Hydrocortisone 17-butyrate (Locoid) 0.1% cream versus hydrocortisone (Uniderm) 1% cream in the treatment of children suffering from atopic dermatitis.

A randomized, double-blind, left-right study to compare the therapeutic efficacy of hydrocortisone 17-butyrate (Locoid) 0.1% cream with hydrocortisone (Uniderm) 1% cream was performed in forty children suffering from atopic dermatitis. The medications were applied to symmetrical bilateral skin lesions twice daily for a maximum of 4 weeks or until complete clinical clearance of such lesions had occurred. Complete clearance of skin symptoms was found in 36% of the Locoid-treated sides and in 23% of the Uniderm-treated sides following 2 weeks of therapy and in 60% and 30%, respectively, after 4 weeks of treatment. This difference in clearance rate after 4 weeks between both preparations was significantly in favour of Locoid cream. The expressed preferences of patients/parents and investigator were also significantly in favour of Locoid cream, both after 2 and 4 weeks. No serious side-effects were reported during this study. It is concluded that Locoid cream is significantly superior to Uniderm cream in the treatment of atopic dermatitis in children.

Occupational contact dermatitis due to spiramycin and/or tylosin among farmers.

Nine farmers suspected of having occupational contact dermatitis had positive patch tests to spiramycin and/or tylosin. After diagnosis the dermatitis cleared or improved markedly in seven patients; five of these stopped using the antibiotics in question, and two began to wear gloves while handling the drugs. The two patients who continued use of the drugs and took no precautionary measures had little change in the activity of the dermatitis.

Reduction of intake of balsams in patients sensitive to balsam of Peru.

64 patients participated in this study. 24 were patients who had positive patch tests to balsam of Peru. The dermatitis of 9 of the patients had flared after open oral challenge with balsam of Peru, and the dermatitis of 31 patients had flared after double-blind oral challenge. All 64 patients were asked to avoid food items suspected of containing balsams for 1 to 2 months. At the end of that time, an evaluation of the diet trial was made; the dermatitis of 37 had cleared or improved markedly. If an improvement had taken place, the patient was asked to continue to diet moderately. 6 months to 3 years after the diet was initiated, a questionnaire was mailed to those patients whose dermatitis had improved after the first trial. The patients were asked to evaluate the long-term benefit of following the diet. 30 felt there was a long-term effect, and 27 still followed the diet instructions to some degree.

Oral challenge with balsam of Peru.

A placebo-controlled, double-blind, oral challenge with balsam of Peru was carried out in 221 patients with various types of dermatitis. 210 patients completed the study, and 45 of them experienced a flare of their symptoms after challenge with balsam of Peru but not after placebo. 15 patients reacted to the placebo, and 5 reacted to both balsam and placebo. Specific reactivity to balsam of Peru was seen particularly in patients with positive patch tests to this compound and in some patch-test-negative patients with vesicular hand eczema, ano-genital and axillary eczema. Dietary restriction of the intake of balsams was followed by marked improvement or clearance of the dermatitis in approximately half of the patients who adhered to the diet for at least 1 month.

Oral challenge with food additives.

A randomized, placebo-controlled oral challenge with food additives (preservatives and food colorings) was carried out in 101 patients with eczema of undetermined origin who suspected that the intake of certain foods aggravated their dermatitis. 37 reacted to 1 or more of the food additives but not to a placebo, while 16 reacted to the placebo, or both the placebo and food additives. 48 had no reactions. The difference between the number of reactions to the food additives and the number of reactions to the placebo was not statistically significant. The reactions could be reproduced in only 1/3 of those challenged twice. It was not possible to correlate the reactions to food additives to reactivity to specific foodstuffs containing the same additives. If intolerance to food additives is suspected, an elimination diet seems warranted, regardless of whether the patient reacts to oral challenge with food additives.

Dietary restrictions in the treatment of adult patients with eczema.

