A high prevalence of sensitization still persists in leg ulcer patients: a retrospective series of 106 patients tested between 2001 and 2002 and a meta-analysis of 1975-2003 data

Potential Allergens in Wound Care Products

Background: Patients with chronic wounds have an increased risk of developing allergic contact dermatitis (ACD). Reports of ACD to wound care products are not uncommon. To minimize contact sensitization in patients with chronic wounds, allergenic ingredients should be avoided when possible. Objective: With more than 5000 wound care products available in the United States, it is essential to understand which products can be chosen to minimize allergen exposures. Methods: Ingredients in wound care products in 5 wound care clinics across 2 institutions were cross-referenced with the American Contact Dermatitis Society core allergen series 2020. Results: Of the 267 wound care products included, 97 (36.3%) contained at least one allergen, including 31 dressings/wraps (22.3%), 25 medications (69.4%), 12 cleaning supplies (36.3%), 16 tapes/glues (80%), 2 instruments (14.3%), 8 emollients and vehicles (61.5%), 1 ostomy product (11.1%), and 2 odor-eliminating products (66.7%). Thirty-four different allergens were identified across all products. The most common allergens present in the included items were acrylates and propylene glycol, followed by parabens, cetyl stearyl alcohol, tocopherol, fragrance, and phenoxyethanol. Conclusions: Many wound care products contain at least one contact allergen, highlighting the importance of clinician education on ACD in the context of wound care product selection.

Lanolin

Lanolin is a complex mixture of high molecular weight esters, aliphatic alcohols, sterols, fatty acids, and hydrocarbons that has been widely used for centuries for its emollient properties. The purification of crude lanolin into lanolin wax and the processing of this wax into various derivatives began in 1882 and continue to this day with newer highly purified anhydrous lanolins. Controversy as to lanolin's allergenicity began in the 1920s and remains an issue. The most appropriate patch test preparation(s) for detecting allergy remain disputed. Detection of lanolin-induced contact dermatitis in diseased skin by patch testing on normal skin may lead to false negative results. Patients with a positive patch test to lanolin may tolerate use of lanolin on normal skin. Although lanolin is a weak sensitizer and the frequency of contact allergy to it in the European population reportedly is 0.4%, there are high-risk concomitant conditions: stasis dermatitis, leg ulcers, perianal/genital dermatitis, and atopic dermatitis (AD). Children and the elderly are also at greater risk of developing contact allergy to lanolin, partly because of comorbidities (AD and stasis dermatitis/leg ulcers, respectively). Finally, in the United States, non-Hispanic white patients are more likely than their non-Hispanic black counterparts to be lanolin allergic.

Potential Allergens in Wound Care Products

BACKGROUND

Patients with chronic wounds have an increased risk of developing allergic contact dermatitis (ACD). Reports of ACD to wound care products are not uncommon. To minimize contact sensitization in patients with chronic wounds, allergenic ingredients should be avoided when possible.

OBJECTIVE

With more than 5000 wound care products available in the United States, it is essential to understand which products can be chosen to minimize allergen exposures.

METHODS

Ingredients in wound care products in 5 wound care clinics across 2 institutions were cross-referenced with the American Contact Dermatitis Society core allergen series 2020.

RESULTS

Of the 267 wound care products included, 97 (36.3%) contained at least one allergen, including 31 dressings/wraps (22.3%), 25 medications (69.4%), 12 cleaning supplies (36.3%), 16 tapes/glues (80%), 2 instruments (14.3%), 8 emollients and vehicles (61.5%), 1 ostomy product (11.1%), and 2 odor-eliminating products (66.7%). Thirty-four different allergens were identified across all products. The most common allergens present in the included items were acrylates and propylene glycol, followed by parabens, cetyl stearyl alcohol, tocopherol, fragrance, and phenoxyethanol.

CONCLUSIONS

Many wound care products contain at least one contact allergen, highlighting the importance of clinician education on ACD in the context of wound care product selection.

