[Scalp burns induced by hair bleaching]. / Brûlure du cuir chevelu induite par les décolorations capillaires.

BACKGROUND: Hair bleaching is increasingly being carried out in hairdressing salons. The products used are a mixture of hydrogen peroxide and persulfates, both active chemical agents. Scalp burns secondary to hair bleaching are a traumatic adverse effect rarely discussed in publications that continue to be little known among healthcare professionals. PATIENTS AND METHODS: We report the case of a 15-year-old girl with a plaque of scarring alopecia on the vertex. This lesion resulted from a deep burn following a hair-bleaching procedure. Healing took around 4 months, resulting in discomfort for our patient. DISCUSSION: This is a rare case of scarring alopecia following a basic chemical burn to the scalp. The oxidation reaction induced by the mixture of hydrogen peroxide and persulfates, prepared in a basic medium, causes bleaching of the melanin pigments in hair. The clinical presentation of a single, well limited, painful, oozing ulceration located at the vertex was similar to the other cases published in the literature. Although a chemical burning mechanism is most often incriminated, the procedure is always coupled with use of a heat source and associated thermal burn may occur. The delayed appearance of the lesion appears to be caused by the forming of surfactants by the hydrogen peroxide/persulfate mixture, resulting in slow dissolution of the oxidizing compounds within the stratum corneum.

[Atopic dermatitis physiopathology]. / Physiopathologie de la dermatite atopique.

Our understanding of the physiopathology of atopic dermatitis has much improved over the recent years. Epidermal barrier alterations are integrated into 2 theories called inside out and outside in. They are related to complex immune abnormalities. Understanding their mechanism makes it possible to foresee new therapeutics. Moreover, environmental biodiversity, the diversity of cutaneous microbiota and genetic predispositions in atopic dermatitis lead to a new, more comprehensive theory, « the biodiversity theory ¼, integrating epigenetics.

[Hypersensitivity to platinum salts and taxanes: The value of skin tests and tolerance induction procedures]. / Hypersensibilité aux sels de platine et aux taxanes : intérêt des tests cutanés et des inductions de tolérance.

AIM: The rate of hypersensitivity reactions to platinum salts (PS) and taxanes (TX) is on the increase. The aim of our study was to show the value of skin testing and efficacy of rapid drug desensitization. PATIENTS AND METHODS: This was a retrospective study conducted between January 2007 and February 2016 in patients consulting for immediate or delayed hypersensitivity to PS and TX. Skin prick tests (pT) and intradermal reaction tests (IDR) were performed according to the ENDA/EAACI recommendations. We used a 12-step desensitization protocol for rapid drug desensitization. RESULTS: Among the 99 patients included (30 men, 69 women, age 60.4) PS were suspected in 86 cases and taxanes in 13 cases. Skin tests were positive in 25 patients (7 pT, 18 IDR), 23 for platinum salts and 2 for taxanes. Rapid drug desensitization was proposed in 50 patients and performed in 33 (30 PS and 3 TX), proved effective in 29 patients, with protocol adaptation being necessary in 7 cases, and was ineffective in 4 patients. The skin tests for the latter 4 patients were positive. Seventy-five percent of patients with positive skin tests to oxaliplatin presented hypersensitivity reactions during desensitization, i.e. twice as many as patients having negative skin tests. Two percent of patient for PS and 7% for TX had cross reactivity. CONCLUSION: This French study confirms the efficacy of the 12-step protocol that allows patients to receive chemotherapy after hypersensitivity reaction. Skin test permits the detection of cross-reactions but their practice must be considered based on the patient's history.

Clinical allergy. Managing generalized interferon-induced eruptions and the effectiveness of desensitization.

