Hand eczema in children referred for patch testing: North American Contact Dermatitis Group Data, 2000-2016

BACKGROUND

Little is known about the aetiologies and relevant allergens in paediatric patients with hand eczema (HE).

OBJECTIVES

To characterize the aetiologies and determine the proportion of positive and currently relevant allergens in children/adolescents (age < 18 years) with HE referred for patch testing.

METHODS

A retrospective analysis (2000-2016) of North American Contact Dermatitis Group data was performed.

RESULTS

Of 1634 paediatric patients, 237 (14·5%) had involvement of the hands. Final physician diagnoses included allergic contact dermatitis (49·4%), atopic dermatitis (37·1%) and irritant contact dermatitis (16·9%). In multivariable logistic regression models, employment was the only association with increased odds of any HE or primary HE. Children with HE vs. those without HE had similar proportions of positive patch tests (56·1% vs. 61·7%; χ² -test, P = 0·11). The five most common currently relevant allergens were nickel, methylisothiazolinone, propylene glycol, decyl glucoside and lanolin. In multivariable logistic regression models of the top 20 relevant allergens, HE was associated with significantly higher odds of currently relevant reactions to lanolin, quaternium-15, Compositae mix, thiuram mix, 2-mercaptobenzathiazole and colophony. The allergens with the highest mean significance-prevalence index number were methylisothiazolinone, carba mix, thiuram mix, nickel and methylchloroisothiazolinone/methylisothiazolinone.

CONCLUSIONS

Children with HE who were referred for patch testing had a high proportion of positive patch tests, which was similar to the proportion found in children without HE. Children with HE had a distinct and fairly narrow profile of currently relevant allergens.

The relationships among individual and regional smoking, socioeconomic status, and oral and pharyngeal cancer survival: a mediation analysis

Poorer survival from oral and pharyngeal cancer (OPC) has been reported for populations of lower socioeconomic status (SES), adjusting for risk factors such as patient and clinical characteristics. Beyond these risk factors, higher rates of tobacco use may be a mediator for the observed poorer OPC survival for low SES populations. In this study, we aimed to examine the impact of the relationships among SES, individual smoking status, and living in a region with a higher smoking rate on OPC survival. We obtained Florida Cancer Data System data from 1996 to 2010 and merged the data with US Census data and Behavioral Risk Factor Surveillance System data from 1996 to 2010. We built multivariable survival models to quantify the mediational effect of individual smoking on overall and OPC-specific survival, adjusting for regional smoking, demographics, and clinical characteristics. We found that lower SES, individual smoking, and living in a region with a higher smoking rate were all strongly associated with poorer survival. We estimated that the indirect effect of individual smoking accounted for a large part (ranged from 13.3% to 30.2%) of the total effect of SES on overall and OPC-specific survival. In conclusion, individual and regional smoking are both significant and independent predictors of poor cancer survival. Higher rate of individual smoking is partially responsible for poorer cancer survival in low SES populations. Results of this study provide rationale for considering a multi-level approach that simultaneously targets both individual and contextual factors for future smoking cessation interventions.

Determinants of First-Time Cancer Examinations in a Rural Community: A Mechanism for Behavior Change

OBJECTIVES

After conducting a media campaign focusing on the importance of oral and pharyngeal cancer (OPC) examinations, we assessed mechanisms of behavior change among individuals receiving an OPC examination for the first time.

METHODS

We used data from 2 waves of telephone surveys of individuals residing in 36 rural census tracts in northern Florida (n = 806). The second survey occurred after our media intervention. We developed media messages and modes of message delivery with community members via focus groups and intercept interviews. We performed a mediation analysis to examine behavior change mechanisms.

RESULTS

Greater exposure to media messages corresponded with heightened concern about OPC. Heightened concern, in turn, predicted receipt of a first-time OPC examination, but only among men.

CONCLUSIONS

We extended earlier studies by measuring an outcome behavior (receipt of an OPC examination) and demonstrating that the putative mechanism of action (concern about the disease) explained the link between a media intervention and engaging in the target behavior. Improving the quality of media campaigns by engaging community stakeholders in selecting messages and delivery methods is an effective strategy in building public health interventions aimed at changing behaviors.

Evaluating tablet computers as a survey tool in rural communities

PURPOSE

Although tablet computers offer advantages in data collection over traditional paper-and-pencil methods, little research has examined whether the 2 formats yield similar responses, especially with underserved populations. We compared the 2 survey formats and tested whether participants' responses to common health questionnaires or perceptions of usability differed by survey format. We also tested whether we could replicate established paper-and-pencil findings via tablet computer.

