Patch tests and hand eczema: retrospective study in 173 patients and literature review

Abstract Background Hand eczema (HE) is a highly prevalent, recurrent, and multifactorial disease. It encompasses a group of eczematous diseases that affect the hands, etiologically classified into irritant contact dermatitis (ICD), allergic contact dermatitis (ACD) and atopic dermatitis (AD). Few epidemiological studies in Latin America have investigated the characteristics of patients with this condition and the origin of the disease. Objectives To analyze the profile of patients diagnosed with HE submitted to patch tests aiming to determine its etiology. Methods A retrospective descriptive study was carried out on epidemiological data and patch tests of patients with HE treated at a tertiary hospital in the city of São Paulo from January 2013 to December 2020. Results A total of 173 patients were studied, whose final diagnosis was 61.8% of ICD, 23.1% of ACD and 5.2% of AD, with diagnostic overlap in 42.8% of the cases. The main positive and relevant patch tests were: Kathon CG (42%), nickel sulfate (33%), and thiuram mix (18%). Study limitations The number of treated cases and socioeconomic profile was limited to a vulnerable population group. Conclusion HE is a diagnosis in which overlapping etiologies are frequent, with the main sensitizers identified in ACD being Kathon CG, nickel sulfate and thiuram mix.

Clinical characteristics of patients with skin adverse reactions of cosmetics: report of 132 cases / 中华医学美学美容杂志

Objective:To analyse the skin clinical characteristics of adverse reactions to cosmetic products.Methods:A total of 132 patients suffered with the skin adverse reactions of cosmetics were collected in the Department of Dermatology in the First Affiliated Hospital of Xinxiang Medical University from January 2021 to December 2021. There were 5 males and 127 females, aged 2-66 (34.0±13.1) years. and the personal information, medical records, clinical characteristics and the cosmetic information as well as laboratory results were collected.Results:The major types of adverse reactions to cosmetic products were contact dermatitis (86.4%). Head was the most commonly affected site, The most common symptoms were pruritus and burning sensation (83.9%), and sores, dryness, tightness of the skin, and the common skin lesions included erythema and papula (92.9%). Suspected cosmetics were mostly skin care products (45 cases) and freckle removing products (30 cases). Only 7 patients accepted patch tests, 1 case had negative results and others were all tested positive.Conclusions:Adverse drug reactions affect young and middle-aged women mostly. Contact dermatitis is the most common adeverse reaction to cosmetic products and the patch test is still the most effective method in helping diagnosing contact dermatitis to cosmetic products.

Allergic contact hand dermatitis due to constituents of nitrile gloves

Purpose: This report of a case of allergic contact hand dermatitis due to constituents of nitrile gloves is to bring to the attention of practitioners four important practice points: 1) allergic contact dermatitis may occur due to exposure to chemicals in nitrile gloves; 2) skin patch testing is used to identify the causative allergens; 3) targeted allergens may be necessary in addition to the baseline European standard series if the standard series is unhelpful; and 4) there are potential interventions to manage nitrile glove dermatitis. Findings: A laboratory analyst had occupational exposure to several allergens and had worn latex gloves. She was exposed to laboratory chemicals and powdered ore dust, containing precious metals. She developed hand dermatitis and was relocated to administrative duties not requiring glove use. Her dermatitis cleared but recurred when she returned to the laboratory and started using nitrile gloves. On history, nitrile gloves and platinum group metal ore dust were consistently associated with her hand dermatitis, but laboratory chemicals were not. Latex-specific immunoglobulin E (IgE) was negative, as were skin patch tests for 13 allergens in the metal series, including salts of platinum group metals. She had positive allergic reactions to cobalt chloride, formaldehyde, nickel sulphate, and quaternium 15 in the European standard series patch tests. She did not react to the rubber chemicals in the European standard series, including thiuram mix. The patient was then tested with the rubber additives series because of the glove-relatedness of her hand dermatitis. She had positive reactions to three thiuram compounds used as accelerators in rubber gloves. The patient went on vacation during which time her dermatitis improved. She was relocated to a position without glove use or ore contact and her dermatitis did not recur. Conclusions: An analytic laboratory worker developed hand allergic contact dermatitis due to nitrile glove constituents. The diagnosis is supported by the improvement in her dermatitis after cessation of glove use, negative metal series patch tests, and positive patch tests to accelerators found in rubber gloves. Nevertheless, a contribution to the dermatitis by metals in the platinum group metal ore dust cannot be excluded. Recommendations: Nitrile glove constituents should be considered in wearers who develop hand dermatitis. Skin patch testing is recommended to investigate putative agents. Specific patch test series for more targeted testing may be required

