Th. Fuchs

National rates and regional differences in sensitization to allergens of the standard series-Population-adjusted frequencies of sensitization (PAFS) in 40,000 patients from a multicenter study (IVDK)

Sensitization rates to contact allergens vary between centers and are influenced by sex and age. Eliminating the latter 2 factors by standardization of data by age and sex, the present analysis address possible differences between centers remaining after elimination of these confounders, and analyzes other factors which might influence rates, e.g. the MOAHL index. Overall standardized rates were well within the range reported in previous studies and may be regarded as representing the rates of the “patch test population” in Central Europe (e.g. nickel sulfate 12.9%, fragrance mix 10.5″. balsam of Peru 7.3%. thimerosal 5.6%). For this analysis, data of those departments which contributed more than 2000 patients or of those with extreme proportion concerning sex, age and occupational cases were selected. Patients from these 10 departments differed considerably will regard to the items of the MOAHL index and with regard to standardized rates. The items of the MOAHL index proved to be suitable for describing different patch test populations and for explaining some differences between centers. Only ‘atopic dermatitis’ seems to have little influence on (standardized) rates. Face dermatitis is not yet represented in the MOAHL index, but should be included, together with age > 40 years, in an extended index (acronym: MOAHLFA). Regional allergen exposure (with striking differences between East Germany, West Germany and to a lesser extent Austria) seems to have a great influence on the sensitization pattern observed in a department. In addition, sociological factors may influence sensitization rates, which is exemplified by high rates of nickel allergy in a socially delined subgroup. Future studies should focus on these factors, as well as on factors concerning patch test practices and quality control.

The European standard series in 9 European countries, 2002/2003 - First results of the European Surveillance System on Contact Allergies

Since January 2001, the European Surveillance System on Contact Allergies (ESSCA), supported by European Union funding (contract QLK4‐CT‐2001‐00343), has started to collect patch‐test data. This comprises a standardized clinical history and the patch‐test results using the European standard series, from 17 centres in 9 European countries listed above. In 2002 and 2003, 10u2003511 patients test results have been pooled and analysed. The anamnestic data partly reflect the subspecialties of some centres. The most common allergen was nickel sulfate (17.3%); however, large international variations were observed. The prevalence of contact allergy to Myroxylon pereirae resin (balsam of Peru) (5.8%) is coming close to the frequency found with the fragrance mix (6.4%). Regarding contact allergy to chromium compounds, different frequencies were noted in the 2 centres focused on occupational dermatitis (2.3% in the FIOH versus 7.4% in the Nofer Institute). These most likely reflect the beneficial effect of addition of ferrous sulfate in one, but not the other country. As differences may partly be due to different patch‐test reading, standardization may need to be refined further. By providing post‐marketing surveillance in the field of contact allergy, ESSCA will meet its objective of increased consumer safety across Europe.

The spectrum of allergic (cross‐)sensitivity in clinical patch testing with ‘para amino’ compounds

Background:u2002Allergic contact sensitization to ‘para amino’ compounds is frequent and the spectrum of cross‐reactivity between members of this chemical group is variable.

Patch test results with serial dilutions of nickel sulfate (with and without detergent), palladium chloride, and nickel and palladium metal plates

Clinical experience suggests the existence of different degrees of sensitivity in nickel‐allergic patients. For quantification of this phenomenon, 462 consecutive patients with previously diagnosed or strongly suspected nickel allergy were tested with serial dilution patch tests with 5 ppm to 5% nickel sulfate in pet. (Ni), and 5 ppm to 1% nickel sulfate in pet. with 1% detergent (Ni/D). Additionally, nickel and palladium metal plates were tested in 103, and cobalt salts, dichromate and palladium chloride (PdCl2) in most patients. 332 patients reacted positively to Ni or Ni/D. The influence of a concomitantly administered detergent was not significant. A significant correlation was found between positive reactions to low concentrations of Ni (or Ni/D), i.e., 0.1% or less (N=166), and concomitant reactions to nickel metal plates, cobalt salts and PdCl2 and a history of ear piercing with metal intolerance. The clinical relevance of reactions to PdCl2 is at present not clear. A subgroup of nickel‐allergic patients with “high sensitivity” can be defined. In future studies further addressing the clinical relevance of high versus low sensitivity, patch testing with 0.01, 0.1, 1.0 and 5% nickel sulfate in pet is recommended instead of routine tests with 5% only.

