Guidelines for the management of contact dermatitis: an update

Patch testing with the European baseline series and 10 added allergens: Single-centre study of 748 patients

BACKGROUND

The European baseline series (EBS) of contact allergens is subject to change. An allergen is considered for inclusion when routine patch testing of patients with suspected contact dermatitis results in ≥0.5% prevalence rate.

OBJECTIVES

We aimed to determine the frequency of sensitizations to 30 EBS allergens and 10 locally added allergens. Additionally, we assessed the strength and evolution of reactions to all tested allergens and co-reactivity of additional allergens.

METHODS

Patch testing with our baseline series of 40 allergens was done in 748 consecutive adults. Tests were applied to the upper back and removed by patients after 48 h. Readings were done on Day 3 (D3) and D6 or D7 (D6/7). Positive reactions fulfilled the criteria of at least one plus (+) reaction. A retrospective analysis was done.

RESULTS

Eight allergens not listed in the EBS had ≥0.5% prevalence rate (i.e., cocamidopropyl betaine, thiomersal, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea, propylene glycol, Compositae mix II and dexamethasone-21-phosphate), and 16.6% of positive reactions would have been missed without D6/7 readings.

CONCLUSION

We propose further studies to evaluate whether cocamidopropyl betaine, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea and Compositae mix II need to be added to the EBS.

Neutrophil extracellular traps are involved in enhanced contact hypersensitivity response in IL-36 receptor antagonist-deficient mice

Loss-of-function homozygous or compound heterozygous mutations in IL36RN, which encodes interleukin-36 receptor antagonist (IL-36Ra), have been implicated in the pathogenesis of skin disorders. We previously reported that Il36rn^−/− mice exhibit an enhanced contact hypersensitivity (CHS) response through increased neutrophil recruitment. In addition, Il36rn^−/− mice show severe imiquimod-induced psoriatic skin lesions and enhanced neutrophil extracellular trap (NET) formation. We hypothesized that NETs may play an important role in the CHS response. To confirm this, we examined the CHS response and NET formation in Il36rn^−/− mice. Il36rn^−/− mice showed enhanced CHS responses, increased infiltration of inflammatory cells, including neutrophils, CD4⁺ T cells, and CD8⁺ T cells, NET formation, and enhanced mRNA expression of cytokines and chemokines, including IL-1β, C-X-C motif chemokine ligand (CXCL)1, CXCL2, and IL-36γ. Furthermore, NET formation blockade improved the CHS response, which consequently decreased inflammatory cell infiltration and NET formation. Consistently, we observed decreased expression of these cytokines and chemokines. These findings indicate that IL-36Ra deficiency aggravates the CHS response caused by excessive inflammatory cell recruitment, NET formation, and cytokine and chemokine production, and that NET formation blockade alleviates the CHS response. Thus, NET formation may play a prominent role in the CHS response.

Comparison of product safety data sheet ingredient lists with skin irritants and sensitizers present in a convenience sample of light-curing resins used in additive manufacturing

Material jetting and vat photopolymerization additive manufacturing (AM) processes use liquid resins to build objects. These resins can contain skin irritants and/or sensitizers but product safety data sheets (SDSs) might not declare all ingredients. We characterized elemental and organic skin irritants and sensitizers present in 39 commercial products; evaluated the influence of resin manufacturer, system, color, and AM process type on the presence of irritants and sensitizers; and compared product SDSs to results. Among all products, analyses identified 23 irritant elements, 54 irritant organic substances, 22 sensitizing elements, and 23 sensitizing organic substances; SDSs listed 3, 9, 4, and 6 of these ingredients, respectively. Per product, the number and total mass (an indicator of potential dermal loading) of ingredients varied: five to 17 irritant elements (8.32-4756.65 mg/kg), one to 17 irritant organics (3273 to 356,000 mg/kg), four to 17 sensitizing elements (8.27-4755.63 mg/kg), and one to seven sensitizing organics (15-382,170 mg/kg). Median numbers and concentrations of irritants and sensitizers were significantly influenced by resin system and AM process type. The presence of undeclared irritants and sensitizers in these resins supports the need for more complete information on product SDSs for comprehensive dermal risk assessments.

