A Case of Estrogen Dermatitis

A 29-year-old Korean woman had erythematous papular patches on her face for six months. The eruptions recurred in a cyclic fashion along with her menstruation. The patient responded positively to an intradermal skin test for estrogen and showed marked improvement with the antiestrogen drug, Tamoxifen. We concluded that sensitivity to her own estrogen caused this dermatitis, that an intradermal skin test with progesterone and estrogen should be carried out routinely in patients with cyclic premenstrual flares, and that tamoxifen can be used as a specific therapy. To the best of our knowledge, this woman is the first patient with estrogen dermatitis reported in Korea.     

Estrogen dermatitis: Case report and examination of estrogen receptor‐β in the skin

Many women experience some skin reaction or trouble in their monthly menstrual cycle, including the exacerbation of pre‐existing diseases and skin eruptions directly associated with sex hormones. We herein report a Japanese woman who experienced repeated systemic urticaria in her premenstrual period, and was diagnosed as having estrogen dermatitis based on a positive result of intradermal estrogen skin test. Of note, the expression of estrogen receptor‐β was increased in small dermal vessels of this case as well as in those of patients with other inflammatory skin diseases. These results suggest that inflammation may induce estrogen receptor‐β expression in small dermal vessels, which potentially modifies the pathological skin inflammation during the menstrual period, leading to the development of estrogen dermatitis.     

Case of autoimmune progesterone dermatitis presenting as fixed drug eruption

Autoimmune progesterone dermatitis is a rare disorder that presents as a cyclical cutaneous eruption during the luteal phase of the menstrual cycle. It typically occurs in women due to an autoimmune phenomenon to endogenous progesterone production. We describe a 34‐year‐old woman with an erythematous round plaque with blistering, which recurred a few days before her menstrual cycle, at the identical site on the left arm. The diagnosis of autoimmune progesterone dermatitis is made with i.d. skin testing on the affected lesion with progesterone. After the beginning of oral prednisolone (40 mg daily) therapy during menstruation, although slight recurrence appeared, the severity was significantly improved.     

Autoimmune progesterone dermatitis

Autoimmune progesterone dermatitis is a rare cutaneous disorder characterized by recurrent cyclic eruptions with variable morphology occurring during the luteal phase of the menstrual cycle. We report a case of a 40-year-old woman with recurrent pruritic eruptions of 8 years' duration. The possibility of autoimmune progresterone dermatitis was raised because of the cyclic nature of the exacerbations. We used oral estrogen both to confirm the diagnosis and to treat the patient. A brief review of the clinical features of the disease is also presented.     

Nickel contact allergy and menstrual cycle

According to some reports in the literature, the hormonal fluctuations which occur during the menstrual cycle may affect the clinical expression of contact allergy to a greater or lesser degree. In clinical practice, too, patient history often shows exacerbation of the contact dermatitis during the days immediately preceding menstruation. On the contrary, the follicular phase of the cycle seems to have a temporary protective role in inhibiting the eliciting phase of allergic contact dermatitis. One possible explanation for this phenomenon is of immunological type: it has been demonstrated that oestradiol induces inhibition of delayed hypersensitivity type reactions, probably by acting indirectly on cells having a regulatory function in cell-mediated immunity. To investigate any inhibitory effect of the ovulatory phase of the menstrual cycle on contact sensitization, 30 selected fertile women, allergic to nickel sulfate and with a regular menstrual cycle lasting between 25 and 32 days, were enrolled. Patch tests were performed with a series of 10 serial aqueous dilutions of nickel sulfate, from 5% to 0.0013%. The 30 women were tested at 2 different times, in the ovulatory phase (demonstrated by transvaginal ultrasound) and the progestinic phase; they were subdivided into 2 groups of 15 women: in one group, the tests were made first in the ovulatory phase, and in the other, first in the progestinic phase of the menstrual cycle. There was a minimum interval of 5 weeks between the 2 test phases. The study shows that during ovulation the patch tests elicited significantly less intense responses than in the progestinic phase. These data therefore suggest that the ovulatory phase of the cycle has a significant inhibitory role on delayed hypersensitivity type reactions. For this reason, negative responses to patch tests executed in this phase could likely be false-negatives, and after careful evaluation of the phenomenon and of the clinical condition and patient history, it may be considered advisable to repeat the tests during the progestinic phase of the menstrual cycle.     