Genotype and phenotype of N‐acetyltransferase 2 (NAT2) polymorphism in patients with contact allergy

We investigated whether patients with contact allergy differed from non‐contact‐allergic, non‐atopic controls with regard to genotype and phenotype of the polymorphic enzyme N‐acetyltransferase 2 (NAT2). 55 contact‐allergic patients recruited from the Information Network of Departments of Dermatology (IVDK) were compared to 85 controls from among local health care personnel. NAT2 activity was calculated from HPLC analysis of the ratio of the caffeine metabolites 5‐acetylamino‐6‐formylamino‐3‐methyluracil (AFMU) and 1‐methylxanthine (1MX) in the urine. NAT2 genotype was determined by polymerase chain reaction (PCR). A statistically significantly increased proportion of rapid acetylators was found in contact‐allergic patients. This may have 2 possible implications: acetylation may enhance contact sensitization; or NAT2 status may be a genetic marker for contact sensitizability.

Sensibilisierung auf Teebaumöl in Deutschland und Österreich – Eine multizentrische Studie der Deutschen Kontaktallergiegruppe

Hintergrund und Fragestellung: Teebaumöl, ein Destillationsprodukt der Blätter des australischen Teebaumes Melaleuca alternifolia, erfreut sich zunehmender Beliebtheit als Alternativheilmittel für die Behandlung diverser Hauterkrankungen. Das Öl ist ein Gemisch aus zahlreichen allergologisch relevanten Substanzen wie Monoterpenen und Sesquiterpenen. In dieser multizentrischen Studie sollte evaluiert werden, ob die Zunahme des Verbrauches von Teebaumöl zu einer Sensibilisierungshäufigkeit in Deutschland und Österreich geführt hat, die die Aufnahme in die Standardreihe rechtfertigen würden.BACKGROUND AND AIMnTea tree oil, a distillation product of the Australian tea tree (Melalence alternitolia) is increasingly used as an alternative remedy for various dermatological diseases. Tea tree oil contains several allergenic monoterpenes and sesquiterpenes. In this multicenter study it was evaluated, whether the increasing use of tea tree oil has lead to an increased frequency of sensitization in Germany and Austria which would justify its inclusion into the standard series.nnnPATIENTS AND METHODnFor patch testing a standardized tea tree oil was used, dissolved 5% in diethylphtalate (DEP). Consecutive patients of 11 dermatological departments in Germany and Austria were tested. Readings were taken on day 2 and 3 according to the guidelines of the German Contact Dermatitis Research Group (DKG).nnnRESULTSn5% tea tree oil was positive in 36/3375 patients (1.1%). Sensitization frequencies showed great regional variations and ranged from 2.3% (Dortmund), 1.7% (Buxtehude), 1.1% (Essen), 0.7% (Graz), to 0% (Berlin, Vienna). 14/36 patients (38.9%) also showed a positive patch test reaction to oil of turpentine.nnnCONCLUSIONnOur results show that tea tree oil is an important contact allergen for some centers. It should be tested, if medical history suggests its previous use. Considering the great regional differences in frequencies of sensitization its inclusion into the standard series is not recommended yet.

Angioedema due to losartan.

also required to ®ll in a simple questionnaire on their personal allergic history (previous or concomitant asthma and/or rhinitis), the existence of potential occupational risk factors, and the possible symptoms (itching, cough, wheezing, angioedema) due to latex exposure; for instance, in the case of latex gloves, manipulation or diagnostic/surgical procedures. Health-care workers were excluded from the study, since they represent a high-risk category. The concentration of latex-speci®c IgE in serum was measured by an automated system (CAP Pharmacia, Uppsala, Sweden). The ranges for the CAP class scoring were as follows: class 0: ,0.35; class I: 0.35±0.70; class II: 0.7±3.5; class III: 3.5±17.5; class IV: 17.5±50; class V: 50±100; class VI: .100 kU/l. Samples in class III or higher were considered strongly positive. All positive samples were reassayed for consistency of results. We evaluated 1025 subjects, 84% male and 16% female, with a mean age of 39.1 years (range: 19±65). Latex-speci®c IgE were found in 36 out of 1025 (3.5%) subjects; six out of these 36 had strong positivities; and 17 subjects were classi®ed in class I and 13 in class II. The prevalence of latex-speci®c IgE was signi®cantly higher in women (31 out of 156) than in men (®ve out of 869): chi square, P=0.001. The prevalence was also higher in subjects with a positive allergy history (19 out of 142 vs 17 out of 893; P=0.001), while no relationship with age was detectable. None of the subjects with classes I and II positivity reported a signi®cant history of latex-induced reactions. The six subjects with class III or higher CAP positivity underwent the skin prick test for latex (StallergeÁnes, France), grass, Parietaria, mugwort, cat, dog, Aspergillus fumigatus, Alternaria, birch, hazelnut, alder, Olea, Dermatophagoides pteronyssinus, and D. farinae (Bayer DHS, Italy). Only one out of these six subjects reported contact urticaria using latex gloves for gardening (Table 1), but the remaining patients had skin positivity to several pollens. The prevalence of serum IgE positivity to latex was overall low (3.5%), compared to that reported by other authors (4). Moreover, strong positivity was very rare (0.6%) and of clinical relevance in only one subject (0.09% of the population). It can be hypothesized that the observed latex-IgE positivities in ®ve cases were due to cross-reactivity with grass allergens, as recently demonstrated (5). Finally, this study could provide a relatively realistic estimation of the prevalence of latex sensitization in the general population, since it was assessed in a large unselected sample by an objective method.

