rashes, and discusses treatment options for rashes. Articles indexed in PubMed, Science Citation, and Google Scholar (January 1946-March 2019) were systematic searched using the following key terms: hypersensitivity, rash, antiepileptic, epilepsy, cross-sensitivity, desensitization, patch testing and supplemented with our clinical experiences. Additional references were identified from a review of literature citations. AEDs are associated with cutaneous adverse reactions. Aromatic AEDs and higher titration rates are associated with increased risk of hypersensitivity reaction. Patient characteristics, underlying health conditions, and genetic variations may increase the likelihood of a hypersensitivity reaction. Once a hypersensitivity reaction occurs, the likelihood of cross sensitivity to another AED increases, especially among other aromatic AEDs. Withdrawal of the causal agent and initiation of a lower risk agent usually leads to resolution of symptoms. Desensitization protocols may be an option for patients whose seizures only respond to the AED causing the rash., (Copyright © 2019 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Allergic contact dermatitis is associated with significant disease and economic burden in the United States. To properly manage allergic contact dermatitis, it is important to accurately identify the substance(s) implicated in the dermatitis to prevent disease recurrence. The commercially available T.R.U.E Test (36 allergens) screening panel has been reported to have a conservative hypothetical allergen detection rate of 66.0%, at most. Importantly, these calculations are based on the 78% of patients who had clinically relevant reactions to allergens present on the North American Contact Dermatitis Group screening series (70 allergens), without the use of supplemental allergens. Testing with supplemental allergens beyond a screening series can more fully evaluate an individual's environmental and occupational exposure, which may significantly increase diagnostic accuracy. Comprehensive patch testing with additional allergens in sunscreens, cosmetics, and fragrances, for example, may increase the diagnostic yield as well as the likelihood of achieving a cure if the dermatitis is chronic and recalcitrant.

Background: Allergic contact dermatitis (ACD) remains a significant burden of disease in the United States. Patch testing is the criterion standard for diagnosing ACD, but its use may be limited by reimbursement challenges., Objective: This study aimed to assess the current rate of patch test utilization among dermatologists in academic, group, or private practice settings to understand different patch testing business models that address these reimbursement challenges., Methods: All members of the American Contact Dermatitis Society received an online survey regarding their experiences with patch testing and reimbursement., Results: A "yes" response was received from 28% of survey participants to the question, "Are you or have you been less inclined to administer patch tests or see patients needing patch tests due to challenges with receiving compensation for patch testing?" The most commonly reported barriers include inadequate insurance reimbursement and lack of departmental support., Conclusions: Compensation challenges to patch testing limit patient access to appropriate diagnosis and management of ACD. This can be addressed through a variety of innovative business models, including raising patch testing caps, negotiating relative value unit compensation, using a fixed salary model with directorship support from the hospital, and raising the percentages of collection reimbursement for physicians.

Background: The use of metal-containing bio-devices is becoming increasingly common. Self-reported history of dermatitis with metal exposure is not established as being predictive for metal allergy., Objectives: To assess the validity of two screening questions addressing metal allergy., Methods: At Massachusetts General Hospital Contact Dermatitis Clinic, 2132 consecutive patients were asked either 'Do you get rashes when jewellery touches your skin' (Q1; N = 1816) or 'Do you get rashes when metal touches your skin?' (Q2; N = 316) before being patch tested., Results: Testing showed that 20% of subjects had positive reactions to nickel, 7.4% had positive reactions to cobalt, and 5.8% had positive reactions to chromium. Q1 was 40% sensitive (95%CI: 35-45%). The positive predictive value (PPV) was 51%, and the negative predictive value (NPV) was 82%. Q2 was 77% sensitive (95%CI: 68-84%). The PPV was 71%, and the NPV was 84%. Q2 was 37% more sensitive than Q1 (p < 0.0001), with a higher relative risk (RR) (4.75, p < 0.001) than Q1 (RR = 3.01, p < 0.001)., Conclusions: Patient-reported metal allergy, although not perfect, is a reasonable method for metal allergy screening to help identify those needing further objective evaluation by patch testing., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Total hip and knee replacement surgery using metal alloy devices is common. Type IV allergic reactions to these implants occur, though infrequently. While uncommon, peri-implant metal allergic reactions may cause significant morbidity for the affected individual-including aseptic loosening, pseudotumor formation and frank device failure. It is challenging to predict who will have these reactions, even in those with established pre-implant metal allergy. At this time, the scientific literature clearly supports few conclusions. Despite this, we believe several conclusions can be made: routine pre-implant testing in asymptomatic individuals is not indicated; listen to patient's concerns about metal allergy if the concern arises; patch testing is probably the best pre- and post-implant screening test; post-implantation testing is controversial and even positive LTT or patch test does not definitively diagnose morbidity from a metal allergy; and complete recovery following revision placement of an immunologically inert device is diagnostic. More research is needed to scientifically approach this issue.

