Oral Hypersensitivity Reactions.

Allergic contact hypersensitivity reactions of the oral mucosa pose a significant medical concern for some patients. Oral hypersensitivity reactions can result from a vast number of allergenic chemicals, but occur commonly from dental materials, flavorings, and preservatives. Clinical presentation is varied and often overlaps with other oral conditions, complicating their diagnosis and management. The most common clinical entities associated with oral hypersensitivity reactions are oral lichenoid reactions and allergic contact cheilitis. In addition to reviewing these conditions and their most common corresponding allergens, this article summarizes the pathogenesis of oral hypersensitivity reactions and addresses patch testing pearls.

Thiuram allergy--a potential dermal allergy among health care workers.

Occupational health nurses should be cognizant of the myriad exposures that can result in dermal reactions among health care workers.

Myxofibrosarcoma in the skin.

Myxofibrosarcoma, also known as myxoid malignant fibrous histiocytoma, is increasingly recognized as a distinct malignant neoplasm of fibroblastic origin with variable clinical and histopathologic features. Myxofibrosarcomas are among the most common malignant mesenchymal neoplasms of older adults, and approximately two thirds develop within the dermis or subcutis. Herein, we describe the clinicopathologic features of four cases of myxofibrosarcoma involving the skin. Three of these cases were initially misdiagnosed as benign cutaneous neoplasms, two as myxoid neurofibroma. These cases illustrate the clinicopathologic spectrum encompassed by myxofibrosarcoma in the skin and highlight the diagnostic difficulties it may present.

Nodular scleroderma: a report of 2 cases.

Nodular scleroderma, also known as keloidal scleroderma, is a rare form of scleroderma that may occur with either systemic sclerosis or localized scleroderma. Clinically, this disorder is characterized by keloidal nodules that form in sclerodermatous areas. These nodules may histologically show the presence of keloidal collagen. Because of the rarity of this condition, clinicians may not be familiar with the clinical and histologic features relevant to this scleroderma variant. In this report, we describe 2 cases of nodular scleroderma.

Clinically relevant patch test reactions in children--a United States based study.

Allergic contact dermatitis in the pediatric population is more common than previously recognized, with recent prevalence estimates of positive patch test reactions in the range of 14-70% of children patch tested. The aim of this study was to confirm the prevalence of clinically relevant allergic contact dermatitis in children at two referral centers and determine the most common contact allergens. We performed a retrospective case series analysis of 65 symptomatic children (35 girls and 30 boys) aged 1-18 years old who were patch tested over a 5-year period for recalcitrant dermatitis. Positive patch test reactions were noted in 54 of the 65 children (prevalence rate of 83%) to 80 different allergens. Fifty children (77%) had positive reactions which were determined to be of "definite" or "probable" current clinical relevance. We conclude that the diagnosis of allergic contact dermatitis to specific relevant allergens is common in children referred for patch testing and that contact allergy should be considered in all children with recalcitrant dermatitis. With this article, we review the literature and present a US based study regarding the clinical relevance of positive patch test reactions in children.

Dispelling the myths behind pediatric patch testing-experience from our tertiary care patch testing centers.

Allergic contact dermatitis is now known to be a common problem in pediatric populations, accounting for up to 20% of all dermatitis seen in children. Seminal studies conducted over the past decade have demonstrated a prevalence rate in the range of 25% to 60% of children referred for epicutaneous patch testing. This patch test procedure is generally accepted as the gold standardin vivo technique to diagnose allergic contact dermatitis. However, the overwhelming majority of research studies to date have been conducted on adult populations. Increasingly, pediatric patients are undergoing patch test procedures with techniques that have been standardized and optimized almost exclusively in adults. With this article, we hope to emphasize common misconceptions and pitfalls encountered with this approach. In addition, we hope to stimulate research interest in this field so as to determine the optimum patch test conditions and techniques for children.

Focal preauricular dermal dysplasia: report of two cases and a review of literature.