Allergisches Kontaktekzem durch Lidocain und latexhaltige Handschuhe

ZusammenfassungEin 65-jähriger Mann berichtet über Schwellung und Rötung des Skrotums und des Penis nach zweimaliger Harnblasenkatheteruntersuchung. Es wurden das Gleitmittel Instillagel® (Lidocain-HCL, Chlorhexidindigluconat, Methyl-4-hydroxybenzoat, Propyl-4-hydroxybenzoat) und ein Tiemann®-Katheter (PVC-Granulat, Di-(2-ethyl)) sowie naturgummilatexhaltige Untersuchungshandschuhe verwendet. Die Hautveränderungen begannen etwa 30xa0min nach der Untersuchung und hielten 2xa0Tage an. Als Ursache wurde eine Naturgummilatexallergie vermutet.Die allergologische Diagnostik ergab im Intrakutantest eine positive Reaktion auf einen Naturlatexmilchextrakt. Weiterführende Prick- und Intrakutantests mit Extrakten aus Latexhandschuhen und eine kontrollierte Handschuhexposition verliefen negativ. Das spezifische IgE auf Naturlatex war erhöht (1,42 KU/l, CAP-Klassexa02). Im Epikutantest mit Instillagel® entwickelte sich nach 48 und 72xa0h eine positive Reaktion auf das Gel und in der Aufschlüsselung auf dessen Inhaltsstoff Lidocain. Weiterhin zeigte sich im Epikutantest eine positive Hautreaktion auf das strukturell verwandte Lokalanästhetikum Cinchocain/Dibucain. Dieser Verlauf zeigt, wie wichtig eine ausführliche allergologische Diagnostik zur Stellung der Diagnose ist. In diesem Fall handelt es sich um ein allergisches Kontaktekzem durch Lidocain bei zusätzlich bestehender Naturlatexsensibilisierung.AbstractA 65xa0year old man suffered from edema of his penis and scrotum 30xa0min after investigation of the bladder using a Tiemann catheter, natural latex gloves, and Instillagel as lubricant. The skin lesions lasted for 2xa0days. This reaction occurred a second time after catheterization of the bladder. At first the diagnosis of a latex allergy was assumed.To confirm this diagnosis, skin prick tests and intracutaneous tests using natural latex milk extracts were performed. The intracutaneous tests turned out to be positive. The specific IgE for latex was analyzed using the CAP method and showed a positive result (1.42xa0KU/l, CAP class 2). To prove the clinical relevance of these findings, a provocation test was performed by wearing natural latex gloves for 30xa0min. Surprisingly, the provocation test caused no symptoms, indicating that, at present, the patient suffers from latex sensitization rather than a clinically relevant natural latex allergy. Further investigation of other suspected agents, such as the catheter and the lubricant, revealed that lidocaine, a component of Instillagel, was the substance most presumably responsible for causing the skin reactions. Additional patch tests with different local anesthetics confirmed these findings. We were also able to demonstrate a skin reaction to cinchocaine. Despite the similarity in the side chains the observed patch test reactions are not to be interpreted as immunological cross-reactions.Hypersensitivity to local anesthetics is a rare phenomenon, whereas natural latex allergy is frequent. Therefore, when the apparent symptoms are more plausibly explained by a more common disease (e.g., latex allergy), the likeliest diagnosis of a bona fide allergy to local anesthetics could easily be missed. However, the correct diagnosis is of particular importance to patients, as contact dermatitis to local anesthetics could sometimes also induce immediate type reactions when applied parenterally. This case demonstrates unequivocally that all suspected substances should be investigated by different diagnostic methods, including provocation tests, in order to make the right diagnosis.