Lanolin Allergic Reactions: North American Contact Dermatitis Group Experience, 2001 to 2018

BACKGROUND

Lanolin is an important cause of allergic contact dermatitis.

OBJECTIVES

The aims of this study were to describe the epidemiology of lanolin allergy and to assess trends in patch test reactions to lanolin over time.

METHODS

This study used a retrospective analysis of patients patch tested with lanolin alcohol 30% or Amerchol L-101 50% in petrolatum by the North American Contact Dermatitis Group between 2001 and 2018 (n = 43,691).

RESULTS

Overall, 1431 (3.3%) had a positive reaction, and 1238 (2.8%) were currently relevant. Prevalence of lanolin allergy was 4.63% between 2011 and 2018 (P < 0.0001). Most lanolin-allergic patients had + (52%) reactions; 18%, and 6% had ++ and +++ reactions, respectively. Common primary anatomic sites of dermatitis were the hands (20.7%), scattered/generalized distribution (19.6%), and face (17.0%). Allergic reactions to lanolin were more common in children (4.5%) than in adults (3.2%, P = 0.0018). Compared with nonallergic patients, lanolin-allergic patients were more likely to have history of eczema or hay fever, male sex, older than 40 years, or Black race (P < 0.05). Common lanolin sources were personal care products and drugs/medications. Only 2.24% of the positive reactions were linked to occupation.

CONCLUSIONS

Lanolin sensitivity was common. Reactions were often clinically relevant and linked to personal care products and medications.

Prevalence and trend of allergen sensitization in patients with a diagnosis of stasis dermatitis referred for patch testing, North American contact dermatitis group data, 2001-2016

BACKGROUND

Few studies explored the relationship between stasis dermatitis (SD) and allergic contact dermatitis (ACD).

OBJECTIVE

To examine trends, associations, and clinical relevance of ACD in patients referred for patch testing who had a final SD diagnosis.

METHODS

Retrospective analysis from 2001 to 2016 of 38,723 patients from the North American Contact Dermatitis Group.

RESULTS

After patch testing, 303 (0.7%) patients were diagnosed with SD; 46.7% had a concomitant diagnosis of ACD. Patients with vs. without a final SD diagnosis had similar proportions of ≥ 1 positive allergic reaction (59.7% vs. 64.7%; Chi-square, P = 0.0724) but higher odds of allergic reactions to fragrance mix I, bacitracin, quaternium-15, Myroxylon pereirae, benzalkonium chloride, ethyleneurea melamine formaldehyde, diazolidinyl urea, and propylene glycol. The most commonly relevant allergens in patients with final SD diagnosis were fragrance mix I, Myroxylon pereirae, bacitracin, quaternium-15, and formaldehyde. The most common allergen sources were personal care products, topical medications and other health aid products.

CONCLUSION

Nearly half of patients with a final SD diagnosis were also diagnosed with ACD, supporting the role of patch testing in select SD patients.

Contact dermatitis: An important consideration in leg ulcers

The prevalence of chronic wounds is increasing with the aging population, with 1% to 2% of the worldwide population experiencing leg ulcers and positive patch tests reported in up to 75% of this population. With the introduction of modern dressings and compression therapies, clinicians should be cognizant of the potential risk of contact dermatitis in patients with leg ulcers. Contact dermatitis (both allergic and irritant) to wound products may present as maceration, pain, and overall impaired wound healing. Herein, we review the literature on contact dermatitis to wound-care products.

Allergic contact versus irritant contact dermatitis in patients with hard-to-heal leg ulcer: clinical and diagnostic approach

BACKGROUND

Dermatitis of surrounding skin may complicate hard-to-heal leg ulcers, delaying wound healing. The coexistence of hard-to-heal leg ulcers and irritant or allergic contact dermatitis may create difficulties for both diagnostic and therapeutic management.

OBJECTIVE

The aim of our study was to evaluate the incidence of dermatitis occurring in the surrounding skin in a population affected by hard-to-heal leg ulcers during treatment, and to differentiate between allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) with the use of a patch test. Furthermore, we investigated which medications were most probably related to these conditions.