BACKGROUND: We evaluated the value of skin tests and the efficacy of a 12-step desensitization protocol to pegylated interferon (IFN) in patients with generalized drug eruptions due to IFNs. METHODS: A retrospective study (1998-2009) was followed by a cross-sectional clinical study conducted prospectively (2009-2011). All patients received a dermatological clinical examination and skin tests. Twelve-step IFN desensitization was proposed for patient with active hepatitis C and no alternative therapy. RESULTS: Twenty-six patients (13 males, mean age, 53.5 years) had generalized reactions to IFNs; 21 were treated with IFN-α and 5 with IFN-ß. Moreover, 21 patients had skin tests. Intradermal tests (IDTs) were positive after an average of 72 h. Cross-reactivity between peg-IFN-α2a and peg-IFN-α2b was observed in 5/10 cases in the prospective study. In 16 of 26 cases, IFN treatment was stopped. In 8 of 16 cases of diffuse eczematous drug eruption, treatment was continued. The corticosteroid and antihistamine were sufficient in 4/8 cases. In three other cases, topical tacrolimus was highly effective. In 3 of 16 cases in which treatment were stopped, patients underwent the early resumption of peg-IFN-α. These three patients had positive tests with peg-IFN-α2a and peg-IFN-α2b and successfully completed the tolerance induction protocol for peg-IFN-α2b. Tolerance induction involved a weekly dose of peg-IFN and a gradual increase in the recovery of an antiviral C. Clinical tolerance was excellent, and the patients' viral load C became negative. CONCLUSIONS: Our study demonstrates the benefit of allergy testing in cases of generalized drug reactions to IFN, cross-reactivities in a single class of IFNs and the importance of delayed IDT reading. We report for the first time the effectiveness of 12-step desensitization with peg-IFN.

Comparison of cytokine gene polymorphism in drug-induced maculopapular eruption, urticaria and drug reaction with eosinophilia and systemic symptoms (DRESS).

BACKGROUND: Polymorphisms of genes controlling cytokine production have not been studied in the genetic susceptibility to cutaneous adverse drug reactions (CADR). OBJECTIVES: The objective was to determine whether polymorphisms in nine cytokine genes were associated to the occurrence of drug reaction with eosinophilia and systemic symptoms (DRESS) compared to drug-induced maculopapular eruption or urticaria and to controls without drug intolerance. METHODS: Results from 118 patients with a well-defined CADR were compared to 236 controls without drug intolerance living in the same area of France. We assessed nine polymorphisms: interleukin (IL)1-alpha-889C>T (rs 1800587), IL1-beta-511C>T (rs 16944), IL1-RN intron-2-VNTR (rs2234663), IL2-330T>G (rs 2069762), IL4-33C>T (rs 2070874), IL5-745C>T (rs 2069812), IL10-592C>A (rs 1800872), IL16-295T>C (rs 4778889) and tumour necrosis factor-alpha-308G>A (rs 1800629). RESULTS: Three polymorphisms exhibited a significant association with CADR (P < 0.05). The combination of the IL1-RN-A2 and IL1-beta-511C alleles was statistically different between cases and controls (P = 0.007) and the A2C haplotype was associated with susceptibility to CADR, particularly in drug reaction with eosinophilia and systemic symptoms (DRESS) patients (odds ratio = 3.22; 95% confidence interval = 1.23-8.41; P = 0.016). The frequency of the IL10-592A allele was higher in DRESS patients than in controls (dominant model CC vs. CA + AA: P = 0.035). These abnormalities were not evident in maculopapular eruptions or urticaria. CONCLUSIONS: This is the first study showing that IL1-cluster polymorphisms and haplotypes and the IL10-592A allele (a low IL10 producer) are associated with DRESS. These gene variants may decrease drug tolerance and promote herpes virus reactivation.

[New pets, allergens and allergic dermatitis]. / Nouveaux animaux de compagnie, allergènes et dermatoses allergiques.

The number of household pets increased greatly during the twentieth century, with the numbers of new pets (NP, i.e. any pet other than cats and dogs) rising especially sharply over the last decade. Contact with such animals, whose owners do not always know how to look after them properly, expose the population to new risks such as trauma, infection and allergy. While the most common allergies are respiratory, allergic skin reactions, both immediate and delayed, may also result from contact with these new allergens. The animal itself or its environment may be the cause. Herein, we review NPs and reports of allergic dermatitis associated with them.

[Immunoallergic skin manifestations associated with new pets: three cases]. / Manifestations cutanées immuno-allergiques liées aux nouveaux animaux de compagnie : trois observations.

BACKGROUND: The number of household pets increased greatly during the twentieth century, with numbers of new pets (NP, i.e. any pets other than cats and dogs) rising especially sharply over the last decade. PATIENTS AND METHODS: We first of all report the case of a female patient with eczema lesions on areas skin coming into contact with a ferret, with removal of the animal resulting in wound healing, followed by two patients presenting atypical polymorphous erythema reactions induced by dermatophytes present in their pet rat. DISCUSSION: While the most common allergies are respiratory, allergic skin reactions, both immediate and delayed, may also result from contact with these new allergens. The animal itself or its environment may be the cause.

A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions.

