Standard and Expanded Series Patch Testing Update by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC)

After the meeting held by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) back in October 2021, changes were suggested to the Spanish standard series patch testing. Hydroxyethyl methacrylate (2% pet.), textile dye mixt (6.6% pet.), linalool hydroperoxide (1% pet.), and limonene hydroperoxide (0.3% pet.) were, then, added to the series that agreed upon in 2016. Ethyldiamine and phenoxyethanol were excluded. Methyldibromoglutaronitrile, the mixture of sesquiterpene lactones, and hydroxyisohexyl 3-cyclohexene (Lyral) were alo added to the extended Spanish series of 2022.

Disseminated lymphangiomas as a cutaneous manifestation of Noonan syndrome

Lymphangioma is a known, but rare manifestation of Noonan syndrome. We present the case of disseminated and circumscribed cutaneous lymphangiomas in the context of Noonan syndrome. Oral rapamycin is a promising treatment in these extensive and morbidity-causing cases.

Is p-Phenylenediamine Still a Prevalent Contact Allergen in Spain?

OBJECTIVES

To analyze trends in the prevalence of contact sensitization to p-phenylenediamine between 2004 and 2014, taking into consideration that the concentration of this product in cosmetics was regulated in 2009. To explore risk factors for contact allergy to p-phenylenediamine.

MATERIAL AND METHODS

Retrospective observational study of patients suspected of having contact dermatitis from allergy to p-phenylenediamine during the years between 2004 and 2015 in 8 tertiary level hospitals. The patients underwent patch testing (TRUE-test) with the standard series of the Spanish Research Group on Contact Dermatitis and Skin Allergies. This series included p-phenylenediamine 1%. We followed international recommendations for the statistical analysis of data related to contact allergies.

RESULTS

Three hundred eighty-six out of 9341 patients (4.1%) had positive reactions to p-phenylenediamine. The prevalence tended to decrease in the early years (2004-2007) and then leveled off at around 4%. Risk factors for developing contact dermatitis from p-phenylenediamine were sex, age over 40 years, multiple sensitivities, and profession, notably workers in hair salons and those who handle rubber and plastics.

CONCLUSIONS

The prevalence of p-phenylenediamine allergy remains high among patients with contact eczema. Risk factors for p-phenylenediamine contact allergy are consistent with previous reports.

Is it Useful to Calculate Minimal Erythema Dose Before Narrowband UV-B Phototherapy?

INTRODUCTION AND OBJECTIVES

The starting dose for narrowband UV-B phototherapy is determined by a patient's skin phototype or minimal erythema dose (MED). Calculation of MED identifies patients with unsuspected photosensitivity. The aim of this study was to investigate the influence of factors such as concomitant use of photosensitizing agents, diagnosis, and combination with acitretin in patients with psoriasis on the frequency and severity of adverse effects in patients with a low MED to narrowband UV-B phototherapy.

MATERIAL AND METHODS

We undertook a retrospective observational cohort study between February 1, 2009 and March 31, 2015. MED values were classified as normal or low.

RESULTS

In total, 302 patients with different skin conditions started narrowband UV-B phototherapy at a dose determined by their MED. No differences were found between patients with a low MED and those with a normal MED for number of drugs taken (P=.071) or use of photosensitizing agents (P=0.806). Following adjustment for age, sex, and phototype, the multivariate analysis showed that psoriasis exerted a protective effect against a low MED (OR=0.31 [95% CI, 0.16-0.58]). No significant risk of erythema or pruritus was detected in patients with a low MED (OR=1.68; 95% CI, 0.91-3.29 and OR=2.04; 95% CI, 0.99-4.22, respectively).

CONCLUSIONS

Psoriasis protects against a low MED. Although erythema and pruritus were more common in patients with a low MED, the differences were not significant.

[Importance of epidemiologic surveillance in contact dermatitis: Spanish surveillance system on contact allergies]

The high prevalence of contact dermatitis means that this common medical problem has considerable personal, societal, and economic impact. Clinical and epidemiologic research is needed if we are to shed light on the real situation of contact dermatitis in Spain. In this article we will look at epidemiologic research from a practical point of view and analyze the role of the dermatologist in planning and designing studies. The advantages of multicenter studies are discussed, along with the roles of national and international surveillance networks. We present the Spanish Surveillance System on Contact Allergies, which serves as a bridge between Spanish dermatologists and the European Surveillance System on Contact Allergies. The present and future aims of the Spanish network are described.