PREDOMINANCE OF CD8 SUBSET IN ID ERUPTION OF POISON OAK-INDUCED DERMATITIS

The pathophysiology and immune mechanisms involved in the clinical syndrome of autoeczematization remain a mystery. In this study of nickel dermatitis without autoeczematization and poison oak dermatitis with autoeczematization, it was noted that the process of autoeczematization was associated with the presence of CD8+ lymphocytes within the epidermis and the expression of HLA-DR antigens on epidermal keratinocytes. It is surmised that since CD8+ clones are induced by poison oak antigen but not by nickel, the inability of nickel to induce CD8+ lymphocytes may explain why uncomplicated nickel dermatitis does not autoeczematize. Since the selective adherence of CD8+ lymphocytes to keratinocytes, probably via the expression of adhesion molecules such as ICAM-1, the generation of antigens on endothelial cells of high endothelial venules involved in lymphocyte trafficking, and the expression of HLA-DR antigens on epidermal keratinocytes are all due to the activity of interferon-8, it is deduced that this lymphokine may play a key role in id eruptions induced by contact allergens.     

The relation between the localization of foot dermatitis and the causative allergens in shoes: a 13-year retrospective study

The purpose of this retrospective study was to test whether the initial pattern of clinical presentation of shoe dermatitis could indicate the causative allergen(s) and to estimate the odds on foot dermatitis in patients with a positive patch test versus those with a negative patch-test result. Between 1990 and 2002, 8543 patients were patch tested with the standard series (and additional allergens, if appropriate). Of them, 1168 (14%) had been referred because of foot dermatitis and 474 of these patients (5.5% of the total group) presented a positive reaction to one or more substances related to shoes. We found that 6 standard allergens in the male group and 8 standard allergens in the female group were statistically significant for the shoe dermatitis group. The data showed a relationship between the distribution pattern of the foot lesions and most of the allergens. These results have clinical applications since the gender of the patients and the localization of the foot eruptions can, indeed, indicate what allergen is involved.     

Demonstration of fusobacteria in eruptions of perioral dermatitis using the tape stripping toluidine blue (TSTB) method

Background and design To dale the pathogenesis of perioral dermatitis has not been completely-understood. The role of fusobacteria was postulated by some investigators during the 1970s and subsequently disputed by others, who failed to confirm the presence of these bacteria. In a 6-year period we investigated 341 patients with various facial eruptions, using the tape stripping toluidine blue (TSTB) method. According 1.0 the first clinical diagnosis 70 patients presented perioral dermatitis and 271 other facial conditions, including seborrheic dermatitis, rosacea, acne, contact dermatitis and bacterial infections. Results Fusobacteria were found in 57 (81%) of the 70 patients with perioral dermatitis, and in 14 (5%) of the 271 with other conditions. When only the clinically typical, unquestionable cases were considered, the percentages were 95% and 0%, respectively. Conclusions Our data support the view that fusobacteria are possibly involved in the pathogenesis of perioral dermatitis.     

Gold sodium thiomalate (GTM) induces hypersensitivity to thiomalate, the thiol carrier of GTM

A case of the gold sodium thiomalate (GTM)-induced eruptions with thiomalate (TM) hypersensitivity was reported. A 61-year-old Japanese woman developed lichenoid and seborrheic dermatitis (SD)-like eruptions with alopetia, when the total dosage of GTM administered for rheumatoid arthritis became 110 mg. The eruptions slowly disappeared with pigmentation after discontinuance of the GTM therapy, and the resumption resulted in the development of similar eruptions. She showed a positive reaction to GTM in an intradermal test. She also showed a positive response to TM, which is the thiol carrier of GTM, in the patch test, but a negative one to metallic gold. After administration of auranofin (AF), she also developed the SD-like eruptions with hypersensitivity to metallic gold as well as AF on patch testing, but did not develop the lichenoid ones. Our animal experiments revealed an almost complete cross reaction between GTM and TM, but only a partial one between GTM and aurothioglucose, which have dissmilar structures in the carrier part for gold. Probable roles of hypersensitivity to TM and metallic gold, which are metabolites of GTM, were discussed, respectively, in the genesis of the GTM-induced lichenoid eruptions and the AF-induced SD-like eruptions.     