BACKGROUND: Drug patch tests (PTs) can reproduce delayed hypersensitivity to drugs and entail a moderate re-exposure of patients to offending drugs. OBJECTIVES: To determine the value of PTs for identifying the responsible drug in severe cutaneous adverse drug reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). METHODS: In a multicentre study, PTs were conducted on patients referred for DRESS, AGEP or SJS/TEN within 1 year of their SCAR. All drugs administered in the 2 months prior to and the week following the onset of the SCAR were tested. RESULTS: Among the 134 patients included (48 male, 86 female; mean age 51·7 years), positive drug PTs were obtained for 24 different drugs. These included positive tests for 64% (46/72) of patients with DRESS, 58% (26/45) of those with AGEP and 24% (4/17) of those with SJS/TEN, with only one relapse of AGEP. The value of PTs depended on the type of drug and the type of SCAR (e.g. carbamazepine was positive in 11/13 DRESS cases but none of the five SJS/TEN cases). PTs were frequently positive for beta lactams (22 cases), pristinamycin (11 cases) and in DRESS with pump proton inhibitors (five cases), but were usually negative for allopurinol and salazopyrin. Of 18 patients with DRESS, eight had virus reactivation and positive PTs. In DRESS, multiple drug reactivity was frequent (18% of cases), with patients remaining sensitized many years later. CONCLUSIONS: PTs are useful and safe for identifying agents inducing SCAR.

[Changes in the European baseline series from 1981 to 2011 in a French dermatology-allergology centre]. / Évolution de la batterie standard européenne de 1981 à 2011 dans un centre de dermato-allergologie français.

BACKGROUND: Periodically updated, the European baseline series (EBS), first introduced in France in 1980, is an indispensable tool for the exploration of contact allergy. The aim of our study was to describe the prevalence of contact sensitization in a French centre between 1981 and 2011 to determine whether certain allergens may be deleted from the current BSE. PATIENTS, MATERIALS AND METHODS: A retrospective study was conducted in a department of dermatology-allergology to analyse the results of all EBS tests performed every 10 years, from 1981 to 2001, and annually from 2007 to 2011. Some added allergens, introduced in 2010, were also studied. Changes in allergen positivity were analysed using a Cochran-Armitage test. RESULTS: Among the 4551 patients included for the 8-year period studied, the prevalence of positivity was 42.91%. The most common allergens in the general population were nickel sulphate (17.25%), with a constantly increasing prevalence, Myroxylon pereirae (10.68%), fragrance mix I (8.11%), cobalt chloride (6.99%) and chromium (6.33%). The least frequent sensitizations, with a decreasing prevalence, were found with clioquinol (0.25%), primin (0.54%) and benzocaine (0.55%). CONCLUSION: Due to modifications in exposure to allergens, the incidence of contact sensitization can change, but nickel sulphate sensitization is increasing despite recent European directives. Allergens with less than 1% of positive results could be withdrawn from the EBS, with benzalkonium chloride, methylisothiazolinone and lavender absolute being added.

[Does hypersensitivity to multiple drugs really exist?]. / La polysensibilisation médicamenteuse systémique existe-t-elle ?

BACKGROUND: Multiple-drug hypersensitivity (MDH) in the literature concerns different entities. Our objective was to define its frequency and characteristics in patients examined for cutaneous adverse drug reaction (CADR) before studying genetic predisposition. MATERIALS AND METHODS: From a database comprising all patients referred for CADR between 2000 and 2010, we selected those meeting the following criteria: sensitisation to at least two chemically unrelated substances, as confirmed by positive skin tests or challenge tests. The following were excluded: patients with haematological diseases, HIV or chronic wounds and sensitization to the excipients. RESULTS: Of the 1925 patients included, 11 (0.6%) were classed as polysensitized: eight women and three men, of mean age 62 years, presenting 2.5 episodes of drug hypersensitivity per patient. Four cases of DRESS were noted. DISCUSSION: The strict criteria stipulated for this study enabled us to select patients with MDH, and to affirm that while it does in fact exist, it seems rare. Compared to polysensitized patients described in the literature, we preferred to distinguish between three groups of MDH: one occurring with different substances in separate episodes of CADR, one occurring with different substances during the same episode of CADR, and one occurring during DRESS and correlating with viral replication. CONCLUSION: MDH exists and genetic predisposition could be investigated by studying cytokine polymorphism in such patients. However, because of its rarity, it is impossible to rule out fortuitous association of two episodes of CADR in the same patient.

[Six cases of spring DRESS]. / Six cas de DRESS printaniers.

