Three-part scoring system (tripartite) for teledermatology versus International Contact Dermatitis Research Group criteria to interpret patch test readings: A comparative, observational study.

Background The International Contact Dermatitis Research Group (ICDRG) grading is the gold standard and is used to interpret patch test results in allergic contact dermatitis (ACD). The ICDRG readings include a combination of visual and palpation findings. Digital photography limits palpation. An alternative scoring system exists to analyse 2D images and interpret patch test readings in teledermatology (TD). Aim To compare tri-partite scoring system (TPSS) (TD) with ICDRG (face-to-face) and to assess the feasibility of TPSS by TD. Methods In this observational study, two investigators each scored the patch test readings for 78 patients at the 48th h, 96th h and on the 7th day. Results The TPSS has a sensitivity of 100%, specificity of 93.34%, positive predictive value of 91.67% and negative predictive value of 100%. At a confidence interval of 95%, Cohen's kappa (0.90) indicated excellent agreement between both investigators. The concordance between both scoring systems was at 93.2% for agreement and 6.82% for disagreement. Polysensitisation (6 patients with 16 allergens) was detected equally in both methods. Limitation A single centre study. Conclusion The readings obtained by TPSS were in agreement with ICDRG. TPSS can reduce the number of patient visits by 50% and may be used during COVID-19 times and beyond.

Contact hypersensitivity to Indian standard patch test series correlates with disease severity among children with atopic dermatitis.

Background There is emerging evidence of a relationship between atopic dermatitis (AD) and allergic contact dermatitis (ACD), though the data available are scarce with conflicting viewpoints. We explored the occurrence of contact hypersensitivity among children with atopic dermatitis by patch testing them with the Indian standard series and tried to correlate the presence of contact hypersensitivity with the clinical severity of AD in these children. Methods In this single-centre, cross-sectional study, children between 6 months and 12 years diagnosed with atopic dermatitis were included and patch tested with the Indian standard series. Outcome parameters were the proportion of patients having positive patch-test reactions, the proportion of positive patch-test reactions for each allergen and factors associated with patch test positivity in atopic dermatitis. Results Of the 136 patients, 80 were boys. The mean age of the study population was 5.6 ± 3.2 years. Twenty-eight (20.6%) patients had patch test positivity at 96 h. Fragrance mix was the commonest allergen, followed by potassium dichromate, cobalt chloride hexahydrate and nickel. SCORing atopic dermatitis (SCORAD) was significantly higher in patients with positive patch tests as compared to patients with negative patch tests (P = 0.009). Conclusion Greater disease severity in atopic dermatitis was found to be associated with patch test positivity. Limitations Inability to establish relevance in about 50% of the patients was a limitation of our study. Follow-up data regarding the impact of allergen avoidance is not available.

Various techniques for marking patch test sites.

Patch test helps in identifying the allergen causing allergic contact dermatitis. Proper identification of the site of individual patch test allergen is very important for identifying the positive allergen. In this article, various techniques for markings patch test sites are discussed.

Kumkum-induced allergic contact dermatitis: Are we missing the actual culprit?

BACKGROUND: Kumkum, made with turmeric and slaked lime along with colour enhancing dyes is known to cause allergic contact dermatitis. The possible contact allergens in kumkum include turmeric, Sudan-1, 4-aminoazobenzene, brilliant lake red R and cananga oil. We report patch test results among patients with suspected contact hypersensitivity to kumkum. OBJECTIVE: To identify the allergen causing kumkum induced allergic contact dermatitis by patch testing and to advise patients about organic kumkum which doesnot contain colour enhancing dyes. METHODS: Eighteen patients with suspected contact hypersensitivity to kumkum were patch tested with undiluted kumkum, undiluted turmeric, Sudan-1 (95%), 4-aminoazobenzene and allergens of the Indian Standard Series. RESULTS: Of the 18 patients, 14 patients had patch test positivity to kumkum and 4 had a negative reaction to kumkum. Patch test with other suspected contact allergens showed positive reaction to turmeric in 4 patients, Sudan-1 in 3 patients and 4-aminoazobenzene in 2 patients. Among the allergens of the Indian Standard Series, positivity to nickel and fragrance mix was seen in 5 and 2 patients respectively. Positive reaction to PPD, chlorocresol and parthenium was seen in 1 patient each. LIMITATION: Small sample size. CONCLUSION: Allergic contact dermatitis to kumkum occurs both due to the dyes (added for enhancing the colour) and turmeric. All patients with suspected allergic contact dermatitis should be patch tested with kumkum, turmeric and dyes, based on which alternative non-allergic material could be advised. Kumkum dermatitis can also occur due to various other allergens, for which too patch testing should be done.

