Corticosteroids hypersensitivity, looking for an ace up one's sleeve

Background: Although hypersensitivity reactions to corticosteroids are rare in the general population, they are not uncommon in high-risk patients who receive repeated doses of them. It is known that delayed reactions are more common than immediate ones. Atopic dermatitis is a risk factor for the development of allergic contact dermatitis from topical corticosteroids. Patients can also develop hypersensitivity reactions to nasal, inhaled, oral and parenteral corticosteroids. Method(s): We reported one case of a 72-year- old man with history of chronic obstructive pulmonary disease (GOLD 4) and atopic dermatitis, who experienced a morbilliform rash after intravenous hydrocortisone administration during his hospital admission for SARS-COV- 2 infection. Since 1995 he had experienced several late skin reactions with corticosteroids and after performing an allergy study he was diagnosed of delayed hypersensitivity to corticosteroids with good tolerance for intravenous hydrocortisone and inhaled mometasone. Closed patch tests were performed with hydrocortisone with immediate and late lectures of 48-96 hours. We also performed a controlled intravenous challenge with hydrocortisone (200 mg) as well as an oral challenge with deflazacort (30 mg) under surveillance in the intensive care unit. Result(s): Patch tests were negative and intravenous hydrocortisone challenge went positive after 48 hours with the same previous skin reaction. Our patient showed a good tolerance to deflazacort. Conclusion(s): Choosing an alternative corticosteroid is pivotal to the patient's safety and also decreases the worry of developing an allergic reaction. This evaluation becomes especially important in high-risk groups where steroids are a life-saving treatment. Baeck et al. classified corticosteroids according to their chemical structure, improving treatment options and recommendations that can be prescribed. Nevertheless, discordance continues to be observed between the results of patch tests and the patient's tolerance to various commercial preparations. In order to provide alternative treatments, it is advisable to perform exposure tests with corticosteroids from a group other than the one the patient is sensitized to. Deflazacort could be an alternative in emergency cases. (Figure Presented).

Allergic contact dermatitis to the elastic bands of an N95 mask

Case report Introduction: In the wake of the COVID-19 pandemic, occupational contact dermatitis related to the use of personal protective equipment (PPE) has become increasingly prevalent. While most cases are irritant in nature, allergic contact dermatitis (ACD) remains an important cause of occupational dermatitis. We report a case of ACD to rubber accelerators in the elastic bands of an N95 mask. Informed consent was obtained from the patient for this report. Case Report: A 27-year-old healthcare worker presented with a progressive pruritic eruption over her face and neck, 1 week after she began wearing N95 masks at work. She had only worn disposable surgical masks. She had no medical history apart from hand dermatitis, which was well controlled with topical medications. Examination revealed linear eczematous plaques along her lateral cheeks and posterior neck, corresponding to contact areas between the mask bands and her skin. Patch tests revealed a positive reaction to several rubber accelerators, including Thimerosal, 2-Mercaptobenzothiazole (MBT), and Methylisothiazolinone. We performed another patch test to several N95 mask straps, to which the patient developed an eczematous reaction to the elastic bands of 2 N95 mask types with elastic bands. Clarification with the manufacturer confirmed the use of rubber accelerators similar in properties to MBT in the production of these masks. A diagnosis of allergic contact dermatitis to rubber accelerator was made. The patient's dermatitis resolved with topical corticosteroids and the avoidance of N95 masks with elastic bands. Discussion and Conclusion(s): The use of facial PPE such as masks is a recognised cause of occupational dermatitis among healthcare workers. A variety of dermatoses are associated with the use of facial PPE, with contact dermatitis being the most common. However, while the majority of contact dermatitis are irritant in nature, ACD remains an important and preventable cause of occupational dermatitis. Commonly implicated allergens associated with mask use include preservatives and adhesives used in their production, as well as metals in the nose clip. Although less common, mask elastic bands have also been reported to be a potential source of ACD, with rubber accelerators being identified as potential allergens. However, there is often a lack of declaration of such chemicals used in the production of PPE. Given the need for continued use in the occupational setting, early identification and avoidance of allergens are key. Failure to do so may result in the progression of skin lesions, ultimately affecting the patients' quality of life and work performance. With the ubiquitous use of masks in the current climate, we wish to highlight the need for greater awareness of rubber accelerators as potential allergens, and their presence in the elastic bands of frequently used PPE.

Symptoms compatible with hypersensitivity reactions after receipt of the first and second dose of COVID-19 vaccine