METHOD

We conducted an observational study from 21 February to 21 July 2017, enlisting all patients affected by hard-to-heal leg ulcers who attended the Wound Care Service of the Dermatologic Department of ASST, Spedali Civili, Brescia, Italy.

RESULTS

We enrolled 95 patients; 81 patients did not develop dermatitis, while 14 patients developed dermatitis of the surrounding skin. These patients underwent a patch test which gave a positive result in seven patients, permitting the diagnosis of ACD.

CONCLUSION

Our study confirmed the incidence of dermatitis of the surrounding skin reported in the literature but reassessed the incidence of ACD as opposed to ICD.

A comparison of hospital-acquired pressure injuries in intensive care and non-intensive care units: a multifaceted quality improvement initiative

Hospital-acquired pressure injuries (HAPI) are a significant cause of morbidity and mortality, and represent a major health concern worldwide. Patients suffering from HAPI report a poor quality of life on several dimensions of health. Moreover, HAPI is reported to lengthen in-hospital stay in the acute setting, posing significant healthcare resource utilisations and costs. Given the clinical and economic burden of HAPI, recent best practice guidelines provide recommendations to reduce the prevalence of pressure injuries. Humber River Hospital (HRH), a large community hospital in Toronto, Canada, has a daily census of approximately 500 patients. The aim of this project was to reduce the prevalence of HAPI within the intensive care unit (ICU) and non-ICU setting at HRH within a 1-year period. Using the International Pressure Injury/Ulcer Prevalence (IPUP) Survey we established a baseline prevalence of HAPI of 27.6% (n=315) for non-ICU and 30% for ICU (n=33) patients at our institution in 2015. Using the Plan-Do-Study-Act (PDSA) method for quality improvement, we implemented a multifaceted approach aimed at improving equipment, digital documentation and education on risk assessment, prevention and treatment strategies. Over multiple PDSA cycles, our prevalence of HAPI reduced to 16% for non-ICU patients with no changes to the HAPI prevalence in ICU patients in 2016. Sustainability continues with HAPI prevalence currently at 10% in 2017 for non-ICU patients, which outperforms the Canadian prevalence (13.7%) by census size for 2017. However, the prevalence of HAPI in the ICU increased to 45% in 2017 despite multiple quality improvement initiatives, suggesting critically ill patients represent a unique challenge for reducing HAPI for these patients at our institution.

[Frequency of contact sensitization to modern dressings used to treat chronic leg ulcer]

INTRODUCTION

Allergic contact dermatitis around chronic leg ulcers (CLU) is a common complication in patients presenting CLU and prolongs healing times. The aim of this study was to describe the rate of sensitization to modern dressings (MD) used in these patients and to assess whether there is a relation between the number of sensitizations and ulcer type, the time from onset of the ulcer, and patient age and gender.

PATIENTS AND METHODS

We conducted a retrospective study at Reims University Hospital between 2010 and 2014 that included all patients with CLU of vascular etiology surrounded by eczematous lesions, and who had one of the patch-tests in the following 3 series: European baseline±leg ulcers±corticosteroids.

RESULTS

Among the 73 patients included, 43 % were polysensitized. Thirty-three patients (45 %) were sensitized to MD (38 % to hydrocolloids, 18 % to hydrogels, 7 % to hydrocellular dressings, 7 % to hydrofiber dressings, 5 % to contact layers and 3 % to alginates). Median age and sex did not differ between "polysensitized" patients and "non-polysensitized" patients (P=0.84 and P=0.25, respectively). Polysensitization was more frequent among patients presenting ulcers for more than 5 years (P=0.032).

CONCLUSION

Practically half of all patients presenting CLU with surrounding contact dermatitis had sensitization to modern dressings (mostly hydrocolloids and hydrogels). The rate of sensitization increased with the length of presence of CLU.

