Guideline for allergological diagnosis of drug hypersensitivity reactions: S2k Guideline of the German Society for Allergology and Clinical Immunology (DGAKI) in cooperation with the German Dermatological Society (DDG), the Association of German Allergologists (ÄDA), the German Society for Pediatric Allergology (GPA), the German Contact Dermatitis Research Group (DKG), the German Society for Pneumology (DGP), the German Society of Otorhinolaryngology, Head and Neck Surgery, the Austrian Society of Allergology and Immunology (ÖGAI), the Austrian Society of Dermatology and Venereology (ÖGDV), the German Academy of Allergology and Environmental Medicine (DAAU), and the German Documentation Center for Severe Skin Reactions (dZh).

Not available.

Allergic contact dermatitis caused by a new temporary blue-black tattoo dye - sensitization to genipin from jagua (Genipa americana L.) fruit extract.

BACKGROUND: Temporary tattoos made with an extract of the jagua fruit (Genipa americana L.) are becoming increasingly popular. It is claimed that it is 'dermatologically tested' and does not contain p-phenylenediamine. Extracts of jagua and gardenia fruits have been used by indigenous people in South America, as well as in traditional Chinese medicine, for centuries. Genipin is currently used for its cross-linking effect in the manufacture of polysaccharides, and is being investigated for its anti-inflammatory and other properties. OBJECTIVES: To report the presence of the allergenic substance genipin in a self-administered temporary tattoo dye made from the fruit juice of jagua (Genipa americana L.). PATIENTS AND METHODS: A 39-year-old female who repeatedly applied 'completely natural and 100% safe' Earth Jagua® tattoo, obtained via the internet, to her left hand developed allergic contact dermatitis within 6 weeks. Analysis of the dye showed the presence of geniposide and genipin. RESULTS: Patch tests with the dye and with its main components, including genipin, gave strong positive reactions to the latter. There was no sensitization to other ingredients or p-amino compounds. CONCLUSIONS: We report an extensively evaluated case of allergic contact dermatitis caused by a temporary Earth Jagua® tattoo. The allergen identified is genipin, a substance that is increasingly used for tattoos and as a therapeutic agent in medicine. This could result in an increase in the number of allergic reactions in the future.

Iron management in chronic kidney disease: conclusions from a "Kidney Disease: Improving Global Outcomes" (KDIGO) Controversies Conference.

Before the introduction of erythropoiesis-stimulating agents (ESAs) in 1989, repeated transfusions given to patients with end-stage renal disease caused iron overload, and the need for supplemental iron was rare. However, with the widespread introduction of ESAs, it was recognized that supplemental iron was necessary to optimize hemoglobin response and allow reduction of the ESA dose for economic reasons and recent concerns about ESA safety. Iron supplementation was also found to be more efficacious via intravenous compared to oral administration, and the use of intravenous iron has escalated in recent years. The safety of various iron compounds has been of theoretical concern due to their potential to induce iron overload, oxidative stress, hypersensitivity reactions, and a permissive environment for infectious processes. Therefore, an expert group was convened to assess the benefits and risks of parenteral iron, and to provide strategies for its optimal use while mitigating the risk for acute reactions and other adverse effects.

Guideline for the diagnosis of drug hypersensitivity reactions: S2K-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI) and the German Dermatological Society (DDG) in collaboration with the Association of German Allergologists (AeDA), the German Society for Pediatric Allergology and Environmental Medicine (GPA), the German Contact Dermatitis Research Group (DKG), the Swiss Society for Allergy and Immunology (SGAI), the Austrian Society for Allergology and Immunology (ÖGAI), the German Academy of Allergology and Environmental Medicine (DAAU), the German Center for Documentation of Severe Skin Reactions and the German Federal Institute for Drugs and Medical Products (BfArM).