[Results and assessment of photopatch testing in Spain: towards a new standard set of photoallergens]

INTRODUCTION

While the standardization of exploration with photoallergy tests or photopatch testing runs its course in Europe, we have carried out an epidemiological study about the current situation of photoallergy in our country.

MATERIAL AND METHODS

We have gathered the results of photopatch testing in seven hospital centres of Madrid, Cataluña, Galicia and Comunidad Valenciana during the years 2004 and 2005. The exploration has included, at least, the standard set of the Spanish Photobiology Group (GEF), with 16 (photo) allergens, that have been irradiated with 10 joules/cm(2). We have assessed the total number of explored patients, their sex, present, past or unknown relevance of positive photopatch testing, cross reactions, and allergens responsible for photosensitization.

RESULTS

Of 224 patients explored by photopatch testing, 39.3 % show one or more positive tests. Seventy-one percent (103) were considered relevant with respect to clinical history, 14 cases (9.6 %) were cross reactions, and 28 (19.3 %) were considered of unknown relevance. The most prevalent allergens were nonsteroidal antiinflammatory drugs, specially ketoprophen (43 patients), followed by bencydamine (7 patients) and etofenamate (5 patients). The mixture of four sunscreens from the standard set of the GEF only detected 10 of 16 patients with photoallergy to sunscreens. Photopatch testing of unknown relevance was mainly due to antiseptics (fenticlor) and topical antihistamines.

CONCLUSIONS

We propose the modification of the standard set of photoallergens from the GEF, that should include the majority of nonsteroidal antiinflammatory drugs and sunscreens available in Spain. Ketoprophen continues to be the most frequent photoallergen in our country. It is also important for the cross sensitizations that may present. Sunscreens should be explored separately and not in form of a mixture.

Multiple myeloma with scleroderma-like changes

We present a case of a patient who presented concomitantly with generalized pruritus, brownish sclerodermatous plaques, sclerodactyly and a monoclonal band for IgG-kappa. The patient was diagnosed as having multiple myeloma by bone marrow examination. The rapidly progressive evolution with acute anuric renal failure, malignant hypertension and the skin sclerosis seem to be related to the neoplastic disorder. The scleroderma-like changes have to be differentiated from systemic scleroderma.

[Hypomelanosis of Ito. A possibly under-diagnosed heterogeneous neurocutaneous syndrome]

INTRODUCTION

Hypomelanosis of Ito (HI) or incontinentia pigmenti achromians is a multisystemic neurocutaneous disorder that is associated to neurological complications in a high percentage of patients.

AIMS

The purpose of this study is to review the most significant features in a series of 14 patients with HI.

PATIENTS AND METHODS

We conducted a retrospective study in which the following data were analysed: age, sex, familial and personal history, clinical features and complementary explorations that were carried out. We report the cases of nine females and five males aged between 4 months and 14 years.

RESULTS

All the patients presented neurological anomalies, including psychomotor or mental retardation in 11 (associated to autistic behaviour in two of them), neuroradiological anomalies in seven, microcephalus in three and epileptic seizures in two. Other significant complications were musculoskeletal and ocular anomalies (each of which were present in nine patients), dental disorders in six, coarse facies and dysmorphic ears in four patients, hypoacusis in five and congenital heart disease in two. The following were also observed, but as isolated events: choanal atresia, cleft palate, segmental dilatation of the colon, cryptorchidism, inguinal hernia, low height, vesicoureteral reflux and premature pubarche.

CONCLUSIONS

There is no biological marker that identifies HI and a number of clinical forms only appear in the skin in a very mild form, which means they sometimes going unnoticed or are not considered to be important enough to establish a diagnosis. This entity may, therefore, be more frequent than we think and its prevalence is perhaps underestimated.

Granulomatous folliculitis at sites of herpes zoster scars: Wolf's isotopic response

Cutaneous eruptions described on herpes zoster scars are variable. We present a case of granulomatous folliculitis occurring 4 weeks after an episode of herpes zoster infection in a woman with cutaneous T-cell lymphoma. The pathogenesis of the lesions remains unclear. The viral genome was detected only in early lesions.