Background: Until January 2022, 8.975.458 cases of COVID-19 have been reported in Spain. In December of 2020, the European Union authorized the first mRNA vaccines against SARS-COV- 2, developed by Pfizer-BioNTech and Moderna, with two doses separated by 21 and 28 days, respectively. Reports of severe allergic reactions, including anaphylaxis, have prompted concern that the new mRNA vaccine platform has the potential to cause allergic reactions (including anaphylaxis) at a greater rate than other vaccines. Method(s): Immunization process started at Hospital Ramon y Cajal (Madrid, Spain) in January 2021. The hospital provided a form to report any adverse effect after the first or second dose of the vaccine. Until today, in our Allergy Department, we have received more than 500 patients with suspected adverse reaction to the vaccine, although the data in this publication are collected from January 2021 to September 2021. All of them were referred from different services (Occupational Risk Prevention Department, Preventive Medicine Department, General Practitioners and other specialties) by telephone, e-mail or personally at our service. Result(s): Out of the 139 vaccinated patients who reported adverse effects, 131 had a reaction with the first dose, of whom 65% were women. 51% were local reactions and 49% systemic, of which 62% were immediate reactions. We performed diagnostic tests in 55% of the patients: prick test (with macrogol, triamcinolone, dexketoprofen, methylprednisolone acetate, PEG), ID test (with triamcinolone, dexketoprofen, methylprednisolone acetate) with immediate reading and delayed reading in case of delayed reactions, epicutaneous tests (with PEG and polysorbate 80) and blood tests in systemic reactions. All diagnostic tests showed negative results. 82% of patients that reported adverse effects after the first dose tolerated the second dose of the vaccine without incidents. Only one patient had a reaction to the first and second dose despite a negative study, a 58-year- old woman who presented an urticarial rash 24 hours after administration. 8 patients, all of them women, were referred for reaction after the second dose, 87% of whom had tolerated the first dose. Conclusion(s): This single-center experience suggests that most patients who had mild reactions to the first dose of mRNA vaccines have received the second dose uneventfully or with only mild repeat reactions.

Acute exantematic pustulosis generalized by meropenem, differential diagnosis with COVID

Case report We present the case of a 63-year- old man with two consecutive admissions, due to COVID19 infection and subsequent bacterial superinfection. Three days after the second admission (04/28), and 43 days from the beginning of the infection an assessment by dermatology and allergology is then requested. The patient had generalized erythematous maculopapular rash in the trunk, back, groin and limbs. On the left side and back, pustular lesions not focused on follicles were also added, with a fever of 37.7degreeC. There were no oral and genital lesions. No psoriasis. The drugs used during the present and previous admissions were reviewed. Previous admission (04/04-22/ 20): Linezolid, ciprofloxacin, meropenem 04/13-22, piperacillin/tazobactam, hydroxychloroquine, azithromycin, ceftriaxone. Upon discharge amoxicillin/acid clavulanic. Present admission (04/25) Cutaneous reaction 04/28. 04/25: meropenem, paracetamol, enoxaparin, insulin, omeprazole, venlafaxine. 04/26: Darbepoetin, furosemide, mycophenolate in single dose. 04/27: Linezolid, macrogol, Clopidogrel, Magnesium, Calcitriol. Medical records: DM type 2, liver transplantation due to HCV cirrhosis, HCV recurrence, uninodular hepatocarcinoma, advanced CKD, secondary hyperparathyroidism, multiple neurological antecedents. We performed a detailed study. We hypothesized with a pharmagological/ drug reaction with several drugs possibly involved and our main suspicion was an allergic reaction to beta-lactams. Biopsy: Subcorneal pustules, basal spongiosis and presence in the superficial dermis of edema and an inflammatory infiltrate with abundant neutrophils. No fungi. Findings compatible with clinical diagnosis of generalized acute exanthematic pustulosis (PEGA). Immunohistochemical study Covid19. (Jimenez Diaz Foundation) Finely granular positivity in endothelium and more coarse in sweaty epithelium. Neutrophilic superficial inflammatory component with presumably spure staining. ACe-2 (positive external control) is not detected. The patient presents a EuroSCAR score of 9, sum of the clinic and the pathological anatomy, and therefore defined diagnosis. Clinical diagnosis: PEGA secondary to meropenem. Conclusion(s): We present the case of a PEGA by meropenem, not very often described in the literature. We highlight the importance of differential diagnosis with viral infections. Skin tests, especially epicutaneous tests, are key to the diagnosis. (Figure Presented).

Contact allergy investigations in healthcare workers with face mask-related skin disease.

BACKGROUND: During the COVID-19 pandemic, the use of face masks has increased among healthcare workers (HCWs). Questionnaire studies have shown a high frequency of self-reported facial adverse skin reactions. Case reports have been published on face mask-induced allergic contact dermatitis and urticaria. OBJECTIVES: To describe the results of the contact allergy investigations in consecutive HCWs investigated for skin reactions to face masks during the COVID-19 pandemic and the results of the chemical investigations of face masks supplied by the hospital. METHODS: Participants were patch tested with baseline series and chemicals previously reported in face masks not included in the baseline series. Face mask(s) brought by the HCW were tested as is and/or in acetone extract. Chemical analyses were performed on nine different face masks for potential allergens. RESULTS: Fifty-eight HCWs were investigated. No contact allergies were found to the face mask(s) tested. Eczema was the most common type of skin reaction, followed by an acneiform reaction. Colophonium-related substances were found in one respirator and 2,6-di-t-butyl-4-methylphenol (BHT) were found in two respirators. CONCLUSION: Based on this report, contact allergies to face masks is uncommon. Patch test with colophonium-related substances and BHT should be considered when investigating adverse skin reactions to face masks.