BACKGROUND: An association between herpes virus reactivations and Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is accepted. We report six cases of DRESS with viral reactivation occurring within a single 1-month period. We attempted to find a common factor for these six cases and carried out clinical and virological examinations. Before and after this "epidemic", the mean number of cases of DRESS seen at the same centre was one per quarter, making the occurrence of six cases within a single month all the more remarkable and prompting us to seek an explanation. PATIENTS AND METHODS: All six patients had taken a partly causative medication from different drug classes three to six weeks prior to the start of symptoms and herpes virus was detected in the blood of all of these subjects at the time of DRESS onset (four reactivations and two primary infections), and one patient subsequently displayed herpetic meningoencephalitis 95 days after the initial episode, associated with recurrence of DRESS. DISCUSSION: There was no common denominator among these six DRESS patients in terms of either drug class or reactivation of a particular type of herpes virus, which raises the possibility of a single unidentified environmental agent. DRESS does not appear fully explainable in terms of a cellular response to drug antigens but seems rather to result from complex interactions between the drug-induced immune response, viral reactivation and antiviral immune response. Several investigators have reported sequential reactivation of herpes viruses in DRESS. A viral epidemic could thus cause a "DRESS epidemic" in patients on medication. CONCLUSION: These cases point to the possible existence of a shared initial environmental factor (infectious or not) that favours reactivation of herpes viruses and induces DRESS in patients on medication. Before and after this "DRESS epidemic", about one patient each quarter was admitted to hospital for DRESS.

Drug re-challenges in cutaneous adverse drug reactions: information and effectiveness in the long-term management of patients.

BACKGROUND: In patients with cutaneous adverse drug reactions (CADR), drug skin tests and re-challenge under hospital surveillance (RCH) are helpful. The aim of this study was to determine if patients with negative drug RCH can tolerate subsequent treatments with the same drugs. PATIENTS AND METHODS: Patients with a negative RCH in the last 10 years answered a telephone questionnaire which was delivered by the same investigator in order to determine if subsequently the patients were able to tolerate the drug with which they had a negative RCH and also to study the reasons why the drugs were not taken again. RESULTS: Six hundred and thirty-seven RCH were analyzed (349 patients, mean age 47 years), 134 drugs were taken again (group A) and 359 were not (group B). In group A, 12 reactions occurred in 10 patients (9%). In group B, drugs were not taken again because 76% of the patients evaluated for an intolerance to antibiotics or radiocontrast media did not require a new course of these products or because their general practitioner (GP) did not want to prescribe these drugs. DISCUSSION: Ninety percent of the RCH (88.5% of the patients) with a CADR followed by investigations and a RCH have a good tolerance to subsequent treatment with the RC drug. The mechanisms involved in this intolerance despite negative RCH are discussed. CONCLUSION: The provocation test procedure, considered as useful by 88% of the patients, has a good negative predictive value. Furthermore, these investigations need to be accompanied by clear information on the patient and his GP.

[Pityriasis rubra pilaris after vaccination]. / Pityriasis rubra pilaire après vaccination.

BACKGROUND: Pityriasis rubra pilaris (PRP) following vaccination is rarely described in the literature. We report a case of PRP occurring two weeks after measles-mumps-rubella (MMR) vaccination. CASE REPORT: A 17-month-old infant was referred for a rash appearing two weeks previously. The child was presenting diffuse erythematous scaly exanthema with follicular papules and orange palmoplantar keratoderma. The clinical features were highly evocative of PRP. The histology was non-specific, displaying epidermal acanthosis with a regular and thick parakeratosis, and without any impairment of the follicular infundibulum. An MMR vaccination had been given two weeks before onset of the rash. Treatment with topical corticosteroids and emollients proved effective. DISCUSSION: Post-vaccinal PRP is rarely described in the literature. We report only the 3rd case. The first case concerned a 32-year-old woman presenting two episodes of PRP 10 days after diphtheria-tetanus-polio vaccination. The second case concerned a 47-year-old woman presenting PRP 18 days after anti-influenza vaccination and requiring treatment with acitretin. No cases have been described with MMR. These three vaccines (DTP, Tetragrip and ROR) have no shared pharmacological constituents, and the trigger mechanism could be immunological or parainfectious. CONCLUSION: Questioning about recent vaccination during history taking appears necessary to assess the importance of this trigger factor as well as the mechanism responsible for the onset of PRP.

[Shiitake dermatitis now occurs in France]. / La shiitake dermatitis (dermatose toxique au lentin) est arrivée en France.