Transient injection site reaction to alirocumab during immune system activation: a case series

Background

Injection site reactions (ISRs) are known side effects of the proprotein convertase subtilisin kexin 9 (PCSK9) inhibitor alirocumab. Transient ISR to alirocumab after a long phase of good tolerability have not been reported previously.

Case summary

A 55-year-old woman (Patient 1) and a 77-year-old man (Patient 2) were treated with alirocumab for the management of dyslipidaemia. Both patients tolerated the treatment without side effects for 7 and 2 months, respectively. After an upper respiratory tract infection in Patient 1 and a first COVID-19 vaccination in Patient 2, both patients suddenly developed ISR with erythema, calor, and itching upon 2 (Patient 1) and 1 (Patient 2) subsequent injection(s), respectively. Symptoms resolved with local steroids, oral antihistamines, and cooling. After termination of the presumed immune system activated state, alirocumab was well tolerated again in both patients without recurrence of any ISR upon repeated applications.

Discussion

These are the first cases to report transient ISR to a PCSK9 inhibitor, possibly triggered by activation of the immune system, after prolonged good tolerability. Based on the transient and benign nature of the reaction, such patients should be encouraged to continue supervised treatment, as tolerability may return after resolution of the pro-inflammatory state.

Irritant Contact Dermatitis — a Review

Purpose of Review

Recent Findings

Summary

Epicutaneous Patch Testing in Type IV Allergy Diagnostics: State of the Art and Best Practice Recommendations

This chapter summarises all relevant aspects of patch testing, closely following recommendations outlined in a recent European, and a German S3 guideline on diagnostic patch testing with contact allergens and medicinal products (drugs). Patch testing is indicated in patients suspected of suffering, or having been suffering, from delayed-type hypersensitivity leading to allergic contact dermatitis or other skin and mucosal diseases. Sections of this chapter include detailed indications, reasons for possibly postponing the test, considerations on choosing haptens (contact allergens) to test, various aspects of the application of patch test allergen preparations (storage, dosing) and of testing with individual materials provided by the patients. Special aspects of patch testing in cutaneous adverse drug reactions, children, or occupational contact dermatitis are outlined. Supplemental test methods, notably the repeated open application test, are briefly described. Finally, the final evaluation in terms of assessment of clinical relevance of reactions and patient counselling are outlined.

Contact Dermatitis in Nail Cosmetics

Many ingredients found within nail cosmetic products are capable of sensitizing patients’ immune systems and causing contact dermatitis (CD). These include but are not limited to tosylamide, (meth)acrylates, and formaldehyde. A clear temporal relationship between nail cosmetic procedures and an eczematous outbreak on the hands, face, or other ectopic body regions can be a key indicator of CD secondary to nail cosmetic exposure. Once an inciting allergen is identified through patch testing, elimination and avoidance becomes a mainstay of treatment alongside the use of emollients and topical anti-inflammatory therapies. Patients should be counselled to approach future nail cosmetic products and procedures with caution and careful attention to ingredients, regardless of whether or not it has a “hypoallergenic” label.

Immunological Mechanisms of Metal Allergies and the Nickel-Specific TCR-pMHC Interface

Besides having physiological functions and general toxic effects, many metal ions can cause allergic reactions in humans. We here review the immune events involved in the mediation of metal allergies. We focus on nickel (Ni), cobalt (Co) and palladium (Pd), because these allergens are among the most prevalent sensitizers (Ni, Co) and immediate neighbors in the periodic table of the chemical elements. Co-sensitization between Ni and the other two metals is frequent while the knowledge on a possible immunological cross-reactivity using in vivo and in vitro approaches remains limited. At the center of an allergic reaction lies the capability of a metal allergen to form T cell epitopes that are recognized by specific T cell receptors (TCR). Technological advances such as activation-induced marker assays and TCR high-throughput sequencing recently provided new insights into the interaction of Ni2+ with the αβ TCR-peptide-major histocompatibility complex (pMHC) interface. Ni2+ functionally binds to the TCR gene segment TRAV9-2 or a histidine in the complementarity determining region 3 (CDR3), the main antigen binding region. Thus, we overview known, newly identified and hypothesized mechanisms of metal-specific T cell activation and discuss current knowledge on cross-reactivity.

