Severe vitamin D deficiency increases the risk of severe cutaneous adverse reactions.

Vitamin D deficiency has been reported to be associated with allergic diseases and dermatological disorders. We investigated the role of vitamin D in drug-induced non-immediate hypersensitivity reactions by measuring serum vitamin D levels in 60 patients diagnosed with non-immediate drug hypersensitivity reactions and in 60 patients who tolerated the same medication without any allergic reactions. The results showed that serum vitamin D levels were significantly lower in patients with severe cutaneous adverse reactions (SCARs) (13.56 ± 6.23 ng/mL) compared to patients with mild reactions (17.50 ± 7.49 ng/mL) and the drug-tolerant control group (17.42 ± 7.28 ng/mL), with p values of 0.031 and 0.015, respectively. The proportion of severe vitamin D deficiency (< 10 ng/mL) was much higher in SCAR patients compared to drug-tolerant subjects (36.7% vs. 11.7%, p value = 0.005). After adjusting for age, gender, region of residence, and concurrent illnesses, patients with severe vitamin D deficiency had significantly increased in-hospital mortality (odds ratio 16.04; 95% CI, 1.25-206.12, p value = 0.03). In conclusion, the risk of developing SCARs and in-hospital mortality was increased in patients with severe vitamin D deficiency. Further investigations should be conducted to elucidate the role of vitamin D in the development of SCARs.

Saline Vehicle Increases the Ability of Drug Patch Test in Cutaneous Adverse Drug Reactions.

BACKGROUND: Drug patch test to identify cutaneous adverse drug reactions (CADRs) has been widely reported. Appropriate vehicles can improve the ability of drug delivery and significantly increase positive reaction of drug patch tests. OBJECTIVE: The aim of this study was to evaluate the efficacy of drug patch tests using 0.9% saline vehicle in comparison with other traditional vehicles in CADRs. METHOD: All patients were patch tested with suspected drugs using 10-30% concentration of the commercialized form of drugs diluted in 0.9% saline, petrolatum, and water. RESULT: Of 100 patients with CADRs, 54 of those had at least one positive drug patch test. In terms of vehicles used, 43 patients had positive drug patch test with saline as compared to 35 with water (p = 0.485) and 25 with petrolatum (p = 0.007). Among CADRs subgroup, saline rendered significantly higher positive rate when compared with petrolatum in drug rash with eosinophilia and systemic symptom (DRESS) (70% vs. 20%, p = 0.025), maculopapular rash (MP) (52.4% vs. 31%, p = 0.046), and lichenoid drug eruption (46.7% vs. 0.0%, p = 0.002). 12/54 (22.2%) of CADRs patients had positive reaction with saline alone. Among these patients, 4/12 (33.3%) were lichenoid drug reaction, 3/12 (25%) were DRESS, and 2/12 (16.7%) were MP rash. Allopurinol was the drug giving positive patch test only with saline. CONCLUSION: Appropriate vehicles are essential to obtain the positive drug patch test. Using saline as a vehicle can increase the positive reaction of drug patch test, particularly in lichenoid drug eruption. We recommend the use of saline as another traditional vehicle in drug patch test.

Allergic contact dermatitis to topical medicaments: Revisited.

BACKGROUND: Allergic reaction to topical drugs varies depending on use and availability of topical drugs and self-medication. OBJECTIVE: We aimed to determine the incidence of contact dermatitis to topical medicaments among patients referred for patch testing. METHODS: All patients with suspected allergic contact dermatitis were patch tested with standard and medicament series. The characterization was performed according to the MOAHLFA index. RESULTS: 59/215 (27.4%) patients had positive reactions to at least 1 medicament but only 13/59 (22.0%) had a relevant history. The 3 most common positive medicaments were framycetin 23/215 (10.7%), miconazole 22/215 (10.2%), and econazole 17/215 (7.9%). Among those positive to medicament, face was the most common location 22/59 (37.3%). 39/215 (18.1%) had more than 2 co-positive standard allergens and showed significant higher rate of topical medicament sensitization. The contributing factors of medicament allergy were the history of suspected allergens in personal care products (OR = 2.09, P = 0.038), topical drugs (OR = 2.93, P = 0.002), topical treatment (OR = 2.47, P = 0.011), and history of drug allergy (OR = 1.78, P = 0.023). CONCLUSIONS: The study showed a high rate of medicament sensitization especially antibiotic and antifungal drugs. The incidence of positive medicament patch test result was associated with facial dermatitis. Polysensitization and history of previous exposure, either as treatment or overusing of drugs, significantly associated with medicament positive patients. This study supports the inclusion of medicaments within the standard series of patch test.

Evaluation of recovery time of tear film function and ocular surface after discontinuing oral isotretinoin treatment for acne vulgaris : Correlation between oral isotretinoin and tear film function.

