Hand eczema and changes in the skin microbiome after 2 weeks of topical corticosteroid treatment.

BACKGROUND: More than 50% of patients with hand eczema (HE) are colonized with Staphylococcus aureus. Comprehensive knowledge of the skin microbiome and its changes in patients with HE may provide insights into future potential therapeutical targets. OBJECTIVE: To describe the skin microbiome in patients with moderate-to-severe chronic HE and assess its changes following treatment with topical corticosteroids (TCS). METHODS: Bacterial samples were collected from lesional and nonlesional skin before and after 2 weeks of TCS treatment using ESwabs and analysed by 16S rRNA and tuf gene sequencing. Clinically, the disease severity was assessed by the Hand Eczema Severity Index (HECSI). RESULTS: A cohort of 31 patients with HE were included and followed up. Compared to nonlesional skin, lesional skin differed in overall bacterial community composition (p = 0.02), displayed higher relative abundance of Staphylococcus, in particular S. aureus (p = 0.01) and lower abundance of Micrococcus (p = 0.02). As disease severity improved with treatment, these microbial characteristics on lesional skin shifted towards that of nonlesional skin on the hands. CONCLUSION: The bacterial skin microbiome was altered in lesions of HE and partly driven by S. aureus colonization, however, shifted towards nonlesional skin following treatment. Our results emphasize the future possibilities for anti-S. aureus treatment strategies.

Severely compromised supply of patch test allergens in Europe hampers adequate diagnosis of occupational and non-occupational contact allergy. A European Society of Contact Dermatitis (ESCD), European Academy of Allergy and Clinical Immunology (EAACI), European Academy of Dermatology and Venereology (EADV) task forces 'Contact Dermatitis' and 'Occupational Skin Disease' position paper.

Patch testing is the only clinically applicable diagnostic method for Type IV allergy. The availability of Type IV patch test (PT) allergens in Europe, however, is currently scarce. This severely compromises adequate diagnostics of contact allergy, leading to serious consequences for the affected patients. Against this background, the European Society of Contact Dermatitis (ESCD) has created a task force (TF) (i) to explore the current availability of PT substances in different member states, (ii) to highlight some of the unique characteristics of Type IV vs. other allergens and (iii) to suggest ways forward to promote and ensure availability of high-quality patch testing substances for the diagnosis of Type IV allergies throughout Europe. The suggestions of the TF on how to improve the availability of PT allergens are supported by the ESCD, the European Academy of Allergy and Clinical Immunology, and the European Academy of Dermatology and Venereology and intend to provide potential means to resolve the present medical crisis.

Healthcare utilization in Danish children with atopic dermatitis and parental topical corticosteroid phobia.

BACKGROUND: Atopic dermatitis (AD) is a prevalent relapsing inflammatory skin disease. There is currently little knowledge about healthcare utilization and medication use along with parental corticosteroid phobia in relation to severity of pediatric AD. OBJECTIVES: To study the association between parental-reported healthcare utilization, medication use, and topical corticosteroid phobia and pediatric AD severity. METHODS: The study population included all children in Denmark with a diagnostic code of AD (ICD-10 code, group L20) given at a hospital department of dermatology between 2014 and 2018. A questionnaire containing 158 response items was sent to the legal parents. We surveyed disease severity, AD treatment, corticosteroid phobia, and healthcare use along with other variables. Disease severity was assessed using the Patient-Oriented Eczema Measure tool, and corticosteroid phobia was assessed using the Topical Corticosteroid Phobia (TOPICOP) score. RESULTS: In total, 1343 (39%) parents completed the questionnaire and 95.3% were completed by the biological mother. Children's mean age was 8.9 ± 4.5 years, and 52.8% were boys. Severe AD was associated with a higher number of healthcare visits to GPs, private dermatologists, and hospital departments. Mean global TOPICOP score was 38.27 ± 19.9%. There was a significant inverse linear trend between global TOPICOP score and parental educational level (Ptrend  < .0005). CONCLUSIONS: The significant association between high global TOPICOP score and low parental educational level, resulting in delayed treatment of AD flares, indicates that improved family education ultimately may reduce healthcare expenses and burden of disease.

