Managing Contact Dermatitis Without Patch Testing.

Allergic contact dermatitis (ACD) is a common skin condition caused by contact with an exogenous agent that elicits an inflammatory response. Patch testing (PT) is considered the gold standard for diagnosing ACD. Unfortunately, PT may not be available to some patients due to insurance and financial limitations, contributing to health care disparity and leaving patients with undiagnosed, incompletely managed dermatitis that can have further detrimental health and occupational effects. For other patients, PT is precluded by lack of availability of specialist/expert care, comorbid medications, or diffuse disease. This article will present a patient with ACD and will work through the differential diagnosis and share strategies for empiric avoidance of suspected/common triggers. The epidemiology of ACD with respect to race and ethnicity, considerations for affordability of hypoallergenic products, access to testing, and the need for future research are addressed in this article.

Prevalence of allergic contact dermatitis in children with and without atopic dermatitis: A multicenter retrospective case-control study.

BACKGROUND: As both allergic contact dermatitis and atopic dermatitis (AD) have similar clinical presentations and are characterized by spongiotic dermatitis on skin biopsy, many children with AD are not referred for patch testing and allergic contact dermatitis is underdiagnosed. OBJECTIVE: To provide updated prevalence data of common contact allergens in children with and without AD. METHODS: This is a retrospective case-control study using the Pediatric Allergic Contact Dermatitis Registry from 2018 to 2022. RESULTS: A total of 912 children were included (615 with AD and 297 without AD). Children with AD were more likely to have a longer history of dermatitis (4.1 vs 1.6 years, P < .0001), have seen more providers (2.3 vs 2.1, P = .003), have greater than 1 positive patch test (PPT) result (P = .005), have a greater number of PPT results overall (2.3 vs 1.9, P = .012), and have a more generalized distribution of dermatitis (P = .001). PPT to bacitracin (P = .030), carba mix (P = .025), and cocamidopropyl betaine (P = .0007) were significantly increased in children with AD compared to those without AD. LIMITATIONS: Technical variation between providers and potential for misclassification, selection, and recall biases. CONCLUSION: Children with AD are significantly more likely to have PPT reactions and should be referred for evaluation of allergic contact dermatitis and obtain patch testing.

Atopic Dermatitis: Diagnosis, Disparity, and Management in Children of Color.

Atopic dermatitis (AD), sometimes referred to as eczema, is the most common chronic skin condition in children. Children of color have a higher reported prevalence of AD compared with their White counterparts. The purpose of this article is to discuss the differences of AD in skin of color (SOC), including clinical findings and management, with an emphasis on early recognition to avoid more severe, persistent disease. School nurses are on the frontline for these students with their ability to guide families and help support students with AD in the school setting.

Delayed allergic skin reactions to vaccines.

Background: Recent advances in vaccination against the severe acute respiratory syndrome coronavirus 2 pandemic have brought allergists and dermatologists to the forefront because both immediate and delayed hypersensitivity reactions have been reported. Objective: This literature review focused on delayed reactions to vaccines, including possible causative agents and practical information on how to diagnose, evaluate with patch testing, and manage subsequent dose administration. Methods: Currently published reviews and case reports in PubMed, along with data on vaccines from the Centers for Disease Control and Prevention web site. Relevant case reports and reviews that focused on delayed reactions to vaccines were selected. Results: Most delayed hypersensitivity reactions to vaccines include cutaneous manifestations, which vary from local persistent pruritic nodules to systemic rashes. The onset is usually within a few days but can be delayed by weeks. Multiple excipients have been identified that have been implicated in delayed vaccine reactions, including thimerosal, formaldehyde, aluminum, antibiotics, and gelatin. Treatment with antihistamines, topical corticosteroids, or systemic corticosteroids alleviates symptoms in most patients. Such reactions are generally not contraindications to future vaccination. However, for more-severe reactions, patch testing for causative agents can be used to aid in diagnosis and approach further vaccination. Conclusion: Delayed-type hypersensitivity reactions to vaccines are not uncommon. If needed, patch testing can be used to confirm agents, including antibiotics, formaldehyde, thimerosal, and aluminum. In most cases, delayed cutaneous reactions are not contraindications to further vaccine administration.

Different role of the supplementary motor area and the insula between musicians and non-musicians in a controlled musical creativity task.

The ability to compose creative musical ideas depends on the cooperation of brain mechanisms involved in multiple processes, including controlled creative cognition, which is a type of creativity that has so far been poorly researched. Therefore, the objective of this study was to examine the brain evoked activations by using fMRI, in both musicians and non-musicians, during a general task of controlled musical creativity and its relationship with general creativity. Results revealed that during a rhythmic improvisation task, musicians show greater activation of the motor supplementary area, the anterior cingulate cortex, the dorsolateral prefrontal cortex, and the insula, along with greater deactivation of the default mode network in comparison with non-musicians. For the group of musicians, we also found a positive correlation between the time improvising and the activation of the supplementary motor area, whilst in the non-musicians group improvisation time correlated with the activation of the insula. The results found for the musicians support the notion that the supplementary motor area plays a role in the representation and execution of musical behaviour, while the results in non-musicians reveal the role of the insula in the processing of novel musical information.