METHODS

We recruited a sample of low-income community members living in the rural southern United States. Participants were 170 residents (black = 49%; white = 36%; other races and missing data = 15%) drawn from 2 counties meeting Florida's state statutory definition of rural with 100 persons or fewer per square mile. We randomly assigned participants to complete scales (Center for Epidemiologic Studies Depression Inventory and Regulatory Focus Questionnaire) along with survey format usability ratings via paper-and-pencil or tablet computer. All participants rated a series of previously validated posters using a tablet computer. Finally, participants completed comparisons of the survey formats and reported survey format preferences.

FINDINGS

Participants preferred using the tablet computer and showed no significant differences between formats in mean responses, scale reliabilities, or in participants' usability ratings.

CONCLUSIONS

Overall, participants reported similar scales responses and usability ratings between formats. However, participants reported both preferring and enjoying responding via tablet computer more. Collectively, these findings are among the first data to show that tablet computers represent a suitable substitute among an underrepresented rural sample for paper-and-pencil methodology in survey research.

Health literacy: a pathway to better oral health

OBJECTIVES

We examined whether health literacy was associated with self-rated oral health status and whether the relationship was mediated by patient-dentist communication and dental care patterns.

METHODS

We tested a path model with data collected from 2 waves of telephone surveys (baseline, 2009-2010; follow-up, 2011) of individuals residing in 36 rural census tracts in northern Florida (final sample size n = 1799).

RESULTS

Higher levels of health literacy were associated with better self-rated oral health status (B = 0.091; P < .001). In addition, higher levels of health literacy were associated with better patient-dentist communication, which in turn corresponded with patterns of regular dental care and better self-rated oral health (B = 0.003; P = .01).

CONCLUSIONS

Our study showed that, beyond the often-reported effects of gender, race, education, financial status, and access to dental care, it is also important to consider the influence of health literacy and quality of patient-dentist communication on oral health status. Improved patient-dentist communication is needed as an initial step in improving the population's oral health.

Comparative effectiveness of instructional methods: oral and pharyngeal cancer examination

This study compared the effectiveness of different methods of instruction for the oral and pharyngeal cancer examination. A group of thirty sophomore students at the University of Florida College of Dentistry were randomly assigned to three training groups: video instruction, a faculty-led hands-on instruction, or both video and hands-on instruction. The training intervention involved attending two sessions spaced two weeks apart. The first session used a pretest to assess students' baseline didactic knowledge and clinical examination technique. The second session utilized two posttests to assess the comparative effectiveness of the training methods on didactic knowledge and clinical technique. The key findings were that students performed the clinical examination significantly better with the combination of video and faculty-led hands-on instruction (p<0.01). All students improved their clinical exam skills, knowledge, and confidence in performing the oral and pharyngeal cancer examination independent of which training group they were assigned. Utilizing both video and interactive practice promoted greater performance of the clinical technique on the oral and pharyngeal cancer examination.

Contact allergenic potency: correlation of human and local lymph node assay data

BACKGROUND

Effective toxicologic evaluation of skin sensitization requires that potential contact allergens are identified and that the likely risks of sensitization among exposed populations are assessed. By definition, chemicals that are classified as contact sensitizers have the capacity to cause allergic contact dermatitis (ACD) in humans. However, this hazard is not an all-or-nothing phenomenon; clear dose-response relationships can be discerned and thresholds identified for both the induction of sensitization and the elicitation of ACD. Commonly, these parameters are grouped under the heading of potency, the determination of which is vital for risk assessment. Preclinical testing for sensitization potential is critically important for hazard assessment before human exposure. The murine local lymph node assay (LLNA) is the most recently accepted test method for sensitization hazard assessment.

OBJECTIVE

The aim was to compare potency estimations derived from LLNA data with clinical determinations of relative potency based on human data.

METHODS

No-effect levels (NOELs) for a range of 21 chemicals were determined from nondiagnostic human repeat patch test studies as reported in the literature. These levels were compared with LLNA EC(3) values, the estimated concentration required to produce a 3-fold increase (positive response) in draining lymph node cell (LNC) proliferative activity.

RESULTS

Using available human repeat patch test data, together with expert judgment, the compounds were classified as strong, moderate, weak, extremely weak, or nonsensitizing. Additionally, the potency of each chemical was classified independently based on its LLNA EC(3) value. The results show clearly that LLNA EC(3) values are very comparable with the NOELs calculated from the literature. Moreover, the potency rankings based upon LLNA EC(3) data support their human classification.