Contact sensitivity in patients with venous leg ulcer: A multi-centric Indian study

Venous leg ulcers are the most common form of non-healing leg ulcers. They are subjected to treatments such as topical medications, dressings, and compression therapies. This can lead to exposure to a number of allergens with subsequent sensitisation and contact dermatitis of the regional skin. This may contribute to the poor ulcer healing. To detect the various contact sensitisers in patients with venous leg ulcers through patch testing, patients from 6 centres across India with venous leg ulcers of longer than 6 weeks duration were enrolled for the study. They were patch tested using a special parch test kit with 27 antigens. A total of 172 patients were included in the study; 82 (48.2%) tested positive for at least 1 antigen. Among them, polyvalent sensitisation was noted in 71% of patients. Wood tar mix (10.4%) and the framycetin (8.7%) were the most common allergens. There is a high frequency of allergic sensitisation to various ingredients of topical therapies used in the venous ulcer management, which may interfere with wound healing. Avoiding them can help obtain a better therapeutic outcome.

Vascular diseases in the mature patient

Aging results in both anatomic and physiologic changes in the skin's structure and vascular system. These vascular changes result in a wide array of dermatologic findings, ranging from the benign to the highly morbid. Herein, we review the impact of both intrinsic and common extrinsic factors of aging on cutaneous vasculature and highlight the manifestations of microvascular, venous, arterial, lymphatic, and neuropathic alterations in the geriatric population.

Compression therapy - current practice of care: level of knowledge in patients with venous leg ulcers

BACKGROUND AND OBJECTIVES

Compression therapy is a mainstay in the causal treatment of patients with venous leg ulcers. It facilitates healing, reduces pain and recurrences, and increases quality of life. Up until now, there is a scarcity of scientific data with respect to the level of care and the specific knowledge of patients with venous leg ulcers.

PATIENTS AND METHODS

At first presentation, patients with venous leg ulcers anonymously answered a standardized questionnaire. Participating facilities nationwide included 55 outpatient care services, 32 medical practices, four wound centers, and one specialized care center.

RESULTS

Overall, 177 patients (mean age of 69.4; 75.1 % women) participated in the study. The average duration of florid venous leg ulcers was 17 months. With regard to compression therapy, 31.1 % of patients received none; 40.1 % used bandages; 28.8 % used stockings. Of the latter, 13.7 % were treated with compression class III; 67.4 %, with compression class II; and 19.6 %; with compression class I. While 70.6 % put on their stockings after getting out of bed in the morning, 21.1 % wore them day and night. In 39.2 % of individuals, the stockings caused them discomfort. Merely 11.7 % owned a donning device. On average, bandages were worn for 40.7 weeks, and 69 % were used without underpadding. In 2.8 % of patients, ankle and calf circumference was measured to monitor therapeutic success. 45.9 % reported doing leg exercises.

CONCLUSIONS

Although it is considered a basic therapeutic measure in venous leg ulcers, one-third of all patients received no compression treatment. Moreover, given the long duration of ulcers, adequate product selection and correct use have to be questioned, too. Our findings indicate that improvements in the level of knowledge among users and prescribers as well as patient training are required.

Kompressionstherapie - Versorgungspraxis: Informationsstand von Patienten mit Ulcus cruris venosum

HINTERGRUND UND ZIELE

Eine Säule der kausalen Therapie bei Patienten mit Ulcus cruris venosum ist die Kompressionstherapie. Sie unterstützt die Abheilung, reduziert Schmerzen und Rezidive und steigert die Lebensqualität. Bislang existieren kaum wissenschaftliche Daten zu dem Versorgungsstand und fachspezifischem Wissen von Patienten mit Ulcus cruris venosum.

PATIENTEN UND METHODIK

Standardisierte Fragebögen wurden bundesweit in 55 Pflegediensten, 32 Arztpraxen, vier Wundzentren und -sprechstunden sowie einem Pflegetherapiestützpunkt von Patienten mit Ulcus cruris venosum bei Erstvorstellung anonym ausgefüllt.

