Rosella Gallo

Allergic reaction to India ink in a black tattoo

An 18-year-old girl presented with intensely pruritic erythematous papules of 2 months duration, discretely scattered within and around a black tattoo on her right outer malleolus (Fig. 1). The tattoo had been made 3 months earlier by an amateur, who had used India ink (Pelikan 17 black) as a pigment. The symptoms were only partly responsive to topical corticosteroid therapy. Patch tests with the GIRDCA standard series were positive to nickel sulfate (π) and neomycin (π). The India ink brought by the patient and applied as is on the back, semi-occluded with MicroporeA tape, yielded a clear eczematous reaction (ππ) at D3 and D4. The patient denied permission for biopsy. According to the manufacturer, Pelikan 17 black India ink contains carbon black and natural resins. X-ray microanalysis of the ink was performed with a scanning electron microscope (SEM-Philips 515) attached to an energy dispersive spectrometer (EDS-EDAX 910). The inorganic component of the tattoo ink showed multiple elemental peaks, namely sodium, chlorine, barium, sulfur, potassium, silicon and traces of aluminium. No nickel was detected. As no further information was available, we could not further identify the sensitizer.

Topical botanically derived products: use, skin reactions, and usefulness of patch tests. A multicentre Italian study

The evidence on the safety of topical preparations containing botanical extracts is limited.

Cost and quality of life in patients with severe chronic hand eczema refractory to standard therapy with topical potent corticosteroids

Little is known about the socio‐economic burden of severe chronic hand eczema in patients refractory to treatment with potent corticosteroids.

Contact dermatitis from para-phenylenediamine used as a skin paint : A further case

Case Report A 26-year-old woman had a design painted on her right shoulder with what she believed to be henna dye. She had never previously used any kind of skin paints or hair dyes. 2 weeks later, she developed an itchy erythematooedematous reaction that exactly reproduced the original design (Fig. 1). The eruption resolved on treatment with topical corticosteroids leaving slight post-inflammatory pigmentation. Patch testing to the GIRDCA standard series and to the ‘‘henna’’ powder brought by the patient showed the following unexpected results:

Rosacea treatments: What's new and what's on the horizon?

Rosacea is a common, chronic, cutaneous disorder presenting with recurrent episodes of facial flushing, erythema, papules, pustules and telangiectasias. It is a multifactorial disease and its various clinical presentations probably represent the consequence of combined different triggers upon a specific background. Its management is largely based on long-established treatments empirically tailored to the specific presenting symptoms and no real breakthrough has occurred to date. However, recent insights into the still rather obscure pathophysiology of rosacea seem to open the way for etiologically oriented treatments. These may include, on the one side, the more effective application of traditional drugs, such as tetracyclines and metronidazole, to specifically selected patients or, on the other side, new therapeutic options, such as vitamin D receptor antagonists.It is to be remarked that the quality of most studies evaluating rosacea treatment is rather poor, mainly due to a lack of proper standardization. For a major breakthrough to occur in the management of rosacea, we need both a better understanding of its pathogenesis and the adherence of future clinical trials to clearly defined grading and inclusion criteria, which are crucial for investigators to correctly compare and interpret the results of their work.

Baboon syndrome from 5-aminosalicylic acid

A 50-year-old man presented with confluent, oedematous erythema of the buttocks and anogenital area, associated with diffuse maculopapular rash of the arms. Pruritus was intense and generalized. A year before, the patient had developed internal haemorrhoids and pruritus ani for which he had been using a vast array of topical and systemic treatments, without benefit. Indeed, eczematous dermatitis of the perianal region and lower arms had eventually developed. 2 months prior to our observation, the patient had undergone haemorrhoid sclerotherapy, after which he was prescribed daily medications with 5-aminosalicylic acid [(5-ASA); mesalazine] foam enemas (Enterasin gel rettale, Crinos, Italy). Within a few days his perianal eczema flared, spreading to the buttocks and upper inner thighs, in a baboon syndrome pattern. Patch testing was performed with the Italian standard series and a number of the patient’s own topical products, including a liquid soap specific for anal hygiene and the 5ASA foam enema. The soap was patch tested at 10% aq. and open tested as is, and the 5-ASA foam was patch tested as is. Readings at D2 and D4 were: π/π to nickel sulfate and neomycin, π/π to both tests with the detergent and π/π to the foam enema. Further patch testing was performed with the components of the latter products, provided by the manufacturers. The sensitizing components of the anal detergent were found to be cocamidopropyl betaine (1% pet.π/π at D2 and D4) and cocamidopropylamine oxide (1% aq. π/π at D2 and D4). Among the components of the foam enema, only 5-ASA, diluted at 3% pet., gave a weak erythematous reaction at D4. The patient and 20 controls were then patch tested with 5-ASA 10% pet. The patient developed a neat erythemato-oedematous reaction at D2 and D4, whereas all controls were negative. The baboon-like manifestation cleared soon after the patient stopped the 5-ASA enemas. His perianal dermatitis improved and eventually subsided with avoidance of all topical preparations, including betaine-containing detergents. We diagnosed a baboon syndrome from 5-ASA, superimposed on a perianal allergic contact dermatitis from topical remedies.