Effects of slime toy poisoning in children and teenagers / Efeitos da intoxicação por slime em crianças e adolescentes

Abstract Objective: The aim of this study was to identify which types of skin reactions are associated with slime toys and which of their ingredients are most frequently involved in cases of poisoning. Data source: Between January and July 2021, articles were selected using PubMed, SciELO, and LILACS databases. The following descriptors were used: (dermatitis OR rash OR eczema OR inflammation) AND slime. Inclusion criteria were articles available in full, in either Portuguese, English, or Spanish, published between January 2000 and July 31, 2021, and articles reporting cases of contact dermatitis or eczema potentially or directly attributed to slime toys. Articles not meeting these criteria and duplicate texts in the databases were excluded. Data synthesis: In total, 65 publications were identified, of which 16 were included in this review. This resulted in a total of 22 children (2 males, 20 females), aged between 4 and 13 years, who were reportedly intoxicated by slime toys, most of these being linked to homemade preparations. Studies reported the occurrence of contact or allergic dermatitis on hands, fingers, nails, forearms, and cheeks. The most allergenic and/or irritant ingredients included liquid detergent and soap. Additionally, patch tests identified positive reactions to methylisothiazolinone and methylchloroisothiazolinone, the preservatives used by chemical industries on preparation of glue, soap, detergents, etc. Conclusions: Although slime toys might be important for improving motor development and parental relationships, homemade slime toy recipes include several allergenic and irritant ingredients which might be exposed to vulnerable children and cause intoxications. Therefore, homemade slime toys preparations should be used cautiously and under the supervision of adults.

Resumo Objetivo: Identificar quais tipos de reações de pele e ingredientes do brinquedo slime estão frequentemente envolvidos em relatos de intoxicação. Fontes de dados: Entre janeiro e julho de 2021, ocorreu a seleção dos artigos, utilizando-se as bases de dados: United States National Library of Medicine (PubMed), Scientific Electronic Library Online (SciELO) e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). Foram utilizados os seguintes descritores: (dermatitis OR rash OR eczema OR inflammation) AND slime. Incluíram-se artigos disponíveis na íntegra, em português, inglês ou espanhol, publicados entre janeiro de 2000 e 31 julho de 2021, que relatassem casos de crianças e adolescentes que apresentaram reação cutânea após a manipulação do brinquedo slime. Foram excluídos artigos sem aderência ao tema e textos duplicados nas bases de dados. Síntese dos dados: Identificaram-se 65 publicações, sendo 16 utilizadas para a elaboração desta revisão. Isso resultou no total de 22 crianças (duas do sexo masculino, 20 do feminino), com idades entre quatro e 13 anos, que teriam sido intoxicadas por slime, a maioria dos casos ligado a preparações caseiras. Estudos relataram a ocorrência de dermatite de contato ou alérgica nas mãos, dedos, unhas, antebraços e bochechas. Os ingredientes mais alergênicos e/ou irritantes foram detergentes líquidos e sabão. Ademais, o patch test identificou reações positivas para metilisotiazolinona e metilcloroisotiazolinona, que são conservantes utilizados em produtos como cola, sabão, detergente, etc. Conclusões: Ainda que o brinquedo slime seja importante para o desenvolvimento motor e das relações parentais, receitas caseiras incluem vários ingredientes alergênicos e irritantes, que podem ser expostos a crianças vulneráveis e causar intoxicações. Sendo assim, as preparações do slime devem ser feitas com cautela e sob supervisão de adultos.