The quest for ingested peanut protein in human serum.

BACKGROUND: There is mounting evidence that systemic uptake of food allergens is key to triggering anaphylaxis. However, direct proof for this theory is still lacking. The purpose of this study was to quantify the absorption and to determine the absorption kinetics of immunoreactive peanut protein in relation to the allergic response in human. METHODS: Quantitative protein assays including mass spectrometry, dot blots and Western blotting were developed to determine the level of Ara h 2 absorption in human serum. The double monoclonal sandwich ELISA was applied to quantify absorbed Ara h 2 and 6, and the basophil histamine release assay and the human passive cutaneous anaphylaxis test were utilized to study the absorption kinetics of immunologically intact peanut proteins. RESULTS: The protein assays worked but were not sensitive enough to trace the minute amounts of absorbed Ara h 2 in human serum. The level of Ara h 6 in serum was found to be up to 0.2 ng/mL, but Ara h 2 could not be detected with the ELISA. Both the in vivo and the in vitro methods were successful in demonstrating that: immunoreactive peanut protein was absorbed shortly after ingestion (≤5 minutes); the peanut protein concentration peaks between 1 and 4 hours; and peanut proteins can circulate for at least 48 hours in the bloodstream. CONCLUSION: Ingested peanut protein is absorbed systemically and retains its immunoreactive capacity in human serum. However, the precise quantities and the implication for the elicitation of anaphylaxis remains to be elucidated.

Cow's milk allergic children-Can component-resolved diagnostics predict duration and severity?

BACKGROUND: Cow's milk allergy (CMA) affects 2% of all children. This study investigatescomponent-resolved diagnostics(CRD) to cow's milk proteins in children suspected of CMA, by correlating the level of CRD with outcome of the oral challenge. Furthermore, we evaluate the ability of serial CRD measurements to distinguish children with persistent CMA from children developing tolerance. METHODS: We included data from 78 children referred to the Allergy Centre during a 13-year period. Results from oral food challenges including threshold, severity, and sensitization data (IgE antibodies to whole milk protein, IgE components toward milk and skin prick test (SPT)) were collected. The milk allergic children were re-evaluated with sensitization data and rechallenges regularly. RESULTS: Thirty-nine children had negative first challenges, and 39 had positive first challenges. The positive group was rechallenged and separated into 3 groups depending on time to remission. At inclusion, children with persistent CMA had significantly larger size of SPT and higher levels of s-IgE to milk and CRD compared to the other groups. SPT wheal size was significantly larger in children with persistent CMA compared to children outgrowing CMA. Furthermore, a correlation between s-IgE level to cow's milk and casein and the severity of the allergic reaction elicited by food challenges was found. CONCLUSION: Oral food challenge cannot be replaced by s-IgE to whole milk protein or milk components nor SPT in the diagnosis of CMA; however, high levels of milk components and s-IgE to milk increase the risk of a long-lasting or persisting CMA.

Early-life sensitization to hen's egg predicts asthma and rhinoconjunctivitis at 14 years of age.