Quality of life and contact dermatitis: a disease-specific questionnaire.

Background: Contact dermatitis (CD) is a chronic disease with a significant impact on quality of life (QoL). There have been relatively few reports in the literature on specific QoL outcomes for patients suffering from CD. Objectives: To develop a new instrument specifically designed to measure QoL in CD and to investigate which disease features could strongly influence QoL. Methods: Three hundred seventy‐two patients affected by CD were administered a 20‐item questionnaire, which comprised some questions taken and modified from the Dermatology Life Quality Index and the Skindex 16. Six more items were added. Univariate analysis and a chi‐square test were performed. Results: Females reported lower QoL scores than males. Three aspects (itching, discomfort, and difficulty in daily activities) were strongly associated with a poor QoL; even if patients who experienced difficulty in using their hands at work had a poor QoL, the statistical significance was very low. Conclusion: A CD‐specific questionnaire can be used to understand a priori the impact on psychological behaviour of the patient and can lead to specific choices, such as the appropriate therapy to be used, the evaluation of treatment efficacy, the choice of preventive devices, and the comparison with QoL of other dermatoses.

Allergic contact dermatitis from thiurams with pemphigus-like autoantibodies

A 42-year-old woman had undergone repeated reconstructive surgery of the lower limbs after a car accident. During rehabilitation, an emollient was applied daily on contracture scars. After 2 months, a severe erythemato-oedematous, vesicopustular, crusted reaction developed at skin donor and graft sites. A course of systemic antibiotics and topical corticosteroids was ineffective. Occlusive dressings of the lower legs with zinc paste bandages resulted in striking localized amelioration, while the thighs kept worsening and new vesicopustular lesions developed on the arms and face. Despite repeated swabs, bacteriological cultures remained negative. Allergic contact dermatitis from the emollient was suspected, but patch testing with the SIDAPA standard series and the emollient as is showed a ππ reaction to thiuram mix only. Further investigation revealed that the patient’s mother had been using latex gloves to apply first the emollient and then the topical corticosteroids. Patch testing with the gloves elicited a discrete vesicopustular reaction at D2 and D3. Epidermolysis, reminiscent of Nikolsky sign, developed, close to the patch test site, upon removal of the Scanpor tape. During patch testing the eczema flared and spread to the trunk. Pruritus was intense. Biopsy of a vesicopustular lesion from a thigh revealed subcorneal blistering and eosinophilic spongiosis. Direct immunofluorescence (DIF) was non-specific, showing only granular deposits of C3 at the dermoepidermal junction. Indirect immunofluorescence (IIF) demonstrated low titre (1/40) IgG autoantibodies to the intercellular substance. Weak serum positivity to desmoglein 1 and desmoglein 3 was found with ELISA. Western blot analysis was negative. Class II HLA-typing revealed the following haplotype: DR15, DR13, DR51, DR52, DQ1. Strict rubber contact avoidance was advised and systemic prednisolone, 0.5 mg/kg daily was introduced. The dermatitis partly subsided, but relapsed when the drug was tapered and took on a chronic relapsing course.

European Surveillance System on Contact Allergies (ESSCA) : Results with the European baseline series, 2013/14

Contact allergy is a common condition and can severely interfere with daily life or professional activities. Due to changes in exposures, such as introduction of new substances, new products or formulations and regulatory intervention, the spectrum of contact sensitization changes.

Leprosy: a diagnostic trap for dermatopathologists in nonendemic area.

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, presenting with different clinicopathological forms. These great variety of presentations make the diagnosis of leprosy a difficult challenge in countries where the disease is not endemic. Moreover, a discordance between the clinical and histopathological diagnosis in classifying a case of leprosy can complicate the issue. We report a 43-year-old woman in whom the diagnosis of leprosy was challenging, especially, because the biopsy was sent without any clinical suspicion and Italy is a nonendemic area. The clinical informations described simply an annular lesion, and histopathology disclosed a superficial and deep moderate perivascular and periadnexal infiltrate in the dermis, predominantly made of lymphocytes with some histiocytes, in the absence of granuloma formation, foamy histiocytes, or giant cells. Only the clinicopathological correlation based upon the patients family history, her Brazilian origin, and her anesthetic lesions led us to the suspicion of leprosy. We reviewed the slides with more serial cuts and with special stains that eventually revealed a slight perineural lymphohistiocytic infiltrate and the presence of rare bacilli in the nerves, more consistent with indeterminate leprosy. However, the clinical features and the detection of just few bacilli in the skin lesions and skin smears were more consistent with a borderline leprosy. The discordance between the clinical and histopathological diagnosis in the setting of leprosy is discussed.