Photosensitive rash induced by nivolumab

Abstract The therapeutic approach to metastatic melanoma has revolutionized the clinical course of this disease. Since 2011, different immunotherapeutic drugs have been approved. Nivolumab is a humanized immunoglobulin IgG4 monoclonal antibody that binds to the PD-1 receptor, blocking its interaction with his ligand PD-L1. The authors present a new case of photosensitivity induced by nivolumab. The photo exposed distribution of the eruption, the sun exposure prior to the beginning of the eruption, and the chronological relationship with the beginning of the treatment are data that have allowed us to confirm the suspected clinical diagnosis.

Sensitizing agents found in children and adolescents with recalcitrant atopic dermatitis: a cross-sectional study with a pediatric battery

Abstract Background Atopic dermatitis is the most common inflammatory skin disease in childhood and has an important impact on quality of life, especially severe cases or those that are recalcitrant to treatments. Sensitization to allergens with the potential for allergic contact dermatitis is a factor associated with cases of recalcitrant atopic dermatitis. Understanding the relationship between atopic dermatitis, allergens, and allergic contact dermatitis is essential. In Brazil, there are no studies on sensitization to allergens found in patch tests with pediatric batteries in patients with atopic dermatitis. Objectives To verify the main sensitizing agents, the prevalence of allergic contact dermatitis and the epidemiological and clinical profile of children and adolescents with atopic dermatitis. Methods Cross-sectional, prospective study in patients between 4 and 18 years of age, with recalcitrant atopic dermatitis, treated at the Sanitary Dermatology Outpatient Clinic (RS). All patients underwent patch tests with a battery of pediatric allergens. Results The prevalence of sensitization and allergic contact dermatitis in the evaluated patients was 37.07% (20/54) and 27.7% (15/54), respectively. The most frequent allergens were: nickel sulfate (16.7%), disperse blue (5.6%), and fragrance mix I (5.6%). Nickel was associated with the female sex (p = 0.019). Study limitations Sample size and selection, absence of a control group. Conclusions A proportion of patients with recalcitrant atopic dermatitis may be sensitized to different allergens and may even have developed allergic contact dermatitis. Recognizing this context is important in the prevention strategy and management of the disease.

Allergic contact cheilitis caused by propolis: case report

ABSTRACT Propolis is a lipophilic resin extracted from plants by bees. The purpose of this case report was to show the importance of this substance as cause of allergic contact cheilitis. A 21-year-old female patient complained of pruritic perioral eczema for 5 years. In the past months it also affected the neck. After diagnosing contact dermatitis, she was submitted to a patch test with a Latin American baseline series. The result was strongly positive for propolis (++) and weakly positive for perfume mix I (+). After the test, the patient revealed she had been using propolis drops, per oris, for 10 years. The worsening of the condition was due to increased dose, aiming "to improve immunity", during the coronavirus disease 2019 (COVID-19) pandemic. The contact allergy to propolis might be increasing due to the widespread use of natural products. Propolis is a sensitizer to be considered in patients with long-lasting cheilitis.