CONCLUSION

The present investigations show that the LLNA can be used to provide quantitative estimates of relative skin sensitizing potency EC(3) values that correlate closely with NOELs established from human repeat patch testing and from our clinical experience.

Patch testing discordance alert: false-negative findings with rubber additives and fragrances

From July 1996 through June 1998, the North American Contact Dermatitis Group evaluated 318 patients for suspected contact dermatitis by patch testing simultaneously with Finn Chambers and the T.R.U.E. Test allergen system. Discrepancies between the two systems were found in some of the results, particularly with fragrance and rubber allergens. These results suggest that positive reactions to fragrance, thiuram, and carba mix allergens may be missed if the T.R.U.E. Test is used alone.

A preliminary report of the occupation of patients evaluated in patch test clinics

BACKGROUND

The interplay between the occupational environment and worker's skin can result in contact dermatitis of both irritant and allergic types. Other forms of dermatitis can also be influenced by occupational exposures.

OBJECTIVE

The aim of this study is to compare the occupations and allergens of occupational contact dermatitis cases with nonoccupational contact dermatitis cases.

METHODS

Diagnostic patch testing with allergens of the North American Contact Dermatitis Group and occupational coding by the National Institute for Occupational Safety and Health methods.

RESULTS

Of 2,889 patients referred for evaluation of contact dermatitis, 839 patients (29%) were found to have occupational contact dermatitis. Of the 839 cases deemed occupational, 455 cases (54%) were primarily allergic in nature and 270 cases (32%) were primarily irritant in nature. The remaining 14% were diagnoses other than contact dermatitis, aggravated by work. The occupation most commonly found to have allergic contact dermatitis was nursing. Allergens strongly associated with occupational exposure were thiuram, carbamates, epoxy, and ethylenediamine.

CONCLUSION

Some contact allergens are more commonly associated with occupational contact dermatitis. Nursing and nursing support are occupations most likely to be overrepresented in contact dermatitis clinics.

Use of mycophenolate mofetil in the treatment of paraneoplastic pemphigus

Paraneoplastic pemphigus (PNP) is a rare autoimmune blistering disease with circulating antibodies that bind the cell surface of the epidermis and other non-stratifying epithelia, and immunoprecipitate a complex of four or five proteins (250 kDa, 230 kDa, 210 kDa, 190 kDa and occasionally 170 kDa).1,2 Combinations of immunosuppressive agents are usually required to obtain even partial control of the skin lesions.3 Mucous membrane lesions are refractory to treatment. We describe a patient with PNP whose skin and oral lesions are quiescent following treatment with oral mycophenolate mofetil.

Pemphigus foliaceus successfully treated with mycophenolate mofetil as a steroid-sparing agent

Pemphigus foliaceus is an autoimmune blistering disease of unknown origin with antibodies produced against desmoglein 1, an adhesive protein found in the desmosomal cell junction in the suprabasal layers of the epidermis. The disease is primarily treated with corticosteroids and corticosteroid-sparing immunosuppressive agents. We report a case of pemphigus foliaceus successfully treated with mycophenolate mofetil. It remains to be seen whether this agent has a significant effect on the course of the disease and remission induction.

Prevention of sodium lauryl sulfate irritant contact dermatitis by Pro-Q aerosol foam skin protectant

Eczematous skin disease is a serious work-related illness. Since 1995, reimbursement by insurance companies for treatment of skin diseases has become the largest cost source in some countries. This study was a randomized controlled trial (N = 20) of the efficacy of Pro-Q, a skin protectant product, in the prevention of contact dermatitis from sodium lauryl sulfate and urushiol, the resinous sap of poison ivy and poison oak. Pro-Q was significantly effective in reducing the irritation from sodium lauryl sulfate but did not prevent the allergic reaction to urushiol.

An environmental hazard assessment of low-level dermal exposure to hexavalent chromium in solution among chromium-sensitized volunteers

To evaluate the potential for elicitation of allergic contact dermatitis from contact with standing water in the environment, 26 persons known to be allergic to hexavalent chromium [Cr(VI)] were exposed to 25 to 29 mg/L Cr(VI) by immersion of one arm for 30 minutes per day on 3 consecutive days in a potassium dichromate bath. Sixteen of the 26 volunteers demonstrated either no or an equivocal response to the Cr(VI) challenge. Ten of the volunteers developed a few papules or vesicles (1 to approximately 15), mild redness, and pruritus on the Cr(VI)-challenged arm. Histopathological examination of the papules revealed spongiosis and perieccrine and perivascular inflammation. The responses were diagnosed as acute perieccrine reactions. It was concluded that exposure to similar concentrations of Cr(VI) in the environment does not pose an allergic contact dermatitis hazard, even to Cr-sensitized persons.