Dermoscopy and patch testing in patients with lichen planus pigmentosus on face: A cross-sectional observational study in fifty Indian patients.

BACKGROUND: Lichen planus pigmentosus (LPP) is a common cause of facial melanosis in the dark-skinned population. At present, information on dermoscopy and patch testing in LPP is limited. OBJECTIVES: To describe dermoscopic findings and study the role of patch testing in patients with LPP on the face. METHODS: Facial lesions of 50 patients with LPP were studied dermoscopically, followed by histological evaluation. Patch and photopatch tests with the Indian Standard Series and Scandinavian series, respectively, and patient's own cosmetics were performed on all patients. RESULTS: The most common dermoscopic finding was dots and/or globules (43/50, 86%) in different patterns: hem-like (20.9%), arcuate (18.6%), incomplete reticular (39.5%), complete reticular (7%), and not otherwise specified (14%). Other patterns were exaggerated pseudoreticular pattern, accentuation of pigmentation around follicular openings, targetoid appearance, and obliteration of the pigmentary network. There were 26 relevant patch tests in 17 (34%) patients: para-phenylenediamine (n = 5), nickel (n = 3), colophony, perfume mix and fragrance mix (n = 2 each), thiuram mix and 3,3,4,5-tetrachlorosalicylanilide (n = 1 each), and patients' own products (n = 9). The only positive photopatch test was to fentichlor. No clinical or histological finding differed significantly based on patch test results. The only dermoscopic finding to be statistically associated with a positive patch test was the non-characteristic arrangement of dots/globules (P = 0.042). LIMITATIONS: Dermoscopic features were not correlated with clinical features or disease duration. Implications of patch testing on the management of LPP cannot be commented upon as ours was a cross-sectional study. CONCLUSIONS: The present study describes the dermoscopic findings of facial lesions in LPP. Our patch test results suggest a probable role of allergens in causing LPP on the face.

Occupational dermatoses: An Asian perspective.

Occupational dermatoses contribute to a significant portion of work-related diseases, especially in Asia, where a major portion of the workforce is in the unorganized sector. This review article is focussed on the frequency and pattern of occupational skin diseases reported across Asian countries and type of allergens implicated in different occupations. The literature was searched systematically using key words 'occupational dermatoses,' 'occupational skin disease' and name of each Asian country. Ninty five full-text articles were considered relevant and evaluated. Some of the dermatoses seen in industrial workers in Asian countries are similar to those in Western countries, including dermatoses due to chromate in construction and electroplating workers, epoxy resin, and chromate in painters, wood dust in workers in the furniture industry, azo dyes in textile workers and formaldehyde and chromates in those working in the leather and dyeing industries, dermatoses in domestic workers, chefs and health-care workers. Dermatoses in workers engaged in agriculture, beedi (tiny cigars) manufacture, agarbatti (incense sticks) production, fish processing, carpet weaving, sanitation and those working in coffee plantations and coal mines appear to be unique to Asian countries. Recognition of clinical patterns and geographic variations in occupational skin diseases will provide an impetus to further strengthen future research in these areas, as well as improving their management.

Patch tests with commercial hair dye products in patients with allergic contact dermatitis to para-phenylenediamine.

