Nadia Raison-Peyron

Delays in diagnosis and melanoma prognosis (I): The role of patients

A prospective survey was conducted to assess the role of patients in the melanoma prognosis. Consecutive patients with primary melanoma were interviewed and examined using a comprehensive questionnaire including a psychological instrument. Main outcome measures were the delay before medical intervention and the tumor thickness. Of 590 melanomas, 70.8% were detected by patients and this proportion was higher in females. Relatives were involved in the detection of half of the cases. Median delays before the patient realized he had a suspicious lesion, before this lesion was seen by a doctor, and before the melanoma was removed were 4 months, 2 months, and 1 week, respectively. Delays up to several years were observed in some cases. The rate of self‐detection tended to be lower, the delays before seeking medical advice to be longer, and the tumor thickness to be higher in old people, in males, in lower‐educated individuals, in those living out of towns, and in people with a low awareness about melanocytic tumors than in other cases. Conversely, individuals with a high number of atypical nevi, those who were aware to be at risk, and those who regularly visited a dermatologist tended to detect their melanoma more rapidly. No specific psychological traits were associated with a late reaction, although negligence and anxiety tended to prolong the delays. Knowledge about melanoma was poor in many patients, especially in males, and wrong beliefs were widespread. This study provides the targets of future education programs. Int. J. Cancer 89:271–279, 2000.

Delays in diagnosis and melanoma prognosis (II): The role of doctors

A prospective survey was conducted to assess physician responsibility in melanoma prognosis. Consecutive patients with primary melanoma were interviewed and examined using a standardized questionnaire. Main outcome measures were medical components of the delay before tumor resection and tumor thickness. Of 590 melanomas, 29.1% were coincidentally detected by physicians and their tumor depth was lower than in melanomas detected by patients (p < 0.001). Physician sensitivity for melanoma diagnosis was evaluated at 86%. Median time intervals to propose resection and to perform removal of melanoma were short: 0 (mean 103) and 7 (mean 68) days, respectively. Melanomas were managed in an inappropriate way in 14.2% of cases. Location on acral areas and absence of pigmentation were associated with longer medical delays and more frequent inappropriate medical attitudes. Melanomas located on hardly visible areas were less frequently detected by physicians than those on visible areas. Medical delays were shorter, doctors attitude was more frequently appropriate, and melanoma thickness was lower (p < 0.001) when the patient visited a dermatologist (54.7%) than when he or she visited a general practitioner (33.4%). Our study shows that doctor responsibility accounts for only a small part of the total delay before melanoma removal. However, systematic total examination and better training of doctors, especially about unusual forms of melanoma, could still improve melanoma detection. Int. J. Cancer 89:280–285, 2000.

Allergic contact dermatitis from shellac in mascara

We report 6 cases of allergic contact dermatitis of the eyelids due to mascara. Allergy occurred in women aged 17–34 years, between September 1999 and June 2001. The main ingredient responsible for allergy was shellac, which gave positive patch test reactions in 5/5 patients. This resinous substance is mainly used in cosmetics, food and industry. The exact nature of the hapten remains unknown, and its presence and level in shellac can vary with the source and the treatments applied to it. One patient was also sensitized to quaternium‐22, a quaternary ammonium compound in the cosmetic. These reports underline the rôle of networks, such as REVIDAL‐GERDA, in monitoring the emergence of contact allergens and disseminating such information among the medical community.

Nickel-elicited systemic contact dermatitis from a peripheral intravenous catheter.

Nickel‐elicited systemic contact dermatitis is a well‐known entity, although it is far less common than allergic contact dermatitis. In most of the cases, the main way of nickel administration is oral. Clinical manifestations are miscellaneous including pompholyx, diffuse exanthema, flexural dermatitis or baboon syndrome. Systemic nickel dermatitis induced by venous catheters is very uncommon, but it is probably underdiagnosed. We report here 2 patients with diffuse recurrent maculopapular rash corresponding to nickel‐elicited systemic contact dermatitis. They were both perfused during the last episode with the assistance of a peripheral polyurethane venous catheter during or just before the cutaneous eruption. At the base of the catheter, there was a small metallic eyelet on which dimethylglyoxime test was positive, indicating a release of nickel. Then, we measured nickel release in normal use conditions and found high nickel levels, although the manufacturer denied that nickel could be released. This diagnosis is important to know because such exanthema often occurred during postoperative or postpartum period. Its frequency is probably underestimated because it is often considered as a cutaneous drug reaction. To our knowledge, only 2 cases have been reported in the literature.