Sweet's syndrome and erythema nodosum: the simultaneous occurrence of 2 reactive dermatoses

BACKGROUND

The simultaneous occurrence of Sweet's syndrome (SS) and erythema nodosum (EN) in 1 patient is rare. Our review of the literature revealed only 11 biopsy-proved cases in which the 2 reactive dermatoses occurred together. None were associated with an underlying malignant neoplasm.

OBSERVATIONS

We report a biopsy-proved case of SS and EN occurring simultaneously in a patient with an underlying malignant neoplasm (specifically, acute myelogenous leukemia). We also report another biopsy-proved case of SS and EN occurring simultaneously in a patient with underlying Crohn's disease.

CONCLUSIONS

The simultaneous occurrence of SS and EN in 1 patient is rarely reported. Both disorders are reactive dermatoses that share many overlapping features. Although individually distinctive, SS and EN are also part of a growing continuum of reactive dermatoses. Our expanded understanding of the similarities and simultaneous manifestation of SS and EN may help us in the future to identify a common underlying mechanism of pathogenesis.

Allergic contact dermatitis to preservatives in topical medicaments

BACKGROUND

Formaldehyde-releasing preservatives are well-known allergens found in many topical preparations including medications.

OBJECTIVE

To analyze the relevance of a positive patch test to formaldehyde-releasing preservatives in medications containing these preservatives.

METHODS

Patients were recruited with a history of allergy to one of these preservatives. Patch and use testing to the medications, vehicles, and preservatives were performed. The following medications and their respective preservatives were used: Renova 0.05% cream/quaternium-15, Dovonex 0.005% cream/diazolidinyl urea, and Temovate-E 0.05% cream/diazolidinyl urea.

RESULTS

Nine patients participated in the study. A positive patch test to the preservative was reproduced in six of nine patients, and a questionable reaction occurred in one. Two patients had a positive patch test to the topical medication and one a questionable reaction. There were no definitive positive patch tests to the vehicle but two questionable ones. Use testing revealed three positive reactions to Renova, one to Renova vehicle, and one to Temovate-E vehicle.

CONCLUSIONS

The concentration of the preservative in the commercial preparation was often below the threshold necessary to produce a clinical reaction. Use testing is a valuable tool in the complete evaluation of the patient with a positive patch test to a formaldehyde-releasing perservative found in topical medication.

North American Contact Dermatitis Group patch test results for the detection of delayed-type hypersensitivity to topical allergens

BACKGROUND

Allergic contact dermatitis is a significant cause of cutaneous disease affecting many individuals. Patch testing, when used properly, often provides support for the diagnosis of allergic contact dermatitis.

OBJECTIVE

This article reports patch testing results from July 1, 1994, to June 30, 1996, by the North American Contact Dermatitis Group (NACDG).

METHODS

Patients evaluated in our patch test clinics were tested with the same screening series of allergens by the use of a standardized patch testing technique. The data from these patients were recorded on a standard computer entry form and analyzed.

RESULTS

Forty-nine allergens were tested on 3120 patients. Budesonide was added to the series in July 1995 and tested on 1678 patients. Of these patients, 66.5% had positive allergic patch test reactions, and 57% had at least one allergic reaction that was felt to be clinically relevant to the present or past dermatitis. The 20 screening allergens commercially available to United States dermatologists in the Allergen Patch Test Kit, accounted for only 54.1% of the patients with positive allergic reactions. The additional 30 allergens on the NACDG screening series accounted for 47% of patients with positive allergic reactions. Had the Allergen Patch Test Kit alone been used, 12.4% of all patients tested may have had their disease misclassified as a nonallergic disorder, and an additional 34.4% of all tested patients would not have had their allergies fully defined. Among those patients with positive responses to the supplemental allergens, 81% of the responses were of present or past relevance. The 12 most frequent contact allergens were nickel sulfate, fragrance mix, thimerosal, quaternium-15, neomycin sulfate, formaldehyde, bacitracin, thiuram mix, balsam of Peru, cobalt chloride, para-phenylenediamine, and carba mix. The present relevance varied with the specific allergen from 10.7% (thimerosal) to 85.7% (quaternium-15). Among newer allergens, methyldibromoglutaronitrile/phenoxyethanol (cosmetic preservative) caused positive allergic reactions in 2% of the patients; tixocortol-21-pivalate and budesonide (corticosteroids), in 2.0% and 1.1% of the patients, respectively; and ethylene urea/melamine formaldehyde mix (textile resin), in 5% of the patients.

