Tokio Nakada

Rôle of ear piercing in metal allergic contact dermatitis

To evaluate the effect of ear piercing on sensitization to gold and other metals, diagnostic patch testing with metals was performed. 377 patients 18 (65 men and 312 women. ranging in age from 15 to 78 years: mean 34.2 S.D±15.1 years) were patch tested; 107 had pierced earlobes. Metals were applied on the hack for 2 days, and the results read with the ICDRG scoring system 3 days after application. Reactions of + to +++ were regarded as positive. There were significantly more patients reacting to gold chloride (P < 0.001), mercuric chloride (P < 0.001). and nickel sulfate (P < 0.05) in patients with pierced ears than in those without. Statistical issues included: (iii) a significant number of patients without referred because of earring dermatitis; (ii) those with pierced ears represented a different age group from those without; (iii) a significant number of patients without eczema in the non‐pierced ear group. However, our data suggests that ear piercing is a risk factor not only for nickel but also for gold sensitization. Gold was the second most frequent metal allergen after nickel in the pierced group.

Use tests: ROAT (repeated open application test)/PUT (provocative use test): an overview

As one step in defining the clinical relevance of exposure to an allergen identified with patch testing, use tests (provocative use test (PUT), and repeated open application test (ROAT)) have been used. In 1/2 of the cases of seemingly reliable patch tests, use tests are negative, suggesting that the patients biologic threshold of response had not been reached with open application dosing. Dramatic differences exist in regional skin reactivity and percutaneous penetration. Negative results of use tests on normal skin may become positive on diseased skin. To refine this assay further, more controlled observations and analysis of reaction differences between normal and damaged skin, and among regional anatomic sites might be performed. In addition, we require a standardized measurement for the results. Use testing has significant potential in refinement of the evidence‐based diagnosis of clinical relevance. However, for general validation, we should fill the deficiencies described above.

Multiple Fixed Drug Eruption Caused by Iomeprol (Iomeron®), A Nonionic Contrast Medium

Most cases of drug eruption caused by nonionic contrast media (NICM) reported to date have been of the erythema multiforme type. Herein we report the first case of multiple fixed drug eruption (FDE) caused by iomeprol (Iomeron®). A 67-year-old woman developed multiple pea-sized erythematous papules on the trunk and extremities 4 days after receiving 100 ml of iomeprol for a computed tomography examination. Some of the papules coalesced, forming 7 large plaques on the limbs. Six months later, the patient was mistakenly administered iomeprol again. On the following morning, erythematous plaques admixed with vesicles recurred at the same sites as during the previous episode. In both episodes, the lesions cleared leaving pigmentation that faded with 6 weeks. Both patch testing and an intradermal test with iomeprol on lesional pigmented skin were positive. The present case indicates that NICM may cause multiple FDE and that repeated administration of the causative agent may increase the severity of the eruption.

Metal patch test results from 1990-2009

Although metals are common contact allergens, clinical findings of metal contact dermatitis have varied. Such patients have subsequently become rare in Japan as gold dermatitis caused by ear piercing or baboon syndrome by broken thermometers. To evaluate such clinical findings and to determine the frequency of metal allergy, we analyzed the results of patch testing with 18 metals from 1990–2009. Nine hundred and thirty‐one patients (189 men and 742 women, mean age 39.0 years [standard deviation ± 17.8]) were tested. Metals were applied on the back for 2 days, and the results read with the International Contact Dermatitis Research Group (ICDRG) scoring system 3 days after application. Reactions of + to +++ were regarded as positive. Differences of positive rates between men and women, and patients from 1990–1999 and those from 2000–2009 were analyzed with the χ2‐test. Differences were considered significant at P < 0.05. The metal to which the most patients reacted was 5% nickel sulfate (27.2%), irrespective of sex and phase. Significantly more women reacted to nickel sulfate (P < 0.01), mercuric chloride (P < 0.05) and gold chloride (P < 0.01) than men. Significantly more patients in the 1990s reacted to palladium chloride, mercuric chloride and gold chloride (all P < 0.01) than from 2000–2009. Nickel has been the most common metal allergen and mercury‐sensitivity has decreased over 19 years in Japan.

Adverse reactions to gefitinib (Iressa): revealing sycosis- and pyoderma gangrenosum-like lesions.

condition the lesions comprise a highly pruritic linear group of excoriated eczematous papules, which are highly refractory to therapy. This condition was also ruled out in this case, as our patient had complained of minimal pruritus; moreover, the histology was not that of ILVEN, i.e. alternate columns of orthokeratosis and parakeratosis. We believe that this patient has psoriasis confined to specific zones of the left half of the body. The most likely explanation for such a presentation is that of mosaicism for the same genetic predisposition, which is universally present in skins of patients with ordinary psoriasis.