Usefulness of dermoscopy in the evaluation of patch test reactions

Abstract Background: Despite being widely used in different areas of dermatology, there have been few studies evaluating the benefit of dermoscopy in the interpretation of patch tests, especially in weak and doubtful reactions. Objectives: To evaluate the role of dermoscopy in the interpretation of patch tests and describe the main findings of the reactions. Method: Prospective study, carried out in dermatology reference centers in southern Brazil, which evaluated the final results of patch tests analyzed with the aid of dermoscopy. Results: 77 patients and 160 reactions were included. The most prevalent substances were nickel sulphate (23.8%), kathon CG (9.4%), and perfume mix (8.8%). The main dermoscopic findings were reaction area greater than half of the chamber site (90%), homogeneous erythema (86.9%), vesicles (30%), crusts (21.3%), perifollicular erythema (35%), pore reaction (19.4%) and pustules (8.8%). Dermoscopy was found to facilitate the definition of erythema in reactions on black skin and when due to substances with deposition of pigment. Of the 64 weak or doubtful reactions, 36 (56.25%) showed a change in the final result after dermoscopy evaluation; of the 36 doubtful reactions, 33 (91.6%) showed a change in the final result after dermoscopy evaluation (p < 0.001). Study limitations: The probable limitation of the study is its sample size. Though certain significance levels have been reached, other possible relationships may not have been observed. Conclusion: Dermoscopy improves significantly the interpretation of patch tests, especially in weak and doubtful reactions.

Allergic contact dermatitis to cosmetics: retrospective analysis of a population subjected to patch tests between 2004 and 2017

Abstract Background: Cosmetics are part of the daily life of the population, and their use can lead to allergic contact dermatitis. Objectives: To assess the profile of patients diagnosed with allergic contact dermatitis to cosmetics treated at a referral center for 13 years, as well as the characteristics of the clinical picture and allergens involved. Methods: This was a retrospective study, with analysis of medical records of patients attended at this service. The individuals included had a diagnostic hypothesis of allergic contact dermatitis to cosmetics and had previously been submitted to epicutaneous tests. Results: A total of 1405 medical records were analyzed, 403 (28.7%) with suspected allergic contact dermatitis to cosmetics and 232 (16.5%) with confirmed diagnosis. Of these, 208 (89.7%) were women, and the age group most affected was 31 − 60 years. The most common locations were face in 195 cases (25.8%), cervical region in 116 (15.3%), and trunk in 96 (12.6%). The main allergens in the contact tests were toluene-sulfonamide-formaldehyde resin in 69 cases (29.7%), paraphenylenediamine in 54 (26.3%), Kathon CG® in 41 (20.7%), and fragrance-mix 1 in 29 (16.4%). In 154 (66.4%) of the 232 patients with a confirmed diagnosis of allergic contact dermatitis to cosmetics it was possible to specify the cosmetic product responsible for the lesions. Study limitations: The absence of some allergens considered important in the world as causes of allergic contact dermatitis, which are not readily accessible among us. Conclusions: The data of the analyzed population (predominance of young women), as well as the location of the lesions (face and cervical area) and the main allergens involved were consistent with those from the world literature.

Unexpected patch test complication: onset of erythema multiforme-like lesions / Complicação inesperada após teste de contato: aparecimento de lesões eritema multiforme-símile

Erythema multiforme is generally associated with infections and drugs. Although less common, there are also reported cases of this disorder after patch testing. We described a 22 year-old female patient who, 24 hours after patch testing, progressed to erythematous iris-shaped plaques and papules with central crust, symmetrically distributed over her hands, arms, and back, with severe itch. The erythema multiforme-like lesions presented in the case were interpreted as a manifestation of systemic allergic contact dermatitis secondary to the exam. Allergic contact dermatitis may be manifested as an erythema multiforme in a hypersensitive person. Few cases of systemic allergic contact dermatitis after patch testing have been reported, for example, due to diethyl thiourea, some textile disperse dyes, and povidoneiodine. The development of erythema multiforme is not noted in most literature references as a complication after patch testing. Although unusual, this disorder needs to be considered as a potential adverse effect of this exam.