CONCLUSION

The usefulness of patch testing is enhanced with the number of allergens tested, because allergens not found on the commercially available screening series in the United States frequently give relevant allergic reactions.

Prevalence of occupationally related hand dermatitis in dental workers

Occupationally related hand dermatitis has been attributed to frequent hand-washing, exposure to possible sensitizers and latex glove use. The authors conducted a study to determine the prevalence of occupationally related hand dermatitis in dental personnel. They found that 75 (19.2 percent) of 390 subjects self-reported they had a positive history of hand dermatitis. Further testing of 53 of these subjects indicated that only 9.4 percent reacted to the 45 allergens tested, and 3.8 percent had an allergy to latex.

Treatment of poison ivy/oak allergic contact dermatitis with an extract of jewelweed

BACKGROUND

Jewelweed (Impatiens biflora) is a plant which has been used for centuries for the treatment of poison ivy/oak allergic contact dermatitis. Numerous claims for its effectiveness exist in the lay press, and over-the-counter medicaments containing jewelweed are reputed to be an effective remedy for poison ivy/oak dermatitis. Despite these claims, few scientific studies testing the effectiveness of jewelweed have been performed.

OBJECTIVE

Our objective in this pilot study was to test the efficacy of an extract of jewelweed in the treatment of experimentally induced allergic contact dermatitis to poison ivy/oak.

METHODS

A randomized, double-blinded, paired comparison investigation was performed. Ten adult volunteers were patch tested to urushiol, the allergenic resin in poison ivy/oak. For each volunteer, one patch test site was treated with an extract prepared from the fresh stems of jewelweed; the remaining site was treated with distilled water to serve as a control. Sites were examined on days 2, 3, 7, and 9 with reactions graded on a numerical scale.

RESULTS

All subjects developed dermatitis at each patch test site. There was no statistically significant difference in the objective scores at the sites treated with jewelweed extract versus the distilled water control sites.

CONCLUSION

This study demonstrated that an extract of jewelweed was not effective in the treatment of poison ivy/oak allergic contact dermatitis.

Betaxolol-associated hyperpigmentation of the fingers in a patient with unrelated contact dermatitis

Betaxolol ophthalmic solution has been associated with periocular skin hyperpigmentation. We report a case of a woman with hyperpigmentation of the fingers associated with oral betaxolol. Based on case reports associated with the topical ophthalmic product, we believe the hyperpigmentation was likely caused by oral betaxolol.

Dermatoses among housekeeping personnel

BACKGROUND

Housekeepers are exposed to irritants and allergens in their work and are at significant risk for developing occupationally induced contact dermatitis.

OBJECTIVE

We studied housekeepers at the Hershey Medical Center to determine the cause and frequency of contact dermatitis and contact urticaria in these workers.

METHODS

All housekeepers were examined. Those with hand dermatitis had an extensive history, patch testing, and latex RAST testing.

RESULTS

Eight of 130 had hand dermatitis. None had a relevant positive patch test or positive RAST test.

CONCLUSIONS

Of our housekeepers, 6.2% had occupationally induced irritant contact dermatitis. None had allergic contact dermatitis or contact urticaria to latex.

Prevention of poison ivy and poison oak allergic contact dermatitis by quaternium-18 bentonite

BACKGROUND

Poison ivy and poison oak are the most common causes of allergic contact dermatitis in North America.

OBJECTIVE

We investigated whether a new topical lotion containing 5% quaternium-18 bentonite prevents experimentally induced poison ivy and poison oak allergic contact dermatitis.

METHODS

A single-blind, paired comparison, randomized, multicenter investigation was used to evaluate the effectiveness and safety of quaternium-18 bentonite lotion in preventing experimentally induced poison ivy and poison oak allergic contact dermatitis in susceptible volunteers. One hour before both forearms were patch tested with urushiol, the allergenic resin from poison ivy and poison oak, 5% quaternium-18 bentonite lotion was applied on one forearm. The test patches were removed after 4 hours and the sites interpreted for reaction 2, 5, and 8 days later. The difference in reactions between treated and untreated patch test sites was statistically analyzed.

RESULTS

Two hundred eleven subjects with a history of allergic contact dermatitis to poison ivy and poison oak were studied. One hundred forty-four subjects had positive reactions to urushiol. The test sites pretreated with quaternium-18 bentonite lotion had absent or significantly reduced reactions to the urushiol compared with untreated control sites (p < 0.0001) on all test days. When it occurred, the reaction consistently appeared later on treated than on control sites (p < 0.0001). One occurrence of mild, transient erythema at the application site was the only side effect from the quaternium-18 bentonite lotion.