ERGEBNISSE

Insgesamt nahmen 177 Patienten (Durchschnittsalter 69,4 Jahre; 75,1 % Frauen) teil. Ein florides Ulcus cruris venosum bestand im Mittel 17 Monate. 31,1 % hatten keine Kompressionstherapie, 40,1 % Binden und 28,8 % Strümpfe. Bei der Bestrumpfung hatten 13,7 % Kompressionsklasse III, 64,7 % Kompressionsklasse II und 19,6 % Kompressionsklasse I. 70,6 % legten die Strümpfe nach dem Aufstehen an, 21,1 % trugen sie Tag und Nacht. 39,2 % bereiteten die Strümpfe Beschwerden. Lediglich 11,7 % hatten eine An- und Ausziehhilfe. Die Binden wurden im Mittel 40,7 Wochen getragen und bei 69 % nicht unterpolstert. Bei 2,8 % wurde der Knöchel- und Waden-Umfang zur Erfolgskontrolle gemessen. Venensport machten 45,9 %.

SCHLUSSFOLGERUNGEN

Ein Drittel hatte keine Kompressionsversorgung, obwohl diese eine Basismaßnahme der Therapie des Ulcus cruris venosum ist. Zudem ist deren korrekte Auswahl und Anwendung angesichts der langen Bestandsdauer der Ulzerationen zu hinterfragen. Weiterführende Fachkenntnisse bei Anwendern und Verordnern sowie Patientenschulungen sind erforderlich.

Stasis Dermatitis: Pathophysiology, Evaluation, and Management

Stasis dermatitis commonly occurs in older age. It is caused by venous hypertension resulting from retrograde flow due to incompetent venous valves, valve destruction, or obstruction of the venous system. Further tissue changes arise from an inflammatory process mediated by metalloproteinases, which are up-regulated by ferric ion from extravasated red blood cells. Stasis dermatitis presents initially as poorly demarcated erythematous plaques of the lower legs bilaterally, classically involving the medial malleolus. It is one of the spectrum of cutaneous findings that may result from chronic venous insufficiency. Its mimics include cellulitis, contact dermatitis, and pigmented purpuric dermatoses. Duplex ultrasound is useful in demonstrating venous reflux when the clinical diagnosis of stasis dermatitis is inadequate. Conservative treatment involves the use of compression therapy directed at improving ambulatory venous pressure. Interventional therapy currently includes minimally invasive techniques such as endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which have supplanted the use of open surgical techniques.

The current spectrum of contact sensitization in patients with chronic leg ulcers or stasis dermatitis - new data from the Information Network of Departments of Dermatology (IVDK)

BACKGROUND

Patients with lower leg dermatitis, chronic venous insufficiency or chronic leg ulcers have a high prevalence of contact sensitization.

OBJECTIVES

To identify the current spectrum of contact allergens in these patients.

PATIENTS AND METHODS

Data of the Information Network of Departments of Dermatology on 5264 patients with the above diagnoses from the years 2003 to 2014 (study group) were compared with data on 4881 corresponding patients from 1994 to 2003 (historical control group) and with a current control group without these diagnoses (n = 55 510).

RESULTS

Allergic contact dermatitis was diagnosed less frequently in the study group than in the historical control group (25.9% versus 16.9%; p < 0.001), and contact sensitization to most allergens had declined. The allergen spectrum, however, was largely unchanged. Important allergens are Myroxylon pereirae (balsam of Peru) (14.8% positive reactions), fragrance mix I (11.4%), lanolin alcohol (7.8%), colophonium (6.6%), neomycin sulfate (5.0%), cetearyl alcohol (4.4%), oil of turpentine (3.1%), and paraben mix (2.6%). Patch testing with additional series showed sensitization to Amerchol L-101 (9.7%), tert-butyl hydroquinone (8.7%), framycetin sulfate (5.0%), and gentamicin sulfate (3.1%).

CONCLUSIONS

Topical preparations for treating the above-mentioned conditions should not contain fragrances, Myroxylon pereirae, and colophonium. The special allergen spectrum has to be considered in patch testing.

[When to worry about before a vascular chronic leg ulcer?]