Palmoplantar inflammation with a broad differential diagnosis made clear upon patch testing

A 51-year-old woman presented to our service with a 2-year history of severely painful, thickened skin of her bilateral hands and feet. She advised of considerable skin pain on mobilizing. She intermittently applied acrylate nails. This was on a background of chronic urticaria, asthma and allergic rhinitis. She described a positive family history of psoriasis. On examination, there was marked hyperkeratosis with welldemarcated erythema on the central palms and entire fingers with deep fissuring and scale. Similar finding were noted on the soles of the feet particularly affecting the heels, arch and also the tips of the toes. The morphology of the lesions favoured psoriasis, but the differential diagnosis included chronic hand dermatitis. She was referred for topical psoralen + ultraviolet A (PUVA) and patch testing to standard battery and acrylates. Treatment with topical PUVA was discontinued and patch testing lists were cancelled as a result of the emergence of COVID-19 in Ireland. Topical therapy of clobetasol propionate was initiated. On follow-up review, the appearances of her feet and hands had deteriorated significantly. She was commenced on acitretin 10 mg once daily, which was escalated to 20 mg 2 months later. Clinical improvement was noted, but appearances deteriorated once again following the application of acrylic nails. Further history revealed the patient had assisted with the application of acrylic nails to clients years prior to her initial review. Patch testing took place 18 months after initial review due to outpatient list cancellations secondary to the COVID-19 pandemic. Upon review 48 h after the application of the (METH) Acrylate Series, the patient was found to have a +2 reaction to 2- hydroxyethyl methacrylate and a further +2 reaction to 2- Hydroxypropyl methacrylate. At her 96-h review, both reaction sites were marked at +1. Following complete avoidance of acrylates, the palmoplantar inflammation entirely resolved. This case highlights the importance of a detailed clinical history where contact dermatitis is considered. In our patient's case, the clinical history and examination of the palmoplantar eruption combined with the first-degree family history of psoriasis were highly suggestive of a diagnosis of psoriasis. The episodic severe flares and its refractory nature to treatment raised suspicion for allergic contact dermatitis. Dermatologists should remain alert for potential contact allergens in cases of severe palmoplantar psoriasis. A further area for consideration is the deleterious effect the COVID-19 pandemic had on the successful diagnosis and treatment of dermatological patients through the cancellation of outpatient services.

Contact allergy to Efudix cream: a reminder and review

5-Fluorouracil (Efudix) cream is established as a topical treatment for superficial malignant and premalignant skin lesions. Its method of action involves the irreversible binding of the pyrimidine analogue fluorouracil to thymidylate synthetase within a cell. This prevents the incorporation of uracil into nuclear RNA, which destroys abnormal cancer cells (https://dermnetnz.org/topics/5-fluorouracil-cream). The expected sequelae of its use involves the development of a marked inflammatory response. We present a case of a severe, disproportionate reaction to Efudix cream, secondary to contact allergy to the excipients. A 61-year-old man attended the cutaneous allergy clinic with a history of severe, florid, inflammatory and ulcerative skin reactions affecting the lower limbs at sites of application of Efudix cream. This had been used as directed, to treat areas of Bowen disease, at intervals between December 2019 and February 2021. Contact allergy to Efudix cream was suspected and patch testing was performed to the British Standard and Cosmetic series, as well as the excipients of Efudix cream, including stearyl alcohol, propylene glycol (PG), methylparahydroxybenzoate, propylparahydroxybenzoate and white soft paraffin. While the patch tests were applied in the department on day 0, subsequent appointments on days 2, 4 and 7 were performed virtually with photographs as the patient developed COVID-19 symptoms, with positive lateral flow and polymerase chain reaction tests. He was patch test positive on days 4 and 7 to stearyl alcohol and propylene glycol, both being excipients of Efudix cream. A review of our database over a period of 17 years revealed 53 other cases with positive patch test to PG (n = 53/8000;0.66%), none of which were attributable to the use of Efudix cream, and only six cases of a positive patch test to stearyl alcohol (n = 6/8000;0.075%), of which one was attributable to the use of Efudix cream. Allergic contact dermatitis to Efudix cream and its excipients stearyl alcohol and propylene glycol is rare, although it has previously been described in the literature with the earliest reports in 1992, and the most recent being 15 years ago [Meijer B, de Waardvan der Spek F. Allergic contact dermatitis because of topical use of 5-fluorouracil (Efudix cream). Contact Dermatitis 2007;57: 58-60]. This case adds to the existing literature and is a reminder to clinicians that, although inflammation is expected with the use of Efudix cream, severe or disproportionate reactions should raise suspicion of possible contact allergy. Furthermore, this case highlights the challenges of patch testing in the current COVID-19 climate and highlights the importance of teledermatology as a novel option for assessment in cutaneous allergy services facing these conditions.

A 30-year Patch Testing Experience at Siriraj Dermatology

Objective: To identify trends of contact allergy and patch testing amendments at the Contact Dermatitis Clinic, Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University. Materials and Methods: Medical records of 6,862 patients referred to our clinic between January 1992 and December 2021 for patch testing were reviewed. Results: The number of patients patch tested increased and reached a peak of 600 patients/year in 2019 before the COVID-19 pandemic. The most frequently used series was baseline, while the most used specific series was cosmetics. The overall positivity rate was 69%. The highest positivity rate was in the cosmetics series (70.2%). Nickel sulfate was the most common contact allergen found (24.2%). Conclusion: Our patch test service has been growing in the last 30 years. The series of allergens used for patch testing has been amended every few years to be up-to-date with current global trends of contact allergies. Continual surveillance of contact prevalence and periodic updating of those series are necessary to enhance our ability to detect culprit contact allergens, which could help us improve care of our patients © All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated

The use of an online teledermatology platform with patient-submitted history and images for waiting list recovery in dermatology

While teledermatology has been a feature of some dermatology services for some time, the COVID-19 pandemic has led to both a deterioration in waiting lists for routine patients, and the use of distance consultation as a means of providing and improving access for such patients. The majority of teledermatology platforms rely on general practitioner (GP)-submitted information and images, and most data suggest that these systems result in around 50% of patients avoiding hospital attendance through the implementation of management plans suggested by hospital-based consultants (Mehrtens SH, Shall L, Halpern SM. A 14 year review of a UK teledermatology service: experience of over 40,000 teleconsultations. Clin Exp Dermatol 2019;44: 874-81). We now report the use of an online platform (Virtual LucyTM) using patient-provided information via a structured questionnaire, and patient images uploaded following clear online guidance, reinforced by call centre interaction. The data are derived from funded National Health Service (NHS) work: there was no specific funding for its generation. In total, 3500 patients from two hospital trusts with routine waiting list pressures were invited to use the system as an alternative to eventual hospital attendance. After secure registration, they completed dermatology and general health questionnaires based on conventional medical history taking, as well as a Dermatology Life Quality Index and then uploaded one or more images as appropriate. The patient data were reviewed by a consultant and a self-populated report provided to the patient, GP and trust within 72 h. Forty-eight per cent of patients were discharged to their GP with reassurance or a management plan. Patients requiring hospital attendance were signposted to appropriate clinics (e.g. isotretinoin, phototherapy, patch testing) or to surgical clinics for biopsy or excision. Hospital trust-based consultants were able to access the platform to view images prior to any surgery. Of patients directed to hospital clinics, 32% were reclassified as being urgent - waiting list duration was the main determinant of the need for reclassification. Of all images, 0.5% were unsatisfactory, and those patients were contacted through the platform to ask for a replacement image with specific advice. One per cent of patients were contacted by clinical staff by telephone or video to clarify or expand on the information given, and approximately 1% of patients used the platform to ask for additional treatment details. There were no patient complaints, and GP and hospital staff issues related to logistics were increasingly uncommon as iterative development of the system and support processes occurred. Teledermatology using patient-derived information and images gives similar outcomes to those seen in published conventional teledermatology, puts fewer demands on clinical staff, is popular with patients and has a significant benefit to the NHS.

Comparison of photographic photonic assessment and conventional clinical assessment in diagnosis of contact allergy with patch testing: a pilot study

The SARS-CoV-2 (COVID-19) pandemic has led to the rapid implementation of virtual clinics across the healthcare sector. Alternatives to the conventional face-to-face patient assessment have been sought and piloted within dermatology departments. Cutaneous patch testing is traditionally assessed on days 2 and 4, and often delayed readings are required. Strategies to minimize physical attendance and the potential risk of COVID-19 transmission were required in order to maintain access to services. Photographic assessment of patch testing was introduced in our department. In addition, we employed photographic phototonics to augment the patch-test result image. Phototonics is the technology of generating, detecting and manipulating physical light, whose quantum unit is the photon. Photonics can be used to assess levels of blood flow in a clinical photograph of skin acting as a surrogate marker for cutaneous inflammation. Our aim was to assess if clinical photography and photonic image analysis can improve the detection of positive reactions in the virtual interpretation of patchtest results. Consecutive patients attending for patch testing were recruited and written consent was obtained. Photographs of patch-test results were taken using a 40-megapixel colour camera, on day 5, contemporaneous to patch-test assessment by the study investigators. The photographs were then analysed using spectral imaging technology software (HyperCube). The analysis employed principal component analysis, a technique used to reduce the dimensionality of datasets. The phototonic images were then examined to determine a combination of variables or colour patterns (red-green-blue) that would indicate a positive result and a surrogate marker for cutaneous inflammation. Thirty patients were recruited from September to November 2020. Two blinded investigators determined whether the results were positive, ?positive, irritant or other. Phototonic, photographic and clinical results were then compared. Photonic evaluation captured 59% of positive patch-test readings, while photographic assessment captured 50%. Interpretation of the results was almost identical between both investigators. This pilot study outlines the potential application of phototonic technology in the interpretation of virtual patch-test results. It is evident that physical attendance for patch-test reading is superior to both photographic phototonic assessment and photographic assessment. However, there may be role for the use of phototonics in order to augment the evaluation of virtual patch-test results. Interpretation of phototonics can be difficult and is generally modelled to validated results. Analysis using a multispectral camera to include specific wavelengths to monitor increased blood flow may have a role.

