Formaldehyde 2% is not a useful means of detecting allergy to formaldehyde releasers- results of the ESSCA network, 2015-2018.

BACKGROUND: Studies suggest that patch testing with formaldehyde releasers (FRs) gives significant additional information to formaldehyde 1% aq. and should be considered for addition to the European baseline series (EBS). It is not known if this is also true for formaldehyde 2% aq. OBJECTIVES: To determine the frequency of sensitization to formaldehyde 2% aq. and co-reactivity with FRs. To establish whether there is justification for including FRs in the EBS. MATERIALS AND METHODS: A 4-year, multi-center retrospective analysis of patients with positive patch test reactions to formaldehyde 2% aq. and five FRs. RESULTS: A maximum of 15 067 patients were tested to formaldehyde 2% aq. and at least one FR. The percentage of isolated reactions to FR, without co-reactivity to, formaldehyde 2% aq. for each FR were: 46.8% for quarternium-15 1% pet.; 67.4% imidazolidinyl urea 2% pet.; 64% diazolidinyl urea 2% pet.; 83.3% 1,3-dimethylol-5, 5-dimethyl hydantoin (DMDM) hydantoin 2% pet. and 96.3% 2-bromo-2-nitropropane-1,3-diol 0.5% pet. This demonstrates that co-reactivity varies between FRs and formaldehyde, from being virtually non-existent in 2-bromo-2-nitropropane-1,3-diol 0.5% pet. (Cohen's kappa: 0, 95% confidence interval [CI] -0.02 to 0.02)], to only weak concordance for quaternium-15 [Cohen's kappa: 0.22, 95%CI 0.16 to 0.28)], where Cohen's kappa value of 1 would indicate full concordance. CONCLUSIONS: Formaldehyde 2% aq. is an inadequate screen for contact allergy to the formaldehyde releasers, which should be considered for inclusion in any series dependant on the frequency of reactions to and relevance of each individual allergen.

Skin and mucous membranes' manifestations of dermatological diseases within the genital area in females.

INTRODUCTION: Lichen sclerosus et atrophicus (LSA) and an inversed type of psoriasis belong to a group of benign dermatoses usually located within the region of female external genitalia. The most common subjective symptoms reported by patients are itching, pain and changes in the color and structure of the skin. AIM: This paper presents 3 cases of patients suffering from selected dermatoses located within the external female genitalia treated at the Department of Dermatology, Poznan University of Medical Sciences. CASE REPORTS: Case 1. A 78-year-old patient admitted to the Department of Dermatology diagnosed with l ichen sclerosus and atrophic as well as scleroderma, which had already been confirmed by histopathological examination in 2014. Laboratory tests demonstrated an increased level of glycemia, elevated ESR and lymphopenia. In the treatment of TFX (Thymus factor X) therapy (immunomodulating treatment), vitamins A + E containing cream and Protopic 0.1% ointment twice daily were recommended. Case 2. A patient aged 49 was admitted to the Department of Dermatology due to exacerbation of skin inflammation in the course of psoriasis. She presented with severe erythematous and papular lesions covered with silvery scales, with the highest intensity within the palmar surfaces of both hands, in the folds of under the breasts, groins, and therefore, the clinical picture was characteristic of inversed psoriasis (psoriasis inversa). Case 3. A 20-year-old patient admitted to the Department of Dermatology in order to proceed with the treatment of a diffuse type of scleroderma. Clinical diagnosis has been already confirmed by the skin biopsy (typical histological features of scleroderma), however exclusion of other dermatoses such as LSA was not possible. CONCLUSIONS: While analyzing the available scientific reports, the physician in charge must adjust therapeutic options individually, taking into account the clinical condition of the patient in case of dermatological diseases within the female genital region.

Multidisciplinary training of cancer specialists in Europe.

The best care for patients with cancer is most likely to be achieved when decisions about diagnosis, staging and treatment are made at multidisciplinary and multiprofessional meetings, preferably when all the professional expertise relevant to the patient's condition is gathered together. Questionnaires were sent to National Societies of Radiation Oncology and Medical Oncology concerning similarities and differences in training programs and multidisciplinary care in member states in Europe. Results indicated wide variation in training systems and practice. Data were lacking for Surgery because Surgical Oncology is not recognised as a speciality in the EU and most specialist training in cancer surgery is organ based. A period of time in cross-disciplinary training in each of the other two disciplines for all trainees in Medical Oncology, Radiation Oncology and Surgical Oncology (including all surgeons training in cancer surgery) is recommended. This is likely to improve the value of multidisciplinary meetings and may result in improved patient care. The Expert Group on Cancer Control of the European Commission has endorsed this recommendation.

