Derk P. Bruynzeel

Angry back or the excited skin syndrome: A prospective study

Allergens eliciting weak positive reactions were retested to ascertain their reproducibility. Weak positive patch test reactions, concomitant to other weak or strong positive reactions, were retested after 3 weeks in 61 patients. 79 reactions were retested; 35 (44.3%) were negative. Allergens which are marginal irritants, e.g., formaldehyde, often gave weak positive reactions which were lost at retesting. In patients without dermatitis but with several strong positive reactions, lost reactions were frequently encountered, suggesting that strong reactions induced a state of hyperirritability. False positive reactions were often found in the proximity of strong reactions. We attempted to develop a nonspecific irritant (sodium lauryl sulfate) as a hyperirritability marker. A correlation between the score of this test and false positive reactions was not found. It is concluded that weak positive reactions should not be accepted as a proof of sensitization. The allergens eliciting these reactions should be retested at a later date.

Allergic reactions, ‘spillover’ reactions, and T-Cell subsets

SummaryA strong positive, allergic patch-test reaction was elicited in 15 patients with an established allergy for a particular allergen. Patches with a marginally irritating concentration of sodium lauryl sulfate (SLS) were applied at fixed distances. The SLS patch situated adjacent to the allergic reaction was significantly enhanced in 12 of 15 patients (P<0.01) compared to more distant SLS reactions (‘spillover’). Only quantitative differences were observed in the histologic pictures of the different types of reaction. The infiltrate consisted of lymphocytes and histiocytes, mainly located perivascular in the upper dermis.T-cell subsets were assessed with monoclonal antibodies using an immunoperoxidase technique. The distribution of the different T cells was the same for both reaction types.T cells located outside the perivascular infiltrates (e.g., in the epidermal vesicles) were OKT-8-positive (cytotoxic/suppressor T lymphocytes). Immunofluorescence examination did not show different patterns for the allergic or ‘enhanced toxic’ reactions with regard to the presence of immunoglobulins and complement.The ‘spillover’ phenomenon may cause falsepositive patch-test reactions.

Penicillin Allergy and the Relevance of Epicutaneous Tests

Epicutaneous tests with penicillins are important in the evaluation of penicillin allergy in patients who have shown a delayed urticarial or maculo-papular rash after the administration of penicillin derivatives. Of 23 patients who showed positive epicutaneous tests only 5 also showed immediate-type reactivity upon subsequent intracutaneous tests with the major determinant of penicillin. Moreover, patients with positive epicutaneous tests were evidently immunologically reactive on penicillins, since lymphocytes from 14 out of 17 patients showed increased DNA synthesis induced by penicillin G and ampicillin in vitro. The performance of epicutaneous tests with various penicillin derivatives is recommended as a first step in establishing penicillin allergy, because it is a safe method and because an extra group of sensitized patients is detected.

Chelating effect of EDTA on nickel

The chelating effect of disodium ethylenediamine tetra‐acetate (EDTA) in nickel‐allergic patients was investigated. After pretreatment of the right half of the patients back with 10% EDTA in a cream, and the left half of the back with the cream base only, various concentrations of nickel sulphate were patch tested on these areas. The blocking effect of the 10% EDTA cream appeared to be significant in comparison with that of the cream base only (p < 0.01).

The angry back syndrome--a retrospective study.

Irrelevant reactions occurred in 68 of 157 patients (43%) with strong positive patch test reactions and concomitant weak positive reactions. A lower figure, 13 of 45 (29%) was found in patients with only weak positive patch test reactions (0.1 > P > 0.05). An allergen eliciting a weak positive reaction should therefore be retested when a conclusion has to be drawn about the epidermal sensitivity of a patient.

Depression or Enhancement of Skin Reactivity by Inflammatory Processes in the Guinea Pig

An animal model for the excited skin syndrome was developed in the guinea pig. Hyperirritability of the skin could be induced by immunization with Freunds complete adjuvant (FCA). This hyperirritability was evident from the enhancement of both patch test reactions to an irritant (sodium lauryl sulfate) and open epicutaneous test reactions to a contact sensitizer (2,4-dinitrochlorobenzene). The skin tests were performed at sites other than those pretreated with FCA. Maximum enhancement was observed in a period 3-5 weeks after FCA immunization. A similar but less marked hyperirritability could be induced by eliciting a localized chronic croton oil dermatitis. The period of hyperirritability induced by FCA or croton oil was preceded by a short period (1-14 days) of depressed skin reactivity.

Toxicity of Handcleaners

The irritancy of commercially available liquid handcleaners was determined by means of soap chamber test (with Big Finn Chambers). This in vivo method appeared to registrate the irritant effects of the cleaners very well. Several alkaline soaps were tested in addition to surfactants and soaps with a neutral or low pH. Alkaline soaps were not extra irritating than other handcleaners. The cleaner with the highest irritancy score had a low pH. It was concluded that the pH was not a useful parameter to predict the irritancy of handcleaners.