Risk stratification of systemic reactions to subcutaneous immunotherapy: A retrospective study.

Background: Subcutaneous allergen immunotherapy (SCIT) is a very effective treatment modality; however, it can be associated with both local and systemic reactions (SR). Identifying patient factors that predict SR remains paramount. Objective: Our aim was to identify the rate of SRs to SCIT as well as identify patient risk factors associated with the development of SRs. Methods: We conducted an institutional review board approved 10-year retrospective chart review of 459 patients who received SCIT in our clinic. The patients were placed into cohorts according to age, which included pediatric (5-18 years), adult (19-64 years), and senior (>65 years) patients. Results: An SR (N = 177) was identified in 24.8% of the patients (n = 114). The incidence of SR per injection was 0.2% (177 SRs of 74,183 total injections). SRs were identified as class 1 (n = 152), class 2 (n = 21), class 3 (n = 2), and class 4 (n = 2) according to the 2010 World Allergy Organization's SR grading system. There were no observed differences in the number of SRs with respect to age group. Female patients were more likely to have an SR (p = 0.02) overall as well as more than one reaction (p = 0.002). Other risk factors included the following: a patient-reported history of food allergy (p = 0.05), drug allergy (p = 0.005), or positive skin test result to cat and/or dog (p = 0.01). In addition, patients who were receiving SCIT to cat and/or dog (p = 0.004) or to dust mite (p = 0.03) were more likely to have an SR. Conclusion: In our patient population, the majority of SRs to SCIT occurred in female patients, patients with a history of drug or food allergies, and those who were receiving pet or dust-mite SCIT.

Utilization of high-fidelity simulation for medical student and resident education of allergic-immunologic emergencies.

BACKGROUND: The advantages of clinical simulation used in medical education include the acquisition of clinical skills in a controlled setting, promoting a multidisciplinary approach to patient care, and a high degree of learner satisfaction. OBJECTIVE: We aimed to identify knowledge gaps among Internal Medicine residents and students in the diagnosis and treatment of anaphylaxis and angiotensin-converting enzyme (ACE)-inhibitor-induced angioedema through their participation in a simulation course. METHODS: We conducted a cohort study involving clinical simulations with a high-fidelity, patient-simulator. The cases (antibiotic-induced anaphylaxis and ACE-inhibitor-induced angioedema) were standardized and algorithmic. Participants completed a pre- and post- simulation knowledge assessment and course evaluation. A follow-up knowledge survey was sent out 6 to 12 months after the course completion. RESULTS: Twelve groups comprising 45 medical students and residents completed the anaphylaxis course. All groups diagnosed anaphylaxis after more than 2-organ-system involvement had manifested, and half of the groups made the diagnosis after the patient-simulator was in anaphylactic shock. Half gave an incorrect dose of epinephrine, and most of the participants were inexperienced in epinephrine auto-injector (EAI) administration. Eight groups comprising 27 participants completed the ACE-inhibitor-angioedema course. Six of the groups correctly diagnosed the patient-simulator, but multiple incorrect treatments were given, and only 1 group successfully intubated the patient-simulator. Knowledge improved immediately after the simulation, and knowledge specific to EAI treatment seemed to be retained long-term. All participants agreed that the simulation was practical to their education. CONCLUSION: Clinical simulation improves knowledge on the diagnosis and treatment of anaphylaxis and ACE-inhibitor-induced angioedema. We advocate that clinical simulation be incorporated at institutions with appropriate capabilities.

Systemic Contact Dermatitis.

Systemic contact dermatitis (SCD) traditionally refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross reacting allergen via a different route. It occurs to allergens including metals, medications, and foods. The exact pathophysiology underlying this disease remains unknown, although it appears to be mediated by type 4 hypersensitivity reactions and possibly type 3 hypersensitivity reactions. The p-I concept (pharmacologic interaction with immunoreceptors) hypothesized that drugs are able to bind directly to a T cell receptor without first being presented by MHC (major histocompatibility complex) molecules and without prior metabolism, which would help explain why SCD can be seen on first exposure to medications. Nomenclature remains a challenge as SCD can be subcategorized using terms such as ACDS (allergic contact dermatitis syndrome) and its four clinical stages, Baboon syndrome, and SDRIFE (symmetrical drug-related intertriginous and flexural exanthema), which share many overlapping features. Food allergens may be responsible for uncontrolled or persistent symptoms in patients with contact dermatitis who do not respond to topical avoidance. With medications, symptoms may be induced by topical application versus systemic administration. Patch testing (PT) may be beneficial in diagnosing SCD caused by metals and many topical medications including corticosteroids, antimicrobials (ampicillin, bacitracin, erythromycin, neomycin, nystatin), NSAIDs (diclofenac, ibuprofen), anesthetics, and antihistamines (chlorphenamine, piperazine). Current treatment options include topical steroids and oral antihistamines for symptom relief and dietary avoidance to causative foods or metals.

