Patch Test Negative Generalized Dermatitis

Patch testing: Uses, systems, risks/benefits, and its role in managing the patient with contact dermatitis

Patch testing is the gold standard diagnostic tool for cell-mediated type IV hypersensitivity reactions like allergic contact dermatitis. Sensitized individuals have primed antigen-specific T lymphocytes that cause a reaction when antigens are applied to the skin owing to prior sensitization. Patch testing can be used in the adult and pediatric populations, but it is contraindicated in patients with a known history of severe allergic reactions to suspected allergens, generalized active dermatitis, or extensive eczema. Patch test systems can be a comprehensive panel (70-80 allergens), but they can also be targeted and limited to a more common allergen series (35 allergens). The decision for allergen selection should be based on an accurate patient history, physical examination, and availability of allergens. Measurement and interpretation of the test results requires training and experience, as well as consideration of relevance and clinical history. Patch testing is generally considered safe with just a few known complications: excited skin syndrome, active sensitization, and rarely anaphylaxis or other cutaneous complications. Appropriately pretesting patient education can help to mitigate some of these complications. Based on patch testing results, patients should be educated regarding proper allergen avoidance measures to resolve symptoms of allergic contact dermatitis.

Achillea Species as Sources of Active Phytochemicals for Dermatological and Cosmetic Applications

Achillea spp. is well known for its broad range of applications and long history of use in traditional medicine around the world. Health benefits of Achillea extracts result from the multitude of secondary metabolites identified in the plants from this genus that include flavonoids, phenolic acids, terpenes, guaianolides, phytosterols, fatty acids, and organic acids. The properties of several Achillea extracts meet also the expectations of a vividly developing cosmetic market. An increasing number of studies on the dermatological properties of Achillea spp. are observed in the recent years, with Achillea millefolium L. being the most studied and used representative of the genus. There is strong scientific evidence showing that also other yarrow species might be rich sources of effective cosmetic ingredients, with skin calming and rejuvenating properties, wound healing activity, and anti-inflammatory potential. Several Achillea extracts and isolated compounds were also shown to display significant tyrosinase inhibitory, antioxidant, and antimicrobial properties and thus are interesting candidates for active ingredients of medications and cosmetic products protecting the skin from the harmful impact of environmental stressors. The aim of this review is to collect the current information on the composition and cosmeceutical significance of different Achillea species.

A diagnostic checklist for generalized dermatitis

Purpose

Generalized dermatitis (defined as histological spongiotic dermatitis affecting more than three anatomical areas of the skin surface) has many potential causes that mimic atopic dermatitis and contact dermatitis. If a treatable cause is missed, the patient may be treated with chronic immunosuppressive therapy that carries more risk than specific treatment for a disease mimicking dermatitis. Checklists have been shown to improve patient safety, primarily in procedural contexts. This work assessed the utility of a diagnostic checklist for subacute and chronic generalized dermatitis in patients who had not improved after at least 1 month of avoidance of contact allergens identified by comprehensive patch testing, if indicated.

Patients and methods

Designed as a quality improvement project using Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, a diagnostic checklist was used by the principal investigator for 1 year in a tertiary referral dermatitis clinic for patients without a confirmed cause for the dermatitis after two to three visits with the investigator. All patients had had diagnostic patch testing if indicated. Almost all had undergone skin biopsy by their referring provider. Fifteen patients met the criteria for inclusion in this study. Outcome measures included provider and patient perception of efficiency and/or confusion caused by the checklist. Length of time from the initiation of use of the checklist to final diagnosis was recorded. Additional diagnoses considered that were not included in the initial checklist were added to the checklist during the course of the study.

Results

The checklist was useful in improving diagnostic efficiency (prompting consideration of diagnoses not otherwise considered upon initiation of the visit that resulted in a final plan of care) in these complex cases of recalcitrant dermatitis. Open utilization of the checklist by the investigator during the clinical encounter was well accepted by patients and families.

Conclusion

Checklists can be useful for complex cognitive diagnostic work.

IRB approval status

University Hospitals Cleveland Medical Center Institutional Review Board # 11-15-34.

Associated factors of widespread pattern of dermatitis among patch test population: 12-Year retrospective study

BACKGROUND/OBJECTIVE

Widespread dermatitis is often associated with diagnostic and therapeutic challenges. Multiple factors influence this widespread pattern of dermatitis. We aim to study the associated factors in patch-tested patients who presented with widespread pattern of dermatitis.

METHOD

This retrospective, case-control study was conducted on patients with dermatitis who were patch tested during January 2005 to December 2016. The demographic data, patient and family histories, diagnoses, and patch test findings were recorded and analyzed.

RESULTS

Of the 3201 included patients, 645 (20.2%) had widespread pattern of dermatitis. Being male, age >60, and history of either atopic dermatitis (AD) or metal allergy were significantly associated with the widespread dermatitis pattern. A multivariate analysis demonstrated that preservatives were the significant offending allergens, especially methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), and methylisothiazolinone (MI) alone.

CONCLUSION

Widespread pattern of dermatitis is associated with gender, age, underlying atopic dermatitis and a history of metal allergy. Preservatives are the significant offending allergens of widespread dermatitis, especially MCI/MI, and MI alone. A thorough history taking and patch testing, including preservatives, are necessary to determine the cause of widespread pattern of dermatitis.