Popper's Dermatitis: A Unique Form of Contact Dermatitis In the MSM Community

Rationale: Men who have sex with men have different contact allergen exposures compared to men who have sex with women due to cultural differences in the LGBTQ+ community. Poppers, a common name for volatile alkyl nitrates, are used more frequently in the MSM community as recreational inhalants. We aimed to identify common anatomic sites and contact allergens associated with popper's dermatitis in the MSM community. Method(s): Covidence, Embase, MEDLINE, PubMed, Web of Science, and Google Scholar were searched to identify relevant articles studying allergic contact dermatitis associated with poppers in the MSM population. Search terms included 'allergic' or 'contact dermatitis' or 'patch testing' or "poppers" or 'Men who have sex with men'. Date, geographical or language restrictions were not used. No exclusion criteria was used. Result(s): : Common allergens associated with popper's dermatitis in the MSM community included amyl nitrate (N=7), isobutyl nitrate (N=3), isopropyl nitrate (N=2), and fragrance mix (N=5). Common anatomic sites included perioral regions (N=3), chest (N=2), nasal orifices (N=3), cheeks (N=5), penis (N=1), and lateral thigh (N=1). Conclusion(s): Sexual orientation is a relevant factor for dermatologists/allergists to consider, as the standard patch test series does not include common allergens associated with popper's dermatitis which disproportionally affects the MSM community. Our community needs to include gender and sexuality demographics when collecting patch test data.Copyright © 2022

Fragranced hand gels: beware the risk of contact allergy

An 11-year-old boy presented to the children's Emergency Department in Autumn 2020 with acute blistering of his palms. No other parts of the body or mucosal surfaces were involved. He was systemically well, with no significant past medical history except for eczema in early childhood. He had recently started back at school and was using hand gel regularly as part of precautions to reduce SARS-CoV-2 (COVID-19) transmission during the pandemic. There had been no other contact with chemicals, plants, crafting materials, glues, paints or homemade slime. Clinical photographs showed swelling and large bullae on the thenar eminence and lateral fingers. There was no erythema, nail involvement or significant scaling. The clinical diagnosis was acute pompholyx that was either irritant or allergic in origin. Testing to the standard series showed inconclusive results to some fragrances in the standard series. The patch testing to fragrance in the standard series was repeated and the fragrance series was added. The repeat test confirmed allergic contact dermatitis to fragrance with a positive to Myroxylon pereirae, linalool, limonene, sandalwood oil and majantol. The hand gels were found to contain linalool and limonene. To curb the spread of COVID-19, regular handwashing and the use of alcohol-based hand sanitizers/gels are part of everyday hygiene guidance for the general public. Therefore, the incidence of hand dermatitis is likely to rise. The World Health Organization and the Food and Drugs Administration advise that a minimum alcohol content of 60% is required to inactivate viral particles;however, it is also important to be aware that hand sanitizers/gels may also contain other constituents, including thickeners, humectants (e.g. propylene glycol) and fragrance. Research into the ingredients of 10 widely used hand sanitizers recently investigated by an independent watchdog for their alcohol content found that six had their ingredients listed online and five contained fragrance. The patient responded to topical treatment with a superpotent topical steroid cream (Dermovate) twice daily, white soft paraffin 50 : 50, an antiseptic emollient (Dermol 500) to wash the hands and allergen avoidance. We highlight to other dermatologists that contact allergy to fragrance or other components in hand sanitizer/gels may present acutely with pompholyx and to consider testing to the standard and fragrance series if this is suspected.

Semi-virtual patch testing: a review of the clinical impact, practicalities, patient experience and environmental impact in a tertiary dermatology centre

The COVID-19 pandemic has influenced the way patch testing is carried out at our tertiary centre. From July 2020 we introduced 'semi-virtual patch testing', where suitable patients remove patches at home on day 2 (D2) and take photos, which were reviewed during the D4 face-to-face appointment. Our aim was to assess the continued efficacy and practicality of this service, as well as the photo quality, patient satisfaction and environmental impact of the changes. Data were collected from patients attending patch testing at the Bristol Royal Infirmary from August to December 2021. Patients/carers were asked at their D4 clinic appointment to complete a pre-prepared questionnaire, with their consent, regarding their patch test experience. A clinician (consultant or clinical fellow) concurrently filled out a questionnaire on image quality. These data were collated with data obtained via telephone questionnaires (July-November 2020). Data were available for 181 patients (age range 0-89 years, 74.8% female and 25.2% male). Ninety-seven per cent (n = 135/139) were happy to have patch testing during the pandemic. Ninety-three per cent (n = 130/140) removed their patches at home on D2. Only 3.9% (n = 5/129) would have preferred to attend hospital. Information was provided by multiple sources: verbally by a nurse (95.2%), a doctor (60.7%), a written information sheet (88.1%) and a video (29.8%). Almost all patients (n = 127/ 136) felt confident/fairly confident removing the patches at home, and 85.0% (n = 108/127) reported it saved > 1 h. Seventy-four per cent (n = 95/129) would have had to take time off work/caring commitments to attend. Almost all patients (n = 131/135) reported that their overall experience was good or very good. Seventy per cent (n = 59/84) of patients travelled independently to their appointment, and 79.8% (n = 67/84) came by car/taxi. The mean mileage (one way) to attend the appointment was 13.3 (range 0.2-46.5;n = 98). Ninety-seven percent (n = 89/92) used a smartphone device for D2 photos. The overall presentation of the D2 reading was clear in 91.2% (n = 83/91), adequate in 6.6% (n = 6/91) and inadequate in 2.2% (n = 2/91). Image focus and colour exposure was good/adequate in 97.8% (n = 90/92) and 97.2% (n = 70/72), respectively. Virtual reading negatively affected the final interpretation of the patch test in 2.2% (n = 2/89) of patients and 9.4% (n = 16/170) would have had additional tests added on D2 if they had attended, the results of which were followed-up virtually. Our review of semi-virtual patch testing in our centre demonstrates this method as being an excellent option for most patients, with very limited adverse clinical impact. There were high levels of patient satisfaction, a reduced need for time away from work/home and a reduction in travel required. The vast majority of patients can competently remove their patch tests and produce high-quality images with good focus and colour exposure, mostly using smartphone technology.