The American Contact Dermatitis Society Core Allergen Series was introduced in 2012. After 4 years of use, changes in our recommended allergens are necessary. For the updated series, we have reordered the first 4 panels to approximately mirror the current TRUE Test and removed parthenolide, triclosan, glutaraldehyde, and jasmine. Polymyxin B, lavender, sodium benzoate, ethylhexylglycerin, and benzoic acid are new additions to the American Contact Dermatitis Society series.

The American Contact Dermatitis Society recognizes the interest in the evaluation and management of metal hypersensitivity reactions. Given the paucity of robust evidence with which to guide our practices, we provide reasonable evidence and expert opinion-based guidelines for clinicians with regard to metal hypersensitivity reaction testing and patient management. Routine preoperative evaluation in individuals with no history of adverse cutaneous reactions to metals or history of previous implant-related adverse events is not necessary. Patients with a clear self-reported history of metal reactions should be evaluated by patch testing before device implant. Patch testing is only 1 element in the assessment of causation in those with postimplantation morbidity. Metal exposure from the implanted device can cause sensitization, but a positive metal test does not prove symptom causality. The decision to replace an implanted device must include an assessment of all clinical factors and a thorough risk-benefit analysis by the treating physician(s) and patient.

Background: The diagnosis of Lyme disease relies on the accurate diagnosis of erythema chronicum migrans (ECM) because serologic tests, culture, and polymerase chain reactions are often inaccurate. Although ECM is classically associated with a targetoid rash, there are many variants of this lesion. These variants of ECM are often initially diagnosed as cellulitis or spider bite reactions and treated with oral antibiotics. Inappropriate treatment further delays the diagnosis of Lyme disease, leading to late complications., Methods: We present four cases of vesiculobullous and hemorrhagic ECM, a less common variant of ECM., Results: All four patients had a history of exposure to wooded areas in Massachusetts during the summer months. In these patients, ECM presented with central vesicles and bullae with hemorrhage, crusting, and in some cases necrosis. Serologic testing was positive in three of the four cases at presentation. In one case, microscopic examination of a skin biopsy showed epidermal spongiosis with parakeratosis, focal necrosis, papillary dermal edema, erythrocyte extravasation, and a superficial and deep perivascular lymphocytic infiltrate with neutrophils and eosinophils of the dermis. No fungal organisms or bacteria were identified. All four patients were treated with doxycycline with complete resolution of symptoms., Conclusions: It is important to recognize the vesiculobullous and hemorrhagic variants of ECM in order to minimize the provision of inappropriate antibiotic treatment for other diagnoses. Early diagnosis of ECM and the initiation of appropriate antibiotics may prevent late complications of Lyme disease., (© 2015 The International Society of Dermatology.)

The use of metals in the medical field has become increasingly prevalent over the past few decades. Patients find themselves being exposed to metals in a variety of ways, ranging from external exposure to instruments such as the stainless steel in surgical blades to internal exposure via medical devices being implanted in their bodies. There has been growing interest in the possibility of developing hypersensitivity reactions to constituent metals in medical implant devices, both in cutaneous and systemic forms. Hypersensitivity reactions to metals are uncommon, but they are reported and require appropriate evaluation and management, particularly if they are symptomatic. In view of the lack of consensus in the field on the appropriate steps to evaluate and manage patients with suspected metal hypersensitivity reactions, this review aims to analyze current evidence on hypersensitivity reactions to metallic implants in orthopedic surgery, endovascular surgery, obstetrics and gynecology, and dental surgery.