Prominent Role of Type 2 Immunity in Skin Diseases-Beyond Atopic Dermatitis

Type 2 immunity, illustrated by T helper 2 lymphocytes (Th2) and downstream cytokines (IL-4, IL-13, IL-31) as well as group 2 innate lymphoid cells (ILC2), is important in host defense and wound healing.¹ The hallmark of type 2 inflammation is eosinophilia and/or high IgE counts and is best recognized in atopic diathesis. Persistent eosinophilia, such as seen in hypereosinophilic syndromes, leads to fibrosis and hence therapeutic Type 2 inhibition in fibrotic diseases is of high interest. Furthermore, as demonstrated in cutaneous T cell lymphoma, advanced disease is characterized by Th1 to Th2 switch allowing cancer progression and immunosuppression. Development of targeted monoclonal antibodies against IL-4Rα (eg, dupilumab) led to a paradigm shift for the treatment of atopic dermatitis (AD) and stimulated research to better understand the role of Type 2 inflammation in other skin conditions. In this review, we summarize up to date knowledge on the role of Type 2 inflammation in skin diseases other than AD and highlight whether the use of Type 2 targeted therapies has been documented or is being investigated in clinical trials. This manuscript reviews the role of Type 2 inflammation in dermatitis, neurodermatitis, IgE-mediated dermatoses (eg, bullous pemphigoid, chronic spontaneous urticaria), sclerodermoid conditions and skin neoplasms.

Pediatric Allergic Contact Dermatitis

Allergic contact dermatitis (ACD) affects up to 20% of adults and children, although children are infrequently patch tested. Available data suggest that children and adults, with or without atopic dermatitis, have the same prevalence of ACD. Patch testing is the gold standard for evaluation of ACD. The Pediatric Baseline Series was recently published by expert consensus for use in pediatric patch testing, with additional allergens tested as guided by history. This article examines methods of patch testing and up-to-date data on pediatric ACD. The top allergens are reviewed, and avoidance strategies are discussed.

Effectiveness of Support Groups for Patients With Contact Dermatitis: A Pilot Study

BACKGROUND

Contact dermatitis can be difficult to manage and overwhelming for patients, often requiring significant lifestyle changes.

OBJECTIVE

The aim of the study was to investigate whether a contact dermatitis support group could help patients find community and learn from others who share similar experiences.

METHODS

Hour-long, monthly support group meetings facilitated by a social worker, research fellows, and a faculty dermatologist were held for approximately 1.5 years. A 32-question, cross-sectional survey was administered to assess perception of contact dermatitis and overall usefulness of the group.

RESULTS

Between 2 and 5 patients attended each group session; 9 participants completed the survey. Most were female (77.8%) and white (77.8%), with an average age of 68.8 years. Eight participants (88.9%) reported that it was important or somewhat important to socialize with others affected by contact dermatitis. Three group members (33.3%) had met with attendees outside of the monthly sessions. The majority (77.8%) reported that the support group had a positive effect on their understanding of contact dermatitis and would recommend the group to others (88.9%).

CONCLUSIONS

Support groups may be helpful for patients learning to cope with the challenges associated with contact dermatitis. Although preliminary feedback is promising, further investigation is warranted to determine whether these groups are effective on a larger scale.