Case Reports. Pityriasis amiantacea as manifestation of tinea capitis due to Microsporum canis

We report three patients, two infants and an adult, in whom their tinea capitis clinically appeared as pityriasis amiantacea. The mycological studies showed infection due to Microsporum canis in all cases. Correct diagnosis as well as adequate antimycotic chemotherapy of this atypical manifestation of tinea capitis remain a challenge to the clinician. Epidemiological aspects must be regarded also.

Expression of growth hormone receptor in benign and malignant cutaneous proliferative entities

The skin has the necessary elements to respond to growth hormone (GH) and suffers clinical changes in the pathological circumstances of excess and deficiency of GH. The GH has been involved in the development of different types of human neoplasms. Based on these data, we have studied the GH receptor (GHR) expression in acrochordons, seborrheic keratosis, melanocytic nevi, histiocytomas, squamous cell carcinomas, basal cell carcinomas, and malignant melanomas by means of the immunohistochemistry with the monoclonal antibody MAb 263. All the entities showed immunoreactivity for GHR. In the histiocytomas, the expression of GHR in the keratinocytes of the hyperplastic epidermis coating the lesion showed a strong nuclear pattern, but the non-hyperplastic epidermis of the edges of the histiocytomas expressed GHR with a cytoplasmic pattern. In the basal cell carcinoma and squamous cell carcinoma, the immunoreactivity was weaker than in normal skin. In the squamous cell carcinoma, the intensity of immunostaining correlated directly with the grade of cellular differentiation. In conclusion, the GH may be involved in the development of different kinds of cutaneous neoplasms, and the intracellular localization of GHR may imply a functional significance, at least in the histiocytomas.

Three cases of type 2 segmental manifestation of multiple glomus tumors: association with linear multiple trichilemmal cysts in a patient

We report 3 cases of congenital multiple glomus tumors seen during the last 5 years. One of them showed autosomal dominant inheritance with male-to-male transmission. The remaining patients had no family history of similar lesions. The clinical and histopathological aspects of our patients support the recently described type 2 segmental manifestation of multiple glomus tumors. One of the cases showed associated multiple and giant trichilemmal cysts with a linear distribution in the scalp.

Unilateral psoriasis: a case individualized by means of involucrin

Several authors have questioned the existence of unilateral (linear) psoriasis. These authors have suggested that the condition is actually an inflammatory linear verrucous epidermal nevus, or the result of an isomorphic effect on a pre-existing epidermal nevus. We report the case of a 25-year-old man, with no relevant personal or family history, who presented with a number of pruritic, punctiform erythematosquamous lesions that were linearly distributed over the left side of the body. Clinical examination and results of histopathologic and histochemical studies indicated unilateral psoriasis. Our findings confirm that involucrin immunohistochemistry can be a useful diagnostic tool in cases of this type. Treatment with keratolytics and topical calcipotriol led to a significant, but only temporary, improvement.

Eccrine angiomatous hamartoma: report of seven cases

Eccrine angiomatous hamartoma is a rare cutaneous lesion. Histologically it is characterized by the proliferation of eccrine glands, vascular structures and occasionally other elements in the middle and deep dermis; we now report seven further cases of this condition, two with lipomatous involvement and also discuss its nosology.

Milia en plaque in a bilateral submandibular distribution

Milia en plaque typically occurs in the retroauricular area. We report the case of an 84-year-old woman with this disorder occurring bilaterally in the submandibular region. The diagnosis was confirmed by histological examination.

Cellular and subcellular distribution of 7B2 in porcine Merkel cells

BACKGROUND

Merkel cells are neuroendocrine cells located in the skin and oral mucosa of various mammalian species. These cells express multiple peptides as well as serotonin. Although the precise function of Merkel cells is still unknown, different studies support its role as mechano-electric transducer. 7B2 granin (secretogranin V) is a polypeptide isolated from the pituitary gland and present in the dense-cored granules of neuronal and paraneuronal cells.

