Fiona M. Lewis

Interleukin 1 receptor antagonist gene polymorphism association with lichen sclerosus

Cytokines play key roles in immune responses, inflammation and fibrosis. The balance between levels of cytokines, their receptors and specific inhibitors controls inflammatory reactions in tissues. The pathogenesis of lichen sclerosus is unknown but probably involves cytokine mediators such as interleukin 1 (IL-1) and interleukin 1 receptor antagonist (IL-1ra). The IL-1ra is a competitive inhibitor of IL-1α and IL-1β, and therefore is a powerful endogenous anti-inflammatory molecule. The gene encoding IL-1ra (designated IL-1RN) has a variable number tandem repeat polymorphism in intron 2. There are five alleles of the gene corresponding to 2, 3, 4, 5 and 6 repeats of an 86-bp sequence. We have determined allele frequencies in a control population and a group of 78 patients with lichen sclerosus. The frequency of one of the alleles is related to increasing disease severity. Thus, IL-1RN may be a candidate gene or severity factor for lichen sclerosus or may possibly be a linked marker to another, as yet undefined, gene.

Patch testing in children and adolescents: Five years' experience and follow-up

BACKGROUND Allergic contact dermatitis in children is a significant clinical problem. Little information is available concerning the value of patch testing and the outcome in these children. OBJECTIVE Our purpose was to assess the value of patch testing in children and the outcome of allergic contact dermatitis in childhood. METHODS Clinical data on 83 children patch tested during a 5-year period were assessed. Clinical follow-up on 68 subjects was performed. RESULTS Overall, 41 children had one or more allergic reactions (49%). Reactions to metals, topical preparations, and food additives were common. The clinical outcome at 6 months was significantly better for 36 children with a relevant allergen on patch testing than in 32 with no allergen or no relevant allergen (p = 0.006). CONCLUSION Patch testing is useful in the management of children suspected of having an allergic contact dermatitis. Patch testing and subsequent allergen avoidance may improve the prognosis in children with a relevant contact allergen.

Contact sensitivity in pruritus vulvae: Patch test results and clinical outcome

BACKGROUND Persistent vulval pruritus is common and may not be associated with signs of a primary vulval dermatosis. Patients with established vulval disease may develop contact sensitivity as a secondary problem after the application of topical therapy. OBJECTIVE A retrospective study was performed to establish the prevalence of allergic contact dermatitis in patients with pruritus vulvae. In addition, the results of patch testing in women with vulval lichen sclerosus were compared with those in patients with primary pruritus vulvae and essential vulvodynia. METHODS Over a 5-year period, 121 women with vulval problems were patch tested to the European Standard Series, selected preservatives, perfumes, local anesthetics, medicaments, and a vulval battery. RESULTS Fifty-seven patients (49%) had one or more relevant allergic positive reactions. Medicaments or their constituents were the most common allergens to give reactions. Seven of the 16 patients (44%) with lichen sclerosus had positive reactions. Symptoms resolved or improved significantly in 67 patients (55.4%) overall. Six of the seven women with lichen sclerosus who had positive reactions noted an improvement in their symptoms. Patients who had a relevant allergy were much more likely to improve than those whose tests were negative (p < 0.001). CONCLUSION Patients with pruritus vulvae and lichen sclerosus are at high risk of contact sensitivity. Patch testing is useful in the management of these patients and many can be helped by allergen avoidance.

Prognosis of occupational hand dermatitis in metalworkers.

Hand dermatitis is common in workers employed in the cutting and grinding of metals. Previous studies have given conflicting results on the prognosis of this common occupational disease. This study was designed to determine the prognosis of hand dermatitis in metalworkers and the responsible allergens. A questionnaire survey was conducted on 64 patients seen between 1 and 5 years previously in the contact dermatitis clinic. Of the 51 patients responding, 82% still had hand dermatitis. There was no difference in outcome between those who continued to work with metals and oils, and those who had changed their occupation. Hand dermatitis in metalworkers carries a poor prognosis, with most workers remaining symptomatic even if they no longer had occupational exposure to metals or oils. This study also demonstrates that biocides are the most important allergen group in the aetiology of hand dermatitis in metalworkers.

Contact sensitivity to food additives can cause oral and perioral symptoms

A 28-year-old woman was referred with an 18-month history of intermittent facial reddening related to her work as an animator, which involved various varnishes and glues. Although prescribed topical corticosteroids, she had never applied them. Patch testing to a standard series, a face series and some substances that she worked with was negative at 2 and 4 days, except for nickel, which was of past relevance. A diagnosis of irritant facial dermatitis was made. She returned 12 days after the last patch test reading with a 2-day history of localised erythema on her back. This area of papules and vesiculation correlated exactly with the application site of tixocortol piva1ate 1% pet. She was unwilling to be patch tested further. Discussion This is, to our knowledge, the 1st case of probable active sensitization to tixocortol pivalate. The patient discussed had no previously known contact with topical corticosteroids, and the patch test site had been examined at 2 and 4 days with no reaction recorded. Tixocortol pivalate is becoming a standard patch test marker for hydrocortisone contact allergy, and large numbers of reactions have been reported, with no active sensitization mentioned in previous reports ( 1 ). We have tested over 10,000 patients to tixocortol pivalate without detecting previous active sensitization. Therefore, although this can probably occur, it is likely to be rare.