Allergic contact dermatitis: From pathophysiology to development of new preventive strategies

As the body's first line of defense, the skin is the organ most frequently exposed to chemicals present in personal hygiene products, household products, or materials used in the work environment. In this context, skin disorders account for more than 40 % of all occupational and work-related diseases, constituting a significant public health burden. Among skin disorders, allergic contact dermatitis (ACD) is the most prevalent occupational disease and the most common form of immunotoxicity in humans. ACD is a T-cell-mediated skin inflammation resulting from the priming and expansion of allergen-specific CD4⁺ and CD8⁺ T cells. The clinical condition is characterized by local skin rash, itchiness, redness, swelling, and lesions, being mainly diagnosed by the patch test. Upon ACD diagnosis, avoiding the exposure to the triggering allergen is the mainstay of treatment to prevent future flares. In cases where avoidance is not possible, the use of a standard of care interim treatments such as steroid creams or ointments, barrier creams, and moisturizers are strongly recommended to alleviate symptoms. In this review, we sought to provide the reader with an overview of the pathophysiology of ACD as well as the currently available pharmacological treatment options. Furthermore, a comprehensive outline of several preventive strategies is also provided.

Demographic and clinical features and subsectoral differences in occupational contact allergens in clothing manufacturing workers

BACKGROUND

Epidemiologic data on the occurrence of contact dermatitis (CD) and the contact allergens involved in clothing manufacturing and its subsectors are scarce. This study aimed to determine the extent of occupational contact allergy and differences between work subsectors in clothing employees with CD.

METHODS

A cross-sectional study was conducted with 272 clothing employees, who complained of CD and were diagnosed with occupational allergic contact dermatitis (OACD). Participants worked in accessory, dyeing, sewing, cutting, knitting, packing, cleaning, and ironing subsectors. Data on demographics, working-subsector, working-duration, and lesion-duration were collected, and participants were examined and patch tested.

RESULTS

Participants included 173 females and 99 males. Dyeing workers were most frequently diagnosed with OACD, whereas cutting workers were least. Lesions were mostly located on the hands only. The most frequently detected allergens were nickel sulfate in accessory work; disperse blue-106 in dyeing, sewing, cutting, and knitting; cobalt chloride in packing; p-phenylenediamine in cleaning; and budesonide in ironing.

CONCLUSIONS

Contact allergens show significant differences in frequency by work subsectors in clothing employees. Careful monitoring of workers for excessive exposures and for early signs of CD is warranted.

Utilization, cost, and provider trends in patch testing among Medicare beneficiaries in the United States from 2012 to 2017

BACKGROUND

Patch testing is the best diagnostic test for allergic contact dermatitis. However, there is presently a lack of data on the test's geographic availability and the characteristics of the providers offering this test across the United States.

OBJECTIVE

To evaluate the geographic variation in the availability of patch testing for the Medicare population and to characterize the temporal trends of patch testing cost, use, and provider specialty from 2012 to 2017.

METHODS

Retrospective cohort study of the Medicare Provider Utilization and Payment Data from 2012 to 2017.

RESULTS

As of 2017, patch testing was available in 20.3% of metropolitan counties and in 1.1% of nonmetropolitan counties. From 2012 to 2017 in metropolitan regions, the number of beneficiaries tested by dermatologists grew by an average annual growth rate of 1.84%, whereas those tested by allergists grew by an average annual growth rate of 20.31%. Most providers that averaged use of 80 or more patches per beneficiary were dermatologists (76.3%).

LIMITATIONS

Analysis was restricted to Medicare Part B claims; data were unavailable on individuals with commercial insurance.

CONCLUSIONS

Most of the increase in patch testing utilization from 2012 to 2017 has been in metropolitan regions. Although growth was especially prominent among allergists in metropolitan counties, the majority of providers performing comprehensive patch testing were dermatologists.

