[ANALYSIS OF PATCH TEST RESULTS USING COCAMIDOPROPYL BETAINE-RELATED SURFACTANTS].

BACKGROUND: A few previous studies have compared the patch test (PT) results obtained using different types of PT units. OBJECTIVES: This study aimed to compare PT results between the Patch Tester 'Torii' and Finn Chamber. METHODS: Thirty-four patients with intractable scalp dermatitis were enrolled in this study. PT were performed with three kinds of amphoteric surfactants, cocamidopropyl betaine (CAPB), high-concentration CAPB (h-CAPB), and lauramidopropyl betaine (LAPB), using both the Patch Tester 'Torii' and Finn Chamber, and the changes in the subjects' symptoms after they stopped using these surfactants were examined. RESULTS: Regarding the PT results for CAPB, h-CAPB, and LAPB, the results obtained with the Finn Chamber included a significantly lower frequency of irritant reactions (CAPB; p=0.003, h-CAPB; p=0.046, LAPB; p=0.002) than those obtained with the Patch Tester 'Torii'. However, there were no significant differences in the frequencies of positive reactions between the Patch Tester 'Torii' and Finn Chamber in each surfactant. The same tendency was seen in PT with LAPB (p=0.041) in 17 selected patients, who showed positive or doubtful reactions in PT performed with the surfactant-containing products they had used and whose symptoms 'markedly improved' or 'improved' after they stopped using these products. Among these surfactants, CAPB exhibited the highest positivity rate; however, the differences were not significant. CONCLUSION: In patients with intractable scalp dermatitis, PT of the abovementioned surfactants performed using the Finn Chamber were superior to those conducted using the Patch Tester 'Torii' because they resulted in fewer irritant reactions.

Analysis of patch testing with cocamidopropyl betaine and its impurities in patients with intractable scalp dermatitis in a single clinic in Japan.

BACKGROUND: The allergen responsible for cocamidopropyl betaine (CAPB) allergies has been debated. OBJECTIVES: To investigate the sensitizing agents of CAPB, the patch test positivity rates of impurities were examined in Japanese patients with CAPB-related allergic contact dermatitis. MATERIALS AND METHODS: Thirty patients with scalp dermatitis and positive patch tests for CAPB and/or lauramidopropyl betaine (LAPB) were enrolled in this study. They were patch tested with the detergents that they had been using at the time of their first visit and with the impurities dimethylaminopropylamine (DMAPA) and lauramidopropyl dimethylamine (LAPDMA). RESULTS: The positivity rate in patch tests of the 37 detergents that the patients had been using was 78.4% (29/37). The positivity rates of DMAPA 1% pet., 1% aq. and 0.2% aq. were 32.1% (9/28), 14.3% (4/28) and 13.3% (4/30), respectively, whereas those of LAPDMA 0.1% and 0.05% were 30.0% (9/30) and 16.7% (5/30), respectively. Among the 30 patients, 6 exhibited positive results for both DMAPA and LAPDMA, 3 showed positive results for DMAPA alone and 6 produced positive results for LAPDMA alone. CONCLUSION: Patch tests produced an overall positivity rate for DMAPA, LAPDMA or both of 50.0% (15/30) in patients with scalp dermatitis and positive patch test results for CAPB and/or LAPB.

[A CASE OF ALLERGIC CONTACT DERMATITIS CAUSED BY DETERGENTS CONTAINING COCAMIDOPROPYL BETAINE IN WHICH AN IMPURITY WAS THE POSSIBLE CAUSATIVE AGENT].

Cocamidopropyl betaine (CAPB) is an amphoteric surfactant. It has several functions, including producing effervescence and washing effects, and thus, it is used in many cleansing products, such as shampoo and liquid body cleansers. Recently, it has become clear that some impurities that arise during the manufacturing process can have sensitizing effects. Herein, we report a case of allergic contact dermatitis caused by detergents containing CAPB, in which an impurity was determined to be the possible causative agent by patch testing and chemical analysis.A 64-year-old Japanese female developed a skin rash on the hairlines of her forehead and nuchal region one month before her first visit to our clinic. Later, the rashes, which were composed of desquamative erythema, expanded to her face, neck, upper back, and chest. Patch tests produced positive results for a shampoo and liquid body cleanser (1% aq.) that she had used as well as for CAPB (1% aq.); lauramidopropyl betaine (LAPB) (1% aq.); and lauramidopropyl dimethylamine (LAPDMA) (0.05% aq.), which is an impurity of CAPB. The rashes resolved completely after we instructed her to use products without CAPB and LAPB. When issuing such instructions, clinicians should have correct knowledge about surfactants, such as the differences between cosmetic ingredient names and quasi-drug ingredient names.

