Protection afforded by controlled application of a barrier cream: a study in a workplace setting.

BACKGROUND: Skin protective creams (PCs) are used widely in industrial work environments to prevent irritant contact dermatitis. However, workplace studies remain equivocal in terms of their effectiveness, which may be partly owing to whether the PC remains on the skin. OBJECTIVES: To assess the practicability of using skin occlusion testing in a workplace as a method to determine whether PCs applied under controlled conditions can reduce skin damage against known irritants. This study also compares two methods of skin evaluation: clinical dermatological assessment and bioengineering techniques. METHODS: Daily occlusion testing for 1 h (over two consecutive weeks) was conducted in an engineering company on the volar forearm of 21 healthy volunteer engineers with sodium lauryl sulfate (SLS) and a PC that was used on site. The engineers conducted their normal work activities during the occlusion testing period. The skin areas tested were assessed using transepidermal water loss (TEWL), Chroma Meter and by visual dermatological scoring. RESULTS: Testing with PC and SLS together showed that PC does not prevent irritant contact dermatitis but significantly reduced skin damage compared with SLS alone (P < 0.01). The changes in skin were evident earlier with the biophysical measurements when compared with the dermatological assessment. CONCLUSIONS: Occlusion testing is a useful method for assessing the potential effectiveness of protective creams and can be used in a workplace without affecting work practices. TEWL and the Chroma Meter provide useful objective information and should be used in combination with dermatological examinations.

Severe adverse cutaneous reaction to insulin due to cresol sensitivity.

We present the case of an 80-year-old lady known to be sensitive to chlorocresol (4-chloro-3-methyl phenol) who developed severe erythrodermic exfoliative dermatitis with atypical features 2 weeks after commencing subcutaneous insulin. All medications except insulin were stopped, without major improvement. It was noted that the insulin contained m-cresol (m-methyl phenol) so a parabens-based insulin was substituted. There was a significant improvement in her clinical condition within 72 hr. Further patch and intradermal testing to the insulin and m-cresol was planned, but she developed a nosocomial infection and died. We hypothesize that the adverse cutaneous reaction was a systemic manifestation of cresol sensitivity, given the rapid clinical resolution on changing insulins and the previously demonstrated sensitivity to chlorocresol, particularly as cross-reactivity between different low molecular weight methyl phenols is documented. Local injection site reactions and systemic side-effects including nausea, diarrhoea and vomiting have previously been reported with cresol-containing insulins, although to our knowledge, this is the first reported case of a severe cutaneous reaction. It is important to be aware of m-cresol as a potential allergen, as it is contained in most commercially available insulins.

Cutaneous and systemic sequelae from exposure to 2-vinylpyridine.

We present the case of an employee of a chemical production factory who became sensitized to 2-vinylpyridine despite wearing full protective polyvinyl chloride clothing. He developed severe dermatitis at the site of contact, secondary eczematization over the flexures and periungual areas, as well as marked systemic upset. Pyridines are known sensitizers although this reaction pattern has not previously been described.

Photopatch testing of 1155 patients: results of the U.K. multicentre photopatch study group.