BACKGROUND: Hair dye is one of the most common causes of allergic contact dermatitis. The main allergen has been identified as para-phenylenediamine. To prevent the recurrence of contact dermatitis to para-phenylenediamine, patients should discontinue the use of para-phenylenediamine-containing hair dye products. However, many patients are unable to discontinue their use for cosmetic or social reasons. Sometimes, they continue to have symptoms even after switching to so-called "less allergenic" hair dyes. OBJECTIVES: To evaluate the safety of 15 commercially available hair dye products in patients with allergic contact dermatitis due to para-phenylenediamine. METHODS: We performed patch tests using 15 hair dyes that were advertised as "hypoallergenic," "no para-phenylenediamine" and "non-allergenic" products in the market. RESULTS: Twenty three patients completed the study and 20 (87.0%) patients had a positive patch test reaction to at least one product. While four (26.7%) hair dye products contained para-phenylenediamine, 10 (66.7%) out of 15 contained m- aminophenol and 7 (46.7%) contained toluene-2,5-diamine sulfate. Only one product did not elicit a positive reaction in any patient. LIMITATIONS: Small sample size and possibility of false-positive reactions. CONCLUSIONS: Dermatologists should educate patients with allergic contact dermatitis to para-phenylenediamine about the importance of performing sensitivity testing prior to the actual use of any hair dye product, irrespective of how it is advertised or labelled.

Role of dental restoration materials in oral mucosal lichenoid lesions.

BACKGROUND: Dental restorative materials containing silver-mercury compounds have been known to induce oral lichenoid lesions. OBJECTIVES: To determine the frequency of contact allergy to dental restoration materials in patients with oral lichenoid lesions and to study the effect of removal of the materials on the lesions. RESULTS: Forty-five patients were recruited in three groups of 15 each: Group A (lesions in close contact with dental materials), Group B (lesions extending 1 cm beyond the area of contact) and Group C (no topographic relationship). Thirty controls were recruited in two groups of 15 individuals each: Group D (oral lichenoid lesions but no dental material) and Group E (dental material but no oral lichenoid lesions). Patch tests were positive in 20 (44.5%) patients. Mercury was the most common allergen to elicit a positive reaction in eight patients, followed by nickel (7), palladium (5), potassium dichromate (3), balsam of Peru, gold sodium thiosulphate 2 and tinuvin (2) and eugenol (1), cobalt chloride (1) and carvone (1). Seven patients elicited positive response to more than one allergen. In 13 of 20 patients who consented to removal of the dental material, complete healing was observed in 6 (30%), marked improvement in 7 (35%) and no improvement in 7 (35%) patients. Relief of symptoms was usually observed 3 months after removal. LIMITATIONS: Limited number of study subjects and short follow up after removal/replacement of dental restoration materials are the main limitations of this study. CONCLUSION: Contact allergy to amalgam is an important etiologic factor in oral lichenoid lesions and removal of restorative material should be offered to patients who have lesions in close proximity to the dental material.

Evaluation of role of Candida in patients with chronic paronychia.

BACKGROUND: Chronic paronychia, earlier considered to be an infection due to Candida, is currently being considered as a dermatitis of the nail fold. Irritant, allergic and protein contact dermatitis are the suggested major pathogenic mechanisms. Hypersensitivity to Candida is more likely to be the etiology, rather than the infection itself. AIMS: To assess the clinico-etiological profiles of patients with chronic paronychia and to determine the role of contact sensitization and hypersensitivity to Candida. METHODS: All consecutive patients of chronic paronychia attending the dermatology outpatient department (OPD) were assessed for risk factors, number of nails affected, clinical presentation and presence of fungus, patch tested for contact allergy and prick tested for hypersensitivity to Candida allergen. RESULTS: A total of 80 patients of chronic paronychia were recruited into our study. There was female preponderance (66 patients, 82.5%), with the most common group affected being housewives (47 patients, 58.8%). Frequent washing of hands (64 patients, 80%) was the most common risk factor. Fungal culture was positive in 56.1% (41 patients), the predominant species cultured was Candida albicans (15 patients, 36.5%). Patch testing with Indian standard series was positive in 27.1% patients (19 out of 70 patients tested), with nickel being the most common allergen. Prick test with Candida allergen was positive in 47.6% patients (31 out of 65 patients tested). LIMITATIONS: Prick test and patch test provide indirect evidence of hypersensitivity, with inherent limitations. CONCLUSION: Our study shows that chronic paronychia is probably a form of hand dermatitis associated with prolonged wet work, and that there is a higher incidence of contact sensitization and Candida hypersensitivity in these patients.