O eritema multiforme está associado comumente a infecções e medicamentos. Embora menos comum, também há casos relatados dessa doença após aplicação do teste de contato. Descrevemos uma paciente de 22 anos que evoluiu, em 24 horas após o teste, com placas e pápulas eritematosas, em formato de íris e crosta central, distribuídas simetricamente nas mãos, braços e costas, além de prurido intenso. As lesões eritema multiformesímile presentes no caso foram interpretadas como uma manifestação alérgica secundária ao exame. Dermatite de contato alérgica pode se manifestar como um eritema multiforme em pessoas hipersensíveis. Poucos casos de dermatite alérgica de contato sistêmica foram relatados após este exame, por exemplo, devido às seguintes substâncias: dietil tioureia, corantes dispersos têxteis e iodopovidona. O desenvolvimento do eritema multiforme não é usualmente apontado como uma complicação do teste de contato alérgico, na maioria das referências literárias. Embora incomum, o surgimento dessa desordem após este exame necessita ser considerado como um efeito adverso.

Positive results of patch tests with fragrance markers: analysis of a 15-year period at a Brazilian dermatology center

Abstract: Fragrances may cause allergic contact dermatitis. Data on patients who were patch tested, between 2000 and 2015, with fragrance allergens included in the Brazilian baseline series (balsam of Peru, colophony and fragrance mix I), were collected and analyzed. Of these patients, 258 (13.8%) were positive for fragrance markers, 9.8% being positive for fragrance mix I. Among these 258 there was a predominance of women in their 40s, with hand eczema. The frequency of sensitization to fragrances, as well as the epidemiological profile, was supported by the literature. Fragrance mix I was the main marker. It is important to expand the fragrance markers used in the Brazilian baseline series of patch tests.

Assessment of patch test results carried out during ten years in a city in southern Brazil

Abstract: Background: Contact dermatitis affects up to 20% of the population. Patch testing for contact allergy may be needed to confirm the diagnosis. Objectives: To describe and discuss the results of patch tests performed in a city in southern Brazil. Methods: A cross-sectional analysis was performed on all skin test results over ten years. Variables such as gender, age at the time of testing, and test results were evaluated. Triggering factors, duration of complain, and previous medications used related to the clinical history were retrieved for some patients by reviewing their medical records. Results: The sample was composed of 539 patch tests, of which 411 (76.2%) were from women. The age of the tested subjects ranged from 5 to 87 years. The prevalence of positive reactions in the patch tests was 391 (72.5%). The most prevalent positive reaction was to nickel sulfate (196; 36.4%), which had statistical significance when associated with female gender (p<0,001). Study limitations: Database obtained through secondary sources (the reports of the exams and the medical records), occurring the incomplete registration of some information. Conclusions: Data analysis at the local level is important to define preventive policies.

Allergic contact dermatitis to shoes: contribution of a specific series to the diagnosis

Abstract: Background: In our country, the Brazilian Standard Series is the most used for the etiological diagnosis of allergic contact dermatitis to shoes. However, there is no assessment of the usefulness of specific allergens for shoes. Objectives: To measure the improvement in diagnostic accuracy of allergic contact dermatitis to shoes with the use of a specific complementary series in patch testing and describe the characteristics of the affected population, such as gender, location of lesions, time of evolution, and the most common allergens. Methods: This retrospective study evaluated the results of 52 patients with suspected shoe dermatitis subjected to patch tests with the standard and specific series to quantify the gain in diagnostic accuracy. Results: Among the 52 suspected cases, 29 cases (56%) were confirmed. In 13 (45%) cases the diagnosis was determined through the specific series, which results in an 81% increase in the number of diagnoses. Study limitation: Small sample size. Conclusions: Women were more commonly affected, with a mean time for the final diagnosis of 45 months, and the most common localization was the dorsum of the feet. There was an increase in diagnostic accuracy with the introduction of new haptens in the patch test of patients with suspected shoes dermatitis.