Allergic contact eczema caused by lidocaine and latex gloves

ZusammenfassungEin 65-jähriger Mann berichtet über Schwellung und Rötung des Skrotums und des Penis nach zweimaliger Harnblasenkatheteruntersuchung. Es wurden das Gleitmittel Instillagel® (Lidocain-HCL, Chlorhexidindigluconat, Methyl-4-hydroxybenzoat, Propyl-4-hydroxybenzoat) und ein Tiemann®-Katheter (PVC-Granulat, Di-(2-ethyl)) sowie naturgummilatexhaltige Untersuchungshandschuhe verwendet. Die Hautveränderungen begannen etwa 30xa0min nach der Untersuchung und hielten 2xa0Tage an. Als Ursache wurde eine Naturgummilatexallergie vermutet.Die allergologische Diagnostik ergab im Intrakutantest eine positive Reaktion auf einen Naturlatexmilchextrakt. Weiterführende Prick- und Intrakutantests mit Extrakten aus Latexhandschuhen und eine kontrollierte Handschuhexposition verliefen negativ. Das spezifische IgE auf Naturlatex war erhöht (1,42 KU/l, CAP-Klassexa02). Im Epikutantest mit Instillagel® entwickelte sich nach 48 und 72xa0h eine positive Reaktion auf das Gel und in der Aufschlüsselung auf dessen Inhaltsstoff Lidocain. Weiterhin zeigte sich im Epikutantest eine positive Hautreaktion auf das strukturell verwandte Lokalanästhetikum Cinchocain/Dibucain. Dieser Verlauf zeigt, wie wichtig eine ausführliche allergologische Diagnostik zur Stellung der Diagnose ist. In diesem Fall handelt es sich um ein allergisches Kontaktekzem durch Lidocain bei zusätzlich bestehender Naturlatexsensibilisierung.AbstractA 65xa0year old man suffered from edema of his penis and scrotum 30xa0min after investigation of the bladder using a Tiemann catheter, natural latex gloves, and Instillagel as lubricant. The skin lesions lasted for 2xa0days. This reaction occurred a second time after catheterization of the bladder. At first the diagnosis of a latex allergy was assumed.To confirm this diagnosis, skin prick tests and intracutaneous tests using natural latex milk extracts were performed. The intracutaneous tests turned out to be positive. The specific IgE for latex was analyzed using the CAP method and showed a positive result (1.42xa0KU/l, CAP class 2). To prove the clinical relevance of these findings, a provocation test was performed by wearing natural latex gloves for 30xa0min. Surprisingly, the provocation test caused no symptoms, indicating that, at present, the patient suffers from latex sensitization rather than a clinically relevant natural latex allergy. Further investigation of other suspected agents, such as the catheter and the lubricant, revealed that lidocaine, a component of Instillagel, was the substance most presumably responsible for causing the skin reactions. Additional patch tests with different local anesthetics confirmed these findings. We were also able to demonstrate a skin reaction to cinchocaine. Despite the similarity in the side chains the observed patch test reactions are not to be interpreted as immunological cross-reactions.Hypersensitivity to local anesthetics is a rare phenomenon, whereas natural latex allergy is frequent. Therefore, when the apparent symptoms are more plausibly explained by a more common disease (e.g., latex allergy), the likeliest diagnosis of a bona fide allergy to local anesthetics could easily be missed. However, the correct diagnosis is of particular importance to patients, as contact dermatitis to local anesthetics could sometimes also induce immediate type reactions when applied parenterally. This case demonstrates unequivocally that all suspected substances should be investigated by different diagnostic methods, including provocation tests, in order to make the right diagnosis.

Skin in Internal Medicine

Paraneoplastic syndromes are skin diseases or alterations of the skin arising in connection with internal malignancies, but without a tumorous histologic structure. Their criteria, clinical pictures, classification, prognostic significance, etc., are generally accepted and well known, but we have less information about their pathomechanism or about the mode how the tumors produce them [1,2]. Based on the literature and on our own experiences we will try to summarize the problem.