PURPOSE: This study aimed to evaluate the recovery time of tear film function and ocular surface after discontinuing systemic isotretinoin treatment. METHODS: This was a prospective, cross-sectional study. 34 eyes of 17 patients treated with low- dose oral isotretinoin (< 0.5 mg/kg/day) were enrolled. The modified OSDI score, tear break-up time, Schirmer test, and corneal staining were performed in all patients at baseline, during the course of treatment and after withdrawing treatment every two weeks until the result returned to baseline. RESULTS: Tear breakup time appeared to be the most sensitive and changed significantly at 2 weeks after starting treatment (p < 0.001) and returned to baseline at 4 weeks after withdrawal from treatment (p < 0.001). The Schirmer test results significantly decreased at 6 weeks and returned to baseline at 4 weeks after withdrawal from treatment (p < 0.001). OSDI scores were significantly changed at 6 weeks after treatment (81.8%) and returned to baseline at 2 weeks (54.5%) after withdrawal from treatment. No significant change was found in the MGD. Corneal staining was significantly positive 90.9% 6 weeks after starting treatment and returned to baseline 6 weeks after withdrawal from treatment (p < 0.001). CONCLUSION: Dry eye disease can return to baseline levels after treatment withdrawal. At least 6 weeks later, they could wear contact lenses again, and it was useful to prepare all patients requiring further ocular surgery.

The Effect of Food Avoidance in Adult Patients with Chronic Idiopathic Urticaria.

BACKGROUND: Recent findings show food allergy is rarely the cause of chronic urticaria. However; reports showed up to 5% of chronic idiopathic urticaria (CIU) was food induced urticaria (FIU) and the remission rate with food avoidance in CIU was varied. According to recent studies, skin prick test (SPT) is not a gold standard for investigating the culprit food allergen in CIU. The clinical response for food avoidance is still unclear. OBJECTIVE: The purpose of the present study is to investigate the association of food allergen and SP7 the clinical response after positive food avoidance in adult Thai patients with CIU. MATERIAL AND METHOD: We conducted a prospective study that included 76 patients, who presented with CIU at the Division of Dermatology, Department of Medicine, Phramongkutklao Hospital, between September 1, 2009 and May 31, 2010. Personal data, general physical examination, and detailed history were obtained. Twenty food allergens were used to perform SPT at the allergy clinic. The positive food allergens were enrolled to avoid the culprit food allergens for two to four weeks and evaluated the clinical response. RESULTS: Fifty-one of 76 patients (67.1%) gave history compatible with FIU. Shrimp (54.9%) and fish (49.0%) were the two most commonly suspected allergens by the patients. Fifteen of 76 patients (19.7%) had positive SPT In comparison to the SPT negative group in terms of clinical severity and effect on their daily lives, there was no significant difference. We then matched the SPT results with the patient's history. Five of 76 (6.6%) patients had results of SPT matching the patients' history. The five allergens in these patients were fish, milk, tomato, shrimp, and yeast. Fifty-one of 76 (67.1%) patients had negative SPT results but the patients suspected that certain foods were the cause of their urticaria. Fifteen of 76 (19.7%) patients had positive SPT results but the patients had never suspected any food allergen. Among these SPT positive patients, 13 food allergens were the culprits, the first three most common SPT allergens in this group were peanut, oyster and tomato. Upon SPT positive food avoidance, 12 of 15 (80%) SPT+ patients had significant improvement of symptom score in term of clinical severity and effect on their daily lives. CONCLUSION: Although SPT still yielded a low sensitivity for the diagnosis of FIU, the present study showed a very good response by food avoidance in patients who were SPT positive.

Cutaneous adverse drug eruption: the role of drug patch testing.

BACKGROUND: Drug patch testing has been proposed as a helpful investigation upon suspecting drug allergy. We evaluated the value of drug patch testing in Cutaneous Adverse Drug Reactions (CADRs). METHODS: All patients with a diagnosis of CADRs were patch tested with suspected drugs. RESULTS: Of 122 patients with CADRs, 44.3% had at least one positive result after drug patch testing, P value = 0.312. Drug rash with eosinophilia and systemic symptom (DRESS) rendered the highest positive patch testing at 53.9%, followed by a maculopapular rash (MP) at 49.0%, fixed drug eruption (FDE) at 48.3%, lichenoid drug eruption and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) at 25.0% each. Lichenoid drug eruption had the longest mean onset of almost 2.5 years. One hundred and twenty-eight drugs and herbal medicines were tested. About 32.8% of these drugs gave a positive result, P value = 0.041. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common positive drug especially for fixed drug eruption (FDE), followed by antiretroviral and antibiotics, which were the most common positive drugs for MP. While anti-Tuberculosis (anti-TB) drugs and antihypertensives together with lipid-lowering drugs were the most common for DRESS and lichenoid eruption, respectively. Subgroup analysis among HIV patients showed a 61.5% positive patch test. The median CD4 count in the positive group was 43.5 cells/mm3 . CONCLUSION: We recommend drug patch testing as a safe method to identify the culprit drug in CADRs, especially DRESS, MP, and FDE. In HIV patients, the positive test was associated with low CD4 count and copositive reaction.