Erythema multiforme, Stevens–Johnson syndrome and toxic epidermal necrolysis: Frozen‐section diagnosis

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) may be fatal. Although classified by body surface area skin detachment, initial stages of both may present with erythema multiforme (EM)‐like lesions. To diagnose and predict disease activity adequately as early as possible for patients revealing EM‐like lesions, we performed frozen‐section diagnosis. Thirty‐five patients clinically diagnosed as EM, SJS or TEN were biopsied to diagnose and predict disease progression within the initial‐visit day. Half of a histological section taken from a lesion was snap‐frozen and immediately cryostat‐sectioned, acetone‐fixed and stained with hematoxylin–eosin. Specimens were examined with light microscopy for presence of epidermal necrosis. A section from unaffected sites was also examined for 11 patients. Specimens were examined with light microscopy for presence of graft‐versus‐host reaction (GVHR)‐like findings: apoptotic keratinocytes and satellite cell necrosis. Epidermal necrosis was seen in nine patients. Initial diagnosis of the nine was one of overlap SJS‐TEN, four of SJS and four of EM, and final diagnosis of those was one of TEN, one of overlap SJS–TEN, four of SJS and three of EM. Dissociation between initial and final diagnosis was seen in three cases. GVHR‐like findings in the epidermis were observed in two patients finally diagnosed as overlap SJS–TEN and TEN. Frozen sections are useful not only to make a diagnosis of erythema multiforme but to assess a potential to exhibit more aggressive clinical behaviors (SJS or TEN).

Patch test materials for mercury allergic contact dermatitis

The objective of this study was to define adequate patch test materials to evaluate mercury allergic contact dermatitis. We applied 0.1% and 0.05% mercuric chloride, and 0.5% and 0.2% mercury in petrolatum to systemic eczematous contact‐type dermatitis (baboon syndrome), and gold‐dermatitis patients. All baboon‐syndrome patients reacted not only to mercuric chloride but also to metallic mercury. In gold‐dermatitis patients, significantly more patients reacted to mercuric chloride than to metallic mercury (21 of 35, 60%, versus 2 of 19, 10.5%, p < 0.0005). We speculated that sensitization to mercury may be of 2 types: one a reaction to ionized mercury only, the other to both ionized mercury and non‐ionized mercury. The possibility that the phenomenon is caused by differences in bioavailability or percutaneous penetration between ionized and non‐ionized mercury cannot be ruled out, but could be explored by penetration measurement. For the evaluation of mercury hypersensitivity it may be more reliable to apply both ionized and non‐ionized mercury rather than only mercuric chloride or ammoniated mercury.

Contact urticaria syndrome from eye drops: Levofloxacin hydrate ophthalmic solution

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Autopsy case of CD4/CD8 cutaneous T-cell lymphoma presenting disseminated pagetoid reticulosis with aggressive granulomatous invasion to the lungs and pancreas.

Pagetoid reticulosis is a rare cutaneous T‐cell lymphoma with striking epidermotropism similar to that present in Pagets disease. There are two forms of pagetoid reticulosis: localized and disseminated. Reported herein is an autopsy case of disseminated pagetoid reticulosis with CD4–/CD8– phenotype T cells and massive invasion of the lungs and pancreas. The abnormal cells in the epidermis expressed a protein derived from a rearranged T‐cell receptor β gene, and this feature was used to confirm the monoclonality of these cells by polymerase chain reaction. At present, the World Health Organization (WHO) classification system considers pagetoid reticulosis to be an indolent form of primary cutaneous T‐cell lymphoma and a variant of mycosis fungoides/Sézary syndrome with prominent epidermotropism. Some differences have been observed between pagetoid reticulosis and mycosis fungoides in terms of clinical course, tumor cell phenotype, and genetic findings; and these differences are highlighted in the present case. The relation between disseminated pagetoid reticulosis,  CD4–/CD8–  cutaneous  T‐cell  lymphoma,  and γδ  T‐cell lymphoma, including whether pagetoid reticulosis is a variant of mycosis fungoides, remains unclear.

Utility of patch testing for patients with drug eruption.

Patch testing is less dangerous than oral provocation testing for identification of the causative drug for patients with drug eruption; however, its usefulness for such identification is controversial.