Drug hypersensitivity reactions are unpredictable adverse drug reactions. They manifest either within 1-6 h following drug intake (immediate reactions) with mild to life-threatening symptoms of anaphylaxis, or several hours to days later (delayed reactions), primarily as exanthematous eruptions. It is not always possible to detect involvement of the immune system (allergy). Waiving diagnostic tests can result in severe reactions on renewed exposure on the one hand, and to unjustified treatment restrictions on the other. With this guideline, experts from various specialist societies and institutions have formulated recommendations and an algorithm for the diagnosis of allergies. The key principles of diagnosing allergic/hypersensitivity drug reactions are presented. Where possible, the objective is to perform allergy diagnostics within 4 weeks-6 months following the reaction. A clinical classification of symptoms based on the morphology and time course of the reaction is required in order to plan a diagnostic work-up. In the case of typical symptoms of a drug hypersensitivity reaction and unequivocal findings from validated skin and/or laboratory tests, a reaction can be attributed to a trigger with sufficient confidence. However, skin and laboratory tests are often negative or insufficiently reliable. In such cases, controlled provocation testing is required to clarify drug reactions. This method is reliable and safe when attention is paid to indications and contraindications and performed under appropriate medical supervision. The results of the overall assessment are discussed with the patient and documented in an "allergy passport" in order to ensure targeted avoidance in the future and allow the use of alternative drugs where possible.

Analysis of an unusual cluster of systemic reactions to subcutaneous specific immunotherapy with respiratory allergens in one allergy center.

Systemic reactions to subcutaneous immunotherapy occur despite all necessary precautions and experienced staff and should prompt a search for causative factors. We present an analysis of 11 reactions, 8 of them within a short period. The patients and reactions were evaluated regarding extract errors (composition, concentration), dosing errors, ignored contraindications to specific subcutaneous immunotherapy, introductions versus maintenance phase and accidental intravascular injection. No single or common cause could be identified. Statistical analysis suggests that exceptional clusters of systemic reactions such as these may be just random cumulations without identifiable cause.

Low-dose triamcinolone acetonide in the phytocosmetic lichtena reduces inflammation in mild to moderate atopic dermatitis.

BACKGROUND: Previously, we reported the efficacy of Lichtena--a phytocosmetic cream product--in atopic dermatitis (AD). Later, fraudulent triamcinolone acetonide (TACA) was detected at low doses (16-40 microg/g) in Lichtena. This suggested that TACA may be effective at much lower concentrations than used in commercial products (1,000 microg/g). OBJECTIVES: To investigate the efficacy in AD of low-dose TACA in Lichtena compared to plain Lichtena. METHODS: Fourteen patients presenting symmetrical lesions of AD were treated for 1 month with Lichtena plus 25 microg/g TACA (= verum) and plain Lichtena (= placebo). The severity of the lesions was assessed by the Severity Scoring of Atopic Dermatitis (SCORAD) on days 0 (= baseline), 7, 14 and 28. RESULTS: Already after 1 week of treatment, significant SCORAD differences to baseline were observed comparing verum- and placebo-treated areas. No improvement was observed using plain Lichtena. CONCLUSIONS: TACA displayed a significant improvement of AD at doses up to 40 times lower than in commercial products.

Effect of self-hypnosis on hay fever symptoms - a randomised controlled intervention study.

BACKGROUND: Many people suffer from hay fever symptoms. Hypnosis has proved to be a useful adjunct in the treatment of conditions where allergic phenomena have an important role. METHODS: Randomised parallel group study over an observation period of two consecutive pollen seasons. Outcome data include nasal flow under hypnosis, pollinosis symptoms from diaries and retrospective assessments, restrictions in well-being and use of anti-allergic medication. We investigated 79 patients with a mean age of 34 years (range 19-54 years; 41 males), with moderate to severe allergic rhinitis to grass or birch pollen of at least 2 years duration and mild allergic asthma. The intervention consisted of teaching self-hypnosis during a mean of 2.4 sessions (SD 1.7; range 2-5 sessions) and continuation of standard anti-allergic pharmacological treatment. RESULTS: Of 79 randomised patients, 66 completed one, and 52 completed two seasons. Retrospective VAS scores yielded significant improvements in year 1 in patients who had learned self-hypnosis: pollinosis symptoms -29.2 (VAS score, range 0-100; SD 25.4; p < 0.001), restriction of well-being -26.2 (VAS score, range 0-100; SD 28.7; p < 0.001. In year 2, the control group improved significantly having learned self-hypnosis as well: pollinosis symptoms -24.8 (SD 29.1; p < 0.001), restriction of well-being -23.7 (SD 30.0; p < 0.001). Daily self-reports of subjects who learnt self-hypnosis do not show a significant improvement. The hazard ratio of reaching a critical flow of 70% in nasal provocation tests was 0.333 (95% CI 0.157-0.741) after having learnt and applied self-hypnosis.