Leg ulcers are a chronic condition. Healing can be long for venous ulcers and the risk of complications is significant. Infection is the most severe complication and can occur in the form of easily diagnosed acute bacterial dermohypodermitis that generally responds well to antibiotic treatment if given at an appropriate dose or in the form of localized infection that is more difficult to diagnosis. Indeed, no consensus has been reached in the literature on the clinical criteria to retain for the diagnosis of localized infection. Similarly, the most appropriate treatment remains to be established. Local care would be a logical starting point, followed by systemic antibiotics if this approach is unsuccessful. Individual conditions also should be taken into consideration (immunodepression, severe arteriopathy warranting more rapid use of systemic antibiotics). The second most frequent complication is an allergic reaction to a topical agent used for wound care. The rate of sensitivization in patients with leg ulcers is high (60 %), although the rate is declining with modern dressings. No product can be considered perfectly safe for these polysensitized patients. Dermocorticoid therapy can be very effective. Allergology tests are needed. Certain leg ulcers require special care from diagnosis. An arterial origin must be suspected for deep, or necrotic ulcers. Arterial supply must be explored rapidly, followed by a revascularization procedure when necessary. Highly painful superficial extensive necrotic ulcers due to necrotic angiodermitis require hospital care for skin grafts that will control the antiodermitis and provide pain. Carcinoma should be suspected in cases of leg ulcers with an atypical localization exhibiting excessive budding. A biopsy is mandatory for leg ulcers with an unusual course (absence of healing despite well-conducted care).

A dynamic landscape of allergen associations in delayed-type cutaneous hypersensitivity

BACKGROUND

Delayed-type hypersensitivity represents a significant clinical and public health challenge. Patients undergoing patch testing may exhibit positive reactions to more than one allergen. It is recognized that reactions to specific pairs of allergens are associated, reflecting a combination of exposure patterns and structural similarity.

OBJECTIVES

To explore the influence of time of testing, age, sex and atopy status on allergen pair associations in a series of 45 110 consecutive patients tested over 30 years.

METHODS

Patch test records of all patients undergoing testing with a modified European baseline series between 1985 and 2014 were retrieved from a database at St John's Institute of Dermatology. Reactions were read on days 2 and 4. For each allergen it was recorded whether the allergen was tested and whether the result was positive or negative.

RESULTS

This is the largest reported study of patch test allergen pair relationships. Our analysis shows a high degree of variability in allergen pair associations. Rigorous statistical analysis reveals a large number of differences between groups, including a significant increase in the association between formaldehyde and multiple formaldehyde-releasing preservatives over the study period, in addition to pair associations with cobalt and formaldehyde-releasing preservatives. These were present to a significantly greater extent in men than in women.

CONCLUSIONS

These observations extend our understanding of cutaneous allergy, with implications for both clinical practice and mechanisms of cutaneous hypersensitivity.

Wound dressings, does it matter and why?

Compression therapy and treating venous insufficiency is the standard of care for venous leg ulcers. The need for debridement on healing venous leg ulcers is still debated. Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. A wide range of dressings is available, including modern dressings with different kinds of biological activity. Microbial burden is believed to underlie delayed healing, but the exact role of microbiofilm in wound healing is uncertain. Before choosing a specific wound dressing, four main functions should be considered: (1) cleaning, (2) absorbing, (3) regulating or (4) the necessity of adding medication. There is no clear evidence to support the use of one dressing over another, as demonstrated by many Cochrane review studies. In addition, the prescriber should enquire about contact allergies that may also develop during wound treatment. It is shown that early intervention and early investment may reduce the cost of treatment. The choice of wound dressings should be guided by cost, ease of application and patient and physician preference and be part of the complete strategy. The role of the medical specialist is evident. Wound dressings matter as part of the optimal treatment in VLU patients.