Background: Psychological factors are known to significantly modulate itch in patients suffering from chronic itch. Itch is also highly susceptible to both placebo and nocebo (negative placebo) effects. Brain activity likely supports nocebo-induced itch, but is currently unknown., Methods: We collected functional MRI (fMRI) data from atopic dermatitis (AD) patients, in a within-subject design, and contrast brain response to nocebo saline understood to be allergen vs open-label saline control. Exploratory analyses compared results to real allergen itch response and placebo responsiveness, evaluated in the same patients., Results: Nocebo saline produced greater itch than open saline control (P < 0.01). Compared to open saline, nocebo saline demonstrated greater fMRI response in caudate, dorsolateral prefrontal cortex (dlPFC), and intraparietal sulcus (iPS) - brain regions important for cognitive executive and motivational processing. Exploratory analyses found that subjects with greater dlPFC and caudate activation to nocebo-induced itch also demonstrated greater dlPFC and caudate activation, respectively, for real allergen itch. Subjects reporting greater nocebo-induced itch also demonstrated greater placebo reduction of allergen-evoked itch, suggesting increased generalized modulation of itch perception., Conclusions: Our study demonstrates the capacity of nocebo saline to mimic both the sensory and neural effects of real allergens and provides an insight to the brain mechanisms supporting nocebo-induced itch in AD, thus aiding our understanding of the role that expectations and other psychological factors play in modulating itch perception in chronic itch patients., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Chronic itch, a highly debilitating condition, has received relatively little attention in the neuroimaging literature. Recent studies suggest that brain regions supporting itch in chronic itch patients encompass sensorimotor and salience networks, and corticostriatal circuits involved in motor preparation for scratching. However, how these different brain areas interact with one another in the context of itch is still unknown. We acquired BOLD fMRI scans in 14 atopic dermatitis patients to investigate resting-state functional connectivity before and after allergen-induced itch exacerbated the clinical itch perception in these patients. A seed-based analysis revealed decreased functional connectivity from baseline resting state to the evoked-itch state between several itch-related brain regions, particularly the insular and cingulate cortices and basal ganglia, where decreased connectivity was significantly correlated with increased levels of perceived itch. In contrast, evoked itch increased connectivity between key nodes of the frontoparietal control network (superior parietal lobule and dorsolateral prefrontal cortex), where higher increase in connectivity was correlated with a lesser increase in perceived itch, suggesting that greater interaction between nodes of this executive attention network serves to limit itch sensation via enhanced top-down regulation. Overall, our results provide the first evidence of itch-dependent changes in functional connectivity across multiple brain regions.

This review summarizes current evidence for acupuncture treatment of allergies. Several randomized controlled trials have demonstrated a specific effect of acupuncture for allergic rhinitis; while a few studies have shown positive effects for atopic dermatitis, asthma and itch. Specifically for allergic rhinitis and asthma, acupuncture may be cost-effective in terms of money spent per quality-of-life gained. Acupuncture plays an increasingly important role as an evidence-based therapy for allergy relief and can be recommended as adjunct therapy for allergic rhinitis. Future randomized controlled trials need to further explore acupuncture efficacy for the treatment of itch, atopic dermatitis and asthma. More experimental research is also needed to investigate mechanisms of action underlying acupuncture for allergy relief.