Allergie de contact aux antiseptiques : 75 cas analysés par le réseau Revidal de dermato-allergovigilance

Resume Objectifs Le but de l’etude etait de determiner les caracteristiques cliniques des allergies de contact aux antiseptiques et de preciser si l’agent responsable etait le principe actif lui-meme ou un excipient. Malades et methodes Il s’agissait d’une etude multicentrique, retrospective, descriptive analysant toutes les observations declarees en 2 ans au Reseau de Vigilance en Dermato-Allergologie (Revidal). Pour chaque dossier etaient precises les caracteristiques cliniques des lesions, l’antiseptique en cause, les modalites d’exposition, les resultats detailles des tests epicutanes. Resultats Soixante-quinze malades (d’âge moyen 44 ans) etaient sensibilises aux antiseptiques suivants : chlorhexidine (14 cas), hexamidine (20 cas), povidone iodee (14 cas), mercuriels (3 cas), triclocarban (Septivon ® ) (17 cas), hexamidine-chlorhexidine-chlorocresol (Cyteal ® ) (4 cas), chlorhexidine-tensioactif (Hibiscrub ® ), cetrimide ou chlorhexidine digluconate (Diaseptyl ® ) dans 1 cas chacun. La source d’exposition etait l’application therapeutique d’un antiseptique (68 cas), professionnelle (6 cas, 5 en milieu hospitalier, 1 eleveur de bovins), aux cosmetiques (1 cas, hexamidine). L’aspect clinique etait, dans la plupart des cas, un eczema au site d’application, cependant dans 9 cas avec l’hexamidine, il s’agissait d’un eczema generalise. La sensibilisation etait liee aux molecules antiseptiques (53 cas) ou limitee aux excipients (22 cas), en particulier dans les 17 cas dus au Septivon ® . Dans 27/75 cas (35 p. 100) les malades avaient une polysensibilisation de contact a des antiseptiques de classes differentes. Conclusion La sensibilisation aux antiseptiques n’est probablement pas rare. Les sources d’exposition sont variees. Les tests epicutanes sont indispensables pour le diagnostic, pour differencier une allergie a l’antiseptique de celle liee a un excipient enfin pour rechercher une polysensibilisation aux topiques medicamenteux.

Acute bullous irritant contact dermatitis caused by EMLA® cream

Nicolas Kluger1,2, Nadia Raison-Peyron1, Carine Michot3, Bernard Guillot1 and Didier Bessis1 1Service de Dermatologie, CHU de Montpellier, Université Montpellier I, FR-34295 Montpellier, Cedex 5, France, 2Department of Dermatology, Allergology and Venereology, Institute of Clinical Medicine, University of Helsinki, Skin and Allergy Hospital, Helsinki University Central Hospital, P.O. Box 160, FI-00029 Helsinki, Finland, and 3Cabinet de Dermatologie, FR-34070 Montpellier, France

Pityriasis lichenoides chronic after measles-mumps-rubella vaccination

1 Drago F, Broccolo F, Rebora A. Pityriasis rosea: an update with a critical appraisal of its possible herpesviral etiology. J Am Acad Dermatol 2009; 61: 303–318. 2 Broccolo F, Drago F, Careddu AM et al. Additional evidence that pityriasis rosea is associated with reactivation of human herpesvirus-6 and -7. J Invest Dermatol 2005; 124: 1234–1240. 3 Kempf W, Burg G. Pityriasis rosea – a virus-induced skin disease? An update. Arch Virol 2000; 145: 1509–1520. 4 Rebora A, Drago F, Broccolo F. Pityriasis rosea and herpesviruses: facts and controversies. Clin Dermatol 2010; 28: 497–501. 5 Drago F, Broccolo F, Zaccaria E et al. Pregnancy outcome in patients with pityriasis rosea. J Am Acad Dermatol 2008; 58: 78– 83. 6 Renner R, Sticherling M. Chronic inflammatory and autoimmune mediated dermatoses during pregnancy: course and prognosis for mother and child. Hautarzt 2010; 61: 1021–1026. 7 Anzivino E, Fioriti D, Mischitelli M et al. Herpes simplex virus infection in pregnancy and in neonate: status of art of epidemiology, diagnosis, therapy and prevention. Virol J 2009; 6: 40. 8 Chuh A, Zawar V, Lee A. Atypical presentations of pityriasis rosea: case presentations. J Eur Acad Dermatol Venereol 2005; 19: 120– 126.