BACKGROUND: In Asia, toxic adverse effects due to picking or consumption of shiitake mushrooms (Lentinula edodes), the second most eaten mushroom in the world are well-known. Its increasing consumption in Europe, let us to emphasize that shiitake dermatitis would occur more and more frequently in Occident. CASE REPORT: A 78-year-old woman was referred for an erythematous, micro-papular, extremely pruriginous rash disseminated all over the body (including face and scalp). No drugs had been recently introduced. Questioning revealed that lesions appeared 48 hours after eating a great quantity of raw shiitake mushrooms, leading to the diagnosis of shiitake dermatitis. DISCUSSION: Clinical features of shiitake dermatitis are small, highly pruriginous, erythematous papules, generalized. They have a whole body spreading and in some area a linear disposition. It is a toxic reaction due to a toxin called lentinan. It occurs in the 48 hours after having eaten raw or slightly cooked mushrooms and vanishes into 10 days. Due to its increasing consumption in Occident, it is essential for European dermatologists to know this dermatosis and how to recognize it.

Negative predictive value of drug skin tests in investigating cutaneous adverse drug reactions.

BACKGROUND: Drug skin tests are useful in aetiological analyses of cutaneous adverse drug reactions to determine if the drug can be rechallenged, or to avoid a cross-reaction with a substitute drug. OBJECTIVES: To evaluate the negative predictive value of drug skin tests. METHODS: We retrospectively analysed the files of patients referred for drug reactions. We have enrolled those having strictly determined drug reactions with clinical features, delayed onset after drug intake, drug causality assessment, and negative drug skin tests followed by drug administration. Oral provocation tests or substitution tests with a drug of the same class as that suspected of causing the drug reactions were performed. RESULTS: From 1957 files analysed, 200 patients were included. After 403 patch tests, 403 prick tests and 304 intradermal tests, which were all negative, 260 oral provocation tests and 143 substitution tests were done; 307 different drugs were rechallenged. There were 42 positive drug re-administrations in 27 oral provocation tests and 15 substitution tests. The negative predictive value of our drug skin tests was 89.6%. The negative predictive value for beta-lactams was 87% for oral provocation tests and 96% for substitution tests, and for corticosteroids it was 100% and 74%, respectively. CONCLUSIONS: Negative drug skin tests do not eliminate the responsibility of a drug in drug reactions, and must be followed by drug re-administration under hospital surveillance.

[AA amyloidosis: a little-known complication of chronic leg ulcer]. / Amylose AA: une complication méconnue des ulcères chroniques de jambes.

INTRODUCTION: AA amyloidosis, secondary to inflammatory chronic diseases like rheumatoid arthritis, is often complicated by renal failure. Chronic inflammatory dermatoses constitute rare causes of AA amyloidosis. CASE-REPORT: We describe two cases of AA amyloidosis discovered after renal failure in patients presenting leg ulcers for several years. AL amyloidosis was suspected in both cases because of a history of monoclonal gammopathy in one patient and of plasmocytoma in the other. The diagnosis of AA amyloidosis was confirmed on renal histology through the detection of AA antibodies in amyloid deposits. No extrarenal amyloidosis was seen in either patient and there were no inflammatory diseases other than chronic leg ulcers. DISCUSSION: AA amyloidosis is caused by serum amyloid protein A (SAA), a reactive inflammatory protein. AA amyloidosis is thus caused by chronic inflammatory diseases, but only rarely by cutaneous inflammatory diseases. To our knowledge, the literature contains only seven other published cases of AA amyloidosis secondary to chronic leg ulcers. A review of the literature does not indicate whether cure of ulcers has any effect on the accompanying renal failure. We imagine that AA amyloidosis secondary to leg ulcer is in fact under-diagnosed. However, since the first specific treatment for AA amyloidosis is currently being evaluated by the Food and Drug Administration, it is essential that this serious complication of chronic leg ulcers be widely recognised.

[Lyme disease could mimic dermatomyositis]. / Borreliose de Lyme mimant une dermatomyosite.

UNLABELLED: We report a dermatomyositis associated with Lyme disease. OBSERVATION: A 73-years-old woman has developed for 5 months an asthenia, a periorbital oedema and a forearm's skin infiltration without other signs suggesting of dermatomyositis. Laboratory studies showed an elevation of muscular enzymes, and inflammation signs. The skin and the muscles biopsies were compatible with the diagnostic of dermatomyositis. The patient was seropositive for Lyme disease. The patient was efficiently treated with doxycycline. DISCUSSION: Lyme disease could mimic a dermatomyositis. Indeed, Lyme disease should be considered as a differential diagnosis of dermatomyositis.