Itch is an aversive sensory experience and while systemic therapies, such as acupuncture, have shown promise in alleviating itch in patients suffering from chronic itch, their antipruritic mechanisms are unknown. As several lines of evidence implicate brain-focused mechanisms, we applied functional magnetic resonance imaging and our validated temperature-modulation itch model to evaluate the underlying brain circuitry supporting allergen-induced itch reduction in atopic dermatitis patients by acupuncture, antihistamine, and respective placebo treatments. Brain response to allergen itch demonstrated phase dependency. During an increasing itch phase, activation was localized in anterior insula and striatum, regions associated with salience/interoception and motivation processing. Once itch reached peak plateau, robust activation was noted in prefrontal cognitive and premotor areas. Acupuncture reduced itch and itch-evoked activation in the insula, putamen, and premotor and prefrontal cortical areas. Neither itch sensation nor itch-evoked brain response was altered following antihistamine or placebo acupuncture. Greater itch reduction following acupuncture was associated with greater reduction in putamen response, a region implicated in motivation and habitual behavior underlying the urge to scratch, specifically implicating this region in acupuncture's antipruritic effects. Understanding brain circuitry underlying itch reduction following acupuncture and related neuromodulatory therapies will significantly impact the development and applicability of novel therapies to reduce an itch.

Background: Cutaneous metal hypersensitivity reactions (MHR) are common but rare with implanted devices., Objectives: This study aimed to characterize the opinions of dermatologists who are actively evaluating/advising patients with MHR., Methods: A questionnaire was distributed to all individuals who attended the European Society of Contact Dermatitis (ESCD) 2012 and the American Contact Dermatitis Society 2013 meetings., Results: A total of 119 individuals responded with a participation rates of 10% (ESCD) and 32% (American Contact Dermatitis Society). Ninety-six percent of the respondents evaluate MHR and 91% were attending physicians. Orthopedic and dental devices were common problems compared with cardiovascular devices. Patch testing is the top choice for evaluating MHR. Lymphocyte transformation and intradermal tests are rarely used. Eighty-two percent of the respondents evaluate plastic/glue components in symptomatic patients postimplant. Most dermatologists use a tray specifically for joint allergy or a history-based custom array of allergens. Those patients with a strong clinical history of metal allergy should be evaluated before metal implantation (54%), whereas others forgo evaluation and recommend a titanium implant based on history alone (38%). Diagnostic criteria for postimplant reactions were evaluated. Eight percent of the respondents felt that no evaluation was necessary, with ESCD respondents being significantly more likely to not recommend evaluation (P = 0.001)., Conclusions: Metal hypersensitivity reactions consultation requests are common for preimplant and postimplant issues. Patch testing is currently the best test for MHR.

Background: Metal hypersensitivity reactions to implanted devices remain a challenging and controversial topic. Diagnostic criteria and methods are not well delineated., Objective: Diagnostic criteria for hypersensitivity reactions after metallic device implantation are evaluated in this study by a multinational group of patch testers using Thyssen's previously published criteria., Methods: A total of 119 dermatologists at the 2012 European Contact Dermatitis Society and 2013 American Contact Dermatitis Society meetings answered a survey regarding their opinions on topics relating to metal hypersensitivity., Conclusions: Four major and 5 minor diagnostic criteria emerged. Approximately 80% of respondents found the following criteria useful (major criteria): chronic dermatitis beginning weeks to months after metallic implantation, eruption overlying the metal implant, positive patch test to a metal component of the implant, and complete clearing after removal of the potentially allergenic implant. Minor criteria (<61% of respondents) were as follows: systemic allergic dermatitis reaction, therapy-resistant dermatitis, morphology consistent with dermatitis, histology consistent with allergic contact dermatitis, and a positive in vitro test to metals (eg, lymphocyte transformation test). In the challenging situation such as a symptomatic or failing orthopedic device, applying these 4 major criteria and the 5 supportive minor criteria may be useful for guiding decision making.

Evaluating patients with potential metal hypersensitivity reactions is challenging. Clear evidence-based guidelines based on randomized studies are lacking. A pragmatic approach to evaluation of these patients is useful due to this lack of evidence. Patch testing remains the gold standard for evaluating type IV reactions on the skin and is also likely the best test for metal reactions to implanted devices until more hard data is available.

Complementary and alternative medicine (CAM) is a conservative and increasingly popular approach to treat pruritus for both patients and medical providers. CAM includes natural products, mind-body medicine, and manipulative and body-based practices. In this overview, we summarize current evidence, possible mechanisms and clinical approaches for treating pruritus with CAM techniques. We focus on pruritus associated with atopic dermatitis, herpes zoster, chronic urticaria, burns, and postoperative contexts where the evidence for CAM approaches is promising., (© 2013 Wiley Periodicals, Inc.)