Vesicular Contact Reaction May Progress into Erythema Multiforme.

Dear Editor, Erythema multiforme is considered an acute skin condition, characterized by a self-limiting and sometimes recurrent course. It is regarded as a type IV hypersensitivity reaction associated with certain infections, medications, and other various triggers. Allergic contact dermatitis is in turn a delayed type of induced allergy as a result of cutaneous contact with a specific allergen to which the patient develops specific sensitivity. This type of cutaneous reaction is associated with inflammation manifesting with erythema, edema, and vesicles. A 27-year old female patient presented with a 3-day history of erythematous and vesicular lesions which developed 24 hours after cesarean section. Initially the lesions were localized in the area of surgery (mainly the abdomen and upper thighs) and on the next day progressed to the buttocks and lumbar area. The patient was referred to the Outpatient Clinic and was treated with antihistamines, but her dermatological state deteriorated rapidly. At the day of admission to the Department of Dermatology, numerous erythematous and vesicular lesions were present on the skin of the abdomen, thighs, and back (Figure 1, a), but the skin of the neck, chest, and extremities was also covered with erythematous and edematous patches. On the second day of hospitalization, we observed the evolution of lesions localized within the chest and extremities into an erythema multiforme-like targetoid eruption (Figure 1, b). Initially the patient was treated with intravenous injections of dexamethasone and ceftriaxone and orally with second-generation antihistamines (in four-fold doses), followed by intravenous metyloprednisolone pulse-therapy (total dose of 3 g). As the new vesicobullous lesions started to appear on the face and arms, we introduced cyclosporine A orally 400 mg daily. We could then observe gradual remission, but on the seventh day of hospitalization the patient developed a massive labial herpes simplex infection and had to be treated with acyclovir intravenously. Eight days after admission, we switched from intravenous metyloprednisolone to its oral formula. Diagnostic methods included: laboratory analyses (leukocytosis, neutrophilia, lymphopenia could be observed, and also serum CRP elevation). Pemphigoid gestationis was excluded on the basis of a direct immunofluorescence from perilesional skin and on the basis of indirect immunofluorescence and also serum analysis using ELISA for serum IgG antibodies to BP180-NC16A (courtesy of Prof. Marian Dmochowski). Histopathological examination revealed: massive edema of dermal papillae, leading to the formation of sub-epidermal vesicles; individual cell necrosis was observed in the upper epidermis. Within the dermis, a dense, perivascular inflammatory infiltrate was detected: the clinical picture suggested erythema multiforme. Another histopathological examination was performed at the University Clinic of Dermatology and Venereology in Magdeburg, courtesy of Prof. Dr. Harald Gollnick and Dr. Med. I. Franke; it also suggested the bullous form of erythema multiforme (dermal type). Three months after remission, the patient was hospitalized again to perform allergological diagnostics. Patch tests were performed with the European Baseline Series (Chemotechnique Diagnostics) supplemented with disinfectants and textiles used during surgical procedure. For patch testing, Finn Chambers on Scanpor were used. Results were recorded at 48 and 72 hour time points. According to the ICDRG (International Contact Dermatitis Research Group), reactions evaluated as ++ and +++ pluses were considered as positive and reaction evaluated as + plus was considered as doubtful. Patch testing revealed polyvalent contact allergy (Table I), (Figure 2a). The patient also reacted to Kodan Tinctur forte used as a skin disinfectant (contains brown dye LF 1889 - mixture of quinoline yellow, sunset yellow, brilliant black) (Figure 2b). It has to be emphasized, that patch test reading procedure was difficult due to patient's skin reactivity toward a plaster mounting Finn chambers. Literature data suggests that erythema multiforme may occasionally occur in conjunction with allergic contact dermatitis to various non-related substances including chemicals (epoxy-based compound, fragrances, epichlorydrine, bromofluorene), medications (antibiotics, acetaminophen, triamcinolone, bufexamac), plant-derived allergens (poison ivy, tea tree oil, red cedar essential oil), but also rubber ingredients and nickel. The severity of the reaction varies from mild erythema to generalized erythema multiforme or even toxic epidermal necrolysis (1,2,3,4). Lesions characteristic for erythema multiforme may appear during the episode of acute contact dermatitis or may follow a nearly resolving vesicular eczematous eruption. The pathomechanism Patomechanism of an erythema multiforme-like eruption developing in association with allergic contact dermatitis still remains unclear. Immune complex-mediated and T-cell-mediated reactions have been proposed as the cause. However, T-cell-mediated cellular mechanisms seems to be more likely, since generalized erythema multiforme often follows contact dermatitis, which is a type IV allergic reaction mediated by T cells (5,6). According to Bushkell et al. (7), an allergen penetration through the skin may result in a type III hypersensitivity reaction, with involvement of circulating immune complexes, and to confirm that, IgM, IgA, C3, and fibrin deposits are detected in some cases of targetoid lesions in erythema multiforme. On the other hand, Wiedemeyer et al. (8) suggest that contact allergens (i.e. paraphenylenodiamine) may be transported in peripheral blood mononuclear cells from the area of initial skin contact even to distant sites. According to Shiohara et al. (9) and Gonzalez-Delgado et al. (10), epidermal expression of adhesion molecule - 1 (ICAM-1) and the number of CD4+ T cells is increased within the iris lesions of erythema multiforme. Thus, it is possible that adhesion molecules may facilitate epidermal invasion of lymphocytes in these lesions, which is also the place of the expression of maintained allergen molecules. In conclusion, in the described case the causative factor also remained uncertain. The patient was found to have contact allergy to six haptens included in the European Baseline Series and also to a disinfectant used during cesarean section. Among these, both colophonium and formaldehyde are used in adhesives and glues or surface coatings. However, formaldehyde is mainly associated with this type of the reaction - in fact, hapten description supplied by Chemotechnique Diagnostics includes the information that "formaldehyde may produce erythema multiforme-like eruptions".