BACKGROUND: Sensitization to both inhalant and food allergens has been shown to be risk factors for development of asthma and rhinoconjunctivitis (RC). However, few studies have addressed the role of transient or persistent IgE sensitization to specific allergens in early life for later development of allergic diseases. The aim of this study was to explore the association between transient and persistent sensitization in early life and the development of asthma and RC at 6 and 14 years. METHODS: The Danish Allergy Research Center (DARC) cohort is a prospective non-interventional birth cohort study comprising 562 children. For the purpose of this study, we examined a subgroup of the original cohort with specific IgE measured at, at least 3 of 4 follow-ups between 3 and 18 months of age (n = 366). Multiple logistic regression models were used to investigate the association between transient and persistent early-life sensitization to groups of and to individual allergens and asthma and RC at 6 and 14 years compared to a reference group with no sensitization. RESULTS: Both transient early-life sensitization and persistent early-life sensitization to cow's milk or hen's egg proteins were associated with asthma (aOR 3.99[1.41-11.32] and 5.95[1.78-19.92]) and RC (aOR 2.94[1.19-7.28] and 6.18[1.86-20.53]) at 14 years, this association being driven mainly by sensitization to hen's egg. Transient early-life sensitization to house dust mite (HDM) had increased risk of asthma (aOR 3.80[1.17-12.41]) at 14 years. CONCLUSIONS: Early transient IgE sensitization and persistent IgE sensitization to hen's egg were associated with asthma and RC at 14 years. Furthermore, sensitization to HDM was associated with asthma at 14 years.

The prevalence of atopic diseases and the patterns of sensitization in adolescence.

BACKGROUND: Atopic diseases are among the most common chronic diseases in adolescents, and it is uncertain whether the prevalence of atopic diseases has reached a plateau or is still increasing. The use of the ISAAC (International Study of Asthma and Allergy in Childhood) questionnaire has provided comparable prevalence rates from many countries, whereas studies including clinical examinations and strict diagnostic criteria are scarce. We aimed to investigate the prevalence of atopic diseases, the pattern of sensitization, and comorbidities at 14 years in a prospective birth cohort. METHODS: The children were examined eight times from birth to 14 years. Visits included questionnaire-based interviews, clinical examination, skin prick test, and specific IgE. RESULTS: Follow-up rate at 14 years was 66.2%. The 12-month prevalence of any atopic disease was high (40.3%) mostly due to a high prevalence of rhinoconjunctivitis (32.8%), whereas the prevalence of asthma was 12.9% and of atopic dermatitis 8.1%. In children with at least one atopic disease, 60% were sensitized, while only 16% of those without atopic diseases were sensitized. The frequency of sensitization depended on the phenotype. Among children with rhinoconjunctivitis only, rhinoconjunctivitis with concomitant asthma or atopic dermatitis or both 62.5%, 81.5%, 70%, and 100%, respectively, were sensitized, whereas it was 7.7% and 33.3% of children with only asthma or atopic dermatitis. CONCLUSION: The prevalence of rhinoconjunctivitis was high in adolescence. Children with rhinoconjunctivitis with and without comorbidities were frequently sensitized. Children with asthma without concomitant allergic rhinoconjunctivitis were rarely sensitized.

Low patch test reactivity to nickel in unselected adolescents tested repeatedly with nickel in infancy.

BACKGROUND: It is questionable how repeated patch tests with nickel sulfate in infancy affect nickel patch test reactivity at a later age. METHODS: The Danish Allergy Research Center (DARC) cohort encompasses 562 infants invited to a clinical examination including patch tests with nickel sulfate six times during the first 36 months of life. At the follow-up investigation at 14 years of age (2013-2014), participants were offered re-patch tests with nickel sulfate. The Odense Adolescence Cohort Study TOACS cohort encompasses 1501 schoolchildren evaluated for the first time at 14 years of age (1995-1996) including clinical examination and nickel sulfate patch tests. The prevalence of nickel sensitization in the DARC cohort was compared to the prevalence in the TOACS cohort at 14 years of age. RESULTS: Nickel sulfate sensitization was found in 1.2% of the participants from the DARC cohort tested repeatedly with nickel sulfate in early childhood and retested at 14 years of age compared to 8.6% of the participants from the TOACS cohort patch-tested for the first time at 14 years of age using the same patch test system and test concentration. CONCLUSION: The significant difference in nickel patch test reactivity comparing the two cohorts may reflect an immunologic effect or the effect of nickel regulation.

Risk of solid cancer, cardiovascular disease, anaphylaxis, osteoporosis and fractures in patients with systemic mastocytosis: A nationwide population-based study.