Evidence for the effectiveness of patch testing and the need for an expanded series that provides experience and evidence-based suggestions for an extended patch testing series are examined in this review. Many of those testing with shorter allergen series are interested in expanding the spectrum of patch testing. The American Contact Dermatitis Society (ACDS) Core Allergen Series Group has arranged a group of suggested allergen groups that can be logically scaled up or down depending on the needs of the patch tester and the community being tested. This is not an "ACDS 80 Standard." We suggest a core group of allergens similar to the TRUE Test (SmartPractice, Phoenix, Ariz) with subsequent trays providing a greater breadth of coverage in a logical fashion, with more likely allergens being higher in the tray. For more extensive testing, specialty trays (ie, cosmetics, metals, plant, etc) are recommended.

Background: Itch is the major symptom of atopic dermatitis (AD). Acupuncture has been shown to exhibit a significant effect on experimental itch in AD. Our study evaluated acupuncture and antihistamine itch therapy (cetirizine) on type I hypersensitivity itch and skin reaction in AD using a patient and examiner-blinded, randomized, placebo-controlled, crossover trial., Methods: Allergen-induced itch was evaluated in 20 patients with AD after several interventions in separate sessions: preventive (preceding) and abortive (concurrent) verum acupuncture (VAp and VAa), cetirizine (10 mg, VC), corresponding placebo interventions (preventive, PAp, and abortive, PAa, placebo acupuncture; placebo cetirizine pill, PC) and a no-intervention control (NI). Itch was induced on the forearm and temperature modulated over 20 min, using our validated model. Outcome parameters included itch intensity, wheal and flare size and the D2 attention test., Results: Mean itch intensity (SE: 0.31 each) was significantly lower following VAa (31.9) compared with all other groups (PAa: 36.5; VC: 36.8; VAp: 37.6; PC: 39.8; PAp: 39.9; NI: 45.7; P < 0.05). There was no significant difference between VAp and VC (P > 0.1), although both therapies were significantly superior to their respective placebo interventions (P < 0.05). Flare size following VAp was significantly smaller (P = 0.034) than that following PAp. D2 attention test score was significantly lower following VC compared with all other groups (P < 0.001)., Conclusions: Both VA and cetirizine significantly reduced type I hypersensitivity itch in patients with AD, compared with both placebo and NI. Timing of acupuncture application was important, as VAa had the most significant effect on itch, potentially because of counter-irritation and/or distraction. Itch reduction following cetirizine coincided with reduced attention., (© 2012 John Wiley & Sons A/S.)

Cutaneous and systemic hypersensitivity reactions to implanted metals are challenging to evaluate and treat. Although they are uncommon, they do exist, and require appropriate and complete evaluation. This review summarizes the evidence regarding evaluation tools, especially patch and lymphocyte transformation tests, for hypersensitivity reactions to implanted metal devices. Patch test evaluation is the gold standard for metal hypersensitivity, although the results may be subjective. Regarding pre-implant testing, those patients with a reported history of metal dermatitis should be evaluated by patch testing. Those without a history of dermatitis should not be tested unless considerable concern exists. Regarding post-implant testing, a subset of patients with metal hypersensitivity may develop cutaneous or systemic reactions to implanted metals following implant. For symptomatic patients, a diagnostic algorithm to guide the selection of screening allergen series for patch testing is provided. At a minimum, an extended baseline screening series and metal screening is necessary. Static and dynamic orthopaedic implants, intravascular stent devices, implanted defibrillators and dental and gynaecological devices are considered. Basic management suggestions are provided. Our goal is to provide a comprehensive reference for use by those evaluating suspected cutaneous and systemic metal hypersensitivity reactions., (© 2011 John Wiley & Sons A/S.)