Clinical relevance of Corylus pollen in Poznan, western Poland.

BACKGROUND: In Central Europe, hazel (Corylus sp.) pollen is considered to be an important aeroallergen in early spring. OBJECTIVE: This study examines hazel pollen levels in Poznan, western Poland, and the clinical relevance of this aeroallergen in the city. METHODS: Corylus pollen data (1996-2010) were obtained by volumetric spore trap located near the centre of Poznan. Clinical data (2006-2010), i.e. skin prick test (SPT) and allergen-specific IgE measurements (asIgE), were supplied by the Allergy Diseases Diagnostic Centre in Poznan. RESULTS: Mean diurnal hazel pollen concentrations peaked around 14:00-16:00 when mean bi-hourly pollen concentrations were ~60 P m(-3). Onset of the hazel pollen season varied up to 87 days annually, and was significantly (r=-0.647; p<0.01) related to mean maximum temperature during late December. SPT data revealed that ~11% of allergy patients had positive skin reactions to Corylus pollen allergens, and most of these (94.4%) reacted to pollen allergens from other members of the Betulaceae family - alder or birch. Of those sensitized, 53% suffered from atopic dermatitis. Of patients examined for serum asIgE, 26.0% had asIgE measurements in classes 5 and 6. CONCLUSIONS: Hazel pollen has a detrimental effect on the allergic population of Poznan, with more than half of those sensitised to hazel pollen allergens showing symptoms of atopic dermatitis. Hazel pollen concentrations reach levels recognized as being able to induce allergy symptoms, especially in the afternoon and early evening when many people are returning home from work. The cross-reactivity with other members of the Fagales order also increases the allergenic potential of hazel pollen.

A case of diffuse large B-cell lymphoma misdiagnosed as an erysipelas of the face.