BACKGROUND: Photoallergic contact dermatitis can be difficult to diagnose if not appropriately investigated. Currently, the most common U.K. photoallergens appear to be sunscreen chemicals. The investigation of choice is photopatch testing (PPT), which is probably underused. In part, this is due to differences in methodology and results interpretation. OBJECTIVES: To conduct PPT using a group of sunscreen chemicals, defined indications and a standardized methodology including interpretation and relevance of reactions in patients attending for investigation at 17 centres across the U.K., Ireland and the Netherlands. METHODS: Patients (n = 1155) who fulfilled the inclusion criteria were investigated with PPT using sunscreen chemicals in addition to suspected topical products. Readings were taken at 24, 48 and 72 h following standardized ultraviolet A irradiation (5 J cm(-2)). The clinical relevance of any reaction was recorded. RESULTS: Of the 1155, 130 had allergic reactions (11.3%). Of these, 51 had photoallergy (PA) (4.4%), 64 had contact allergy (CA) (5.5%), and 15 patients had combined PA and CA (1.3%). Multiple PA was seen in some. The most common photoallergen was benzophenone-3 (27 reactions; 21%). Most reactions (60%) were clinically relevant. The most common indication for testing in patients found to have PA was a history of reacting to a sunscreen (41%). The other 59% had an exposed-site dermatitis/skin problem or a photodermatosis. Some centres (n = 8) performed readings after the standard 48-h reading, and an extra 32 PA and 22 CA reactions were detected, which were not evident at 48 h. A new photoallergen (octyl triazone) was detected in two patients. CONCLUSIONS: Sunscreen PA and CA are probably equally uncommon. Most reactions, of both reaction types, were relevant clinically. A large proportion of patients (59%) found to have PA was unaware of reacting to a sunscreen chemical, suggesting that PA should be considered as an explanation in any exposed-site dermatitis. Although this study focused on reactions at 48 h postirradiation, readings performed up to 96 h, while inconvenient, add value by detecting additional relevant responses. A previously unknown photoallergen was found, highlighting the need for awareness of novel photoallergens in the marketplace. A standardized PPT method not only encourages more use of this investigation, but also facilitates comparison of results between centres and so will improve our understanding of PA.

Lichen sclerosus et atrophicus of the scalp.

A patient is described who developed pruritic lesions of the scalp with increasing hair loss and plaque formation over a period of 15 years, in association with patches of white atrophic skin on her trunk and vulva in the last 5 years. Biopsies of the scalp and trunk lesions both showed lichen sclerosus et atrophicus. This would appear to be the first recorded case of lichen sclerosus et atrophicus of the scalp in the English literature.

Granulomatous cheilitis and a positive Kveim test.

A female patient with a protracted history of multitudinary symptoms more recently developed granulomatous cheilitis (GC) and underwent extensive investigations. Her Kveim test was positive.

Human skin battery potentials and their possible role in wound healing.

Measurements of transcutaneous voltage have been made on seventeen normal volunteers. The results show the presence of 'skin battery' voltages comparable in size to those previously reported for amphibian and mammalian skin. No correlation was found between battery voltage and age or sex in the group studied, but consistent anatomical variations were observed. The possible role of these voltages in the natural wound healing process is discussed.

Allergic potential of neutrals in unmodified colophony, and a method for their separation from resin acids.

An ion-exchange fractionation technique for the separation of total resin acid and neutral fractions of unmodified colophony is described. The allergic potential of these fractions was assessed by patch testing colophony-sensitive individuals, and this showed that both the neutral components and the resin acids play an important role in colophony sensitization. A greater frequency of positive reactions was obtained using the 60% colophony patch test preparation compared with the currently recommended 20% colophony preparation. Furthermore, some individuals were found to produce positive reactions to only the neutral components in colophony. We suggest that the use of a colophony patch test battery comprising resin acids, neutrals, oxidized resin acid and some colophony derivatives, will facilitate detection of colophony-sensitive individuals. Moreover, we consider that this will help to provide a better estimate of the prevalence of colophony dermatitis, which is currently underestimated.

A double-blind trial of the H2 receptor antagonist cimetidine, and the H1 receptor antagonist promethazine hydrochloride in the treatment of atopic dermatitis.

Twenty young adults with atopic dermatitis were allocated randomly in a clinical trial to compare the action of the H2 receptor antagonist cimetidine (Tagamet) and the H1 receptor antagonist promethazine hydrochloride (Phenergan), singly and in combination. No significant differences were found, clinically or in the laboratory investigations, between the patients on either drug alone or the combination of the two.

Basal-cell carcinoma complicating a port-wine stain.

A rare radio-resistant basal-cell carcinoma is described which presented as a recently enlarged non-ulcerated nodule on a port-wine stain. The literature on basal-cell carcinoma occurring on a port-wine stain is reviewed, and the aetiological significance of thorium-X, sun-exposure and vascular changes in the development of malignancy on this type of haemangioma is discussed.

Allergic contact dermatitis from resin hardeners during the manufacture of thermosetting coating paints.