Contact dermatitis due to orchids (Cymbidium and Oncidium)

A 64-year-old male who cultivated orchids as a hobby, had noticed itchy erythematous lesions on both hands since 6 months earlier. His eruptions had gradually worsened and scales and fissures had appeared. Although he was treated with topical corticosteroids by a doctor, his erythema showed no improvement. Patch tests with the orchids he cultivated, fertilizers, antiseptics and insecticides showed positive reactions to the stems of Cymbidium and Oncidium orchids. A diagnosis of contact dermatitis attributable to the cultivated orchids was made.     

Purpuric allergic contact dermatitis to paraphenylenediamine *

A 59-year-old saleswoman of black hats presented with a severe purpuric eruption of the exposed areas of the face, neck and arms. Patch testing to paraphenylenediamine produced a purpuric test reaction. Similar eruptions have been reported due to N-isopropyl-N-phenylparaphenylenediamine (IPPD), a rubber antioxidant. The patient had previous dermatitis underneath the elastic portions of her undergarments. It was determined that IPPD is added to elastic material used in some elastic trim on undergarments in the United States. This relationship is discussed.     

Autoimmune progesterone dermatitis.

A 35-year-old woman had recurrent urticarial erythemas on her trunk and extremities for 3 years. The eruptions appeared regularly 3 to 5 days prior to menstruation and persisted for several days. The patient showed a positive skin test response to progesterone and had circulating antiprogesterone IgG antibodies. A speculative concept of the possible autoimmune damage to the ovary, the major organ producing progesterone, is discussed.     

Airborne contact dermatitis due to Japanese cedar pollen

Contact dermatitis caused by airborne antigen is a well-recognized problem. Previously, airborne contact dermatitis after contact with Japanese cedar pollen [Japanese cedar pollen dermatitis (JCPD)] has been reported in Japan. However, there is still no diagnostic test to evaluate contact dermatitis due to Japanese cedar pollen. Skin tests with Japanese cedar pollen have been used to investigate these patients. A histological analysis was also conducted to clarify the mechanism of JCPD. We performed a scratch-patch test, scratch test and assays for total immunoglobulin E (IgE) and specific IgE in 13 patients suspected to have skin symptoms from Japanese cedar pollen, 5 patients with Japanese cedar pollinosis and 15 control normal subjects. All subjects were tested with Japanese cedar pollen allergen extract. A skin biopsy was performed from a Japanese cedar pollen-scratch-patch-test positive in patients with JCPD. The result after 48 hr of scratch-patch test was compared with the patient's history and the findings of corresponding scratch test and specific IgE. 100% of the 13 patients with JCPD showed a positive scratch-patch-test reaction to Japanese cedar pollen extract. However, 20% of the patients with the Japanese cedar pollinosis without any eruptions showed a positive scratch-patch-test reaction. The percentage of positive results for specific IgE and the scratch test did not differ substantially between Japanese cedar pollionosis patients with a history of chronic erythema after contact with Japanese cedar pollen and those without such a history. No side-effects were observed regarding the scratch-patch test. Control subjects showed 7% positive reaction. Histological examination showed that eczematous change (spongiosis, intracellular oedema and acanthosis), and infiltration of lymphocytes and eosinophils were all observed at the scratch-patch-test-positive sites. We therefore concluded that the use of the scratch-patch test with Japanese cedar pollen extract was useful for accurately diagnosing JCPD.     

Patch testing in cutaneous reactions caused by carbamazepine

The usefulness of patch testing in the diagnosis of carbamazepine-induced allergic skin eruptions was studied in 18 patients with previous histories of skin eruptions caused by carbamazepine. The etiological role of carbamazepine was ascertained by peroral or topical provocation in 15 (out of 18) patients. The clinical reactions caused by the drug were classified as maculopapular exanthema with general symptoms (7 patients), other type of exanthema (3). exfoliative dermatitis (erythroderma) (3), fixed drug eruption (3), erythema multiforme (1) and urticaria (1). Patch testing showed positive reactions to carbamazepine in 7 patients; in addition. 2 patients had doubtful reactions. Positive patch test reactions were seen only in patients with exfoliative dermatitis (all 3 patients) and maculopapular exanthema (4 out of 7). None of the patients with fixed drug eruption, erythema multiforme or urticaria, or the control subjects, had positive patch test reactions 10 carbamazepine. The present study suggests that patch testing is useful in the diagnosis of carbamazepine allergy in patients with maculopapular eruptions or erythrodermas.     