Contact allergy in patients with oral symptoms: A study of 47 patients

BACKGROUND Patients may present with a range of unexplained oral symptoms, and there has been debate about the role of contact sensitivity in these patients. OBJECTIVE The aim of this study was to review patch test results in patients presenting with oral and perioral symptoms and to determine the relevance of positive reactions. METHODS Forty-seven patients with oral symptoms were studied. Patients were tested to the European Standard Series and a range of other allergens, including bakery products, dental materials, medicaments, and metals. RESULTS Sixty-four percent of the patients had one or more positive allergic reactions. In 14 patients (30%), the results were believed to be relevant to their clinical problem. Relevant allergens included metals, rubber chemicals, food additives, and dental products. Symptoms resolved rapidly in all of the 13 patients in whom the source of the offending allergen was removed. CONCLUSION Patch testing is a useful investigation in patients with unexplained oral and perioral symptoms. Avoidance of the relevant allergen can result in complete resolution of symptoms.

Scrotal pyoderma gangrenosum associated with dermatomyositis

Pyoderma gangrenosum (PG) of the scrotum is extremely rare. We report a case of scrotal PG associated with dermatomyositis. Initial healing was slow despite the use of oral prednisolone and azathioprine. Healing was accelerated by the local use of a potent topical corticosteroid. PG should be considered in the differential diagnosis of ulcerating lesions of the genitalia.

Allergic contact dermatitis from resin‐reinforced plaster

Discussion Contact allergy to topical corticosteroids has become increasingly recognized recently (1-3). Patients with varicose eczema are likely to be at particular risk of sensitization. Tixocortol pivalate has been reported to be one possible marker for corticosteroid allergy (2, 4), although intradermal testing to corticosteroid may be required (5)~ For this reason, we have included it in our standard series since 1991. A positive reaction in this patient led us to more detailed testing of the Glaxo range of corticosteroids. This failed to confirm hydrocortisone allergy, but showed a + + allergic reaction to Dermovate ointment, as is. Rather to our surprise, when the components of Dermovate ointment were tested, the actual allergen proved to be the emulsifier sorbitan sesquioleate, with a negative response to the steroid component. Sorbitan sesquioleate is contained in fragrance mix: though our patient was not tested to the individual constituents of the mix, this may well have been the one that caused her + + + reaction. The + reaction to Dermovate cream at 3 days, with negative testing to its constituents, is best labelled a false-positive reaction. Emulsifiers are common constituents of cosmetics and medicaments. Contact allergy to emulsifiers is probably under-reported. In 1976, Hanimksela et al. (6) patch tested 1200 eczema patients to 8 emulsifiers including sorbitan sesquioleate. 2.1% had allergic reactions, 8 to sorbitan sesquioleate, with cross-reactions occurring between sorbitan sesquioleate and sorbitan monostearate and monoleate. The majority of patients with allergy to emulsifier were allergic to other agents in the standa:t:d series. SHORT COMMUNICATIONS

Contact sensitivity in atopic dermatitis

Abstract Background: There is some debate about whether the prevalence of contact allergy in patients with atopic dermatitis is the same as in the general population. Objective: The aim of this study was to estimate the prevalence of allergic and irritant patch test reactions in patients with atopic dermatitis and to relate these to clinical patterns of disease. Methods: One hundred twenty-two patients with atopic dermatitis were patch tested during a 3-year period. Results: Sixty patients (49%) had one or more positive allergic reactions, and 49 patients (40%) had one or more irritant reactions. Positive allergic responses to topical preparations were found in 25 patients (21%) with six reacting to topical steroids. Overall, 54 (44%) had allergic reactions considered to be relevant to their clinical problem. Nickel sulfate, fragrance mix, lanolins, and neomycin were the most common allergens giving allergic reactions. Conclusion: This study showed the importance of allergic and irritant factors in the causation of exacerbations of atopic dermatitis. Patch testing is helpful in the management of patients with worsening atopic dermatitis and should be undertaken at an early stage in patients whose disease is difficult to control.

Promoter region polymorphism in the human TNF-alpha gene is not associated with lichen sclerosus.

Abstract The pathogenesis of lichen sclerosus remains unknown. However, it has been frequently associated clinically with autoimmunity. The MHC haplo‐type A1, B8, DR3 is associated with many autoimmune conditions and has also been associated with the uncommon allele of the tumour necrosis factor (TNF‐α) promoter polymorphism. This allele is also associated with higher production of TNF in vivo and in vitro, and thus it has been speculated that it is the TNF‐α gene which underlies the genetic association of many diseases with the autoimmune haplotype. There have been many reports of HLA associations with lichen scleroses, but these have not been concordant. We therefore decided to analyse the TNF‐oc polymorphism in patients with lichen scleroses to determine if TNF‐α was likely to play a role in susceptibility or severity of lichen scleroses. No association between alleles of the TNF‐α polymorphism and lichen scleroses was found.