Nickel, chromium and cobalt: the relevant allergens in allergic contact dermatitis. Comparative study between two periods: 1995-2002 and 2003-2015

Abstract: Background: Metals are common agents of allergic contact dermatitis, occupational or not, with decreasing incidence over the last years in some countries that have regulated the amount of nickel in objects. Objectives: To analyze and compare with previous studies the profile of metal sensitization between 2003-2015. Methods: Patients who underwent patch testing between 2003-2015 were evaluated retrospectively regarding the sensitization rates to metals, the associations between them, the relationship with profession and epidemiology. Results: Of the 1,386 patients tested, 438 (32%) had positive test to some metal, similar results to the 404/1,208 (33%) of the previous study (1995-2002) performed at the same service (p=0.32). The frequency of nickel (77%), cobalt (32%) and chromium (29%) changed slightly (p=0.20). Most cases of sensitization to chromium were related to the occupation (64%), in contrast to nickel and cobalt (p<0.0001). There was a predominance of females among those sensitized to metal in both studies (p=0.63) and the age group of 20-49 years old (p=0.11); the number of fair-skinned individuals increased (p<0.001), as well as the lesions in the cephalic segment (50.5%; p<0.0001) and hands (45%; p<0.0001), which are not the most frequent location anymore. The number of cleaners decreased (39% vs. 59%; p<0.0001), which still lead in front of bricklayers/painters, which increased (14% vs. 9%; p=0.013). The frequency of wet work reduced (65% vs. 81%; p<0.0001). Study limitations: The study included a single population group; only patients with positive tests to metals were considered - the others were not evaluated for the possibility of false negatives. Conclusion: The sensitization to metals, occupational or not, has been significant over the last 21 years, with few epidemiological changes.

The Evaluation of Contact Sensitivity with Standard and Cosmetic Patch Test Series in Rosacea Patients

BACKGROUND: Rosacea is a common dermatosis characterized by erythema, telangiectasia, papules and pustules. OBJECTIVE: We aimed to evaluate contact sensitivity in the rosacea patients. METHODS: We included 65 rosacea patients and 60 healthy volunteers in the study. The patient and control groups were patch tested with European baseline series and cosmetic series. RESULTS: A positive reaction to at least 1 allergen in the European standard series was found in 32.3% of rosacea patients and 20.0% of subjects in the control group while the relevant numbers were 30.8% of rosacea patients and 10% of controls with the cosmetic series (p=0.08). In total, we found a positive reaction to at least 1 allergen in 38.5% of patients and 25.0% of controls (p=0.15). We did not find a statistically significant relationship between a positive reaction to 1 allergen in total and the gender, skin type, rosacea type, ocular involvement, age and disease duration. There were more symptoms in patients with a positive reaction to allergens (p < 0.001). CONCLUSION: Contact sensitivity was detected more common in rosacea patients. Patch testing may be useful in the treatment and follow up of rosacea patients especially if symptoms such as itching, burning and stinging are present.

Increased Skin Irritation by Hydroquinone and Rsetinoic Acid Used in Combination

BACKGROUND: Hydroquinone (HQ) is frequently combined with retinoic acid (RA) to enhance lightening efficacy, which may also affect skin irritancy. Although skin irritation leads to postinflammatory hyperpigmentation, little research has been performed to compare skin irritancy between each component and the combination. OBJECTIVE: This study was done to examine whether HQ-RA combination increased skin irritation induced by HQ or RA alone. METHODS: Patch testing was performed using maximum therapeutic and higher concentrations of HQ and RA in 10 volunteers, and then, it was performed using their popular therapeutic concentrations and combination in the other 20 volunteers. In vitro irritation was also assessed in primary cultured normal human keratinocytes treated with 80% and 50% cell survival doses of HQ, 80% cell survival dose of RA, and their combination. RESULTS: The combination in patch testing induced stronger erythema than the corresponding concentrations of HQ and RA, which was remarkable with use of combination of higher concentrations. In cultured keratinocytes, the RA combination significantly decreased cell viability, but increased cytotoxicity and extracellular interleukin 1 alpha release with corresponding doses of HQ. CONCLUSION: The results of patch tests and in vitro irritation assessment tests suggested that HQ and RA increased skin irritation when used in combination.