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention

Nickel is a ubiquitous metal added to jewelry and metallic substances for its hardening properties and because it is inexpensive. Estimates suggest that at least 1.1 million children in the United States are sensitized to nickel. Nickel allergic contact dermatitis (Ni-ACD) is the most common cutaneous delayed-type hypersensitivity reaction worldwide. The incidence among children tested has almost quadrupled over the past 3 decades. The associated morbidities include itch, discomfort, school absence, and reduced quality of life. In adulthood, individuals with Ni-ACD may have severe disabling hand eczema. The increasing rate of Ni-ACD in children has been postulated to result from early and frequent exposure to metals with high amounts of nickel release (eg, as occurs with ear piercing or with products used daily in childhood such as toys, belt buckles, and electronics).To reduce exposure to metal sources with high nickel release by prolonged and direct contact with human skin, Denmark and the European Union legislated a directive several decades ago with the goal of reducing high nickel release and the incidence of Ni-ACD. Since then, there has been a global reduction in incidence of Ni-ACD in population-based studies of adults and studies of children and young adults being tested for allergic contact dermatitis. These data point to nickel exposure as a trigger for elicitation of Ni-ACD and, further, provide evidence that legislation can have a favorable effect on the economic and medical health of a population.This policy statement reviews the epidemiology, history, and appearances of Ni-ACD. Examples of sources of high nickel release are discussed to highlight how difficult it is to avoid this metal in modern daily lives. Treatments are outlined, and avoidance strategies are presented. Long-term epidemiological interventions are addressed. Advocacy for smarter nickel use is reviewed. The American Academy of Pediatrics supports US legislation that advances safety standards (as modeled by the European Union) that protect children from early and prolonged skin exposure to high-nickel-releasing items. Our final aim for this article is to aid the pediatric community in developing nickel-avoidance strategies on both individual and global levels.

Understanding the correlation between structure and dynamics of clocortolone pivalate by solid state NMR measurement

Structural characteristics of clocortolone pivalate are unique in the topical corticosteroid field having high penetration power through the stratum corneum of skin as well as low corticosteroid-related adverse effects.

Idiopathic Pruritus Ani and Acute Perianal Dermatitis

This article reviews the etiologies, pathophysiology, clinical evaluation, and treatment of idiopathic pruritus ani and perianal dermatitis. It underscores a practical approach to each of these common proctologic conditions.

Patient-reported symptoms of 'calm', 'irritated' and 'infected' skeletal external fixator pin site wound states; a cross-sectional study

OBJECTIVE

To explore the frequency, severity and variances in patient-reported symptoms of calm, irritated and infected skeletal pin sites.

METHODS

A cross-sectional within-subjects repeated-measures study was conducted, employing a self-report questionnaire. Patients (n = 165) treated with lower limb external fixators at 7 English hospitals completed a designed questionnaire. Three sets of retrospective repeated-measures data were collected relating to calm, irritated and infected pin sites.

RESULTS

Significant differences were revealed between each of the three pin site states (calm, irritated & infected) in the degree of: redness, swelling, itchiness, pain, wound discharge, heat/burning, shiny skin and odour. In relation to difficulty or pain using the affected arm or leg, difficulty weight bearing on the leg, nausea and/or vomiting, feeling unwell or feverish, shivering, tiredness/lethargy and disturbed sleep, significant differences were demonstrated between infected and irritated states and infected and calm states, but not between irritated and calm.

CONCLUSIONS

The findings provide greater depth of understanding of the symptoms of pin site infection and irritation. Patients may be able to differentiate between different pin site states by comparing the magnitude of the inflammatory symptoms and the presence of other specific symptoms that relate solely to infection and no other clinical state. The irritated state is probably caused by a different pathological processother than infection and may be an indication of contact dermatitis.

Relative efficacy of 5-fluorouracil compared with other treatments among patients with actinic keratosis: A network meta-analysis

OBJECTIVE

The purpose of this study was to compare the efficacy of 5-fluorouracil (5-FU) with that of other treatments of actinic keratosis (AK).

METHODS

A systematic literature review of five databases (including Medline and EMBASE) was first performed to identify randomized controlled trials (RCTs). A network meta-analysis (NMA) based on a random-effects Bayesian model was then performed on the outcomes for patients with total clearance and lesions reduced from baseline. Five treatments (viz., 0.5% 5-FU with 10% salicylic acid [5-FU/SA], 5% 5-FU cream, 3% diclofenac sodium, cryosurgery, and vehicle) were evaluated.