In patients with systemic mastocytosis (SM), several aspects of morbidity remain poorly understood. We assessed the risk of solid cancers, cardiovascular disease, anaphylaxis, osteoporosis, and fractures in SM patients. Using Danish medical registries, we conducted a nationwide population-based cohort study including 687 adult (≥15 years) SM patients diagnosed during 1997-2012. A comparison cohort of 68,700 subjects from the general Danish population who were alive and without SM at the given SM subject's diagnosis were age- and gender-matched. Outcomes were a new diagnosis of solid cancer, venous thromboembolism (VTE), myocardial infarction (MI), stroke, anaphylaxis, osteoporosis, or fracture. For solid cancers the hazard ratio (HR) was 2.4 (95% confidence interval [CI] 1.9-2.8) with a 10-year absolute risk (AR) in the SM-cohort of 12.6% (95% CI 9.4-16.3). Specifically, we found a HR of 7.5 (95% CI 4.4-13.0) for melanoma and a HR of 2.5 (95% CI 1.7-3.5) for non-melanoma skin cancers (NMSCs). For VTE we found a HR of 1.9 (95% CI 1.2-3.0), with a 10-year AR of 3.9% (95% CI 2.3-6.1); for MI a nonsignificant increased HR of 1.4 (95% CI 0.9-2.3), with a 10-year AR of 1.8% (95% CI 0.9-3.2); and for stroke a HR of 1.6 (95% CI 1.1-2.3) with a 10-year AR of 4.6% (95% CI 2.8-6.9). The HR for anaphylaxis was 7.2 (95% CI 5.3-9.9), and the 10-year AR was 3.1% (95% CI 1.9-4.9). For osteoporosis the HR was 3.6 (95% CI 2.7-4.6) with a 10-year AR of 7.2% (95% CI 5.2-9.8). For fractures the HR was 1.2 (95% CI 0.9-1.6) and the 10-year AR was 5.9% (95% CI 3.9-8.4). SM patients are at increased risk of solid cancers - especially melanoma and NMSC-and cardiovascular disease. The risk of anaphylaxis and osteoporosis is clearly increased in SM, though absolute risk was low in this population-based study. The fracture-risk was only slightly increased. Am. J. Hematol. 91:1069-1075, 2016. © 2016 Wiley Periodicals, Inc.

Allergic contact dermatitis in Danish children referred for patch testing - a nationwide multicentre study.

BACKGROUND: Although contact allergy among children was previously considered to be rare, data from the past decade have shown that it is common among children and that the prevalence may be increasing. OBJECTIVES: To describe the demographics of all children referred for patch testing in Denmark during 2003-2011, to examine the frequency and relevance of positive patch test reactions, and to assess the most common allergens. METHODS: A retrospective analysis of the patch test data from the Danish National Database of Contact Allergy was performed. RESULTS: Of 2594 children and adolescents aged 1-17 years, 25.1% had one or more positive patch test reactions. The associated relevance was 66.4%. The most common sensitizers were metals, fragrances, and hair dyes. The frequency of positive patch test reactions and allergic contact dermatitis was significantly higher among girls. CONCLUSIONS: Allergic contact dermatitis in children is a significant clinical problem. Contact allergy should always be considered when children with recalcitrant eczema are encountered, and special attention should be paid to girls. Patch testing is important, and children may be tested with the same patch test concentrations as adults.

A concept for integrated care pathways for atopic dermatitis-A GA2 LEN ADCARE initiative.

