What is in? What is out? Updating the British Society for Cutaneous Allergy facial series.

BACKGROUND: Allergic contact dermatitis (ACD) to cosmetics is widely reported. To ensure we are accurately diagnosing ACD, patch test series should be continually reviewed to identify relevant and emerging allergens and highlight those that are outdated. The current British Society for Cutaneous Allergy (BSCA) facial series recommends 26 allergens and was last modified in 2012. OBJECTIVES: To review and update the BSCA facial series. METHODS: We retrospectively reviewed the results from 12 UK and Ireland patch test centres' facial series from January 2016 to December 2017. We recorded the number of allergens tested in each centre and the detection rate for each allergen. Using a 0·3% positive rate as the inclusion threshold, we established which allergens in the BSCA facial series had positive patch test rates < 0·3% and > 0·3%. Allergens not in the BSCA facial series that had a positive patch test rate > 0·3% were identified. RESULTS: Overall, 4224 patients were patch tested to the facial series. The number of allergens included in individual centres' facial series ranged from 24 to 66, with a total of 103 allergens tested across all centres. Twelve of the 26 allergens in the BSCA facial series had a positive patch test rate < 0·3% and 14 had a rate > 0·3%. Twenty-five allergens not recommended in the BSCA facial series had a positive patch test rate > 0·3%. CONCLUSIONS: This audit has highlighted the significant variation in practice that exists among patch test centres, despite a recommended facial series. The BSCA facial series has been updated and now contains 24 allergens. Fifteen allergens remain, 11 allergens have been dropped and nine new allergens have been added.

Irritant contact dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study.

COVID-19 healthcare workers (HCWs) require frequent handwashing and use of personal protective equipment (PPE) to prevent infection. However, evidence is emerging that these practices are causing adverse effects on their skin integrity. A single-centre, cross-sectional study of HCWs from an Irish hospital was undertaken to evaluate the degree of COVID-19-related irritant contact dermatitis (ICD) between April and May 2020. Of 270 participants surveyed, 223 (82.6%) reported symptoms of ICD. The hands were the most commonly affected site (76.47%) and the most frequently reported symptom was dry skin (75.37%). Nearly all (268; 99.26%) HCWs had increased hand-washing frequency, but 122 (45.35%) did not use emollients. In the ICD group, 24.7% cited a history of dermatitis compared with 4.3% of unaffected staff (P < 0.001). The ICD group recorded PPE usage for an average of 3.15 h compared with the non-ICD group at 1.97 h (P = 0.21). Promoting awareness of COVID-19-related ICD is vital to highlight prevention and treatment for frontline staff.

Skin Cancer Excision Is More Efficient and Cost Effectivein a Specialist Secondary Care Service.

Aim To compare the relative efficiencies of skin excisions in primary and secondary care. Methods We compared the benign: malignant ratio for specimens referred by General Practice, General Surgery and the Skin Cancer Service to the regional pathology laboratory over one month. We used cost minimization analysis to compare the relative efficiencies of the services. Results 620 excisions were received: 139 from General Practice, 118 from General Surgery and 363 from the Skin Cancer Service. The number (%) of malignant lesions was 13 (9.4%) from General Practice, 18 (15.2%) from General Surgery and 137 (37.7%) from the Skin Cancer Service. Excision was cheaper in General Practice at €84.58 as compared to €97.49 in the hospital day surgical unit. However, the cost per malignant lesion excised was €1779.80 in general practice versus €381.78 in the Skin Cancer Service. Conclusion Our results indicate that moving skin cancer treatment to General Practice may result in an excess of benign excisions and therefore be both less efficient and less cost effective.

Distance as a Barrier to Melanoma Care

Aim Our aim was to review cases of melanoma diagnosed histologically in UHK in 2016 and to compare them to cases of melanoma nationally and in Kerry. Methods For each patient we recorded age, Breslow depth, and shortest distance to travel by car and travelling time (without traffic) to the South Infirmary Victoria University Hospital (SIVUH) from their primary residence (calculated using Google maps™ (2018)). Results 20 cases of invasive melanoma were diagnosed in UHK in 2016. Of the 20 cases, 9 (45%) presented at a very advanced stage with a Breslow depth of greater than 4mm. A further 7 (35%) cases had a depth of 1.5-4mm. These patients with invasive melanoma had a mean age of 72.5 (±15). The mean shortest distance to travel from the patient's primary residence to the SIVUH was 114.8km (±15.5) taking an average of 102 minutes (±14.6) by car. Conclusion Cases of melanoma diagnosed locally in UHK presented at an advanced stage compared to the national average. We suspect that the long distances to travel to the SIVUH pigmented lesion clinic is a barrier for these patients.

Recommendation to test limonene hydroperoxides 0·3% and linalool hydroperoxides 1·0% in the British baseline patch test series.