Getting to the root of it: contact anaphylaxis from polyethylene glycol in a dental lubricant

A 46-year-old man with no known allergies or history of atopy was referred for the investigation of a severe anaphylactic reaction following root canal dental treatment. The procedure had been done under local anaesthetic and involved drilling the tooth, removal of dental pulp, cleaning and insertion of a temporary filling. Preliminary skin prick tests (SPTs) and intradermal tests were negative to natural rubber latex, articaine (the local anaesthetic used for his procedure), lidocaine and chlorhexidine. He had negative specific IgE to chlorhexidine and latex, and a negative lidocaine challenge, confirming that he was not allergic to lidocaine. He returned for further dental treatment, which was done without local anaesthetic. As the procedure was completed, he developed severe anaphylaxis again. He made a full recovery and his dentist was asked for detailed information and samples of all the materials used during the procedure. Subsequent SPT showed a positive weal of 12 x 6 mm to the dental lubricant, Glyde, which was used on both occasions. Its ingredients included polyethylene glycol (PEG) 4253. SPT to other high-weight macrogol-containing products showed positive reactions to a 5% lidocaine ointment, Movicol, EMLA cream and Depomedrone. On further questioning he recalled minor immediate irritation after using a brand of children's shampoo, but a SPT to the shampoo was negative. An open test, closed test and SPT to a lower-molecular-weight patch-test allergen (PEG400 in petrolatum) were negative. PEGs or 'Macrogols' are hydrophilic polymers used in food, cosmetics and pharmaceutical reagents. They have recently attracted attention as they are excipients in several COVID-19 vaccines and have been suggested as a possible cause of anaphylaxis. Anaphylaxis to higher-molecular-weight PEGs has been reported from the use of bowel preparations and parenteral steroids. There are a handful of reports of contact urticaria to PEG-containing medicaments. We report this case to raise awareness of severe immediate hypersensitivity to these apparently innocuous ingredients and a novel source of exposure. A low index of suspicion, lack of standardized nomenclature and commercial reagents for testing are current barriers to diagnosis.

Is it time to patch test methylisothiazolinone (MI) and methylchloroisothiazolinone/MI mix in petrolatum? A concerning recent rise in sensitization also revealed

We wanted to test the hypothesis that patch testing to methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI) mix 0.02% in petrolatum (pet.) and MI 0.2% pet. is more sensitive than the same concentrations in aqueous (aq.). In 2021 these were added to an extended baseline series. Our results were startling. Regarding MI 0.2%, of 180 people tested in pet. 20.0% were positive (+/++/+++) vs. 11.4% of 236 tested in aq. Of 176 tested concurrently, 23% (n = 40) had positive reactions, of which 45% (n = 18) only in pet., 42.5% (n = 17) in both and 12.5% (n = 5) only in aq. Regarding MCI/MI 0.02%, of 127 people tested in pet. 12.6% were positive vs. 3.9% of 233 tested in aq. Of 120 tested concurrently, 13.3% (n = 16) had positive reactions, of which 62.5% (n = 10) only in pet., 31.2% (n = 5) in both and 6.3% (n = 1) only in aq., although the latter was positive to MI in aq. and pet., so would have been identified. Current relevance was found in 88.9% and 81.2% tested to MCI/MI in aq. and pet., 77.8% and 86.1% to MI in aq. and pet. In total, 120 people were tested concurrently to MCI/MI 0.02% aq. and pet., MI 0.2% aq. and pet., benzisothiazolinone (BIT) 0.1% pet. and octylisothiazolinone (OIT) 0.1% pet. Thirty-six (30%) were positive to one or more isothiazolinone, 28 (23.3%) to one or more MCI/MI or MI preparation. Fourteen (11.7%) were positive to one preparation only of which 35.7% (n = 5) to MI 0.2% pet., 7.1% (n = 1) to MI 0.2% aq. and 57.1% (n = 8) to BIT. One person was positive to all six haptens, this being the only person positive to OIT. Our data also show that there may be a new increase in sensitization to MI +/- MCI. Rates of sensitization to MI tested in aq. were 18.0%, 6.0%, 8.1% and 11.4%, in 2015, 2018, 2020 and 2021, respectively, but rising to 20.0% in 2021 when tested in pet. We found a similar trend for MCI/MI in aq. (13.5%, 2.9%, 3.1% and 3.9% for the same years) rising to 12.6% in 2021 in pet. However, in 2020 and 2021 we tested only people with severe disease (due to COVID-19 restrictions), so the rates may be falsely high. Reassuringly, rates to BIT and OIT were relatively stable during this time-frame (BIT: 10.8%, 16.0% and 13.5% in 2015, 2019 and 2021, respectively;OIT: 1.7%, 2.9% and 0.9%, in 2015, 2019 and 2021, respectively). In summary, 62.5% and 45% of people positive to MCI/MI and MI, respectively, would have been missed if patch tested to these haptens in aqueous alone. We recommend testing in petrolatum. We also found a concerning rise in sensitization to MCI/MI and MI.