We report a case of a woman with diffuse large B-cell lymphoma (DLBCL). Primary cutaneous lymphomas (PCLs) represent distinct clinical and histopathologic subtypes of extranodal T- and B-cell lymphomas. Cutaneous B-cell lymphomas comprise 20-25% of all primary cutaneous lymphomas. The patient presented an erythematous tumour mass of the left nasolabial fold, nose and left cheek as well as disseminated infiltrative plagues on the trunk, arms and left lower leg. Skin biopsy revealed a diffuse infiltrate of lymphocytes around hair follicles and blood vessels within dermis and subcutaneous tissue. An immunohistochemistry showed a diffuse infiltrate of large non-cleaved B-cells, with a high proportion of centroblast-like cells within dermis. Tumor cells expressed CD20, bcl-2 protein and did not express CD10. The patient was misdiagnosed as the erysipelas of the face and unsuccessfully treated with long-term antibiotic therapy by a laryngologist and a dermatologist. The correct diagnosis was delayed and established after 6 months' history of DLBCL lesions. Therefore, we would like to strongly stress the importance of considering diagnosis of cutaneous lymphomas in chronic skin lesions non-responsive to adequate therapies.

Topical calcineurin inhibitors in the treatment of atopic dermatitis - an update on safety issues.

Atopic dermatitis is a common chronic skin disorder whose management is complex. Topical corticosteroids have been the mainstay of atopic dermatitis treatment for more than 50 years but have multiple side effects. Topical calcineurin inhibitors including tacrolimus and pimecrolimus are safe and efficacious in atopic dermatitis. In 2005 the FDA issued "black box" warnings for pimecrolimus cream and tacrolimus ointment because of potential safety risks, including skin cancers and lymphomas. However, these concerns are not supported by current data. Topical calcineurin inhibitors are particularly indicated for treating patients with atopic dermatitis in whom topical corticosteroid therapy cannot be employed or may cause irreversible side effects. They can be used advantageously in problem zones. A novel regimen of proactive treatment has been shown to prevent, delay and reduce exacerbations of atopic dermatitis. Therapy with topical calcineurin inhibitors should be managed by an experienced specialist and each patient should receive proper education on how to use them and what possible unwanted effects may be expected.

Eosinophilic fascitis: a report of two cases treated with ultraviolet A1 phototherapy.

Eosinophilic fascitis (EF) (synonyms: Shulman's syndrome, diffuse fascitis with eosinophilia) is a disease characterized by a complex set of symptoms with scleroderma-like skin lesions, the absence of Raynaud's phenomenon and other non-mandatory symptoms including eosinophilia, elevated erythrocyte sedimentation rate, hypergammaglobulinemia and high levels of circulating immune complexes. EF is probably not a separate disease entity, but an acute variant of localized scleroderma. This rare disease of unknown etiology is usually seen in middle-aged adults. Sclerodermiform indurations without Raynaud's symptoms develop rapidly usually on the extremities and more rarely on the trunk or the face. The skin becomes hard, tightly bound to the underlying structures, so that contractures can develop in as little as a few weeks. The course of the disease is usually chronic but spontaneous remission is possible. Standard therapy includes high doses of corticosteroids, immunosuppressive drugs such as methotrexate, cyclosporin A, cyclophosphamide or azathioprine and others such as psoralen and ultraviolet A radiation.

Dermatomyositis-like eruption induced by hydroxyurea: a case report.

A 74-year-old patient, suffering for 20 years from polycythemia rubra vera, was treated with hydroxyurea for 2 years. Intensive xerosis (ichthyosis-like) and violaceous papules on the dorsal hand surfaces were observed. There was also reddish purple periorbital erythema resembling "heliotrope erythema". Such a disease pattern has been described as "hydroxyurea-induced dermatomyositis-like eruption" - a drug-adverse reaction associated with hydroxyurea therapy. The reaction has typical dermal features of dermatomyositis without any systemic symptoms (in the case of our patient, antinuclear antibodies absent and creatine phosphokinase within the normal range). The above reaction is associated with chronic hydroxyurea uptake and, after withdrawing the drug, alleviation of skin lesions usually takes place after 10 days to 18 months with no recurrences. In the case of our patient, we observed clinical improvement after 3 months; xerosis decreased, heliotrope erythema vanished, and there was also a decrease in both the number and intensity of violaceous papules on the dorsal hand surfaces.

Principles of dermatologic ultrasound diagnostics.