[ANALYSIS OF PATCH TEST RESULTS FOR INDIVIDUAL INGREDIENTS IN PATIENTS WITH ALLERGIC CONTACT DERMATITIS CAUSED BY 10% EFINACONAZOLE NAIL SOLUTION].

BACKGROUND: Ten percent efinaconazole nail solution (EFCZ solution) is a new topical triazole antifungal drug, and we sometimes encounter patients with allergic contact dermatitis (ACD) caused by EFCZ solution in our outpatient clinic. However, no previous reports have summarized the patch test (PT) results obtained for individual ingredients in several patients with EFCZ solution-induced ACD. OBJECTIVES: This study aimed to 1) confirm the causative agent of EFCZ solution-induced ACD based on PT of individual ingredients and 2) analyze the optimal concentration and vehicle for such PT on the basis of previous studies. PATIENTS AND METHODS: We clinically diagnosed eight patients with EFCZ solution-induced ACD from Sep. 2014 to Aug. 2021, and performed 48-hour closed PT using EFCZ solution and its ingredients. Readings were done on days (D) 2, 3, and 7 according to the International Contact Dermatitis Research Group criteria. RESULTS: Six of the 8 patients underwent PT with EFCZ solution, and all showed + to +++ reactions on D3. The results for the main component, EFCZ, were + to +++ on D3 in all patients. Two patients were patch tested with both 10% EFCZ in ethanol and 10% EFCZ in petrolatum, which produced similar reactions. One patient had an allergic reaction to ethanol. CONCLUSIONS: The causative agent of EFCZ solution-induced ACD was EFCZ in all patients. For PT, we recommend EFCZ solution as is, its 10-fold dilution and 1% and 0.1% EFCZ in petrolatum.

Serum zinc levels in patients with phlegmons as a marker of the severity of infection and the potential of zinc supplementation to reduce the risk of recurrence.

We analyzed the serum zinc levels of 37 patients with 40 phlegmon lesions. The mean serum zinc level was 52.1 ± 16.4 µg/dL. The serum zinc level was negatively correlated with the C-reactive protein (CRP) level (r = -0.66) and white blood cell (WBC) count (r = -0.56). It was also positively correlated with the serum levels of albumin, hemoglobin, and hematocrit (r = 0.57, 0.50, and 0.50, respectively). Patients with serum zinc levels of <60 µg/dL had higher CRP levels and WBC counts (p < 0.005 and p < 0.05, respectively) and lower albumin, hemoglobin, and hematocrit levels (p < 0.001, p < 0.01, and p < 0.01, respectively), and were more likely to be hospitalized (p < 0.05) than those with serum zinc levels of ≥60 µg/dL. Patients with low serum zinc levels were given zinc tablets. Three of the seven patients who developed recurrent phlegmons did not develop any further lesions after taking zinc tablets for >10 months. Of the remaining patients, one only developed a minimal lesion, and another two experienced recurrence twice but did not have any further lesions for 10 and 15 months, respectively. These findings indicate that in patients with phlegmons the serum zinc level is a suitable marker of the severity of infection, and zinc supplementation reduces the risk of further recurrence in patients whose lesions relapse.

[ALLERGIC CONTACT DERMATITIS DUE TO NITRILE RUBBER GLOVES: ETHYL ISOTHIOCYANATE AND BUTYL ISOTHIOCYANATE AS POSSIBLE CAUSATIVE CHEMICALS].

BACKGROUND: The causative chemicals responsible for nitrile rubber glove-induced allergic contact dermatitis have not been fully elucidated. SUBJECT: This case involved a 36-year-old female, who developed an erythematous rash on her hands after one and a half months of wearing nitrile rubber gloves at her workplace. METHODS: Patch tests were performed using the gloves as is, and the Japanese standard allergen 2008 and their components. The gloves were chemically analyzed and several detected substances were subjected to further patch testing. RESULTS: The patient exhibited positive patch test reactions to nitrile rubber gloves as is, as well as to the dithiocarbamate mix and thiuram mix in the Japanese standard allergen 2008. Further patch testing revealed positive reactions to zinc diethyldithiocarbamate (ZDEC) and tetraethylthiuram disulfide (TETD) and weak positive reactions to zinc dimethyldithiocarbamate (ZDMC) and tetramethylthiuram monosulfide (TMTM). Chemical analysis revealed that ethyl isothiocyanate (EITC) and butyl isothiocyanate (BITC), which might have been produced from dithiocarbamate-type accelerators (DTCs) or thiuram-type accelerators (thiurams) during the vulcanization process, were present in the nitrile rubber gloves the patient used at her workplace, as was ZDBC. No other DTCs or thiurams were detected. Patch testing of the detected materials produced positive reactions to EITC and BITC, but not to ZDBC. CONCLUSION: We diagnosed the patient with allergic contact dermatitis due to the EITC and BITC present in nitrile rubber gloves, and considered that alkyl isothiocyanate might also have played a causative role. We propose that nitrile rubber gloves should be produced without using vulcanization accelerators.