INTRODUCTION: The integrated care pathways for atopic dermatitis (AD-ICPs) aim to bridge the gap between existing AD treatment evidence-based guidelines and expert opinion based on daily practice by offering a structured multidisciplinary plan for patient management of AD. ICPs have the potential to enhance guideline recommendations by combining interventions and aspects from different guidelines, integrating quality assurance, and describing co-ordination of care. Most importantly, patients can enter the ICPs at any level depending on AD severity, resources available in their country, and economic factors such as differences in insurance reimbursement systems. METHODS: The GA2 LEN ADCARE network and partners as well as all stakeholders, abbreviated as the AD-ICPs working group, were involved in the discussion and preparation of the AD ICPs during a series of subgroup workshops and meetings in years 2020 and 2021, after which the document was circulated within all GAL2 EN ADCARE centres. RESULTS: The AD-ICPs outline the diagnostic procedures, possible co-morbidities, different available treatment options including differential approaches for the pediatric population, and the role of the pharmacists and other stakeholders, as well as remaining unmet needs in the management of AD. CONCLUSION: The AD-ICPs provide a multidisciplinary plan for improved diagnosis, treatment, and patient feedback in AD management, as well as addressing critical unmet needs, including improved access to care, training specialists, implementation of educational programs, assessment on the impact of climate change, and fostering a personalised treatment approach. By focusing on these key areas, the initiative aims to pave the way for a brighter future in the management of AD.

One-week oral challenge with penicillin in diagnosis of penicillin allergy.

Many patients experience reactions during penicillin treatment. The diagnosis may be difficult and is mainly based on short-term tests. The European Network for Drug Allergy (ENDA) guidelines proposed for diagnosing penicillin allergy do not include long-term challenge. In this study a total of 405 patients were evaluated. The ENDA guidelines were extended, to include a 7-day oral treatment (p.o.7) with penicillin for all patients who were negative in the ENDA programme. Among the 405 patients; 85 had an immediate reaction to penicillin, and a further 13 reacted during p.o.7. Among the 307 patients with a negative outcome, 88 had a case history of reaction to other ß-lactam antibiotics and were subsequently tested with the culprit drug. Thirteen patients had a positive outcome: 3 on single-dose challenge and 10 during p.o.7. The extended penicillin diagnostic work-up was positive in 111 patients, 30.0% showed immediate reactions and 5.7% reacted during p.o.7. Approximately 20% of all patients with positive outcome during penicillin challenge are detected by adding p.o.7 with penicillin to the original ENDA guidelines.

Does treatment with antidepressants, antipsychotics, or benzodiazepines hamper allergy skin testing?

BACKGROUND: Treatment with commonly used drugs such as antidepressants (ADs), antipsychotics (APs), and benzodiazepines (BDs) may hamper the use of allergy skin testing due to possible antihistaminic effects. OBJECTIVE: To examine the antihistaminic effect of AD, AP, and BD as measured by the ability of these drugs to suppress the normal wheal reaction caused by skin prick test (SPT). METHODS: Skin prick test was performed in patients receiving treatment with AD, AP, and/or BD. Double SPT was performed with histamine solutions of 10, 30, and 100 mg/ml and mean wheal diameter calculated. RESULTS: A total of 313 patients were included. 236 (75%) patients were treated with one of the examined drugs and 77 (25%) patients with more than one of these drugs. Drugs most frequently used was sertraline (n = 65), citalopram (n = 63), mirtazapine (n = 36), venlafaxine (n = 33), and quetiapine (n = 32). Treatment with mirtazapine and/or quetiapine was associated with negative SPTs in 30/36 (83%) and 22/32 (69%), and the antihistaminic effect of these drugs was dose-dependent. For patients treated with selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin norepinephrine reuptake inhibitors (SNRIs), or BD alone, almost all SPTs were positive (94%, 95%, 100%, and 100%, respectively). Negative SPTs in patients treated with SSRI, TCA, SNRI, or BD and ≥1 other of the examined drugs were associated with simultaneous treatment with mirtazapine or quetiapine in 39/44 (89%) patients. CONCLUSION: Skin testing has little meaning in patients treated with mirtazapine or quetiapine. Treatment with SSRI, SNRI, and BD does not seem to affect the results of SPTs, whereas skin tests in patients treated with TCA should be interpreted with caution.