Acebrophylline-induced generalized fixed drug eruption confirmed by an oral provocation test

The diagnosis of fixed drug eruption is straightforward because of characteristic findings, including recurrence of similar lesions at the same site and healing with residual hyperpigmentation. However, generalized or multiple fixed drug eruption, a rare variant form, can be a diagnostic challenge. Acebrophylline is a widely prescribed oral bronchodilator with mucosecretolyic and anti-inflammatory activity and is known to be relatively safe. A 34-year-old woman presented with recurrent numerous erythematous patches after ingestion of cold medications containing clarithromycin, loxoprofen, acebrophylline, and pseudoephedrine. Skin biopsy results showed vacuolar degeneration of the basal cell layer, scattered necrotic keratinocytes in the epidermis, and perivascular lymphohistiocytic infiltration in the upper dermis. A patch test showed negative results. However, in an oral challenge with acebrophylline 3 hours later, lesions reappeared at the same sites. To the best of our knowledge, this is the first case report of acebrophylline-induced generalized fixed drug eruption.

KAAACI Standardization Committee Report on the procedures and applications of the diagnostic tests for drug allergy

Diagnostic methods for drug allergy include the patient's history, in vivo skin test, in vitro laboratory test, and provocation test. However, the history is often not reliable, procedures for in vivo and in vitro tests are not standardized, and provocation tests are sometimes harmful to patients. Generally, skin prick and intradermal tests are useful for immediate reactions; in contrast, patch test and delayed reading of both skin prick and intradermal tests are helpful for delayed reactions. A drug provocation test is the gold standard for both responses, and it is necessary to be aware of exact indications and contraindications with appropriate drugs, doses, and intervals. To date, several methods have been developed to detect culprit agents for drug hypersensitivity reactions, but they are neither completely well validated nor standardized. Based on this awareness and necessity, the Korean Academy of Asthma, Allergy and Clinical Immunology launched the Standardization Committee to review the international guidelines and the literature, and then developed the consensus report on the procedures and applications of diagnostic tests for drug allergy.

DRESS (drug reaction with eosinophilia and systemic symptom) syndrome caused by both first-line and second-line antitubercular medications: A case report with a brief literature review

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but potentially fatal drug-induced systemic hypersensitivity response characterized by erythematous eruption, fever, leukocytosis with eosinophilia, and internal organ involvement. Antitubercular agents are potential causative agents for DRESS syndrome but difficult to verify as a culprit drug, since antitubercular agents are coadministered as a combination regimen. A 42-year-old female with endobronchial tuberculosis was diagnosed with DRESS syndrome after 4-week treatment of isoniazid, rifampicin, ethambutol, and pyrazinamide with prednisolone 50 mg. All the antitubercular agents were stopped and replaced with levofloxacin, cycloserine, p-aminosalicylic acid, and kanamycin. However, severe exacerbation of DRESS syndrome compelled the patient to discontinue the administration of the second-line antitubercular agents. Two months later, the patient underwent a patch test for all the antitubercular agents which had been used, and the results showed positivity to isoniazid and cycloserine. We report a rare case of DRESS syndrome that reacted to cycloserine as well as isoniazid. Development of coreactivity to other drugs should be differentiated with a flare-up reaction in the management of DRESS syndrome.