BACKGROUND: There is a significant rate of sensitization worldwide to the oxidized fragrance terpenes limonene and linalool. Patch testing to oxidized terpenes is not routinely carried out; the ideal patch test concentration is unknown. OBJECTIVES: To determine the best test concentrations for limonene and linalool hydroperoxides, added to the British baseline patch test series, to optimize detection of true allergy and to minimize irritant reactions. METHODS: During 2013-2014, 4563 consecutive patients in 12 U.K. centres were tested to hydroperoxides of limonene in petrolatum (pet.) 0·3%, 0·2% and 0·1%, and hydroperoxides of linalool 1·0%, 0·5% and 0·25% pet. Irritant reactions were recorded separately from doubtful reactions. Concomitant reactions to other fragrance markers and clinical relevance were documented. RESULTS: Limonene hydroperoxide 0·3% gave positive reactions in 241 (5·3%) patients, irritant reactions in 93 (2·0%) and doubtful reactions in 110 (2·4%). Linalool hydroperoxide 1·0% gave positive reactions in 352 (7·7%), irritant reactions in 178 (3·9%) and doubtful reactions in 132 (2·9%). A total of 119 patients with crescendo reactions to 0·3% limonene would have been missed if only tested with 0·1% and 131 patients with crescendo reactions to 1·0% linalool would have been missed if only tested with 0·25%. In almost two-thirds of patients with positive patch tests to limonene and linalool the reaction was clinically relevant. The majority of patients did not react to any fragrance marker in the baseline series. CONCLUSIONS: We recommend that limonene hydroperoxides be tested at 0·3% and linalool hydroperoxides at 1·0% in the British baseline patch test series.

Eccrine porocarcinoma arising within an area of Bowen disease.

Summary Very little is known about the aetiology of eccrine porocarcinoma (EP), a rare malignant sweat-gland tumour. Most reported cases have arisen de novo, or from a benign eccrine poroma. We report an unusual case, in which eccrine porocarcinoma arose at the exact site of pre-existing Bowen disease (BD).

Gentamicin-induced anaphylaxis.

BACKGROUND: Gentamicin is a common cause of allergic contact dermatitis but immediate (type 1) hypersensitivity is unusual. AIMS AND METHODS: We report a case of anaphylaxis to gentamicin in a 69-year-old man who developed urticaria, hypotension and loss of consciousness within minutes of receiving intravenous gentamicin. RESULTS: The patient was successfully resuscitated and made a full recovery. Prick testing and patch testing to gentamicin was positive. CONCLUSIONS: Although allergic reactions to gentamicin are well recognised, there are few reported cases of anaphylaxis to gentamicin.

An exploratory prospective observational study of environmental factors exacerbating atopic eczema in children.

BACKGROUND: Possible exacerbating factors are a major concern of parents of children with atopic eczema (AE). However, there is minimal evidence for their direct role in leading to disease flares. OBJECTIVES: To assess the association between 'trigger factors' and disease flares in AE. METHODS: Twenty-five children with AE were recruited. Participants completed diaries, recording severity and exposure to potential exacerbating factors (18 variables) over 28 days. Severity was assessed at baseline and study completion. The relationship between severity and exposures was assessed. RESULTS: At episode level, on the day of exposure (lag 0), hot weather correlated to increased scratch scores (P=0.043). At a lag of 2 days after exposure, damp weather was associated with raised scratch scores (P=0.027). At lag 3 days, elevated scratch scores were associated with sweating and stress (P=0.029 and 0.019, respectively). Outside damp was associated with elevated scores (P=0.001) at lag 4. Multivariate analysis of all significant variables showed that only damp at lag 4 was significantly associated with flares (P=0.039). CONCLUSIONS: This study suggests association between stress, damp and heat and disease flares. These findings need to be studied over a longer period, using objective exposure measures.

The importance of a dedicated patch test clinic.

BACKGROUND: A specialist patch test clinic was set up in April 1997 at the Department of Dermatology, South Infirmary-Victoria Hospital, Cork, Ireland. The number of batteries available was expanded from six to 21 and the routine testing of patients to their own products was introduced, as was prick testing for latex hypersensitivity. OBJECTIVES: To assess the impact of introducing this clinic on the detection of allergic contact dermatitis. METHODS: Patch test results for the first full year of operation of the clinic (1998) were compared with those in the year prior to setting it up (1996). RESULTS: Although the number of patients tested rose after the introduction of the new clinic, the difference was not significant as the number of new dermatology general referrals had also risen. Thirty-one of the 91 patients tested in 1996 had positive patch tests compared with 84 of 158 tested in 1998 (P = 0.0036). Eighteen allergens were detected in 1996 and 53 in 1998. Two patients were positive to their own products in 1996, compared with 12 in 1998 (P = 0.04). The commercial batteries were negative in four of these cases. Three cases of latex hypersensitivity were detected in 1998. CONCLUSIONS: The introduction of a specialist patch test clinic resulted in an increase in detected cases of allergic contact dermatitis. The larger range of batteries available and the more widespread testing of patients' own products were the principal factors involved.