Omalizumab treatment in severe adult atopic dermatitis.

Atopic dermatitis (AD) is one of the most common chronic skin diseases. Treatment options include lubricants, antihistamines, and corticosteroids in either topical or oral forms. Severe AD is frequently recalcitrant to these medications. We reported three cases of severe AD patients who had elevated of IgE levels and failed to response to several prior medical treatment. After being treated with Omalizumab (humanized monoclonal anti-IgE antibody), the patients had marked alleviation of symptoms with improved Eczema Area and Severity Index (EASI) and pruritic scores. No patient experienced adverse effect.

Systemic pigmented contact dermatitis to cobalt following ingestion of cobalamin supplement.

Systemic contact dermatitis (SCD) is a condition occurring in previously sensitized individuals after systemic re-exposure to the same or cross-reacting substance. Pigmented systemic contact dermatitis after intake of cobalt containing diet has never been reported.

Incidence and risk factors of gonococcal urethritis reinfection among Thai male patients in a multicenter, retrospective cohort study.

Gonococcal urethritis (GU) is the second most common sexually transmitted infection (STI). Epidemiologic studies of the situation of GU reinfection and its related risk factors among patients with a history of GU in Thailand remain somewhat limited. A hospital-based retrospective cohort study was conducted between January 1, 2010 and December 31, 2020 to determine the incidence and risk factors of GU reinfection among male patients visiting in Royal Thai Army (RTA) Hospitals. A total of 2,465 male patients presenting a history of GU was included in this study. In all, 147 (6.0%; 95% CI 5.1-6.9) male patients presented GU reinfection, representing an incidence rate of 1.3 (95% CI 1.1-1.5) per 100 person-years. The independent risk factors for GU reinfection were age < 30 years (AHR 1.7; 95% CI 1.0-2.8), number of sexual partners equal to 2 (AHR 3.4; 95% CI 1.0-11.2), ≥ 3 (AHR 5.6; 95% CI 2.7-11.6), and participants residing in the north (AHR 4.1; 95% CI 2.3-7.5) and northeast regions (AHR 2.1; 95% CI 1.1-3.9). Incidence of GU reinfection among male patients visiting RTA Hospitals was significantly high among younger aged patients, especially in the north and northeast regions. Multiple sex partners played a major role in GU reinfection. Effective STI prevention programs should be provided to alleviate reinfection and its complications.

A case report of limited Wegener's granulomatosis presenting with a chronic scalp ulcer.

Wegener's granulomatosis (WG) is manifested by granulomatous necrotizing inflammatory lesions involving multiple organs. Limited WG is classification of WG with the absence of disease features that pose immediate threats to either a critical individual organ or to the patient's life. The most common skin lesions are palpable purpura, necrotic ulcerations, papules and nodules with many histological pattern, leukocytoclastic vasculitis, granulomatous vasculitis, and palisading granulomas. We report a patient with a limited form of WG who presented with a chronic large scalp ulcer that rapidly responded to an immunosuppressive therapy.

Diagnosing Allergic Contact Dermatitis Through Elimination, Perception, Detection and Deduction.

Several authors have commented upon the skills of detection required in making a diagnosis of allergic contact dermatitis. Here, we emphasise the search for clues in a systematic manner. We describe four stages as part of a systematic method for diagnosing allergic contact dermatitis. Firstly, elimination (or inclusion) of non-allergic diagnoses. Secondly, perception: the pre-patch test diagnosis and the 'three scenarios' principle. Thirdly, detection: optimising the sensitivity of the patch test process. Fourthly, deduction: diagnosing allergic contact dermatitis by associating the dermatitis with the allergen exposure. We further compare and contrast the pre-patch test history and examination with the markedly different one ('microhistory' and 'microexamination') used after patch testing. The importance of knowledge of contact dermatitis literature is emphasised with a review of recent publications. Finally, we also highlight the use of contact allergy profiling as an investigative tool in the diagnosis of allergic contact dermatitis.

Proposed ICDRG Classification of the Clinical Presentation of Contact Allergy.

The International Contact Dermatitis Research Group proposes a classification for the clinical presentation of contact allergy. The classification is based primarily on the mode of clinical presentation. The categories are direct exposure/contact dermatitis, mimicking or exacerbation of preexisting eczema, multifactorial dermatitis including allergic contact dermatitis, by proxy, mimicking angioedema, airborne contact dermatitis, photo-induced contact dermatitis, systemic contact dermatitis, noneczematous contact dermatitis, contact urticaria, protein contact dermatitis, respiratory/mucosal symptoms, oral contact dermatitis, erythroderma/exfoliative dermatitis, minor forms of presentation, and extracutaneous manifestations.