RESULTS

A total of 11 studies involving 2,256 patients with AK were included in this NMA. The overall risk of bias among the included studies was low. All treatments were significantly better than the vehicle both for patients with total clearance and for lesions reduced from baseline. Among patients with total clearance, 5% 5-FU cream (56.8%) and 5-FU/SA (35.7%) were likely to be more effective than the other treatments, whereas 5% 5-FU cream (98.6%) was likely the most effective in the group of lesions reduced from baseline.

CONCLUSION

5-FU, diclofenac sodium, and cryosurgery are all useful for AK treatment, with 5-FU being the most effective.

Investigating the therapeutic potential of a probiotic in a clinical population with chronic hand dermatitis

BACKGROUND

Hand dermatitis or hand eczema (HD) is one of the most common dermatologic conditions. Lesions, scaling, pruritus and pain are chronic and relapsing. Improved HD has been reported with the probiotic composed of Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R and Lactobacillus rhamnosus CLR2 (Bio-K+).

PURPOSE

Investigation of the therapeutic potential of this probiotic as the sole systemic treatment for adults with nonacute HD.

SUBJECTS AND METHODS

A single-center study documented clinical ratings and patient-reported outcomes in adults with chronic HD. The probiotic was taken orally for 12 weeks, adjunctive to standard topical treatments and preventative measures.

RESULTS

Most of the 30 subjects with mild to severe HD were compliant with the probiotic. Around 22 of the 30 subjects were able to complete the study, and of these subjects, an improvement was noted in 19. One required systemic therapy, and one subject was not able to tolerate the probiotic and therefore discontinued the study. 23% of the subjects achieved clear or almost clear hands by the end of 12 weeks. Pruritus, which was a common complaint at baseline, was improved with 59% of symptomatic patients within 2 weeks.

CONCLUSION

It is feasible and safe to administer Bio-K+ for HD. Clinicians saw an improvement in most subjects' hands, and cases of significant improvement in dermatitis were documented. Pruritus was the most rapidly relieved symptom, as reported by patients.

Management of Central Venous Access Device-Associated Skin Impairment: An Evidence-Based Algorithm

Patients relying on central venous access devices (CVADs) for treatment are frequently complex. Many have multiple comorbid conditions, including renal impairment, nutritional deficiencies, hematologic disorders, or cancer. These conditions can impair the skin surrounding the CVAD insertion site, resulting in an increased likelihood of skin damage when standard CVAD management practices are employed. Supported by the World Congress of Vascular Access (WoCoVA), developed an evidence- and consensus-based algorithm to improve CVAD-associated skin impairment (CASI) identification and diagnosis, guide clinical decision-making, and improve clinician confidence in managing CASI. A scoping review of relevant literature surrounding CASI management was undertaken March 2014, and results were distributed to an international advisory panel. A CASI algorithm was developed by an international advisory panel of clinicians with expertise in wounds, vascular access, pediatrics, geriatric care, home care, intensive care, infection control and acute care, using a 2-phase, modified Delphi technique. The algorithm focuses on identification and treatment of skin injury, exit site infection, noninfectious exudate, and skin irritation/contact dermatitis. It comprised 3 domains: assessment, skin protection, and patient comfort. External validation of the algorithm was achieved by prospective pre- and posttest design, using clinical scenarios and self-reported clinician confidence (Likert scale), and incorporating algorithm feasibility and face validity endpoints. The CASI algorithm was found to significantly increase participants' confidence in the assessment and management of skin injury (P = .002), skin irritation/contact dermatitis (P = .001), and noninfectious exudate (P < .01). A majority of participants reported the algorithm as easy to understand (24/25; 96%), containing all necessary information (24/25; 96%). Twenty-four of 25 (96%) stated that they would recommend the tool to guide management of CASI.

Allergy Testing

Allergic diseases are common in outpatient primary care. Allergy testing can guide management to determine allergy as a cause of symptoms and target therapeutic interventions. This article provides a review of common methods of allergy testing available so that physicians may counsel and refer patients appropriately. Immediate-type hypersensitivity skin tests can be used for airborne allergens, foods, insect stings, and penicillin. Radioallergosorbent testing can be used to evaluate immediate-type hypersensitivity. Delayed-type hypersensitivity or patch-type skin tests are used in patients with suspected contact dermatitis.

