A case series of hydroxychloroquine exacerbating the dermatomyositis rash.

Hydroxychloroquine (HCQ) is an antimalarial agent that is commonly used in the management of rheumatic skin disease. Few reports exist documenting exacerbation of dermatomyositis (DM) related to HCQ. Herein, we describe three adult patients with worsening DM cutaneous disease after starting HCQ and resolution or improvement with cessation. The time to exacerbation ranged from two weeks to nine months after the initiation of HCQ 400mg/day. Two of the three patients had antibodies to transcription intermediary factor 1γ (TIF1γ) and the other had antibodies to anti-nuclear matrix protein 2 (NXP2). After discontinuation of HCQ, the time to improvement or resolution of cutaneous symptoms ranged from six weeks to six months. Hydroxychloroquine may be associated with worsening cutaneous features in DM. In patients who are not improving despite escalation of immunosuppressive medications, or are worsening, we recommend a trial of discontinuing HCQ.

Patch testing with sodium disulfite: North American Contact Dermatitis Group experience, 2017 to 2018.

BACKGROUND: Sodium disulfite (SD), also known as sodium metabisulfite, is an increasingly recognized cause of allergic contact dermatitis. OBJECTIVES: The objective of this work was to characterize individuals with positive patch test reactions to SD as well as analyse reaction strength, clinical relevance, and sources. METHODS: This is a retrospective analysis of patients patch tested with SD (1% petrolatum) by the North American Contact Dermatitis Group (NACDG), 2017 to 2018. RESULTS: Of 4885 patients patch tested with SD, 132 (2.7%) had a positive reaction. Common primary anatomic sites of dermatitis were face (28.8%), hands (20.5%), and a scattered/generalized distribution (13.6%). Compared with SD-negative patients, SD-positive patients were more likely male (odds ratio 2.81, 95% confidence interval 1.98-4.00) and/or over 40 years (odds ratio 1.95, 95% confidence interval 1.30-2.94). Reactions were most commonly + (50.4%) or ++ (34.1%); 65.2% were considered currently relevant. About 15.2% were definitively confirmed in sources, commonly personal care products (18.9%, especially hair dye), and drugs/medications/alcoholic beverages (9.1%). Only 2.3% of positive reactions were linked to occupation. CONCLUSIONS: Positive reactions to SD occurred in 2.7% of tested patients. Reactions were often clinically relevant and linked to personal care products and drugs/medications/alcoholic beverages.

Delayed-onset cutaneous eruption associated with lenalidomide in setting of multiple myeloma.

Lenalidomide (LEN) is increasingly being used for the treatment of multiple myeloma (MM). Adverse cutaneous reactions to LEN are common and present almost exclusively within one month of initiating therapy. We report a case of delayed-onset LEN-associated eruption presenting over three years after starting treatment. Histopathologic findings are also described, which are infrequently reported for LEN-associated eruptions. Our case serves as a reminder that proper recognition and management of LEN-associated eruption is important in the treatment of MM. Dermatologists should be aware of the potential for delayed presentations of adverse cutaneous reactions to LEN, even years after initiation.

Patch Testing to Ethylhexylglycerin: The North American Contact Dermatitis Group Experience, 2013-2018.

BACKGROUND: Ethylhexylglycerin (EHG) is a recently recognized contact allergen. OBJECTIVE: The aims of the study were to characterize individuals with positive patch test reactions to EHG and to analyze reaction strength, clinical relevance, and allergen sources. METHODS: This study was a retrospective analysis of the patients patch tested to EHG (5% petrolatum) by the North American Contact Dermatitis Group (2013-2018). RESULTS: Of 15,560 patients tested to EHG, 39 (0.25%) had positive (final interpretation of "allergic") reactions. Most were female (71.8%) and/or older than 40 years (76.9%). There were no statistically significant differences between age, sex, or atopic history when compared with EHG-negative patients. The most common anatomic sites of dermatitis were the face (28.2%) and scattered generalized distribution (25.6%). Most EHG-positive reactions were + (35.9%) or ++ (33.3%). Current clinical relevance was high (79.5%); none, however, were related to occupation. Personal care products were the most common source of exposure to EHG (59.0%). CONCLUSIONS: Ethylhexylglycerin is a rare contact allergen; the positive frequency of 0.25% is similar to other low allergenic preservatives including parabens, benzyl alcohol, and phenoxyethanol. The patch test concentration of 5.0% seems to be nonirritating. Although relatively uncommon, EHG reactions were usually clinically relevant (79.5%), often because of moisturizers/lotions/creams.

Importance of Supplemental Patch Testing Beyond a Screening Series for Patients With Dermatitis: The North American Contact Dermatitis Group Experience.