Kontaktsensibilisierungen von Patienten mit chronischen Wunden

Patients with chronic wounds frequently acquire clinically relevant contact sensitization. We examined the results of the skin patch tests in patients with chronic wounds, who were treated between 1999-2004 in the Department of Dermatology, University School of Medicine, Essen, Germany. Altogether 105 patients with chronic wounds underwent patch testing. In 68 individuals, contact sensitization to at least one substance was detected. The most frequent contact allergens were to balsam of Peru, Amerchol L-101, fragrance mix, wool wax alcohols and rosins. Contact sensitization to wound dressing materials was also identified in 4 patients. Our results demonstrate the current spectrum of contact sensitization of patients with chronic wounds. Our results show the importance of paying attention to the ingredients in wound dressings and performing patch testing if there is any clinical suggestion of allergic contact dermatitis.

Contact sensitisation in patients with chronic leg ulcers

The aim of our study is to identify the allergens in patients with leg ulcers who have contact dermatitis surrounding the skin of the ulcer and compare them with a control group consisting of patients with lower extremity contact dermatitis. A total of 40 patients with chronic leg ulcers (CLU) and contact dermatitis around the skin of ulcer were included in the study. As a control group, 20 patients with contact dermatitis of lower extremity without leg ulcers were included. The patient and control groups were patch tested with 37 allergens of the European Standard Series. Of the 40 patients, 31 (77·5%) had positivity to one or more allergens, and 10 (50%) of the control group patients had positivity to one or more allergens. The number of patients who had positivity to at least one allergen was significantly higher in the patient group (P < 0·05). Positivity to the balsam of Peru and benzocaine was significantly higher in the patient group than that in the control group (P < 0·05). Contact sensitisation to benzocaine and balsam of Peru was found to be associated with the presence of CLU. The efficacy of therapy in patients with leg ulcers might be increased by avoiding these allergens.

[Treatment of superficial bacterial cutaneous infections: a survey among general practitioners in France]

BACKGROUND

Superficial bacterial skin infection and superinfection of skin diseases are usually treated by general practitioners using antiseptics or antibiotics. However, acquired resistance to biocidal agents, both systemic and topical, is growing.

OBJECTIVES OF THE STUDY

Our aim was to assess the skill of GPs in clinical situations involving common skin infections.

MATERIAL AND METHODS

On 16 June 2010, we sent a questionnaire to all GPs in a rural region of France (the Cher department) together with a stamped addressed envelope for the reply. The questionnaire contained seven pages of multiple-choice questions and five clinical cases, each one illustrated with a photograph (sty, furuncle, whitlow, colonized chronic wounds and impetigo). Anonymity of responses was guaranteed. Data was analysed using the Clinsight(®) software package.

RESULTS

The response rate was 51% (102 responses). GPs reported little difficulty in treating these patients (median 3, range 1 to 8 on a scale of increasing difficulty from 0 to 10). The main results of the study are firstly the frequency of combination of at least one antiseptic with one antibiotic (46%); secondly, the frequency of combination of two antibiotics (20% of cases); thirdly, the frequent prescription of systemic antibiotics for chronic wounds colonized by Pseudomonas aeruginosa (61%).

DISCUSSION

Our study shows the high frequency of prescriptions for combined therapy to treat superficial skin infections despite the fact that monotherapy with either an antiseptic or an antibiotic would probably suffice. It also shows the unnecessary prescription of antibiotics for colonization of a chronic wound. The study was limited in terms of size and design: it was a questionnaire rather than an analysis of prescriptions actually made in "real life", and the response rate was 51%. In addition, aside from impetigo, for which randomised studies and recommendations were given, the other surface infections (sty, folliculitis, whitlow) tend to be treated more empirically.

CONCLUSION

Dissemination of recommendations regarding the respective role of antiseptics and antibiotics (and their route of administration, topical or systemic) in superficial skin infections would doubtless be useful for prescribers, and more rational use of these agents would help limit bacterial resistance.