CONCLUSION

Quaternium-18 bentonite lotion was effective in preventing or diminishing experimentally produced poison ivy and poison oak allergic contact dermatitis.

Epidemiology of hand dermatitis in dental personnel

BACKGROUND

Dental personnel are prone to frequent bouts of hand dermatitis. This has been attributed to hand washing, occupational exposure to a multitude of possible sensitizers, and frequent latex glove use. There has been some conflict in the literature as to the true frequency of allergic contact dermatitis in dental personnel.

OBJECTIVE

The purpose of this investigation was to quantify the frequency of allergic contact dermatitis and contact urticaria in a large group of Air Force dental personnel.

METHODS

Four hundred forty-nine dental personnel were surveyed for hand dermatitis. Positive responders were interviewed and examined. Patients with histories most consistent with allergic contact dermatitis were patch tested to a standard and a dental tray.

RESULTS

Of the 449 personnel completing our survey, 169 had a positive history of hand dermatitis. One hundred twenty of these were interviewed and examined, of which 27 patients gave a history most consistent with allergic contact dermatitis and were subjected to patch testing. Only 3 patients had relevant positive reactions to the allergens on the standard or dental trays. All others (93) were diagnosed with irritant contact dermatitis. None had contact urticaria to latex.

CONCLUSION

The frequency of hand dermatitis in our dental personnel is consistent with that in other published studies (37.6%). The majority of hand dermatitis occurring in this group is due to irritant contact dermatitis; the frequency of allergic contact dermatitis is very low (0.67%). None had contact urticaria.

Designing a biological monitoring program to assess community exposure to chromium: conclusions of an expert panel

The possible benefits of biological monitoring of large groups of people potentially exposed to environmental contaminants has become an area of much interest in recent years. Because chromite-ore processing residue has been found in some soils in northern New Jersey, urinary chromium monitoring of people in the community was evaluated as a potentially useful tool. In an attempt to identify those who could be exposed and to quantify the magnitude of exposure to the chromium in these soils, the New Jersey Department of Health (NJDOH) initiated a public health screening project. In 1992, the NJDOH proposed to evaluate over 4000 people who lived or worked near these sites. Volunteers were administered a questionnaire and were given a limited physical examination, and a single spot urine sample was collected. Because of the difficulties in using urinary chromium to assess low-level exposure and the potential implications of any regulatory decisions that could be based on the results of this project, a panel of experts was convened to evaluate the protocol. The panel consisted of five scientists and physicians with expertise in toxicology, dermatology, epidemiology, biological monitoring, and analytical chemistry. Like a World Health Organization group, the panel concluded that although urine biomonitoring can be useful in evaluating high levels of exposure to chromium, it is not reliable for assessing low-level exposure similar to that which may have occurred in northern New Jersey. The panel also noted that when urinary biomonitoring is to be used to assess the public's possible exposure, a large number of precautions must be taken to ensure the accuracy and usefulness of the results. The single most important recommendation was to collect a second, and perhaps a third, spot urine (or 24-h urine) sample before concluding that a person may be routinely overexposed. These suggestions are applicable to designing a biomonitoring program for nearly any environmental contaminant to which a community may be exposed. A review of scientific literature associated with biological monitoring of chromium is provided.

A clinical and pathologic study of histiocytosis X in adults

BACKGROUND

Histiocytosis X is a neoplastic disorder of Langerhans cells that usually occurs in children. Because histiocytosis X rarely occurs in adults, the diagnosis can frequently be missed by both clinicians and pathologists.

OBJECTIVE

The purpose of this investigation was to characterize the clinical and pathologic findings of histiocytosis X in adults.

METHODS

A retrospective study of four adults with histiocytosis X was undertaken. Paraffin-embedded biopsy specimens were stained with a panel of antibodies including S-100, vimentin, Ham-56, leukocyte common antigen, proliferating cell nuclear antigen (PCNA), UCHL-1, CD43, and Ki-1.

RESULTS

The predominant lesions were papules and pustules that usually involved the groin, axilla, and scalp. Histologically the infiltrate exhibited a periappendageal distribution. Strong positive staining for PCNA appeared to correlate with the clinical course.

CONCLUSION

Histiocytosis X in adults has a predilection for skin sites rich in appendages and histologically shows a periappendageal infiltrate. PCNA staining of the histiocytes may indicate progressive disease and serve as a useful prognostic marker.