[Psychiatric, medical and environmental factors in patients suffering from environment-related disorders]. / Psychiatrische, medizinische und umweltanalytische Faktoren bei Menschen mit umweltbezogenen Gesundheitsstörungen.

BACKGROUND: A multidisciplinary approach and a multi-modal methodology are needed to assess idiopathic environmental illnesses. SAMPLE: 61 patients took part in all diagnostic steps. METHOD: In the Basel pilot research project on environmental illness, a threefold diagnostic approach was established: patients had a medical and allergological examination, a psychiatric and psychological exploration and an environmental analysis of their homes. RESULTS: There is a clear psychological impact on environmental illness: 46 % of the symptoms could be traced back to psychological factors, and 18 % seemed to be influenced by them. Nevertheless, in 28 % more than one of the three dimensions was seen as important. Values within the self reporting questionnaires show high correspondence. Whereas patients and experts agree in many instances that there are psychological factors, they disagree in attributing clinical relevance to them. This discrepancy is helpful for explaining the difficulties therapists may encounter as to the patients' compliance. CONSEQUENCES: Environmental illness should be diagnosed and treated on an interdisciplinary basis including psychosomatic medicine.

Are environmental medicine problems relevant in Switzerland?

BACKGROUND AND AIM: In Switzerland, the prevalence of health problems attributed to environmental exposures is unknown, and views differ regarding its magnitude. In the present study we investigated the frequency of environmentally related health problems amongst the patients of Swiss sentinel physicians and assessed symptoms and suspected environmental exposures. METHODS: During 2002, nearly 250 "Swiss Sentinel Surveillance Network" physicians were asked to record the number of patients presenting with environmental health problems and to complete a questionnaire inquiring about suspected environmental exposures and health problems. Physicians offering "alternative" medical therapies also participated in the study. The results were compared with the experience of a Basel University pilot project which evaluated patients with environment-related health problems simultaneously from the medical, psychiatric and environmental viewpoint. RESULTS: 354 environment-related consultations were reported by 72 physicians, corresponding to 0.03% of all sentinel-physician consultations. There were considerable differences both within the group of Sentinella physicians, and between physicians offering "alternative" medical therapies and the Sentinella physicians, in the frequency of environmentally-related consultations, the character of the reported symptoms and the suspected environmental exposures. CONCLUSION: Overall, environmental medicine consultations in general practice were rare. However, experience of the environmental medicine pilot project showed that concerned persons seek help from various health care providers and from environmental agencies. Effective treatment should include counselling by medical, psychiatric and environmental professionals.

Symptoms attributed to the environment--a systematic, interdisciplinary assessment.

PROBLEM: To assess symptoms attributed to the environment from an interdisciplinary perspective and to evaluate the plausibility of the participants' individual theory of a causal relationship between exposure and health impairment. METHOD: We assessed the medical, psychiatric and environmental background in every participant in an environmental medicine project and discussed the explanatory value of our findings for each reported symptom. RESULTS: Every second participant had at least one symptom that could be plausibly explained by simultaneously occurring medical, psychological or environmental findings. In 40% of the participants the research team rated the association between an environmental exposure and the health complaints to be 'plausible'. Psychiatric disorders were frequent, but did not exclude environmentally caused symptoms. CONCLUSION: Only an interdisciplinary structure including medical, psychiatric and environmental expertise is likely to adequately diagnose and advise persons with environmentally related symptoms.

Unregulated alternative medicine.

Unconventional (i.e. alternative, traditional, or complementary) treatments are used by many individuals for a variety of symptoms and disorders. Reports on fraudulent products used for unconventional treatments are not uncommon. These include herbal remedies offered as "natural" while containing non-labeled synthetic pharmacological ingredients or even toxic agents, patients not being informed of active ingredients, products containing no active substances, or unqualified individuals or "clinics" delivering dangerous advice or treatment. Reports on tainted topical products remain rare due to the high analytical demands necessary to detect minimal traces of unknown ingredients, the fact that patients often use medications from different sources, and patient over-reliance on the effectiveness of folk remedies or advertised claims. The patients' assumption of receiving a safe and effective therapy by "natural" products has shown to be unreliable. The authors urge that quality standards for "natural" and pharmaceutical products should be the same and that only qualified professionals should deliver treatment and medical advice.