Improvement was seen in the dermatitis of 262 of 675 patients who followed a restrictive diet for approximately 1 month. Patients included in the study were sensitive to metal salts, balsams or classical food allergens or reacted to oral challenge with food additives. Also included were patients who did not react to diagnostic tests but who experienced improvement of their dermatitis while maintaining an elimination diet. A follow-up study was carried out 1-3 years after diet treatment was instituted. Each of the 262 patients was asked to complete a questionnaire to describe the long-term course of the dermatitis. 206 responded to the questionnaire, and for 144 of them (70%; 95% confidence limits 64-76%), there was long-term improvement of the dermatitis. Long-term improvement was more common among atopic patients than among non-atopics. Symptoms of contact urticaria were more common among patients with hand eczema than those with other types of eczema.

Aluminium allergy.

13 children ranging in age from 1 to 13 years and 1 adult patient had positive patch tests to 2% AlCl3 in water. 13 of them had pruritic excoriated papules, 9 at sites of hyposensitization therapy with aluminium-bound pollen extracts, and 4 at sites of childhood immunization with an aluminium-bound vaccine (Di-Te-Pol). For the 1 adult patient, the positive patch test was not considered to be of current relevance. Aluminium is most likely to sensitize when present in preparations used for immunization.

Diagnostic procedures for eczema patients.

Of 7887 patients with eczema seen in a private dermatological practice over a period of 2 years and 4 months, a specific final diagnosis was found in 5376 (68%), while a final diagnosis of non-specific eczema was made in 2511 cases (32%). The most common final diagnoses were seborrhoeic dermatitis (1351), contact dermatitis (1317), atopic dermatitis (1009) and nummular eczema (822). Battery patch testing was the initial diagnostic procedure performed, and 897 of the 3164 patients who were patch tested had one or more positive patch tests. In 545 cases, the reactions were considered of relevance to the current dermatitis. Tests for immediate-type allergy were carried out in 618 patients, and 284 of these had one or more positive tests. In 86 patients, these test results were of diagnostic significance. 257 patients with positive patch tests were challenged orally with the relevant substance, and 53 of 156 reacted to metal salts, most commonly nickel, while 25 of 101 reacted to orally ingested balsam of Peru. Among patch-test-negative patients, 66 of 408 had positive reactions to one or more metal salts; 41 of 180 reacted to balsam of Peru, while 15 of 41 reacted to various food additives.

Dermatitis induced or aggravated by selected foodstuffs.

The eczema of 113 patients with dermatitis other than classical urticaria or typical atopic dermatitis cleared or showed marked improvement after one to two months of dietary restriction. In their response to a questionnaire completed at least 6 months after the initiation of the diet, 61 (54%) of these patients said that diet restriction was effective in reducing the activity of or preventing recurrence of their dermatitis. Their most common symptoms were recurrent symmetrical hand eczema, anogenital eczema, pruritic papules and excoriations of the trunk as well as a "fixed" type of eczema. Forty-nine of the 113 patients were able to reproduce their symptoms at least 3 times with certain food items, most commonly eggs, milk, tomato, cheese and fish. It is likely that both the classical food allergens and foods containing or producing histamine or other vasoactive substances could be the cause of such dermatoses or act as a non-specific aggravating factor. This type of reactivity was most common among patients with a personal and/or family history of atopic diseases (asthma, hay fever and/or atopic dermatitis). Symptoms corresponding to those of contact urticaria to food items were commonly seen among the patients.

Oral challenge with nickel and cobalt in patients with positive patch tests to nickel and/or cobalt.

During a 3-year period, 146 patients with positive patch tests to nickel and/or cobalt, for whom a systemic cause of dermatitis was suspected, were challenged orally with a single dose of 2.5 mg nickel given as nickel sulphate and 1 mg cobalt given as cobalt sulphate using a double-blind, placebo-controlled method. No following-up was possible for 2 patients. Seventy-five of the remaining 144 (52%) had flares of their dermatitis after challenge with nickel and/or cobalt, while 45 patients (31%) had no reaction and 24 (17%) reacted only to the placebo or to the placebo in combination with nickel or cobalt. Seven out of 13 patients with positive patch tests to cobalt experienced flares of their dermatitis only after challenge with cobalt.