We report two cases of focal preauricular dermal dysplasia and review the available literature. Focal preauricular dermal dysplasia is a form of aplasia cutis congenita in which atrophic skin lesions occur in a stereotypical bilateral distribution in the preauricular region. Although focal preauricular dermal dysplasia and membranous cutis aplasia of the scalp share clinical similarities, focal preauricular dermal dysplasia represents a form of aplasia cutis congenita that is not typically associated with extracutaneous anomalies.

Allergic contact dermatitis caused by colophony in an epilating product.

Considering the widespread use of colophony-containing epilating products and the frequency of sensitization to colophony, it is somewhat surprising that reports of allergic contact dermatitis from these products are so infrequent. Reactions to colophony can be severe, and they may present even after initial exposure (primary sensitization). Consequently, health care practitioners should be aware of potential colophony-induced allergic contact dermatitis in patients exposed to epilating products. Patch testing with commercially available colophony unmodified rosins often fails to detect reactions to the modified-rosin derivatives found in the actual epilating products. Therefore, the evaluation of colophony allergy may require testing with the patient's own products as well as additional modified colophony rosins. We describe a case of allergic contact dermatitis caused by colophony found in an epilating product.

Two cases of compositae dermatitis exacerbated by moisturizer containing feverfew.

A 45-year-old woman presented in October 2005 with a history of an eruption involving her scalp and face, including her eyelids and behind her ears. The eruption began at the end of August. It flared after she used a calming moisturizer containing feverfew (Tanacetum parthenium). A second patient, a 25-year-old woman, presented complaining of a 1-month history of an eruption around the eyes that started after she began using a moisturizer containing feverfew. Both patients were patch-tested with the North American Contact Dermatitis Group series, cosmetic and plant series, and their own skin care products. Patient 1 had a + reaction to sesquiterpene lactone mix, a + reaction to Compositae mix, a + reaction to parthenolide, a + reaction to Tanacetum vulgare, and a + reaction to the calming moisturizer. Patient 2 had + reactions to sesquiterpene lactone, Compositae mix, and the same calming moisturizer. It is thought that both of these eruptions are a result of contact dermatitis from the Compositae plant family.

A Survey Examining Photopatch Test and Phototest Methodologies of Contact Dermatologists in the United States: Platform for Developing A Consensus.

BACKGROUND: There is currently no standardized protocol for photopatch testing and phototesting in the United States. Certain testing paramaters (such as chemicals tested, time between test application and irradiation, and time of final interpretation) vary from provider to provider. These variations may impact comparability and consistency of test results. OBJECTIVE: The goal of our survey-based study was to outline the photopatch test and phototest protocols used by US contact dermatologists. The information obtained will aid in the development of a national consensus on testing methodologies. METHODS: Based on a literature search conducted on differences in testing methodologies, we constructed a questionnaire. The survey was distributed at the American Contact Dermatitis Society annual meeting and via the American Contact Dermatitis Society Web site. Standard descriptive analysis was performed on data obtained. RESULTS: Of the 800 dermatologists contacted, 117 agreed to participate in the survey. Among these respondents, 64 (54.8%) conduct photopatch testing. Results of the survey are presented, and they confirm that a variety of techniques and testing materials are used. CONCLUSIONS: It would be beneficial to enlist a panel of expert contact dermatologists to create by formal consensus, using these research findings, a standard photopatch test protocol for use in this country.

Patch Testing for Evaluation of Hypersensitivity to Implanted Metal Devices: A Perspective From the American Contact Dermatitis Society.

The American Contact Dermatitis Society recognizes the interest in the evaluation and management of metal hypersensitivity reactions. Given the paucity of robust evidence with which to guide our practices, we provide reasonable evidence and expert opinion-based guidelines for clinicians with regard to metal hypersensitivity reaction testing and patient management. Routine preoperative evaluation in individuals with no history of adverse cutaneous reactions to metals or history of previous implant-related adverse events is not necessary. Patients with a clear self-reported history of metal reactions should be evaluated by patch testing before device implant. Patch testing is only 1 element in the assessment of causation in those with postimplantation morbidity. Metal exposure from the implanted device can cause sensitization, but a positive metal test does not prove symptom causality. The decision to replace an implanted device must include an assessment of all clinical factors and a thorough risk-benefit analysis by the treating physician(s) and patient.