[Multiform exudative erythema caused by hydroxychloroquine, diagnosed by epicutaneous tests: A case report]. / Eritema exudativo multiforme provocado por hidroxicloroquina, diagnosticado mediante pruebas epicutáneas: reporte de un caso.

INTRODUCTION: Multiform exudative erythema is a rare delayed hypersensitivity reaction associated with medications. The manifestations caused by hydroxychloroquine are exceptional; however, due to the increase in its prescription due to the recent SARS-CoV-2 pandemic, adverse reactions have been exacerbated. CASE REPORT: A 60-year-old female patient, who attended the Emergency Department for a picture of erythematous rash of one week of evolution, with involvement of the trunk, face and palms of the hands. Laboratory studies reported: leukocytosis with neutrophilia and lymphopenia, without eosinophilia or abnormal liver enzymes. The lesions continued to descend towards her extremities, with subsequent desquamation. She was prescribed prednisone 15 mg/24 h for three days, tapering to 10 mg/24 h, until her new assessment, in addition to antihistamines. Two days later, new macular lesions appeared in the presternal area and on the oral mucosa. Control laboratory studies did not show alterations. Skin biopsy reported: vacuolar interface dermatitis with spongiosis and parakeratosis, compatible with erythema multiforme. Epicutaneous tests were carried out with meloxicam and 30% hydroxychloroquine in water and vaseline, occluded for two days and interpreted at 48 and 96 hours, with a positive result for the latter. The diagnosis of multiform exudative erythema due to hydroxychloroquine was established. CONCLUSIONS: This study confirms the efficacy of patch tests in patients with delayed hypersensitivity reactions to hydroxychloroquine.

INTRODUCCIÓN: El eritema exudativo multiforme es una reacción de hipersensibilidad retardada poco frecuente asociada con medicamentos. Las manifestaciones provocadas por hidroxicloroquina son excepcionales; sin embargo, debido al incremento de su prescripción, por la reciente pandemia de SARS-CoV-2, las reacciones adversas se han exacerbado. REPORTE DE CASO: Paciente femenina de 60 años, que acudió al servicio de Urgencias por un cuadro de exantema eritematoso de una semana de evolución, con afectación hacia el tronco, la cara y las palmas de las manos. Los estudios de laboratorio informaron: leucocitosis con neutrofilia y linfopenia, sin eosinofilia ni alteración de las enzimas hepáticas. Las lesiones continuaron descendiendo hacia las extremidades, con posterior descamación. Se le indicó prednisona 15 mg/24 h durante tres días, con disminución a 10 mg/24 h, hasta su nueva valoración, además de antihistamínicos. Dos días posteriores aparecieron nuevas lesiones maculares en la zona preesternal y en la mucosa oral. Los estudios de laboratorio de control no mostraron alteraciones. La biopsia cutánea informó: dermatitis de interfase vacuolar con espongiosis y paraqueratosis, compatible con eritema multiforme. Se llevaron a cabo pruebas epicutáneas con meloxicam e hidroxicloroquina al 30% en agua y vaselina, ocluidos dos días e interpretados a las 48 y 96 horas, con resultado positivo para esta última. Se estableció el diagnóstico de eritema exudativo multiforme por hidroxicloroquina. CONCLUSIONES: Este estudio confirma la eficacia de las pruebas epicutáneas en pacientes con reacciones de hipersensibilidad retardada a hidroxicloroquina.

SEVERE ALLERGIC ERYTHEMATOUS REACTION POSTMESSENGER RNA-BASED COVID-19 VACCINE

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Covid 19 pandemic has infected 125 million people so far (1). The development of safe and effective vaccines is crucial to lessen the impact of SARS-COV 2 on global health. Some adverse events of the covid 19 vaccination have been reported including few dermatological reactions. We report a case of severe allergic erythematous drug reaction that occurred 3 days after the second dose of messenger RNA (mRNA) Pfizer vaccine. CASE PRESENTATION: A 42 year old female with past medical history of Grover's disease and Multiple Sclerosis presented to the Emergency department from the nursing home with complaints of erythematous, scaly, painful rash that occurred 3 days after the second dose of mRNA covid 19 vaccine. Patient states she had a generalized rash after the first dose of vaccine but it resolved spontaneously and did not require treatment. This time the rash started on the scalp and gradually progressed to the rest of the body. It was associated with severe itching, burning and serosanguinous discharge. Patient did not report any change in medication, use of new detergent or contact with an offending agent. The patient denied fever, chills, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain or palpitations. She had no history of similar complaints in the past. On physical examination, she was afebrile and hemodynamically stable but in severe distress due to pain. The rash covered 95% of the body surface area and was more severe around the mouth, in the axilla, neck and the inframammary area. Erosions could be seen in the skin folds with serosanguinous discharge. The laboratory results were positive for eosinophilia with absolute eosinophil count of 0.7. Remaining laboratory results were within normal limits. The pathology report for the erythematous rash was consistent with drug reaction. A slight vacuolar degeneration along the dermal epidermal junction with few apoptotic keratinocytes were noted. A compact horn and band-like lymphoid infiltrate were also noted. The patient was started on high dose steroids, analgesics and antihistamines. Petroleum gel impregnated gauze was used for dressing. She was placed in the intensive care unit for careful monitoring. Her rash resolved gradually and her symptoms improved. DISCUSSION: mRNA vaccines are associated with type 1 interferon responses that result in inflammation and autoimmune conditions. This could explain the skin manifestations associated with these vaccines. Allergenic components in the vaccines could also be a possible cause of these reactions. A patch test can be performed to prevent these reactions in susceptible individuals. CONCLUSIONS: This report highlights the need for vigilance to detect severe allergic reactions after covid 19 vaccination to improve the safety of the vaccine. Reference #1: WHO coronavirus (COVID-19) dashboard. [ Jul;2021 ];https://covid19.who.int/ 2021 DISCLOSURES: No relevant relationships by Ruhma Ali No relevant relationships by Sneha Bijoy No relevant relationships by Chrystina Kiwan no disclosure on file for Richard Miller;No relevant relationships by Aditya Patel No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim

Hand Eczema: Diagnostic approach and management

Hand eczema (HE) is a chronic inflammatory disorder of the hand with a prevalence of 14.5% worldwide. The incidence of HE has increased considerably during Coronavirus-19 (COVID-19) pandemic due to increased hand hygiene practice. Despite not affecting the mortality rate, HE can decrease the patient's quality of life significantly and increase morbidity. In general, HE can be classified based on its onset, etiology, precipitating factors, and clinical morphology. The diagnosis of HE is established through history taking and physical examination, however, several diagnostic tests should be performed to identify the etiology and exclude the differential diagnosis, including dermoscopic examination, histopathological examination, patch test, and prick test. In addition to diagnostic tests, the severity of HE should also be established to determine the appropriate therapy and monitor the therapeutic responses. After HE is identified, comprehensive management should be provided immediately so that HE will not progress into a chronic disorder which will further decrease the patient's quality of life.

Creation, Implementation, and Assessment of a Multilingual Tool to Direct Self- Removal of Patch Testing by Patients

Objectives: Patch testing requires optimal technique and patient counseling over multiple visits. 1,2 Recommendations exist to guide in-office removal of patch testing 3,4 seldomly addressing removal by patients. To address the need for improved patient education 3,5,6,7 and minimize exposures during the COVID-19 pandemic, 8 we created a patient tool to conduct patch testing self-removal. Methods: An English and Spanish instructional video depicting patch testing self-removal steps and best practices was shared with intervention group participants. Control group participants received standard counseling. All completed surveys (pre-/ post- in intervention group) measuring confidence and knowledge on a Likert Scale. Dermatologists additionally measured adherence to recommendations through a five-category physician assessment (PA). Group characteristics and survey results were compared with chi-square tests and paired/unpaired t-tests, respectively. P < 0.05 was considered significant. Results: Of forty-three participants (20 intervention and 23 control) who were demographically similar, most were female, English-speaking, younger than 50 and Non-Hispanic White. Confidence in performing (pre-M = 3.5, post-M = 4.5, p = 0.0008) and describing (pre-M = 3.1, post-M = 4.5, p = 0.0002) self-removal of patch testing increased in the intervention group but not when these were compared to the control (Mi = 4.5,Mc = 4.3, p = 0.5 and Mi = 4.5,Mc = 4.6, p = 0.8). Knowledge (80 and 100% content questions correct) and adherence (80% achieved max PA score) were high but unchanged after the intervention (pre, post-M = 1.8 in Q1, pre, post- M= 1 in Q2) and comparing to controls (Mi = 1.8,Mc = 1.9, p = 0.6 in Q1,Mi, Mc = 1, p = 0.3 in Q2, Mi = 0.8, Mc = 0.9, p = 0.6 in PA). Conclusions: Our tool increased confidence in the self-removal process, highlighting its utility to improve communication and outcomes without additional visits.

Piloting Photographic Photonic Patch Testing: Pioneering Equitable Diagnosis of Contact Dermatitis

Objectives: Due to restricted access to cutaneous patch testing (PT) during the SARS-CoV-2 pandemic innovative strategies were necessary to promote equitable healthcare. Photonics generates, detects and manipulates physical light (photons) which can assess blood-flow in a clinical photograph and potentially act as a surrogate marker for cutaneous inflammation. We wished to assess if clinical photography and photonic image analysis could improve the virtual interpretation of PT results. Methods: PT photographs of 30 consecutive patients were taken using a 40- megapixel colour camera contemporaneous to PT assessment by study investigators. Photographs were then analysed using HyperCube using Principal Component Analysis (PCA), a technique used to reduce the dimensionality of datasets. Photonic images were then examined to determine a combination of variables or colour patterns indicating a positive result. Results: Thirty patients were recruited from September-November 2020. Two blinded investigators determined whether the results were positive, ?positive, irritant or other. Photonic, photographic and clinical results were compared. Initial blinded photonic evaluation captured 40% of positive PT while photographic assessment captured 51%. Unblinded evaluation captured 90% of both PCA and clinically positive results. Conclusions: The SARS-CoV-2 pandemic catalysed many changes in healthcare delivery and introduced opportunities to produce patient centred care. This pilot study employs innovative technology to improve rural accessibility to PT, promote inclusivity and reduce carbon emissions by reducing patient travel. Further development is necessary as while PCAanalysis of digital images improves pick-up of positive PTvirtually it remains inferior to face-to-face assessment. Multispectral imaging has the potential to expand the range of wavelengths further.