A case of allergic contact dermatitis caused by Olanedine solution-A diagnostic patch-testing method involving dried filter paper.

BACKGROUND: Olanedine solution is a new antiseptic, and several cases of allergic contact dermatitis caused by the agent were reported in 2018; however, these cases were diagnosed based on positive results in 2-day closed patch testing of Olanedine solution "as is." OBJECTIVES: To present another case of Olanedine-induced allergic contact dermatitis and to analyze the optimal patch-testing method for this condition. METHODS: A 34-year-old Japanese female patient and 25 healthy control subjects were patch tested using wet filter paper, which had been treated with 15 µL Olanedine solution, and dried filter paper, which had been treated with 15 µL Olanedine solution and then dried. RESULTS: The patient and all of the control subjects exhibited false-positive reactions due to irritation in the 2-day closed patch tests with wet filter paper containing Olanedine solution "as is." The tests with dried filter paper produced a positive reaction on day 7 in the patient, and negative reactions in all control subjects. CONCLUSIONS: It is preferable to perform 2-day closed patch tests using filter paper with the test solution "as is," which had been dried before application in order to correctly diagnose antiseptic-induced allergic contact dermatitis.

Case of cholinergic urticaria accompanied by anaphylaxis.

Cholinergic urticaria occasionally occurs in combination with anaphylactic symptoms. However, this has not been widely reported. Herein, we report the case of a 14-year-old Japanese male who was diagnosed with cholinergic urticaria accompanied by anaphylaxis. The patient, who was suffering from atopic dermatitis and bronchial asthma, had developed wheals after exercising or bathing, which would have increased his core body temperature, since summer 2014. He experienced two episodes of severe systemic symptoms and wheal development when he took a bath after eating in December 2014 and the following January. His symptoms included wheezing, numbness of the lips, respiratory distress, blindness and fainting. Laboratory tests revealed the following results: serum IgE level, 7060 IU/mL; titers of specific immunoglobulin E antibodies against Malassezia and MGL_1304, 31.70 UA/mL and 112.5 ng/mL, respectively. A histamine release test against human sweat revealed a class 4 response. Skin prick and intradermal tests against autologous sweat produced immediate-type positive reactions. According to these findings, we diagnosed him with the sweat-hypersensitivity type of cholinergic urticaria accompanied by anaphylaxis. He was successfully treated with lafutidine, a histamine H2 receptor antagonist, in combination with fexofenadine. It is important for dermatologists to be aware that cholinergic urticaria can progress to anaphylaxis.

Pyoderma gangrenosum and underlying diseases in Japanese patients: A regional long-term study.

Pyoderma gangrenosum (PG) is a chronic inflammatory disease of unknown cause that presents as an inflammatory and ulcerative disorder of the skin. PG is often associated with an underlying systemic disease. However, the frequencies of the underlying diseases are unclear in Japanese patients. In this retrospective, observational study, all patients diagnosed with PG who visited dermatology departments of nine regional hospitals in and around Ibaraki Prefecture were collected from 1982 to 2011 or 2014. The diagnoses of PG were based on the characteristic clinical and histological appearances and ruling out of infection. Sixty-two PG patients, including 29 males and 33 females, were identified. The ages of onset were 16-89 years, and the mean age was 50.2 years. Fifty (80%) of the 62 patients presented with an ulcerative PG, and the lower leg was the most common site (74%). Forty-six (74%) PG patients had underlying diseases. The most frequent was ulcerative colitis (32%), followed by myelodysplastic syndrome (11%), rheumatoid arthritis (6%) and aortitis syndrome (5%). For treatment, 54 cases (87%) received systemic corticosteroids and 10 received additional treatment with cyclosporin. There was no significant correlation between underlying diseases and response to the initial treatment. Multivariate analysis revealed that the number of affected sites negatively correlated with successful initial treatment. Fifteen (24%) of the 62 cases relapsed. In conclusion, ulcerative colitis and hematological disorders were frequently associated with PG while approximately a quarter of the cases were idiopathic.

