Glen H. Crawford

Tea tree oil: cutaneous effects of the extracted oil of Melaleuca alternifolia.

The use of botanical extracts for their perceived therapeutic benefits has gained increased popularity in this country and abroad. In particular, tea tree oil (the extracted oil of Melaleuca alternifolia) has gained widespread use for its purported antimicrobial and therapeutic effects. In parallel with this increased use is an expanding series of reported adverse effects, including allergic contact dermatitis, systemic contact dermatitis, linear immunoglobulin A disease, erythema multiforme-like id reactions, and systemic hypersensitivity reactions. We present a review of tea tree oil with regard to its history, chemistry, purported medicinal uses, and possible adverse cutaneous effects.

Nodular Scleroderma : A Report of 2 Cases

Nodular scleroderma, also known as keloidal scleroderma, is a rare form of scleroderma that may occur with either systemic sclerosis or localized scleroderma. Clinically, this disorder is characterized by keloidal nodules that form in sclerodermatous areas. These nodules may histologically show the presence of keloidal collagen. Because of the rarity of this condition, clinicians may not be familiar with the clinical and histologic features relevant to this scleroderma variant. In this report, we describe 2 cases of nodular scleroderma.

Patch Testing for Evaluation of Hypersensitivity to Implanted Metal Devices: A Perspective From the American Contact Dermatitis Society.

The American Contact Dermatitis Society recognizes the interest in the evaluation and management of metal hypersensitivity reactions. Given the paucity of robust evidence with which to guide our practices, we provide reasonable evidence and expert opinion–based guidelines for clinicians with regard to metal hypersensitivity reaction testing and patient management. Routine preoperative evaluation in individuals with no history of adverse cutaneous reactions to metals or history of previous implant-related adverse events is not necessary. Patients with a clear self-reported history of metal reactions should be evaluated by patch testing before device implant. Patch testing is only 1 element in the assessment of causation in those with postimplantation morbidity. Metal exposure from the implanted device can cause sensitization, but a positive metal test does not prove symptom causality. The decision to replace an implanted device must include an assessment of all clinical factors and a thorough risk-benefit analysis by the treating physician(s) and patient.

The role of patch testing in the evaluation of orthopedic implant-related adverse effects: current evidence does not support broad use.

In recent years, there has been a growing interest in the use of skin patch testing to evaluate patients for orthopedic, implant-related adverse effects. This may be done preoperatively to avoid implanting a material to which an individual may be allergic or postoperatively to implicate sensitivity as a cause for implant failure. There is emerging evidence that patch testing might have utility in the workup of implant-related adverse events; however, the level of evidence at the present time is weak and based only on a collection of case reports, series, and retrospective cohort studies (level IV evidence as per United States Department of Health and Human Services guidelines); there are no randomized controlled trials (level I evidence) with which to guide medical decision making. Recent reports have advocated that patch testing be broadly used in the preoperative evaluation of all patients self-reporting a history of metal sensitivity. In addition, several authors have advocated that patch test results should guide preoperative implant selection and postoperative implant removal. It is the opinion of this author that these recommendations are premature, lacking robust clinical evidence, and unfeasible given the broad-reaching logistical impact and societal costs involved. More robust clinical data are needed, and thorough cost-benefit analyses must be performed before such far-reaching and costly systematic practices should be broadly implemented.

Allergic contact dermatitis caused by colophony in an epilating product.

Considering the widespread use of colophony-containing epilating products and the frequency of sensitization to colophony, it is somewhat surprising that reports of allergic contact dermatitis from these products are so infrequent. Reactions to colophony can be severe, and they may present even after initial exposure (primary sensitization). Consequently, health care practitioners should be aware of potential colophony-induced allergic contact dermatitis in patients exposed to epilating products. Patch testing with commercially available colophony unmodified rosins often fails to detect reactions to the modified-rosin derivatives found in the actual epilating products. Therefore, the evaluation of colophony allergy may require testing with the patients own products as well as additional modified colophony rosins. We describe a case of allergic contact dermatitis caused by colophony found in an epilating product.