Allergic contact dermatitis to fragrances. Part 1

Fragrances are a large group of substances and the second most common cause of allergic contact dermatitis in Spain. These potential allergens are extremely common and the general population is subject to continuous exposure on a daily basis. While the fragrance markers included in the current Spanish standard patch test series are good, there is room for improvement. New markers that have emerged in recent years have proven to be of value in standard series used in other countries. Diagnosing fragrance allergy has taken on even greater importance since the European Union added 26 fragrances to its list of mandatory ingredients to be specified on product labels. The aim of this review is to provide an update on allergic contact dermatitis to fragrances. We examine the main sources of exposure and clinical manifestations of this condition and propose a diagnostic and treatment protocol.

Manejo clínico de úlceras venosas na atenção primária à saúde

OBJETIVO: Discutir o manejo clínico de úlceras venosas realizado na atenção primária à saúde, com base na visão dos usuários que convivem com esta afecção. MÉTODOS: Estudo de natureza qualitativa exploratório, descritivo, realizado com 25 usuários adultos em tratamento nas Unidades de Saúde da Família. Os dados foram coletados no segundo semestre de 2008, utilizando-se um formulário estruturado com questões de caracterização sociodemográfica, tipo de limpeza, coberturas, uso de terapia compressiva, medicamentos e orientações prescritas. RESULTADOS: São usados para a limpeza produtos que agridem o tecido de granulação, como coberturas com várias substâncias, dentre elas o óleo de girassol e pomadas antibióticas; a maioria dos usuários não utiliza medidas para controle do edema. CONCLUSÃO: fazem-se necessárias a elaboração e a adoção de protocolos clínicos para o cuidado com úlceras venosas, bem como a capacitação permanente dos profissionais de saúde.

Contact sensitization in the elderly

Contact dermatitis from irritant and allergic sources is the reason for 6% to 10% of all dermatologic visits with considerable morbidity and economic impact. Allergic contact dermatitis is a T-cell-mediated inflammatory reaction and develops in predisposed individuals as a consequence of environmental exposure to allergens. Aging is correlated with the rate and type of contact sensitization because of "immunosenescence." The number of old people is growing around the world. This contribution reviews the main findings from published epidemiologic studies on contact allergy in elderly populations. In all examined studies, patch testing was performed in patients with cutaneous manifestations possibly related to contact dermatitis; the prevalence of contact dermatitis in the elderly was from 33% to 64%. Establishing the most frequent allergens responsible for allergic contact dermatitis in the elderly is a hard task. The commonest allergens reported were nickel sulfate, fragrance mix, diamino diphenylmethane, lanolin alcohols, paraben mix, Euxyl K400, quinoline mix, and balsam of Peru. We emphasize that allergens surveillance is needed to realize an "elderly series" for having a useful adjunct to contact allergy that may help the treatment of each patient.

Contact dermatitis in older adults: a review of the literature

Contact dermatitis is a significant health problem affecting the elderly. Impaired epidermal barrier function and delayed cutaneous recovery after insult enhances susceptibility to both irritants and allergens. Exposure to more numerous potential sensitizers and for greater durations influences the rate of allergic contact dermatitis in this population. Medical co-morbidities, including stasis dermatitis and venous ulcerations, further exacerbate this clinical picture. However, while these factors tend to increase the degree of sensitization in the elderly, waning immunity can actually decrease such a propensity. This interplay of both intrinsic and extrinsic factors makes a generalization on trends for contact dermatitis in older adults challenging. The literature has varying reports on the overall incidence of allergic contact dermatitis with advancing age. Nevertheless, it does clearly show that sensitivity to topical medicaments increases with age. Irritant contact dermatitis studies are more consistent, with less reactivity (to irritants) in older compared with younger skin. Diagnosis of both irritant and allergic contact dermatitis is based on a thorough history, complete skin examination, and comprehensive patch testing. The mainstay of therapy is avoidance of the offending chemical substances and the use of topical along with systemic therapies, depending on the severity of the condition.

Investigation of the patient with a venous ulcer

This review concentrates on the investigation of the patient with venous ulceration with a view to presenting current best practice. The aim is to maximize benefit for patients and their medical team by directing appropriate investigation leading to optimized results in the treatment of this highly prevalent, quality of life reducing and socioeconomically costly condition.