Patients' attitudes toward resident participation in dermatology outpatient clinics.

The attitudes of patients toward resident participation in a university-based dermatology outpatient clinic were evaluated. Of 206 patients asked to participate, 191 patients completed the self-administered questionnaire (92.7%). The overwhelming majority of patients (99.5%) were satisfied (81.8% "very satisfied" and 17.7% "satisfied") with the resident's participation in their care. Many more patients expressed a willingness to allow residents to take histories (93.6%), perform physical examinations (87.2%), and counsel on preventive measures (74.5%), than to allow surgical excisions of skin cancers (19.7%), perform skin biopsies (43.6%), or prescribe medications (44.7%). Of respondents to the questionnaire, 83.2% self-reported an understanding of the difference between "resident" and "attending" physicians. However, only 31.3% (95% confidence interval 24.5-38.1) were able to broadly categorize the amount of training completed by dermatology residents. Dermatology resident participation in outpatient clinics is essential to quality dermatologic education. Consistent with the results of prior studies in other medical disciplines, our study demonstrated an overwhelming patient satisfaction with the participation of dermatology residents in their care.

Use of aromatherapy products and increased risk of hand dermatitis in massage therapists.

OBJECTIVES: To determine the 12-month prevalence of hand dermatitis among massage therapists, to investigate a potential association between hand dermatitis and the use of aromatherapy products, and to study potential associations with other known risk factors for hand dermatitis. DESIGN: Mailed survey. SETTING: Philadelphia, Pa. PARTICIPANTS: Members of a national massage therapy organization who live in the greater Philadelphia region. MAIN OUTCOME MEASURES: Self-reported and symptom-based prevalences of hand dermatitis. RESULTS: The number of respondents was 350 (57%). The 12-month prevalence of hand dermatitis in subjects was 15% by self-reported criteria and 23% by a symptom-based method. In multivariate analysis, statistically significant independent risk factors for self-reported hand dermatitis included use of aromatherapy products in massage oils, lotions, or creams (odds ratio, 3.27; 95% confidence interval, 1.53-7.02; P =.002) and history of atopic dermatitis (odds ratio, 8.06; 95% confidence interval, 3.39-19.17; P<.001). CONCLUSIONS: The prevalence of hand dermatitis in massage therapists is high. Significant independent risk factors include use of aromatherapy products in massage oils, creams, or lotions and history of atopic dermatitis.

Rosacea: II. Therapy.

Despite an incomplete understanding of the pathogenesis of rosacea, therapeutic modalities continue to expand. The principal subtypes of rosacea include erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea. These phenotypic expressions are probably caused by divergent pathogenic factors and consequently respond to different therapeutic regimens. A subtype-directed approach to therapy is discussed in part II of this review. We provide an overview of the available topical, oral, laser, and light therapies in the context of these cutaneous subtypes, review the evidence that supports their use, and outline their therapeutic approach. Suggestions for future areas of study also are provided. Learning objective At the completion of this learning activity, participants should be familiar with the subtype-directed approach to therapy for rosacea including available topical, oral, laser, and light therapies.

Rosacea: I. Etiology, pathogenesis, and subtype classification.

Rosacea is one of the most common conditions dermatologists treat. Rosacea is most often characterized by transient or persistent central facial erythema, visible blood vessels, and often papules and pustules. Based on patterns of physical findings, rosacea can be classified into 4 broad subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular. The cause of rosacea remains somewhat of a mystery. Several hypotheses have been documented in the literature and include potential roles for vascular abnormalities, dermal matrix degeneration, environmental factors, and microorganisms such as Demodex folliculorum and Helicobacter pylori. This article reviews the current literature on rosacea with emphasis placed on the new classification system and the main pathogenic theories. Learning objective At the conclusion of this learning activity, participants should be acquainted with rosacea's defining characteristics, the new subtype classification system, and the main theories on pathogenesis.