The influence of acetylsalicylic acid and alcohol on absorption kinetics of hen´s egg white in a human passive cutaneous anaphylaxis model.

Background: Despite the well-known fact that acetylsalicylic acid (ASA) can induce anaphylaxis in patients susceptible to wheat-dependent exercise-induced anaphylaxis, few studies have sought to investigate the effects of cofactors on type-1 food allergy and none with ASA and hen's egg and hen's egg and alcohol combined. Methods and results: We applied the experimental model of 'passive cutaneous anaphylaxis' in humans to study whether the absorption kinetics of egg white is altered while being treated with ASA or under the influence of alcohol. Donor sera from four egg allergic patients with specific immunoglobulin E (s-IgE) to ovalbumin (0.1-8.87-19.5-170 kUA/L) were injected intracutaneously into the forearm of 12 healthy volunteers who were then challenged separately to: 1) egg white 2) egg white + ASA and 3) egg white + alcohol. 'Time to wheal' and 'wheal size' were compared among the three experiments.We saw that 'time to wheal' with both ASA (P = 0.001) and alcohol (P = 0.019) added as cofactor significantly decreased compared with baseline. Conclusion: In this passive cutaneous anaphylaxis model, ASA and alcohol affected both reaction time and size of reactions elicited after egg ingestion. This suggests that patients with egg allergy could have faster and more severe reactions during ASA treatment or under alcohol influence.

Patients with suspected allergic reactions to COVID-19 vaccines can be safely revaccinated after diagnostic work-up.

BACKGROUND: When initiating the Danish vaccination program against COVID-19, the incidence of anaphylaxis was estimated to be 10 times higher compared to other virus-based vaccines. In this study, we present data on patients referred with suspected allergic reactions to COVID-19 vaccines. The main purpose of the study is to investigate the incidence and severity of the allergic reactions, and to evaluate the safety of revaccination. METHODS: All patients in the region of Southern Denmark with case histories of allergic reactions to COVID-19 vaccines in a defined period are included in this study. Diagnostic work up consisted of a detailed case history, evaluation of Brighton level of diagnostic certainty and World Allergy Organization grade of anaphylaxis and skin prick testing- and basophil histamine release testing with COVID-19 vaccines and relevant drug excipients. Patients were revaccinated at the Allergy Center when possible. RESULTS: Sixty-one patients are included in this study. In 199,377 doses administered, nine patients fulfilled the criteria of anaphylaxis when using the Brighton Criteria (incidence being 45 per million). Of 55 patients with reactions to the first dose, 52 patients were revaccinated without adverse reactions. We found no proven cases of immediate anaphylaxis due to COVID-19 vaccines. By skin prick test, we diagnosed three patients with drug excipient allergy and further a patient with mastocytosis was found. CONCLUSIONS: Anaphylactic reactions to COVID-19 vaccines are rare and the incidence is similar to what is seen with other virus-based vaccines. Revaccination is safe in the majority of patients; however, allergological evaluation is important since some prove to have drug excipient allergy.

Fragrance mix I patch test reactions in 5006 consecutive dermatitis patients tested simultaneously with TRUE Test® and Trolab® test material.