Principais sensibilizantes em pacientes idosos e não idosos com dermatite de contato / Main allergens in elderly and non-elderly patients with contact dermatitis

OBJETIVOS: Avaliar a prevalência dos principais sensibilizantes da dermatite de contato alérgica em pacientes idosos e não idosos. MÉTODOS: Estudo retrospectivo com revisão dos prontuários de pacientes com diagnóstico clínico de dermatite de contato, atendidos no período de agosto de 2000 a janeiro de 2012 no Ambulatório de Alergia da Faculdade de Medicina de Marília e em clínica particular de Alergia e Dermatologia na cidade de Marília, estado de São Paulo. Os critérios de inclusão foram diagnóstico clínico de dermatite de contato, realização de teste cutâneo de contato (patch test) no período do estudo e não uso de corticosteroide sistêmico ou outra medicação imunossupressora. Foram analisados idade, sexo, história de outros tipos de alergia e sensibilizantes utilizados. Os resultados do patch test foram lidos 48 horas e 72 horas após a colocação dos contensores. RESULTADOS: Foram incluídos 362 pacientes, entre o quais 60 idosos (idade maior ou igual a 60 anos) e 302 não idosos. Além da dermatite de contato foram observados outros tipos de alergias em 20 (33,3%) dos idosos e em 113 (37,4%) dos não idosos (p=0,54). Houve um total de 162 reações positivas ao patch test entre os idosos e 738 reações positivas entre os não idosos (p=0,24). Quanto às reações positivas fortes ocorreram 41 (68,3%) entre os idosos e 156 (51,6%) entre os não idosos (p=0,02). Somando-se reações positivas fortes e muito fortes, foram 44 (73,3%) em idosos e 214 (70,8%) em não idosos (p=0,69). As substâncias mais sensibilizantes foram o sulfato de níquel (em 33,3% dos idosos e 38 % dos não idosos) e o perfume mix (em 25% dos idosos e 27,8% dos não idosos), sem diferença estatística entre os dois grupos etários. CONCLUSÕES: A taxa de positividade do patch test entre os pacientes com dermatite de contato foi alta, não havendo diferença entre idosos e não idosos, sendo o sulfato de níquel e o perfume mix as substâncias mais sensibilizantes. Na investigação etiológica da dermatite de contato deve-se pensar principalmente na possibilidade de sensibilização aos perfumes e ao níquel, independentemente da faixa etária.

AIMS: To evaluate the prevalence of the main allergens found in allergic contact dermatitis among elderly and non-elderly patients. METHODS: Retrospective study of the medical records of patients clinically diagnosed with contact dermatitis treated from August 2000 to January 2012 at the Allergy Outpatient Clinic of Marília Medical School and at an Allergy and Dermatology private clinic in Marília, state of São Paulo, Brazil. The inclusion criteria were clinical diagnosis of contact dermatitis, patch test performed during the study period, and no treatment with systemic corticosteroids or any other immunosuppressants. Age, sex, history of other types of allergy and allergens used were assessed. The patch test results were read 48 hours and 72 hours after application of the test chambers. RESULTS: A total of 362 patients were included in the study: 60 elderly patients (aged 60 years or older) and 302 non-elderly patients. In addition to contact dermatitis, other types of allergies were observed in 20 (33.3%) of elderly patients and in 113 (37.4%) of non-elderly patients (p=0.54). There were 162 positive reactions on the patch test among elderly patients and 738 positive reactions among non-elderly patients (p=0.24). Strong positive reactions were present in 41 (68.3%) elderly patients and in 156 (51.6%) non-elderly patients (p=0.02). Strong and very strong positive reactions, when assessed together, were detected in 44 (73.3%) elderly patients and in 214 (70.8%) non-elderly patients (p=0.69). The most common allergens were nickel sulfate (in 33.3% of elderly and 38% of non-elderly patients) and fragrance mix (in 25% of elderly and 27.8% of non-elderly patients), with no statistical difference between the groups. CONCLUSIONS: There was a high rate of positive reactions on the patch test among patients with contact dermatitis, with no difference between elderly and non-elderly individuals, and the most common allergens were nickel sulfate and fragrance mix. Therefore, it is important that allergy to nickel and fragrances be included in the etiologic investigation of contact dermatitis, regardless of age.