Hypersensitivity reactions to metal implants: laboratory options

Background

All implant compounds undergo an electrochemical process when in contact with biological fluids, as well as mechanical corrosion due to abrasive wear, with production of metal debris that may inhibit repair processes. None of the commonly-used methods can diagnose implant allergies when used singly, therefore a panel of tests should be performed on allergic patients as pre-operative screening, or when a postoperative metal sensitisation is suspected.

Methods

We analysed patients with painful prostheses and subjects prone to allergies using the Patch Test in comparison with the Lymphocyte Transformation Test. Cytokine production was evaluated to identify prognostic markers for early diagnosis of aseptic loosening. Metal debris endocytosis and cytoskeletal rearrangement was visualised by confocal microscopy.

Results

Our results demonstrate that the Lymphocyte Transformation Test can identify patients who have a predisposition to develop allergic reactions and can confirm the diagnosis of hypersensitivity in patients with painful prostheses.

The prevalence of a Th2-cytokine pattern may be used to identify predisposition to the development of allergic diseases, while the selective presence of osteoclastogenic cytokines may be used as predictor of a negative outcome in patients with painful prosthesis.

The hypothesis of the prognostic value of these cytokines as early markers of aseptic loosening is attractive, but its confirmation would require extensive testing.

Conclusions

The Lymphocyte Transformation Test is the most suitable method for testing systemic allergies. We suggest that the combined use of the Patch Test and the Lymphocyte Transformation Test, associated with cytokine detection in selected patients, could provide a useful tool for preventive evaluation of immune reactivity in patients undergoing primary joint replacement surgery, and for clinical monitoring of the possible onset of a metal sensitization in patients with implanted devices.

International survey on skin patch test procedures, attitudes and interpretation

BACKGROUND

Skin patch test is the gold standard method in diagnosing contact allergy. Although used for more than 100 years, the patch test procedure is performed with variability around the world. A number of factors can influence the test results, namely the quality of reagents used, the timing of the application, the patch test series (allergens/haptens) that have been used for testing, the appropriate interpretation of the skin reactions or the evaluation of the patient's benefit.

METHODS

We performed an Internet -based survey with 38 questions covering the educational background of respondents, patch test methods and interpretation. The questionnaire was distributed among all representatives of national member societies of the World Allergy Organization (WAO), and the WAO Junior Members Group.

RESULTS

One hundred sixty-nine completed surveys were received from 47 countries. The majority of participants had more than 5 years of clinical practice (61 %) and routinely carried out patch tests (70 %). Both allergists and dermatologists were responsible for carrying out the patch tests. We could observe the use of many different guidelines regardless the geographical distribution. The use of home-made preparations was indicated by 47 % of participants and 73 % of the respondents performed 2 or 3 readings. Most of the responders indicated having patients with adverse reactions, including erythroderma (12 %); however, only 30 % of members completed a consent form before conducting the patch test.

DISCUSSION

The heterogeneity of patch test practices may be influenced by the level of awareness of clinical guidelines, different training backgrounds, accessibility to various types of devices, the patch test series (allergens/haptens) used for testing, type of clinical practice (public or private practice, clinical or research-based institution), infrastructure availability, financial/commercial implications and regulations among others.

CONCLUSION

There is a lack of a worldwide homogeneity of patch test procedures, and this raises concerns about the need for standardization and harmonization of this important diagnostic procedure.

Contact dermatitis: a practice parameter-update 2015

This parameter was developed by the Joint Task Force on Practice Parameters, which represents the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Contact Dermatitis: A Practice Parameter-Update 2015." This is a complete and comprehensive document at the current time. The medical environment is changing and not all recommendations will be appropriate or applicable to all patients. Because this document incorporated the efforts of many participants, no single individual, including members serving on the Joint Task Force, are authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information or interpretation of this practice parameter by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by the pharmaceutical industry in drug development or promotion. Previously published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available at http://www.JCAAI.org or http://www.allergyparameters.org.