To patch or not to patch: what is your threshold for patch testing?

Patch testing is as much art as it is science; we all are influenced by our clinical experience as well as by the literature. In an effort to assist those new to this often underutilized technique, we have solicited comments from five experienced clinicians about when to patch test and when not to patch test. Their responses should be a guide for us all.

Multiple chemical sensitivities syndrome: a review.

Multiple chemical sensitivities (MCS) syndrome is a controversial diagnosis that has arisen in the latter half of the 20th century. Clinical ecologists strongly believe that multiple common environmental chemicals assault the immune system in certain individuals, producing multisystem disease. Mainstream medicine, however, largely believes that the symptoms of MCS syndrome can be attributed to a conditioned response to the environment and psychiatric disease. This review examines the controversy surrounding MCS syndrome in regard to the etiology, diagnosis, and management.

Immune-associated cells in basal cell carcinomas of skin.

Increased numbers of mast cells (MCs) and lymphocytes infiltrating in basal cell carcinomas (BCCs) have been observed. The presence of these infiltrating cells has been considered a sign of an immunologic anti-tumor response in the host, but the relationship of these two cell populations has not been examined. To elucidate this possible relationship, 30 non-ulcerated BCCs were analyzed. Frozen sections of the tumors were stained with monoclonal antibodies for Langerhans' cells, lymphocyte subsets and natural killer cells. Fluorescein isothiocynate (FITC)-avidin as well as anti-tryptase and anti-CD45RO monoclonal antibodies were used on formalin-fixed, paraffin-embedded sections for mast cell and T cell identification, respectively. B cells and natural killer cells were rarely observed in these tumors. MCs and T cells were quantified by direct enumeration and expressed as number of cells per high power field (hpf). FITC-avidin and anti-tryptase antibodies were equivalent in their ability to identify MCs. MC content in BCCs ranged from 1.0 to 31 cells/hpf. The number of T cells ranged from 0 to 50 cells/hpf with helper/suppressor cell ratios of 0.2 to 10. There was no correlation between helper/suppressor ratios and mast cell numbers; however, an inverse relationship was observed between the numbers of T cells and the number of mast cells in these tumors. These studies indicate that T cells and MCs are the primary immune cell populations responding to BCCs, and that decreased numbers of T cells are associated with more aggressive tumors.

Leukemia cutis in congenital leukemia. Analysis and review of the world literature with report of an additional case.

BACKGROUND: Congenital leukemia cutis is rarely reported in the dermatology literature despite various authors citing 50% of infants with congenital leukemia have skin involvement. These seemingly disparate facts prompted a review of the world literature that was performed by searching the MEDLINE database from 1966 up to and through December 1992, reviewing Index Medicus for the years prior to computerized MEDLINE search, and reviewing appropriate case report references. OBSERVATIONS: A 2-month premature male infant was born with 182 x 10(9)/L circulating monoblasts, prominent hepatosplenomegaly, and multiple firm blue and red cutaneous nodules. CONCLUSION: Approximately 175 cases of congenital leukemia have been reported with at least 41 and possibly 56 cases identified with leukemia cutis. Specific cutaneous leukemic infiltrates occur in 25% to 30% of infants with congenital leukemia and usually appear as firm blue, red, or purple nodules in a generalized distribution. In contrast to the 50% incidence of gingival and oral infiltrates reported in adult monocytic leukemia, only 1% of congenital leukemia patients have oral involvement. Congenital leukemia cutis may precede other manifestations of leukemia by as much as 4 months. Whereas leukemia cutis is associated with a poor prognosis in adult leukemics, the natural history of congenital leukemia is not altered by leukemia cutis.

Mid-dermal elastolysis with inflammation.

A 71-year-old white woman had finely wrinkled, erythematous patches of skin that met the clinical and histologic criteria for mid-dermal elastolysis. In addition to the loss of mid-dermal elastin described in previous cases, histopathologic examination revealed a superficial and deep perivascular inflammatory infiltrate of lymphocytes and plasma cells and interstitial collections of multinucleated giant cells containing phagocytized elastin. These results support a previously postulated inflammatory pathogenesis for mid-dermal elastolysis.

Chickenpox-associated acute retinal necrosis syndrome.

Acute retinal necrosis (ARN) syndrome usually occurs as the result of secondary reactivation of latent, previously acquired, varicella-zoster or herpes simplex virus. The authors report four patients who developed a mild form of ARN within 1 month (5 to 28 days) after the onset of chickenpox. In contrast to typical cases of ARN, these cases were less severe, with retinitis limited to two quadrants or less (three patients), no retinal detachment (four patients), minimal vitreitis (four patients), and no loss of visual acuity (four patients). Thus, ARN may occur during the course of primary varicella-zoster infection.