Statistical reviewing policies in dermatology journals: results of a questionnaire survey of editors.

BACKGROUND: Problems with statistical methods and reporting have been noted in articles published in dermatology journals. Conclusions presented in published reports may be misleading if based on inappropriate or misinterpreted statistical analysis. OBJECTIVE: We sought to assess dermatology journal editors' policies and perceptions regarding statistical review of submitted manuscripts. DESIGN: We mailed and e-mailed a questionnaire survey. PARTICIPANTS: A total of 43 dermatology journal editors, representing 35 dermatology journals from the United States and abroad, participated in this study. RESULTS: In all, 32 editors (74.4%), representing 30 journals (85.7%), returned questionnaires. A total of 24 editors (75%) reported having requested statistical reviews on less than 5% of published manuscripts containing original quantitative analysis (ie, excluding reviews and case reports), whereas 3 editors (9.4%) reported having requested statistical reviews on more than 75% of such manuscripts. Most editors reported requesting statistical reviews on a case-by-case basis either after initial favorable review by subject-matter (nonstatistical) reviewers (12 editors; 37.5%) or at the same time that subject-matter review was requested (6 editors; 18.8%). A total of 4 editors (12.5%) reported requesting statistical review for all manuscripts at the same time they are sent for subject-matter review. Another 10 editors (31.3%) said their journals had no general policy on statistical reviewing, and statistical review is almost never needed. For 15 editors (46.9%), ideal statistical reviewing policy was identical to their current policy, whereas 13 (40.6%) favored a more rigorous and 3 (9.4%) a less rigorous policy. CONCLUSIONS: Dermatology journals infrequently perform statistical reviews of submitted manuscripts. Dermatology journal editors' statistical review policies range from no general policy to (most frequently) requesting reviews on a case-by-case basis to reviewing all submitted manuscripts. Many editors favor more rigorous statistical reviewing policies for their journals. Increased use of statistical reviewing may increase the reliability of conclusions published in dermatology journals.

Tea tree oil: cutaneous effects of the extracted oil of Melaleuca alternifolia.

The use of botanical extracts for their perceived therapeutic benefits has gained increased popularity in this country and abroad. In particular, tea tree oil (the extracted oil of Melaleuca alternifolia) has gained widespread use for its purported antimicrobial and therapeutic effects. In parallel with this increased use is an expanding series of reported adverse effects, including allergic contact dermatitis, systemic contact dermatitis, linear immunoglobulin A disease, erythema multiforme-like id reactions, and systemic hypersensitivity reactions. We present a review of tea tree oil with regard to its history, chemistry, purported medicinal uses, and possible adverse cutaneous effects.

The role of patch testing in the evaluation of orthopedic implant-related adverse effects: current evidence does not support broad use.

In recent years, there has been a growing interest in the use of skin patch testing to evaluate patients for orthopedic, implant-related adverse effects. This may be done preoperatively to avoid implanting a material to which an individual may be allergic or postoperatively to implicate sensitivity as a cause for implant failure. There is emerging evidence that patch testing might have utility in the workup of implant-related adverse events; however, the level of evidence at the present time is weak and based only on a collection of case reports, series, and retrospective cohort studies (level IV evidence as per United States Department of Health and Human Services guidelines); there are no randomized controlled trials (level I evidence) with which to guide medical decision making. Recent reports have advocated that patch testing be broadly used in the preoperative evaluation of all patients self-reporting a history of metal sensitivity. In addition, several authors have advocated that patch test results should guide preoperative implant selection and postoperative implant removal. It is the opinion of this author that these recommendations are premature, lacking robust clinical evidence, and unfeasible given the broad-reaching logistical impact and societal costs involved. More robust clinical data are needed, and thorough cost-benefit analyses must be performed before such far-reaching and costly systematic practices should be broadly implemented.