Two cases of compositae dermatitis exacerbated by moisturizer containing feverfew.

A 45-year-old woman presented in October 2005 with a history of an eruption involving her scalp and face, including her eyelids and behind her ears. The eruption began at the end of August. It flared after she used a calming moisturizer containing feverfew (Tanacetum parthenium). A second patient, a 25-year-old woman, presented complaining of a 1-month history of an eruption around the eyes that started after she began using a moisturizer containing feverfew. Both patients were patch-tested with the North American Contact Dermatitis Group series, cosmetic and plant series, and their own skin care products. Patient 1 had a + reaction to sesquiterpene lactone mix, a + reaction to Compositae mix, a + reaction to parthenolide, a + reaction to Tanacetum vulgare, and a + reaction to the calming moisturizer. Patient 2 had + reactions to sesquiterpene lactone, Compositae mix, and the same calming moisturizer. It is thought that both of these eruptions are a result of contact dermatitis from the Compositae plant family.

A Healthy Patient With Iron Deficiency Anemia and a Perianal Papule

Diagnosis: Subacute disseminated histoplasmosis. The differential diagnosis for umbilicated papules without a keratotic plug includes molluscum contagiosum and infections such as Cryptococcus, Histoplasma, Coccidioides, Aspergillus, and Penicillium marneffei. Histology of the polyps and the perianal nodule showed many histiocytes containing intracellular spores, also known as parasitized histiocytes (see Figures 1 and 2). These findings were suggestive of histoplasmosis, and the diagnosis was confirmed with urine antigen testing. Histoplasmosis is a fungal disease most often caused by inhalation of spores from Histoplasma capsulatum var. capsulatum. This fungus grows in the soil in warm, moist climates and has worldwide distribution, although it is classically considered endemic to the Mississippi and Ohio river valleys [1]. Bird and bat excrement may contain spores, resulting in higher risk of infection among miners, farmers, guano collectors, cavers, bird watchers, and ecotourism travelers. Histoplasmosis is usually a subclinical infection [2]. Among those with symptoms, the most common presentation is an acute upper respiratory illness. The risk of developing disseminated disease after an acute pulmonary infection is approximately 1 in 2000, but the risk is much higher in immunosuppressed patients [3, 4]. Cutaneous involvement occurs in approximately 6% of those with disseminated histoplasmosis, but patients with AIDS more frequently have skin findings (10%–25%) [5]. Cutaneous manifestations of histoplasmosis are widely variable and may include polymorphous papules and plaques, pustules, erosions, ulcers, lesions mimicking molluscum contagiosum, cellulitis, erythroderma, and panniculitis [2, 6]. This case represents an unusual subacute presentation of disseminated histoplasmosis. The patient remained afebrile, and radiographic evaluation of the lungs demonstrated no pulmonary involvement. He is currently undergoing treatment with 1 year of oral itraconazole [7]. Within 4 months of treatment initiation, the perianal nodule resolved. Within 8 months, the urinary antigen level became undetectable.

Oral Mucositis: A Case Series and Review of the Literature from the Perspective of a Referral Patch Test Clinic

arthritis. An adverse reaction, a development of dermatitis at the site other than the injection site, has been reported in a number of patients receiving anti-TNF therapy. We report two patients who developed spongiotic dermatitis after initiating adalimumab therapy for arthritis. Skin patch testing with adalimumab was negative in both patients. However, one of the two patients developed an immediate type I hypersensitivity reaction at the injection site. Basophil histamine release, performed on peripheral blood leukocytes isolated from both patients, showed significant release of histamine after stimulation with adalimumab in one patient. Next, histamine release was induced when basophils from a nonatopic donor with negative basophil histamine release on prior challenge with adalimumab underwent lactic acid stripping and sensitization with serum from the patient with significant basophil histamine release to adalimumab. This study suggests that an IgE-mediated process may play a role in the development of dermatitis in patients receiving adalimumab therapy.