Bullous pemphigoid after allogeneic hematopoietic stem cell transplantation.

Bullous pemphigoid (BP) is an autoimmune skin disorder characterized by subepidermal blisters due to deposit of autoantibody against dermal basement membrane protein. It has been reported that BP can occur after allogeneic hematopoietic stem cell transplantation (HSCT). We describe a patient with BP having autoantibody against BP180 after unrelated-donor HSCT against T lymphoblastic leukemia. The patient was treated with steroid leading to complete resolution of BP, but T lymphoblastic leukemia progressed rapidly after steroid hormone treatment. Given that immunosuppressant may reduce graft-versus-tumor effect, immunomodulatory agents such as nicotinamide and tetracycline, erythromycin, and immunoglobulin may be appropriate as soon as typical blister lesions are seen after HSCT.

Case of acrodermatitis continua of Hallopeau following psoriasis with atypical clinical presentation.

We present a 63-year-old Japanese woman who had clinically unique symmetrical skin rashes on her lower face, inframammary area, back and extremities, with some pustules on the cheeks. Skin biopsy specimens showed typical findings of psoriasis, and Psoriasis Area and Severity Index score was 5.9. After the skin lesions were treated successfully with vitamin D3 ointment, pustules developed on the tips of the fingers and toes, with paronychial and subungual involvement. The pathology of the nail matrix was consistent with pustular psoriasis, and the patient was diagnosed with acrodermatitis continua of Hallopeau (ACH) following psoriasis with an unusual clinical presentation. ACH was well controlled with a low dose of cyclosporin. Our patient is a rare case chronologically affected by two diseases in the same category. We confirmed that ACH is a variant of pustular psoriasis, and believe that the patient could provide another clue to determining the entity of ACH.

[A case of an allergic reaction due to Anisakis simplex possibly after the ingestion of squid--successful detection of four A. simplex allergens, Ani s 1, Ani s 2, Ani s 12 and troponin C-like protein].

A 62-year-old man ingested dressed salmon and its roe (ikura) and grilled mackerel and one hour later further ingested raw tuna and squid as an evening meal at a bar. Soon after the ingestion of raw seafood, he showed wheals, loss of consciousness and low blood pressure. Specific serum IgE to the nematode Anisakis simplex was positive but those to some seafoods were negative. Moreover, a skin prick test using the crude extract was positive for A. simplex but negative for the seafoods, which he ingested on the day of the above episode. When the A. simplex extract was analyzed by IgE-binding immunoblot analysis using the patient serum, two highly intense protein bands were recognized at 18 and 17 kDa, one intense band at 35 kDa and two weak bands at 28 and 26 kDa. ELISA with 11 natural or recombinant A. simplex allergens (Ani s 1-6, 8, 9, 11 and 12 and troponin C-like protein) showed that the patient serum strongly reacted to Ani s 1 and Ani s 12 and weakly to Ani s 2 and troponin C-like protein. Based on these results, he was diagnosed as IgE-mediated A. simplex allergy due to four allergens (Ani s 1, Ani s 2, Ani s 12 and troponin C-like protein), possibly infested in the raw squid which he had ingested just before manifestation of allergic reactions.

Epstein-Barr virus-associated lymphoproliferative disorder presenting with classical Hodgkin lymphoma and developing as peripheral T-cell lymphoma 9 years later: a case report of composite lymphoma.

We describe a patient who was diagnosed with classical Hodgkin lymphoma (CHL) at 67-years-old and peripheral T-cell lymphoma, not otherwise specified (PTCL) at 76-years-old, and died 5 months later. Both tumors showed prominent epithelioid cell reaction admixed with neoplastic cells. Hodgkin and Reed-Sternberg cells in the swollen lymph node were positive for CD30 and EBV-encoded RNA (EBER). PTCL cells in the skin tumor were positive for cytoplasmic CD3ε, CD4 and EBER. A rearrangement band of the T-cell receptor gene was detected in the skin tumor. This case is the first documented EBV-associated composite lymphoma composed of CHL and PTCL. The patient may show the possibility that both EBV infection and/or immunodeficiency induce the development of CHL and PTCL.