Allergic complications following insertion of metallic orthopaedic implants include allergic dermatitis reactions but also extracutaneous complications. As metal-allergic patients and/or surgeons may ask dermatologists and allergologists for advice prior to planned orthopaedic implant surgery, and as surgeons may refer patients with complications following total joint arthroplasty for diagnostic work-up, there is a continuous need for updated guidelines. This review presents published evidence for patch testing prior to surgery and proposes tentative diagnostic criteria which clinicians can rely on in the work-up of patients with putative allergic complications following surgery. Few studies have investigated whether subjects with metal contact allergy have increased risk of developing complications following orthopaedic implant insertion. Metal allergy might in a minority increase the risk of complications caused by a delayed-type hypersensitivity reaction. At present, we do not know how to identify the subgroups of metal contact allergic patients with a potentially increased risk of complications following insertion of a metal implant. We recommend that clinicians should refrain from routine patch testing prior to surgery unless the patient has already had implant surgery with complications suspected to be allergic or has a history of clinical metal intolerance of sufficient magnitude to be of concern to the patient or a health provider. The clinical work-up of a patient suspected of having an allergic reaction to a metal implant should include patch testing and possibly in vitro testing. We propose diagnostic criteria for allergic dermatitis reactions as well as noneczematous complications caused by metal implants., (© 2011 The Authors. BJD © 2011 British Association of Dermatologists.)

Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. The first case of a dermatitis reaction over a stainless steel fracture plate was described in 1966. Most skin reactions are eczematous and allergic in nature, although urticarial, bullous, and vasculitic eruptions may occur. Also, more complex immune reactions may develop around the implants, resulting in pain, inflammation, and loosening. Nickel, cobalt, and chromium are the three most common metals that elicit both cutaneous and extracutaneous allergic reactions from chronic internal exposure. However, other metal ions as well as bone cement components can cause such hypersensitivity reactions. To complicate things, patients may also develop delayed-type hypersensitivity reactions to metals (ie, in-stent restenosis, prosthesis loosening, inflammation, pain, or allergic contact dermatitis) following the insertion of intravascular stents, dental implants, cardiac pacemakers, or implanted gynecologic devices. Despite repeated attempts by researchers and clinicians to further understand this difficult area of medicine, the association between metal sensitivity and cutaneous allergic reactions remains to be fully understood. This review provides an update of the current knowledge in this field and should be valuable to health care providers who manage patients with conditions related to this field.

Background: many topical products are used in the genital region. Allergic contact dermatitis (ACD) may develop from product use or due to treatment of an underlying dermatosis., Objectives: our goal was to identify the frequency of ACD and identify top allergens in the genital region., Methods: data were analyzed for 1,238 patients tested between January 1990 and December 2006. Fifteen allergens caused reactions at rates greater than 1%. Thirteen anatomic regions were assessed. Statistical analyses were by chi-square test and Fisher exact test. Adjusted level of significance due to multiple testing was α  =  .002., Results: of individuals with genital dermatitis (n  =  37; aged 24-77 years, 48.6% female), 41% (15 of 37) had at least one positive patch-test result although only 30% (11 of 37) had a final diagnosis of relevant ACD. Mean age was 46 years for males and 41 years for females. The top five allergens were balsam of Peru (10.8%), fragrance mix I (8.1%), tolu balsam (8.1%), phenylmercuric acetate (8.1%), and neomycin (5.4%). Females were more often allergic (50%) compared to males (37%); 59.5% of patients had no positive reactions., Conclusion: genital dermatitis is rare; the minority tested positively for ACD. The top five allergens were present in toiletries and cosmetics used on genital skin. The top three allergens are fragrance related, underscoring the importance of using fragrance-free products on mucosal skin.