Patch testing with substances not included in the standard series.

During a 5-year period, 3664 consecutive patients were patch tested in a private dermatology practice with the Standard Series of the International Contact Dermatitis Research Group (ICDRG). 454 of these were tested with one or more additional substances which were suspected of having caused their dermatitis. 194 of the 454 patients had positive reactions to one or more of the additional substances. Most of these reactions were of current relevance, and in only 25% of the patients could the allergies have been predicted by the use of the Standard Series alone. In approximately 50% of the patients, the reactions to additional substances could be traced to occupational sources.

Oral challenge with metal salts. (I). Vesicular patch-test-negative hand eczema.

202 patients, 68 males and 134 females, with patch-test-negative, symmetrical vesicular hand eczema were challenged orally in a controlled study with 2.5 mg nickel, 2.5 mg chromium and 1 mg cobalt given as salts of the respective metals. Initially a mixture of the 3 metal salts was given, and if this produced a flare of the eczema, the salts were administered individually at 1 week intervals. 55 patients reacted to the mixture of salts as well as to 1 or 2 of the individual salts. 3 other patients were challenged openly with nickel alone. Male patients reacted primarily to chromate and cobalt, while female patients more commonly reacted to nickel and cobalt. 56 patients were instructed to follow diets planned to reduce the daily intake of the respective metals. The dermatitis of 36 patients cleared or improved markedly after 1 month of dieting. Responses to a questionnaire sent to these 36 patients indicated that 28 of them had followed the prescribed diet rigorously or intermittently for at least a year, because they experienced recurrence of the dermatitis if they stopped dieting. 6 noted no long-term benefit and 2 did not respond.

Contact dermatitis in children.

168 children, 14 years of age or younger, were patch tested with the Standard Series of the International Contact Dermatitis Research Group (ICDRG) over a 5-year period. 77 of the children had 1 or more positive reactions; relevant test results were found in 80% of them. 8 boys and 24 girls were allergic to nickel, which proved to be the most common allergen; 5 boys and 6 girls reacted to chromate, and 5 boys and 4 girls reacted to one or more of the rubber chemicals.

Oral challenge with metal salts. (II). Various types of eczema.

299 patients with chronic dermatitis of obscure origin were challenged orally in a controlled study with 2.5 mg nickel, 2.5 mg chromium, and 1 mg cobalt given as salts of the respective metals. Flares of the dermatitis were seen in 12 of 61 patients with patch-test-negative hyperkeratotic eczema, in 9 of 32 patients with patch-test-negative perianal eczema, and in 7 of 143 patients with various other patch-test-negative eczemas. In this latter group, flares were seen only among patients with nummular eczema or hand eczema. Among 34 patients with various positive patch tests not relevant to the current dermatitis, 3 with hand eczema experienced flares. Patients who reacted to oral challenge with the metal salt to which they had a positive patch test, included 3 of 9 with nickel allergy, 2 of 5 with cobalt allergy and 6 of 15 with chromate allergy. These patients were tested openly. Low metal diets were prescribed for 33 patients who had flares after oral challenge with specific metal salts. For 23 of these, the dermatitis cleared or improved markedly after following the diet for at least 4 weeks. Responses to a questionnaire sent to the 23 patients indicated that 16 had followed the prescribed diet rigorously or intermittently for at least a year.

Patch testing with perfume mixture.

145 of 1116 patients patch tested with the standard series of the International Contact Dermatitis Research Group, including the recently introduced perfume mixture, had positive patch test reactions to at least one of the traditional screening agents for fragrance allergy or to the perfume mixture. In 96 of 145 patients the positive patch tests could be explained as being related to fragrance allergy. The perfume mixture was considered a useful screening agent for fragrance allergy. However, the results indicate that it is still necessary to employ several screening agents to detect this type of hypersensitivity.