Ultrasound is a valuable diagnostic tool widely used in medicine. Recently, high-frequency ultrasonography has been introduced to dermatology owing to technical advances. Currently, the most often used frequency for skin imaging is between 20 and 25 MHz. Ultrasound images can be generated in different modes, i.e. one-dimensional A mode, two-dimensional B mode and C mode. This type of skin imaging is known as a noninvasive, reproducible and quantitative method, which can be used to evaluate skin characteristics in a variety of dermatologic diseases. It can found application in the assessment of skin tumors, morphea, psoriasis, lipodermatosclerosis, skin aging and photodamage, hypertrophic scars, wound healing processes and allergic reactions. Although skin ultrasonography and its clinical applications are still being explored, most probably it will be implemented in the routine dermatologic diagnosis in the forthcoming future.

Peripheral blood eosinophilia in atopic dermatitis.

BACKGROUND: Eosinophil granulocytes and eosinophilic granule proteins are deposited in the skin lesions of AD patients. Increased Th2 activity in the acute phase of AD is associated with IL-5 expression and results in enhanced eosinophilopoiesis, eosinophilic activation, and chemotaxis. MATERIAL AND METHODS: Thirty AD patients attending the Allergic Diseases Diagnostic Center and hospitalized in the Department of Dermatology were examined. Two control groups were included: 30 patients suffering from chronic urticaria and 30 healthy individuals without any symptoms of allergic diseases. Laboratory tests included the number of eosinophils expressed as a percentage of a differential white blood cell count, the absolute number of eosinophils in mm(3) (Carpentier's eosin method), and an evaluation of antigen-specific IgE (asIgE) in serum using fluoroenzyme immunoassay (CAP System FEIA, Pharmacia). RESULTS: The number of eosinophils/mm3 in the peripheral blood was 290.0 +/- 205.7 in AD patients, and 113.3 +/- 93.7 and 153.3 +/- 113.7 in the two control groups; the difference was statistically significant. Patients with severe AD had higher eosinophilia than patients with mild to moderate AD, but the difference was not significant. In AD patients with positive SPT tests and detectable specific IgE in serum, and also in patients with symptoms of other atopic diseases, the peripheral blood eosinophilia was more prominent compared to patients with negative SPTs and without symptoms of other atopic diseases. CONCLUSION: The results point to the role of eosinophils in etiopathogenesis of AD. Peripheral blood eosinophilia could serve as a diagnostic parameter in differentiating allergic AD from non-allergic AD.

Drug-related hospital admissions--an overview of frequency and clinical presentation.

Adverse drug reactions (ADR) are the cause of hospital admissions for millions of patients every year and are believed to be a major problem in terms of morbidity and hospital expenses. ADR are characterized by exceptional variety, both considering pathomechanism and clinical symptoms. During the time period between 2000-2004 at the Department of Dermatology a project was undertaken to monitor patients who were hospitalized as a result of ADR. Within five years 57 patients, including 30 men and 27 women were observed. The majority of the patients developed maculaopapular rash (16), urticaria medicamentosa and Quincke's edema (16) and erythema multiforme (15). The other cases included erythroderma (5), anaphylactic shock (2), lichenoid exanthem (1), bullous eruption (1) and Hoigne's syndrome (1). The most probable factors producing these changes were concluded to be non-steroid antiinflammation drugs (33%), antibiotics (7%) and other drugs from different pharmacological and chemical groups (carbamazepine, diltiazem, hydrocortisone, methotrexate and herbs). The frequency of occurrence of skin changes of particular type in age groups were also analyzed. The greatest number of skin changes in response to drug therapy was in the age group 41 - 60, while for the age group > 60 ADR revealed the greatest diversity in the clinical picture. The most probable explanation of these findings are the polypragmasy applied in the elderly patients and interdrug interaction as well as decreased efficiency of the organic clearances.

[Leukotriene receptor antagonists--possible therapeutic option in the treatment of atopic dermatitis ]. / Leki antyleukotrienowe--mozliwosci zastosowania w terapii atopowego zapalenia skóry.

Cysteinyl leukotrienes have been shown to be important in the pathogenesis of such atopic disorders as asthma and allergic rhinoconjunctivitis. Therefore, leukotriene receptor antagonists are expected to be effective in the treatment of these diseases. Also in the case of patients with atopic dermatitis attempts have been made at administration of leukotriene receptor antagonists and this article reviews current data on the experimental evidence and clinical efficacy of this type of treatment of atopic dermatitis.