Systemic contact dermatitis to dorzolamide eye drops

An 80-year-old woman presented with conjunctival inflammation and severe periorbital eczematous dermatitis of the right eye, which have been evolving for 6 months. Since then, she had also a few round patchy ‘fixed’ eczematiform lesions on the abdomen. For more than 2 years, she had been using Xalatan (latanoprost, Pfizer, Paris, France) in both eyes for open-angle glaucoma. Cosopt , a combination of dorzolamide hypochloride and timolol maleate (Merck Sharp and Dohme-Chibret, Paris, France), was initiated 6 months ago and applied strictly in the right eye. Soon afterwards, she developed unilateral periorbital dermatitis and conjunctivitis. Cosopt was switched to Combigan (brimonidine tartrate, timolol maleate, Allergan, Sophia Antipolis, France) 1 month prior to consultation, with a discrete improvement. She had no history of atopy or previously known allergic contact dermatitis. All eye drops were withdrawn and the dermatitis was successfully treated with topical corticosteroids ointment and anti-allergic eye drops, Opatanol (olopatadine, Alcon, Rueil-Malmaison, France). All these 4 eye drops contained benzalkonium chloride, a known contributor to irritant contact dermatitis and more rarely allergic contact dermatitis (9). Therefore, this vehicle componentwas ruled out as a possible cause. Patch testing was performed with the European standard series, benzalkonium chloride (0.1% pet.), Cosopt, Xalatan, and Combigan eye drops (as is). The patient was also prick tested to all the eye drops. All tests were negative at 20 min, 2 D, and 3 D. A ROAT was performed with Cosopt and Timoptol (timolol maleate, Merck Sharp and Dohme-Chibret), each applied to one of the volar aspects of a forearm for 2 weeks. The test was positive with Cosopt after 3 D but negative with Timoptol after 15 D. Moreover, a discrete dermatitis of the right eye recurred, despite no eye drop being started again, as well as a reactivation of the fixed eczematous lesions of the abdomen. Then, 1 month later, a new ROAT was performed with Trusopt (dorzolamide hypochloride, Merck Sharp and Dohme-Chibret) using the same technique. This test was positive after 2 D. Severe recurrence of the right periocular dermatitis and of the eczematous lesions of the abdomen was observed at the same time.

Allergic contact cheilitis caused by carnauba wax in a lip balm

A 33-year-old woman was referred to our clinic after suffering from desquamative cheilitis and perioral dermatitis for a few months. She had a history of atopic dermatitis and asthma during childhood, and allergic contact dermatitis caused by jewellery. Over a period of several months, the patient developed desquamative cheilitis with perioral dermatitis after she started using a lip balm for ‘cracked lips’. She had also applied lipsticks as make-up, but had stopped using them, without improvement of her symptoms. She was patch tested with the European baseline series, additional series containing propolis, a cosmetic series, and the individual components of fragrance mixes I and II, and her own lipsticks, lip balm, and toothpaste, tested ‘as is’ with 2 days occlusion with IQ ChambersTM. The patch tests read at D2 and D3 were positive only for nickel sulfate 5% pet. (++ at D2 and D3) and for the hypoallergenic lip balm ‘for cracked lips’ (Uriage®) tested ‘as is’ (1+ at D3). A repeated open application test was positive for the same lip balm within 7 days. Further patch testing with all of the ingredients of the lip balm, provided by the manufacturer, was performed. There was a positive reaction only to copernicia cerifera cera tested as is (Fig. 1). Patch testing in 10 control subjects gave negative results.

Eczéma de contact systémique au nickel d'un cathéter périphérique : un nouveau cas

BACKGROUND Nickel-elicited systemic contact dermatitis is a rare event seen in previously skin sensitized patients. We report a case of systemic contact dermatitis due to nickel released into the bloodstream from a metal section of a catheter during infusion. CASE REPORT A 39-year-old woman presented papular and vesicular flexural dermatitis and pompholyx 72h after cervical spine surgery. She received numerous treatments during the perioperative period. A challenge test with one of the suspected treatments, cefazolin, was performed by intravenous infusion over a six-hour period using the same Optiva) peripheral catheter (Johnson & Johnson, USA). Six hours after withdrawal of the catheter, an eruption occurred. A further cefazolin challenge test performed later under identical conditions but using a different type of catheter (nickel-free) was negative. Nickel-elicited systemic contact dermatitis due to nickel release from a catheter was diagnosed. The patients medical history was notable for contact dermatitis with jewellery. Patch tests confirmed marked nickel sensitization. DISCUSSION A little-known way of systemic nickel absorption is through insertion of a venous catheter with a metal section containing nickel and a metallic eyelet containing nickel can in fact remain in place after catheter placement. Nickel can thus be released into the circulation during infusion and an eruption may occur during the postoperative period. This diagnosis is noteworthy as such eruptions can easily be mistakenly diagnosed as cutaneous drug eruptions.