5 production operators from 2 factories manufacturing thermosetting coating paint developed work-related skin disorders within 12 months of the introduction of a new powdered paint product. All 5 workers were found to have allergic contact dermatitis from 2 epoxy resin hardeners, both of which were commercial preparations of triglycidyl isocyanurate (TGIC). 2 of the workers had concomitant sensitization to epoxy resin in the standard series and several of the epoxy resin preparations at the workplace. TGIC has been reported as a contact sensitizer both in persons producing the chemical and among end-users of TGIC-containing products. These 5 reported cases document allergic contact dermatitis from commercial TGIC among exposed workers during an intermediate process of powdered paint manufacture. The possibility of substituting this epoxy resin hardener with less sensitizing alternatives should be explored.

Occupational dermatitis from Synacril Red 3b liquid (CI Basic Red 22).

A carpet factory worker, exposed to a number of different dyes, developed a severe hand dermatitis. The handling of warm, wet and freshly-dyed yarn with unprotected hands was thought to have caused the onset of dermatitis. Patch testing indicated that the patient was sensitive to only one of the dyes handled, namely Synacril Red 3B liquid, which is based on the single dyestuff Basic Red 22 (CI 11055). Chemical analysis revealed the dyestuff to be of high purity (greater than 95%), suggesting that sensitization was caused by the Basic Red 22 dyestuff itself and not by an avoidable impurity.

Allergy to phosphorus sesquisulfide: 0.5% pet. is a more appropriate concentration for patch testing.

Patch testing was performed with phosphorus sesquisulfide P4S3 in 2 groups containing equal numbers of patients using different concentrations (0.5% P4S3 in pet. and 1% P4S3 in pet., the usual suggested test concentration as recommended by the International Contact Dermatitis Research Group). We found that there was a statistically significant increase in the number of clinically irrelevant irritant reactions in the group tested with the concentration (chi 2 = 16, p < 0.0004). We recommend that patch testing with phosphorous sesquisulfide should be at a reduced concentration of 0.5% pet.

High-performance liquid chromatography of unmodified rosin and its applications in contact dermatology.

Rosin is a well recognised skin sensitiser and is also amongst the most common causes of occupational asthma. Due to its complex chemical composition, it is difficult to isolate its many components and this has hindered progress in the identification of the specific respiratory and contact allergens it contains. This paper reports the application of high-performance liquid chromatography and other analytical techniques to the isolation and identification of contact allergens in complex mixtures such as rosin. HPLC methods were developed in order to isolate as many rosin components as possible and these were then patch tested on rosin sensitive individuals. The structure of the most dermatologically active component was then determined using mass spectrometry, nuclear magnetic resonance and infrared techniques. An HPLC method has also been developed which will enable the identification of rosin in commercial products, providing a valuable tool for determining the cause of rosin contact allergy. Furthermore, mass spectral data for the common abieitic-type resin acids are compiled which were used to confirm the identification of the HPLC resin acid peaks and have not been reported previously.

Protein losing enteropathy due to systemic lupus erythematosus.

We report the case of a 29 year old woman with a protein losing enteropathy caused by systemic lupus erythematosus presenting with periorbital oedema. Only three other cases of protein losing enteropathy due to systemic lupus erythematosus have been described, two of which were thought to be because of a primary enteropathy, although the exact pathogenesis was unknown. We suggest that both the protein losing enteropathy and periorbital oedema in this patient were because of increased capillary permeability to serum albumin, as a result of products of plasma C3 conversion which were present in large amounts. It is also of interest that the antigen/antibody system in this patient was RNP/anti-RNP and that DNA antibodies were not detected. This patient falls into a subset of systemic lupus erythematosus in which anti-DNA antibodies are not present, some of which appear to have a more favourable prognosis.

A cutaneous manifestation of acute lymphoblastic leukaemia mimicking urticaria pigmentosa.

A 37-year-old female developed what appeared to be the typical cutaneous manifestations of urticaria pigmentosa. These preceded the peripheral blood changes of acute null cell lymphoblastic leukaemia and skin biopsy revealed that the cutaneous changes were due to leukaemic infiltration. Chemotherapy resulted in clearance of the rash. The importance of skin biopsy in patients presenting with suspected urticaria pigmentosa is emphasized.