Sensitive skin: an overview.

Sensitive skin is less tolerant to frequent and prolonged use of cosmetics and toiletries. It is self-diagnosed and typically unaccompanied by any obvious physical signs of irritation. With the change in lifestyle and also with increased opportunity to use many new brands of cosmetics and toiletries, there has been an increase in females complaining of unique sensation in their facial skin. Sensitive skin presents as smarting, burning, stinging, itching, and/or tight sensation in their facial skin. The condition is found in more than 50% of women and 40% of men, creating a sizable demand for products designed to minimize skin sensitivity. Good numbers of invasive and non-invasive tests are designed to evaluate and predict the sensitive skin. Management includes guidelines for selecting suitable cosmetics and toiletries in sensitive skin individuals.

Evaluation of photopatch test allergens for Indian patients of photodermatitis: preliminary results.

BACKGROUND: There is a strong need to develop a photopatch test tray suitable for Indian patients of photodermatitis as European/Scandinavian photopatch test trays may not be wholly relevant for them. AIM: We carried out this study using photoallergens relevant in the Indian context to determine their relevance in patients of photodermatitis. METHODS: Thirty patients (M:F, 23:7) between 19 and 76 years of age of photodermatitis and 10 controls were patch- and photopatch tested with 20 common photoallergens. In addition, the patients were also (photo) patch tested with articles of daily use as and when these were suspected to be the cause. RESULTS: Forty-three positive reactions to one or more antigens were seen in 22 (74%) patients. Fourteen positive photopatch tests to seven allergens were observed in 10 (33%) patients, and nine (30%) of them had a definite relevance. The most common contact allergen was fragrance mix (FM) (30%), followed by p-phenylenediamine (20%) and Parthenium hysterophorous (17%). The definite relevance of the patch- and photopatch tests could be correlated in 47% of these patients. CONCLUSIONS: FM is the most common contact and photocontact allergen among the various photopatch test antigens. Although differences in technique and evaluation make direct comparison between different centers difficult, still photopatch testing remains an integral part and gold standard for the work-up of the photosensitive patients.

Irritancy potential of 17 detergents used commonly by the Indian household.

BACKGROUND: Detergents are used by almost every household in the developed and developing world. Soap and most detergents are anionic surfactants and attack the horny layer of the skin and increase its permeability with little or no inflammatory change and may result in hand eczema, which is very distressing and incapacitating. AIM: To evaluate the irritant potential of common household detergents (laundry and dish wash) used by the Indian population using a 24-hour patch test and to convincingly educate the patients on the detergents less likely to cause irritation in the particular individual. METHODS: Seventeen commonly used detergents found in Indian market were included in the study, of which, 12 were laundry detergents (powders--seven, bar soap--five) and five were dish wash detergents (powder--one, liquid--one, bar soap--three). The irritant potential of the 17 detergents were evaluated in 30 volunteers. Thirty microliters of each of the detergent bar solutions, distilled water (negative control), and 20% SDS (positive control) were applied to Finn chambers with a micropipette and occluded for 24 hours. Erythema, scaling, and edema were graded in comparison to the reaction at the negative control site (distilled water) for each volunteer separately. The scoring of erythema/dryness and wrinkling on a 0-4 point scale and edema on another 0-4 point scale was based on the Draize scale. The pH of each of the detergent solutions was determined using litmus papers (Indikrom papers from Qualigens fine chemicals). RESULTS: The difference between detergents (F value) was significant for erythema/dryness and wrinkling (F = 3.374; p = 0.000), but not significant for edema (F = 1.297; p = 0.194). [Table 2] lists the means for erythema/dryness and wrinkling, and edema. The F value of the totals of the means for erythema/dryness and wrinkling and edema was significant (F = 2.495; p = 0.001). The pH of all the detergents was found to be alkaline except Pril utensil cleaner which tested acidic (pH 6). The positive control, 20% SDS also tested acidic (pH 6). CONCLUSION: Similar to patch testing in allergic contact dermatitis, 24-hour patch testing with detergent solutions (8% w/v), will educate the patient on what detergent to avoid. This may bring down the total medication requirement and frequent hospital consultations for these patients.