American Academy of Dermatology Patch Testing Survey: use and effectiveness of this procedure

The results of an American Academy of Dermatology (AAD)-sponsored survey on the use and effectiveness of patch testing are presented. Academy members' responses indicate that 27% do not patch test at all. Reasons given for not testing included (1) the patient history was adequate for diagnosis, (2) patch testing was too time-consuming, and (3) reimbursement was not sufficient. Dermatologists in residency training programs who responded to a similar survey are testing frequently and report a high degree of positivity and relevancy among tests applied. Recommendations are presented with a focus toward increasing interest in patch testing among the membership.

Frequency of postoperative allergic contact dermatitis to topical antibiotics

BACKGROUND AND DESIGN

Topical antibiotics are one of the most common causes of allergic contact dermatitis and are frequently used in postoperative wound care. We prospectively followed up patients having cutaneous surgery to determine the frequency of allergic contact dermatitis to topical antibiotics used on postoperative wound care.

RESULTS

Nine (4.2%) of 215 patients who had undergone surgery who were using a topical antibiotic had an eruption develop postoperatively that was consistent with an allergic contact dermatitis from the topical antibiotic. Seven of the nine patients agreed to patch testing with the standard tray and selected topical antibiotics. Five patients had a positive patch test to neomycin sulfate and four had a positive patch test to bacitracin. The frequency of allergic contact dermatitis proved by patch testing to neomycin and bacitracin is five (5.3%) of 94 and four (2%) of 198, respectively, in the patients who used these antibiotics. All proved sensitivities to bacitracin occurred in patients using a topical antibiotic that also contained neomycin and were patch tested positive to the neomycin. No patients using only pure bacitracin had allergic contact dermatitis.

CONCLUSIONS

Allergic contact dermatitis to a topical antibiotic, especially neomycin, should be considered in any patient who has development of a dermatitis after cutaneous surgery. Because of the frequency of allergic contact dermatitis, neomycin-containing antibiotics should be avoided in postoperative wound care.

Methylchloroisothiazolinone-methylisothiazolinone reactions in patients screened for vehicle and preservative hypersensitivity

More than 1100 patients were tested with methylchloroisothiazolinone-methylisothiazolinone, 100 ppm, in aqueous and petrolatum-based patch test materials from 1985 to 1987 by members of the North American Contact Dermatitis Group. Thirteen reactions to the aqueous materials and 10 to the petrolatum-based materials were observed. Irritant reactions were infrequent, and about half the reactions were deemed relevant. From 1984 to 1985, patch tests with this substance at a concentration of 250 ppm in petrolatum were conducted. Thirteen persons were identified as allergic, but three others were sensitized by the patch test procedure. Sensitization as not observed in tests with aqueous or petrolatum-based substance at a concentration of 100 ppm, and this concentration appears to be the best compromise between safety and sensitive detection of allergy. Use tests are helpful but not infallible as a guide in establishing relevance with methylchloroisothiazolinone-methylisothiazolinone. Wash-off products are frequently well tolerated by patients with positive reactions to this substance.

Allergic contact dermatitis to nasturtium

In conclusion, oil of mustard, contained in many plants and recognized mainly as a skin irritant, is also capable of causing an allergic contact dermatitis. Nasturtium, which contains mustard oil, should be added to the list of plants capable of causing this dermatitis and must be suspected in any patient who handles plants and presents with hand dermatitis.

Dermatoses among floral shop workers

Concern about the increasing incidence of hand dermatitis in floral shop workers in the United States and its possible association to the plant Alstroemeria, a flower that has become popular since its introduction in 1981, prompted investigation of the prevalence and cause of hand dermatitis in a sample of floral workers. Fifty-seven floral workers were surveyed, and 15 (26%) reported hand dermatitis within the previous 12 months. Sixteen floral workers (eight with dermatitis) volunteered to be patch tested to the North American Contact Dermatitis Group Standard and Perfume Trays, a series of eight pesticides and 20 plant allergens. Of four of seven floral designers and arrangers who reported hand dermatitis, three reacted positively to patch tests to tuliposide A, the allergen in Alstroemeria. Patch test readings for all other plant extracts were negative. A positive reading for a test to one pesticide, difolatan (Captafol), was noted, the relevance of which is unknown.

Treatment of apocrine chromhidrosis with topical capsaicin

A 30-year-old white woman with facial apocrine chromhidrosis was treated successfully with topical capsaicin once or twice daily. Paired comparison of treated versus untreated sides and active drug-treated versus vehicle-treated sides showed suppression of the chromhidrosis only when capsaicin was used. After treatment was discontinued, the chromhidrosis returned within 2 days.