BACKGROUND: The prevalence of contact allergy to fragrance mix (FM) I varies from study to study, depending on factors such as test population, patch test material, and technique. OBJECTIVES: To compare the outcome of routine patch testing with FM I TRUE Test and FM I Trolab. MATERIALS AND METHODS: A total of 5006 consecutive eczema patients were patch tested with both patch test materials according to the International Contact Dermatitis Research Group. RESULTS: A total of 9.9% patients tested had a positive reaction to one of the FM I mixes; 4.4% to FM I TRUE Test, 9.3% to FM I Trolab, and 3.7% to both (P < 0.0001). Patients with a stronger reaction to FM I TRUE Test almost all reacted to FM I Trolab, whereas the reverse situation showed a lower association. Clinical relevance of a positive patch test reaction to FM I TRUE Test was found in 73.0%, and clinical relevance of a positive patch test reaction to FM I Trolab was found in 64.3%; 68.4% of the patients with a positive reaction to FM I TRUE Test and 54.3% with a positive reaction to FM I Trolab were positive to one or more of the eight constituents of the mix. LIMITATIONS: The study is retrospective, and supplementary testing with FM components in patients with a positive reaction to the mixes was performed in a selected group of patients. Determination of clinical relevance may be biased. CONCLUSIONS: From this study, we cannot conclude which of the two FM I test preparations is the best for diagnostic purposes. Inclusion of both FM I tests in the baseline series to obtain a graded degree of FM I allergy for the individual patient is one option. Prospective controlled patch test studies with FM I patch test material are recommended.

Assessing severity of anaphylaxis: a data-driven comparison of 23 instruments.

BACKGROUD: The severity of an allergic reaction can range from mild local symptoms to anaphylactic shock. To score this, a number of instruments have been developed, although heterogeneous in design and purpose. Severity scoring algorithms are therefore difficult to compare, but are frequently used beyond their initial purpose. Our objective was to compare the most used severity scoring instruments by a data-driven approach on both milder reactions and anaphylaxis. METHODS: All positive challenges to foods or drugs (n = 2828) including anaphylaxis (n = 616) at Odense University Hospital, Denmark from 1998 to 2016 were included and severity was scored according to Sampson5. Based on recommendations from an expert group, the symptoms and values from Sampson5 were for all reactions and anaphylaxis only translated and compared by kappa statistics with 22 instruments, ranging from 3 to 6 steps. RESULTS: For milder reactions, there was a significant correlation between the number of steps in an instrument and the number of challenges that could be translated, whereas all instruments were good to identify food anaphylaxis. Some instruments scored reactions more severely than Sampson5, other scored them milder and some scored food and drug challenges differently. Instruments for hymenoptera reactions were difficult to apply on food and drug reactions, and thus distributed severity differently. Algorithms hampered the translation between instruments, and 7 instruments were poor concerning drug anaphylaxis, including the only instrument developed specifically for drug reactions. CONCLUSION: The distributions of severity differed between the 23 instruments in both food and drug allergy, and thus rendering translation especially between scoring systems with 3 and 5 grades difficult. Fine-graded and simple instruments are preferred for comparison especially among milder reactions, and instruments applied to non-intended situations may not reflect a true severity picture.

Insulin allergy can be successfully managed by a systematic approach.

BACKGROUND: Type I insulin allergy can be a challenging condition, and there is no international consensus on how to establish the diagnosis. Measurement of specific IgE and skin testing have been cornerstones in the diagnostic work-up. However, these tests have limitations, mainly lack of correlation between test results and clinical findings. At the Allergy Centre, Odense University Hospital, patients with suspected insulin allergy have been evaluated since 2003. The aim of this study was to establish a systematic approach to diagnose and treat patients with insulin allergy. METHODS: The study was conducted retrospectively by retrieving data from the Allergy Centre database on patients with suspected insulin allergy evaluated from 2003 to 2017. The examination comprised a comprehensive medical history, specific IgE against insulin and intracutaneous tests (ICT) with different insulins. RESULTS: A total of 144 patients were examined on suspicion of insulin allergy of which 110 had negative specific IgE in serum. Of the remaining 34 patients, 33 had ICT performed; 2 had negative ICTs, while 31 had one or more positive ICT. All 34 patients had mild symptoms, and 4 could obtain symptom relief with antihistamines or local steroids, 9 could be managed with oral antidiabetics, and 7 were switched to other insulins. The final 14 patients were offered an insulin pump because of reactions to many different insulins, many positive ICTs, unmanageable diabetes, young age and compliance, or convenience. CONCLUSION: Insulin allergy can be managed by a systematic approach, and symptom relief is obtainable in most patients.