IMPORTANCE: Patch test screening series for patients with dermatitis are limited and may miss clinically relevant contact allergens. OBJECTIVE: To characterize individuals with dermatitis who showed clinically relevant patch test findings to supplemental (nonscreening) allergens or substances. DESIGN, SETTING, AND PARTICIPANTS: A 17-year, retrospective cross-sectional analysis (January 1, 2001, to December 31, 2018) of North American Contact Dermatitis Group (NACDG) data from multiple centers in North America was conducted. A total of 43 417 patients with dermatitis underwent patch testing to the NACDG screening series in a standardized manner with 65 to 70 allergens and supplemental allergens as clinically indicated. Patients with 1 or more clinically relevant reactions to a supplemental (nonscreening) allergen/substance were analyzed between November 18, 2020, and March 12, 2021. MAIN OUTCOMES AND MEASURES: The main outcomes were to assess the number of patients with clinically relevant reactions to supplemental (nonscreening) allergens and compare characteristics (including demographic characteristics and occupations) between patients with a clinically relevant patch test reaction to 1 or more supplemental allergens or substances (supplement-positive) and those without a reaction (supplement-negative) using odds ratios (ORs) and 95% CIs. Secondary outcomes included sources of allergic contact dermatitis and, for occupationally related cases, specific occupations and industries. RESULTS: Of 43 417 patients included in the study who underwent patch testing to the NACDG screening series (65-70 allergens), 9507 individuals (21.9%) had currently relevant reactions to 1 or more supplemental allergens or substances. Of these, 6608 were women (69.5%) and the mean (SD) age was 47.2 (0.54) years. Compared with patients who had supplement-negative results, patients with supplement-positive findings were significantly less likely to be male (OR, 0.90; 95% CI, 0.85-0.94; P < .001) and/or have atopic dermatitis (OR, 0.89; 95% CI, 0.84-0.93; P < .001). Common primary sites of dermatitis in 9499 patients with supplement-positive findings included the face (2856 [30.1%]), hands (2029 [21.4%]), and scattered/generalized distribution (1645 [17.3%]). Frequent sources of supplemental allergens in 9235 patients included personal care products (4746 [51.4%]) and clothing/wearing apparel (1674 [18.1%]). Of 9362 patients with available data, supplemental allergens/substances were occupationally related in 1580 (16.9%); of those with identified occupations, 25.1% (384 of 1529) were precision production, craft, or repair workers. Of 9507 patients with supplement-positive findings, 2447 (25.7%) had no currently relevant reactions to NACDG screening allergens. CONCLUSIONS AND RELEVANCE: This cross-sectional study found that 21.9% of patients who underwent patch testing to an allergen screening series of 65 to 70 allergens had at least 1 relevant reaction to supplemental allergens/substances. Of these, one-quarter reacted only to a supplemental allergen/substance. Screening series include common, important allergens, but these findings suggest that the addition of specialty allergens and personal or work products is critical for the successful diagnosis and management of allergic contact dermatitis.

Patch Testing to Methyldibromoglutaronitrile/Phenoxyethanol: North American Contact Dermatitis Group Experience, 1994-2018.

BACKGROUND: Methyldibromoglutaronitrile/phenoxyethanol (MDBGN/PE) is a broad-spectrum preservative mixture used in consumer and industrial products. OBJECTIVES: The aims of the study were (1) to characterize the prevalence and clinical relevance of patch test reactions to MDBGN/PE and the epidemiology of positive patients and (2) to determine the frequency of concomitant reactions of MDBGN/PE and its components. METHODS: This study used a retrospective analysis of cross-sectional data compiled by the North American Contact Dermatitis Group from 1994 to 2018. RESULTS: Of 55,477 tested patients, 2674 (4.8%) had positive patch test reactions to MDBGN/PE (1.0%-2.5% petrolatum [pet]); most were + (63.3%) or ++ (22.3%). Clinical relevance was considered definite in 3.0% and probable in 19.3% of reactions. Common dermatitis sites included the hands (26.4%), scattered/generalized distribution (24.7%), and the face (18.3%). Patients with a positive reaction to MDBGN/PE and/or MDBGN and/or PE were significantly more likely to be male and older than 40 years and/or had hand dermatitis (P ≤ 0.0033). Positivity to MDBGN/PE 2.0% pet decreased significantly over time (from 6.0% in 1998-2000 to 2.5% in 2017-2018, P < 0.0001). Personal care products were the most common exposure source (53.2%). CONCLUSIONS: Over time, positivity to MDBGN/PE 2.0% pet decreased significantly from 6.0% (in 1998-2000) to 2.5% (in 2017-2018). The high proportion of weak (63.3%) reactions underscore the need for careful interpretation of patch test sites. Important demographic associations included male sex and age older than 40 years.