Hyposensitization to poison ivy after working in a cashew nut shell oil processing factory

19 adults were patch tested to urushiol, the allergen in poison ivy/oak, to determine their sensitivity to this allergen after working in a cashew nut shell oil (CNSO) processing plant. The cashew nut tree and poison ivy/oak are in the same botanical family. Anacardiaceae, and they share similar chemicals which cause allergic contact dermatitis. 13 of the 19 workers had a preemployment history of poison ivy sensitivity, with 10 developing CNSO dermatitis. After working in this factory for several months, 9 of the 13 noticed a decreased sensitivity or no sensitivity to poison ivy/oak. When tested to urushiol extract, only 3 reacted positively, 2 minimally. These results imply that hyposensitization to poison ivy/oak occurred in these employees after development of hardening to cashew nut shell oil.

Milk tester's dermatitis

Hand dermatitis is a frequent problem among workers in milk testing laboratories. An epidemiologic study was conducted at the Pennsylvania Dairy Herd Improvement Association Milk Testing Laboratory, where more than 300,000 milk samples are examined monthly for protein, butterfat, and "somatic" cells. These samples are preserved with potassium dichromate for transport from the farm to the laboratory. A survey of the laboratory was conducted and workers were interviewed. Eight of 16 subjects reported a history of occupationally exacerbated hand dermatitis. Three of 16 subjects had positive patch test results to potassium dichromate. Two of 15 subjects who underwent patch testing to milk preserved with potassium dichromate had positive reactions. None reacted to milk alone, bronopol, or Kathon CG. Two workers are receiving workers' compensation because of severe allergic contact dermatitis of the hands to potassium dichromate. We conclude that milk testing laboratory workers are at substantial risk for acquiring allergic contact dermatitis from milk preserved with potassium dichromate.

Allergic contact dermatitis to Alstroemeria

Two female florists developed dermatitis of the fingertips. Patch testing revealed allergic contact dermatitis to the flower, Alstroemeria, used in floral arrangements. They had positive patch tests to portions of Alstroemeria, and to tuliposide A, the allergen in this plant. Vinyl gloves were not helpful since tuliposide A readily penetrates through these gloves. Nitrile gloves may be protective since they prevented positive patch test to tuliposide A.

Dermatologic problems of office workers

Occupational dermatoses among office personnel are infrequent. Nevertheless, the dermatologist should be aware of the various suspected causes of these dermatoses (poor ventilation, visual display terminals, paper, etc.), since some patients will attribute their cutaneous as well as extracutaneous symptoms to office work.

Acyclovir resistance in a patient with chronic mucocutaneous herpes simplex infection

Chronic cutaneous herpes simplex virus infection is described in a 68-year-old man who was immunocompromised because of chronic lymphocytic leukemia. The herpes infection was not amenable to therapy with acyclovir. Clinical isolates of herpes simplex virus were assessed for viral thymidine kinase activity, which was markedly decreased in two isolates. By the method of viral plaque autoradiography, these isolates were determined to be composed primarily of mutant thymidine kinase-negative herpes simplex virus mixed with occasional standard thymidine kinase-positive herpes simplex virus. Viral plaque autoradiography permitted the quantitation of proportions of thymidine kinase-negative and thymidine kinase-positive herpes simplex virus in the mixed virus populations. The chronic cutaneous infection persisted, unlike other reported infections by thymidine kinase-negative herpes simplex virus.

Changes in lymphocyte and Langerhans cell populations in allergic and irritant contact dermatitis

We observed in situ changes in lymphocyte subpopulations and Langerhans cells during allergic and irritant contact dermatitis using immunohistochemical staining methods with monoclonal antibodies to cell surface antigens. In both types of contact dermatitis, there was a perivascular infiltrate of T lymphocytes, with helper/inducer T cells predominating. B cells were absent, and natural killer cells were absent or sparse. During the course of allergic contact dermatitis, Langerhans cells showed a striking sequential change in location, with the cells first in the epidermis, then perivascularly in the dermis (days 1-14), and returning to the epidermis (days 14-21). In irritant contact dermatitis, the Langerhans cells were initially identified in the epidermis and then appeared diffusely in the dermis (days 1-2). The numbers in the dermis then decreased abruptly (day 4). They were again identified in normal numbers in the epidermis (day 21). The response of Langerhans cells appears to be different between allergic and irritant contact dermatitis.

PA Patch--a new patch testing device. Preliminary report

The PA Patch, a new multiple-antigen, predispensed patch testing device, was compared to the Finn Chamber in subjects with previous positive patch tests. After pressing the PA Patch well, the PA Patch performed as well as the Finn Chamber in nine subjects tested.