Purpose: To identify frequency and pattern of contact sensitization among patients with periorbital dermatitis., Design: Cross-sectional retrospective investigation of 1247 patients referred for patch testing over a 17-year period., Methods: Data were collected for patients undergoing patch testing to the standard and customized trays between January 1990 and December 2006 at the Massachusetts General Hospital, Contact Dermatitis Clinic. Our study group consisted of 266 patients affected by periorbital dermatitis. Findings were compared to 981 referrals without periorbital dermatitis (controls). Patch test results were read after 48 and 72 hours and classified as allergic, questionable, irritant, or negative. Statistical analyses were carried out by using chi(2) test and Fisher exact test., Results: General epidemiologic data among periorbital dermatitis patients showed significant predominance of female gender (87.6%) and of individuals aged 40 to 59 years (45.9%). Nickel (16.5%) and fragrance mix (13.2%) were the top-ranking sensitizers. Ingredients of topical ophthalmologic products did not result in significant sensitization. Comparison of the periorbital dermatitis group to the controls did not reveal significant differences in sensitization pattern. Patch testing confirmed the likelihood of allergic contact dermatitis in 50.8% of the periorbital dermatitis patients tested., Conclusions: Allergic contact dermatitis is a common cause of periorbital dermatitis. Patch testing should be considered in all patients with periorbital dermatitis when suspecting contact allergy in order to identify and avoid offending allergens., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: Allergic contact sensitization may occur at any age, showing specific rates of sensitization and allergen frequency related to periods of life., Objective: To describe sensitization rates of specific allergens with respect to age distribution in adults in a cross-sectional study., Methods: Data of 713 patients referred for patch testing at the Massachusetts General Hospital Contact Dermatitis Clinic were analyzed. Testing was conducted with baseline (29 allergens) and customized series between January 1996 and December 2006., Results: Although trends were noted, there was no statistically significant difference with respect to rate of sensitization or number of positive allergens in the various age groups. Fragrance mix and nickel sulfate were the most common allergens through all age groups. In older age groups, a statistically significant higher sensitization rate was shown for fragrance mix (p = .005) and balsam of Peru (p < .005) whereas the rate for nickel was lower (p = .002)., Conclusions: For specific allergens such as nickel and fragrances, significant variations occur in different stages of life. Even with these variations, we found that the overall rates of positive patch-test reactions were similar in the three age groups evaluated.

Background: The diagnostic tool to detect allergic contact sensitization is patch testing., Objective: Results of patch testing performed from January 1998 to December 2006 at the Massachusetts General Hospital (MGH) are analyzed and compared to our 1990-1997 data as well as to data from North American and European contact dermatitis societies., Methods: Data were collected from retrospective chart reviews and analyzed, focusing on the Hermal standard tray., Results: The most common sensitizers were fragrance mix (18.3%) and nickel (16.7%). Significant increases over time were seen for balsam of Peru (p < .0005; CI, 1.34-2.76) and wool alcohols (p = .002; CI, 1.38-4.38) while gender-related statistical predominance was seen for nickel in females (p < .0005; CI, 2.92-8.20) and for epoxy resin in males (p < .0005; CI, 0.14-0.58). Our findings are similar to those of the North American and European contact dermatitis societies. The retrospective study sample was drawn from a selected group of referred patients that may not be representative of the general population. Analysis of data focused on the Hermal standard tray and might not reflect trends resulting from additional allergens in supplemental trays., Conclusion: Sensitization rates and the most important allergens at MGH have been stable over the past 17 years.

Lichen-derived additives to commercial products are becoming a more frequent cause of allergic contact dermatitis. The most common lichen-derived additives are usnic acid and oak moss absolute. Both are useful for screening patients using "natural" or "botanical" products that may contain lichen-derived additives.

Background: Grenz ray therapy (GRT) has been used to treat dermatoses refractory to other therapy. Patient's assessments to GRT alone have not been previously reported., Objective: (1) To report the patterns of use of GRT at our center over a 10-year period and evaluate the efficacy of GRT in treating recalcitrant skin conditions, (2) to evaluate patient perceptions about GRT, and (3) to evaluate whether patients felt this form of treatment was worthwhile., Method: Cross-sectional survey by mailed questionnaire to patients treated with GRT from 1990 to 2001., Results: Of 351 patients treated with GRT from 1990 to 2001, 98 (28%) returned the questionnaire; 64% reported decreased severity or clearing of disease (p = .003), and 63% reported decreased or no discomfort (p = .006) 3 months following treatment. Overall, 54% said GRT was worthwhile, and 53% would choose it again; 40% reported mild side effects. Number of treatments (p = .2) or total dose (p = .25) were not significantly different among responders to GRT and nonresponders to GRT. In a subgroup of treated patients with a diagnosis of contact dermatitis (94% with hand dermatitis), 64% felt GRT was worthwhile and 77% indicated that they would choose this therapy again if needed., Conclusions: Many patients treated with GRT for recalcitrant dermatitis reported that this treatment was an effective therapy in decreasing the discomfort and severity of their skin condition. Overall, just more than half of treated patients believed GRT was a worthwhile therapy that they would use again.

