Jennifer K. Chen

Gold contact allergy: clues and controversies.

AbstractIn 2001, gold was named Contact Allergen of the Year. More than a decade later, we continue to face several challenges in defining the role of gold in contact allergy. First, interpretation of gold reactions in the setting of epicutaneous patch testing may be difficult; in addition to being a common irritant, gold may be associated with significantly delayed and persistent reactions. Second, although gold compounds are commonly positive on patch testing, clinical relevance is relatively low and may be challenging to determine. Third, the complex interplay between gold and the human body is still poorly understood. In this review, we provide an overview of the literature concerning gold patch test positivity and present recommendations for epicutaneous patch testing with gold.

A Pragmatic Approach to Patch Testing Atopic Dermatitis Patients: Clinical Recommendations Based on Expert Consensus Opinion

Allergic contact dermatitis (ACD) may complicate the clinical course of atopic dermatitis (AD), and patch testing remains the criterion standard for diagnosing ACD. To date, there have been no guidelines or consensus recommendations on when and how to patch test individuals with AD. Failure to patch test when appropriate may result in overlooking an important and potentially curable complicating comorbidity. In this article, we present consensus recommendations regarding when to perform patch testing in the AD patient, best practices, and common pitfalls. Patch testing should be considered in AD patients with dermatitis that fails to improve with topical therapy; with atypical/changing distribution of dermatitis, or pattern suggestive of ACD; with therapy-resistant hand eczema in the working population; with adult- or adolescent-onset AD; and/or before initiating systemic immunosuppressants for the treatment of dermatitis. A suggested patch testing algorithm for AD patients is provided.

Corticosteroids in Myositis and Scleroderma

Idiopathic inflammatory myopathies (IIMs) involve inflammation of the muscles and are classified by the patterns of presentation and immunohistopathologic features on skin and muscle biopsy into 4 categories: dermatomyositis, polymyositis, inclusion body myositis, and immune-mediated necrotizing myopathy. Systemic corticosteroid (CS) treatment is the standard of care for IIM with muscle and organ involvement. The extracutaneous features of systemic sclerosis are frequently treated with CS; however, high doses have been associated with scleroderma renal crisis in high-risk patients. Although CS can be effective first-line agents, their significant side effect profile encourages concomitant treatment with other immunosuppressive medications to enable timely tapering.

Hand Dermatitis: an Allergist’s Nightmare

Hand dermatitis is a common skin complaint. We use our hands to explore our environment; subsequently, our hands are in frequent contact with potential allergens and irritants. Patients with hand dermatitis may present to their allergist with this complaint. Approaching the diagnosis and treatment of hand dermatitis can be challenging, as both internal and external factors may contribute to the overall condition. Furthermore, the differential diagnosis of hand dermatitis is broad and the cause often multifactorial. Obtaining a thorough history and performing a focused examination may help the clinician differentiate between multiple causes of hand dermatitis. Numerous treatment options exist for hand dermatitis, and new potential treatments are in development as well. We aim to provide the allergist with a streamlined toolkit for help in the diagnosis and management of hand dermatitis.

Return to Work for Nurses With Hand Dermatitis.

BackgroundOccupational skin disease is common in healthcare workers. If the healthcare worker develops moderate to severe dermatitis, return to work (RTW) may be challenging. ObjectivesThe study objectives were to review the impact of an RTW program on the work status of nurses with occupational hand dermatitis and to identify successful intervention methods and strategies. MethodsNurses who received RTW services at a tertiary occupational medicine clinic were identified, and information related to their diagnosis and RTW was abstracted from their charts. ResultsEighteen nurses with irritant hand dermatitis who received RTW services were identified. Twelve nurses (67%) were performing administrative duties because of their skin condition when admitted to the RTW program, and others were performing patient care with modifications. A graduated RTW trial was commonly implemented with optimized skin care management and monitoring by physicians and the RTW coordinator. Upon discharge, 14 nurses (78%) had returned to their nursing roles with direct patient care, 3 (17%) were working as nurses in non–patient care roles, and 1 (6%) was on permanent disability. ConclusionsA graduated RTW trial to reduce cumulative irritant exposure is a crucial strategy to facilitate nurses’ transition back to work and to maintain direct patient care nursing roles.

Metals in Coins

Coins in current circulation are made of diverse alloys, with copper-nickel constituting the most widely used alloy in coins worldwide. Coins have been reported to be a relevant source of exposure to nickel and copper and may result in exacerbation or elicitation of allergic contact dermatitis particularly to nickel in select clinical settings. Allergic contact dermatitis to coins is dependent on many variables, including local factors affecting nickel release (e.g., humidity, temperature, pH); duration, type, and frequency of exposure; skin barrier factors affecting individual susceptibility (e.g., xerosis, preexisting hand dermatitis); as well as baseline nickel allergy prevalence for the region. In this chapter, we review relevant methodologies and literature to date evaluating metal deposition on the skin and induction of allergic contact dermatitis. Patients who handle coins occupationally and consumers with nickel allergy appear to be at particular risk. Coins should not be overlooked as a potential source of allergen exposure.

Erythematous Plaques on the Buttock

A 75-year-old woman with rheumatoid arthritis, treated with long-term prednisone, and genital herpes simplex virus 2 presented with a 1-week history of a painful, pruritic rash on the left buttock. She denied any recent trauma to the area or any new skin exposures. She denied experiencing fevers, lymphadenopathy, and other constitutional symptoms. Of note, she had recently tapered her prednisone dose from 10 mg to 5 mg, with subsequent flare of her rheumatoid arthritis, after which she started pregabalin for pain 3 days before her eruption. Following rash onset, she had also started valacyclovir for 1 week, without benefit. She was not receiving other treatments for rheumatoid arthritis, such as nonsteroidal anti-inflammatory drugs or anti–tumor necrosis factor alpha (anti–TNF-α) therapies. Physical examination revealed warm, indurated, and well-circumscribed erythematous plaques, with subtle vesicles and collarettes of scale, on the left buttock (Figure). Edema, erythema, and pain of the left wrist joint were also noted. The remainder of the physical examination was unremarkable.