METHODS

The expression of the 7B2 in Merkel cells of pig snout skin was analysed by immunohistochemical techniques. The streptavidin-biotin peroxidase complex procedure was employed for light microscopy. A postembedding method using immunoglobulin-colloidal gold complexes was employed for the ultrastructural studies.

RESULTS

Immunoreactivity for 7B2 was observed in virtually all Merkel cells, both in epidermis and vibrissae. The immunostaining was shown in the basal side of cytoplasms where neuroendocrine granules were accumulated. Immunoelectron microscopy allowed us to demonstrate that 7B2 labelling was located on the electrondense granules. Nuclei and epidermal nerve terminals associated with merkel cells did not show immunoreactivity.

CONCLUSIONS

The polypeptide 7B2 is present in the dense-cored granules of Merkel cells. This result is consistent with the possible role for 7B2 in secretory granules' processing. To our knowledge this is the first evidence of 7B2 protein in Merkel cells.

Plantar infection by Scopulariopsis brevicaulis

A 42-year-old woman presented with a well-defined pruritic erythematous scaly plaque on the sole of each foot. The lesions, first noted about 15 years previously, were located in the medial plantar region and extended laterally. Mycological study revealed infection by Scopulariopsis brevicaulis. Treatment with oral itraconazole led to temporary improvement, but the symptoms returned after treatment had been stopped (presumably due to re-infection from ungual foci). Similar results were subsequently obtained with oral terbinafine. S. brevicaulis is an aetiologic agent of onychomycosis, panophthalmia following a penetrating eye injury and generalized infections in immunocompromised patients, but it is not considered as habitual fungal pathogen of the skin. Cutaneous lesions caused by S. brevicaulis are very rare. Our case was resistant to terbinafine and itracomazole.

Sarcoid-like granuloma following prolonged etretinate treatment

We report on a patient in whom prolonged therapy with etretinate was associated with the appearance of disseminated nodules, whose histopathologic study showed a sarcoid-like granuloma. Although the role of etretinate in the occurrence of this granulomatous reaction is not proven, we speculate on possible mechanisms of such a link.

Cutaneous manifestations in Kartagener's syndrome: folliculitis, nummular eczema and pyoderma gangraenosum

We report the case of a 47-year-old male with Kartagener's syndrome (KS; situs inversus, bronchitis and sinusitis) who showed three types of cutaneous lesions: recurrent outbreaks of nummular eczema, recurrent deep folliculitis and two episodes of pyoderma gangraenosum. The patient had also IgA gammopathy of undetermined significance. This is the second case of KS associated with cutaneous lesions published so far and suggests that primary ciliary dyskinesia syndromes may have skin symptoms.

Porokeratotic eccrine ostial and dermal duct nevus

A case of porokeratotic eccrine ostial and dermal duct nevus (PEODDN) affecting all 4 extremities is described. Clinically, palmo-plantar lesions resembled those of nevus comedonicus and the remaining lesions those of linear verrucous epidermal nevus. Histologically, all lesions were identical with cornoid lamellae in the eccrine ostia and epidermal ducts.

Morphometric characterization of the human neuroendocrine Merkel cells

In this study, the neuroendocrine Merkel cells (NEMCs) from adult human epidermis are defined morphometrically, using the MOP 20 image analyzer to measure 21 parameters of either the cell as a whole, or particular cellular structures. Maximum diameter (8.09 microns), perimeter (26.51 microns), area (36.87 microns2) and form factor (0.626) for the cell as a whole, and maximum diameter (5.08 microns), perimeter (18.74 microns), area (12.54 microns2) and form factor (0.452) for the nucleus were determined. Also measured were nuclear-cytoplasmic ratio (0.5595), filament thickness (10 nm), and granular numerical density (7.02 granules/micron2). Maximum diameter, area, and form factor of neurosecretory granules were 94.23 nm, 5020.05 nm2, and 0.93, respectively. Length of desmosomes linking NEMCs to keratinocytes was determined (286.9 nm) and compared with that of interkeratinocytic desmosomes (385 nm). In addition, length and diameter of cellular processes (spine-like processes (1.58 micron X 0.26 micron), interstitial processes (1.39 micron X 0.25 micron), and microvilli (0.35 micron X 0.25 micron) were measured after separation and classification according to the particular morphologic characteristics of each.