Erlotinib is a reversible inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase (TK) newly approved for the treatment of refractory, locally advanced, or metastatic nonsmall cell lung cancer. Acneiform skin reactions with EGFR inhibitors are common, with a dose-dependent skin reaction being seen in 50 to 100% of patients. This case illustrates the typical skin reaction seen with EGFR-TK inhibitors and illustrates the lack of reaction in skin with sebaceous glands that have been destroyed by radiation. Discussion of this skin reaction in the literature of dermatology is limited; this case illustrates a pattern of reaction that may suggest a mechanism for this skin reaction pattern to erlotinib.

Occupational skin disease (OSD) is an important and costly problem within occupational medicine. Ten to 15% of all occupational illness is caused by skin disease with contact dermatitis being the cause of up to 95% of all OSD. While irritant contact dermatitis is the most frequent cause of OSD, allergic contact dermatitis (ACD) is an important cause of chronic skin disease. In this chapter, various methods of protecting a worker from work-related allergy, including immediate and delayed-type hypersensitivities, are considered and reviewed. Concepts such as elimination of harmful exposures and allergen identification are considered. Personal protective equipment is an important component of prevention, including barrier creams, gloves and protective clothing. Methods for preventing allergy are discussed including prevention of sensitization, prevention of skin barrier breakdown, postexposure skin care and the role of educational programs. Protecting a worker from initial sensitization is the primary goal in prevention, but this is challenging considering the small amounts of an allergen needed to initiate and potentiate dermatitis. Patients diagnosed as having ACD can have symptoms that are more persistent, despite accurate diagnosis and therapy. With the high prevalence of contact dermatitis in the occupational setting, prevention is a key to healthy skin.

Mycoplasma pneumoniae is an important and highly relevant cause of bullous erythema multiforme, isolated mucositis, and Stevens-Johnson syndrome in children. In this article, we present two children with respiratory Mycoplasma pneumoniae infection and associated cutaneous findings within the spectrum of erythema multiforme. We review the literature associating these three entities with Mycoplasma pneumoniae infection and discuss controversies regarding the classification of erythema multiforme, as well as update reported infectious causes of the bullous form. Many understand the erythema multiforme spectrum to include bullous erythema multiforme, mucositis, and Stevens-Johnson syndrome in the order of increasing severity. We feel that this relationship should be reconsidered to help better understand the prognosis and outcomes. It is our opinion that bullous erythema multiforme is a separate, yet related condition that can occur in the context of Mycoplasma pneumoniae infection. With many similarities to mucositis and Stevens-Johnson syndrome, bullous erythema multiforme can be considered part of a spectrum of disease that includes Stevens-Johnson syndrome. Unlike mucositis and Stevens-Johnson syndrome, bullous erythema multiforme caused by Mycoplasma pneumoniae infection has low morbidity for the child. Mycoplasma pneumoniae-associated mucositis and Stevens-Johnson syndrome seem to occur along a spectrum with separate prognosis and potential pathogenesis compared with bullous erythema multiforme. Making the distinction between these conditions is valuable for predicting the child's prognosis. Patients who develop symptoms consistent with these conditions should be appropriately evaluated for Mycoplasma pneumoniae infection and closely monitored.

Bacitracin is an antibiotic widely used by both the medical profession and the general public. It is most commonly found in a variety of topical ointments and creams used after surgical procedures, for acute skin injuries, and for chronic wounds. The incidence of allergy to this agent has been increasing over the last 10 years, probably because of more frequent use. This article reviews basic information about bacitracin as an allergen, including sources of exposure, chemical composition, types of allergic reactions, and patch testing.