Skin testing and drug challenge outcomes in antibiotic-allergic patients with immediate-type hypersensitivity.

BACKGROUND: The evaluation of antibiotic immediate-type hypersensitivity is intricate because of nonstandardized skin testing and challenge method variability. OBJECTIVE: To determine the safety outcomes and risk factors for antibiotic challenge reactions in patients reporting a history of antibiotic immediate-type hypersensitivity. METHODS: A 5-year retrospective review of patients evaluated for immediate-type antibiotic allergy was conducted. Data analyzed included patient demographics, index reaction details, and outcomes of skin testing and challenges, classified as single-step or multistep. RESULTS: Antibiotic hypersensitivity history was identified in 211 patients: 78% to penicillins, 10% to fluoroquinolones, 7.6% to cephalosporins, and 3.8% to carbapenems. In total, 179 patients completed the challenges (median age 67 years, range 50-76 years, 56% women), and compared with nonchallenged patients, they reported nonanaphylactic (P < .001) and remote index (P = .003) reactions. Sixteen patients (8.9%) experienced challenge reactions (5 of 28 for single-step challenge, 11 of 151 for multistep challenge), and 11 of these patients had negative skin testing results before the challenge. Challenge-reactive patients were significantly younger (P = .007), more often women (P = .036), and had additional reported antibiotic allergies (P = .005). No correlation was detected between the reported index and observed challenge reaction severities (κ = -0.05, 95% confidence interval -0.34 to 0.24). Anaphylactic rates were similar during single-step and multistep challenges (3.6% vs 3.3%). CONCLUSION: In the present population, younger women with multiple reported antibiotic allergies were at greatest risk for challenge reactions. Negative skin testing results did not exclude reactions, and index severity was not predictive of challenge outcome. The multistep and full-dose methods demonstrated a comparable reaction risk for anaphylaxis.

The role of contact dermatitis in patients with atopic dermatitis.

Because both atopic dermatitis (AD) and contact dermatitis (CD) are characterized by a similar morphologic appearance and similar distribution of skin involvement, the diagnosis of CD in AD has been difficult. Historically, it was thought that patients with AD were unable or less likely to develop CD due to various studies in which patients with AD stimulated with strong allergens failed to develop sensitization at rates similar to patients without AD. However, more recent evidence from the United States and Europe has shown that patients with AD have similar if not higher rates of positive patch test results to common contact allergens, including metals and fragrance, than those patients without AD. In this review, we highlight evidence for and against the role of contact allergy in patients with AD and seek to give clinically relevant management recommendations for the evaluation of CD in the patient with AD.

Patch testing for drugs.

Adverse drug reactions occur commonly and primarily manifest in a myriad of cutaneous eruptions. The use of drug patch testing in the diagnosis of specific drug eruptions is increasing; however, a standardized approach to this methodology is currently lacking. A review of current literature was performed on the available evidence of patch testing for drugs. This review addresses the use of patch testing for specific cutaneous adverse drug reactions and for specific classes of drugs including antimicrobials, anticonvulsants, antiretrovirals, glucocorticoids, and nonsteroidal anti-inflammatory drugs. In addition, the approach to performing patch testing to drugs in the clinical arena as well as current contraindications for drug patch testing is reviewed.

Systemic contact dermatitis and allergy to biomedical devices.

Systemic contact dermatitis (SCD) refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross-reacting allergen via the systemic route. It occurs to allergens including metals, medications, and foods. There has been recent interest in metal allergy as it relates to the implantation of devices such as orthopedic, dental, cardiac, and gynecologic implants. This review will briefly address all causes of systemic contact dermatitis with a special and expanded focus on metal implant allergy. We present literature on SCD to various metal biomedical devices, patch testing for diagnosis of metal allergy pre and post implantation and treatment.

Mobile Phones: Potential Sources of Nickel and Cobalt Exposure for Metal Allergic Patients.

The use of cellular phones has risen exponentially with over 300 million subscribers. Nickel has been detected in cell phones and reports of contact dermatitis attributable to metals are present in the literature. We determined nickel and cobalt content in popular cell phones in the United States. Adults (>18 years) who owned a flip phone, Blackberry®, or iPhone® were eligible. Seventy-two cell phones were tested using SmartPractice's® commercially available nickel and cobalt spot tests. Test areas included buttons, keypad, speakers, camera, and metal panels. Of the 72 cell phones tested, no iPhones or Droids® tested positive for nickel or cobalt. About 29.4% of Blackberrys [95% confidence interval (CI), 13%-53%] tested positive for nickel; none were positive for cobalt. About 90.5% of flip phones (95% CI, 70%-99%) tested positive for nickel and 52.4% of flip phones (95% CI, 32%-72%) tested positive for cobalt. Our study indicates that nickel and cobalt are present in popular cell phones. Patients with known nickel or cobalt allergy may consider their cellular phones as a potential source of exposure. Further studies are needed to examine whether there is a direct association with metal content in cell phones and the manifestation of metal allergy.