Formaldehyde contact sensitivity and the use of shampoos

Most shampoos contain low concentrations of formaldehyde as preservative. The low concentration and short contact with the skin are probable reasons why dermatological problems from shampooing are rare in the ordinary user (1, 2). Even in hairdressers, with much more frequent contact, formaldehyde contact sensitivity is rare (3). There, dermatitis from shampoos affects the fingers, while in the ordinary user, the face (around the eyes and ears) is involved and usually not the seal p. Recently we saw 2 women with eruptions attributed to the use of a shampoo. Patient no. I complained of itching and redness on the scalp, face, neck, wrists and chest. On examination, she still had a slight dermatitis and excoriations on the scalp. The itching on the scalp was intense after shampooing. Patch tests with the standard battery (ICDRG) showed a 1 + positive reaction to formaldehyde after 72 h (negative at 24 and 48 h). The original shampoo she had been using was not available for testing. The one she used at this time, which also caused itching, was tested (3% in water) and gave negative results (readings at 24 and 48 h). The problems disappeared and did not return after prescribing a formaldehydefree shampoo. Patient no. 2 was seen shortly after patient no. 1. She presented with a large itchy, red scaly patch on the scalp combined with some hair loss. On alternate days, she used a shampoo, which was recommended for daily use. This contained 2 mg formaldehyde per gram, estimated according to the method described by Wilson ( 4) in so far as the formed 3,4-diacetyl1 ,4diahydrolutine was extracted with n-butanol. The butanol phase was measured colorimetrically at 410 nm. The eruption disappeared soon after the replacement of the shampoo by a formaldehyde-free product. A patch test reaction to nickel sulphate was positive; avoidance of non-precious metals in clothing and jewelry was sufficient to keep her free of dermatitis. The patch test reaction to the shampoo was red and slightly papular and extended well beyond the test area. Only 3 patients (nos. 3, 4 and 5) with a combination of sensitization to formaldehyde and shampoo were retrieved from old patients records (1972-1983). This illustrates the rarity of the combination (see Table 1). Patient no. 3 had redness and scaling of the scalp connected with shampooing. She also showed positive reactions to several textile finishes containing compounds like melamine and urea formaldehyde. These positive reactions explained the itching caused by some underwear and clothes. Patient nos. 4 and 5 were patch tested with shampoos, because one had a dermatitis on the ears and the scalp, while the other still showed signs of dermatitis around the eyes. Despite the positive reactions to formaldehyde and the shampoo, there was no clear relationship with the skin eruption according to patient history. In fact they both presented with a dermatitis of the feet. This was attributed to sensitization to bichromates (no. 4) and para-tertiarybutylphenol formaldehyde resin (nos. 4 and 5). Our experience is in accordance with earlier reports (I, 3). Formaldehyde in shampoos is rarely a cause of skin eruptions, even in patients with a strong sensitization to formaldehyde. It should be regarded as a coincidence that we saw 2 patients with skin problems due to shampoo within one month.

Drug Eruptions: Allergic Reactions?

Drugs often cause adverse reactions, many of which involve the skin. Life-threatening skin reactions such as toxic epidermal necrolysis are rare, just like anaphylactic shock. Less severe but still worrisome eruptions are abundant but may develop into serious reactions. Only a part (20%) of these eruptions are evoked by an allergic mechanism. Usually one does not know if the drug or a metabolite is the antigen. As a consequence, tests in vitro and in vivo will be rather unreliable. Negative tests are not helpful and not decisive as the test could be false negative. It might be necessary to carry out a provocation test, the gold standard. A provocation test is not without dangers and does not discriminate between allergic and nonallergic reactions. More clinically reliable skin and laboratory tests should be developed to identify allergic reactions and to detect the allergenicity of new drugs.

Allergy to antibacterials.

handle than home brew for fine-bore enteral feeding, Mr Keighley and others do not give enough information to substantiate their suggestion that pathogens are the major source of diarrhoea in his home brew group. There is good evidence that diarrhoea in the malnourished is often the result of malabsorbtion secondary to atrophy of the bowel itself rather than the osmolarity of the feed or its contamination by pathogens. (See Keys for an excellent review of the subject of starvation diarrhoea in Western Europe at the end of the second world war.) One of the major factors in maintaining the mass and functional integrity of the bowel is its continued use to absorb food. This was demonstrated by Levine,2 who fed the same diet to two groups of rats, one enterally and the other parenterally. After a week the parenterally fed group had suffered a relative loss of 28% of the mucosal mass, 62% of the maltase and sucrase activity, and 44%O of the lactase activity in the small bowel. On the basis of this evidence, it is hardly surprising that starved patients often react to enteral feeding by producing malabsorbtion diarrhoea. Mr Keighley and others draw their conclusions from the behaviour of a mixed group of patients, who were orally starved, either relatively or absolutely for an unspecified length of time, and, although pathogens may be involved, the conclusion that they were responsible for the diarrhoea in four patients is thus invalid. T J ARCHER