Significance of elevated serum LDH (lactate dehydrogenase) activity in atopic dermatitis

Serum lactate dehydrogenase activity (LDH) was elevated in most cases with the severe type of atopic dermatitis (AD). We examined whether LDH correlated specifically with the clinical courses and the severity of AD skin eruptions. Blood eosinophil numbers (Eo), LDH and its isoenzymes, and serum IgE (IgE) levels in eighty patients with AD were measured before and after treatment. In improved groups, Eo and LDH decreased or returned to normal values after treatment. In contrast, both levels increased in patients who worsened after treatment. Thus changes in Eo and LDH correlated well with the clinical picture. However, IgE levels did not correlate with the clinical condition. High LDH levels were detected in the severe type of AD more frequently than in the mild type. A large majority of patients with elevated LDH (higher than 300 IU/l) before treatment had more severe skin eruptions. When the LDH before treatment was within normal limits, the LDH levels in improved patients showed a further decrease. Eo, LDH and IgE were correlated closely with the clinical scores of AD, and the relationship between LDH and clinical score was the highest. Elevations of LDH5 and LDH4 among the LDH isoenzymes were more prominent in the severe type of AD than in the mild type. We concluded that LDH was useful as a marker for evaluating the disease condition and severity of skin eruption of AD.     

Foot dermatitis in children: causative allergens and follow-up

Allergic contact dermatitis from shoes may have a typical pattern of presentation, but we have found that the distribution of dermatitis is often unhelpful in establishing the diagnosis. In this study, we aimed to define the features of foot dermatitis in children and to assess its outcome, in comparison to adults with foot eruptions. Relevant allergens were found in 15 out of 29 children and 26 out of 57 adults with foot eruptions. The most common allergens in children were rubber chemicals and topical medicaments. Adults showed a similar pattern, but also reacted to clothing dyes. The prognosis in both groups was good, with the dermatitis improving or resolving in 2/3.     

Two cases of autoimmune progesterone dermatitis. Immunohistochemical and serological studies

Two cases of autoimmune progesterone dermatitis are reported. The patients developed recurrent pruritic erythematous and edematous eruptions on the extremities, trunk or face, with occasional vesicles on the palms and soles. The eruptions appeared 7 to 10 days prior to their menstruation and persisted for several days. They showed immediately positive skin tests with 0.1 mg/ml and 0.2 mg/ml of aqueous progesterone suspension, respectively. The patients had IgG serum factor which bound rat corpus luteum. Positive indirect basophil degranulation tests against progesterone were demonstrated in both patients. Circulating autoantibodies to patients' own progesterone may cause or modulate the intermittent eruptions of the disease.     

Autoimmune progesterone dermatitis with persistent amenorrhoea

A case of autoimmune progesterone dermatitis is reported. The patient developed a recurrent eruption, primarily on the extremities, after receiving oral progesterone for the treatment of persistent amenorrhoea. Intradermal injection of 17 alpha-hydroxyprogesterone produced a positive skin reaction after 30 min, but no delayed onset reaction was observed. A patch test with progesterone in petrolatum was negative. The lymphocyte transformation test was normal. Histamine release from passively sensitized peripheral blood leukocytes was increased by progesterone preincubated in normal serum as a stimulating antigen. Conjugated oestrogen therapy suppressed the rash. Cyclical eruptions with elevated basal body temperature persisted for more than 20 months without menstruation.     

Autoimmune progesterone dermatitis: Case report of an unexpected treatment reaction

Autoimmune progesterone dermatitis (APD) is a rare skin condition with a varying morphology, which appears on a monthly basis during the luteal phase of the menstrual cycle and resolves spontaneously with the endogenous decrease in progesterone during menses. We present the case of 39‐year‐old multiparous Caucasian woman with generalised, self‐limited urticaria in her perimenstrual period. APD was diagnosed in light of the cyclical nature of the symptoms. An intradermal test with the administration of 0.5 mg/mL of medroxyprogesterone acetate showed a positive result. She started using vaginal hormonal contraceptive that paradoxically exacerbate the symptoms, which ceased after the removal of the device. An oral combined contraceptive was initiated instead, with complete resolution of the symptoms. We share the case because of the rarity of the situation, emphasising the importance of a multidisciplinary team for differential diagnosis and patient follow up.     

Childhood Granulomatous Periorificial Dermatitis

Childhood granulomatous periorificial dermatitis (CGPD), also known as facial Afro-Caribbean childhood eruption (FACE), is a distinctive granulomatous form of perioral dermatitis. It is a condition of unknown etiology, characterized by monomorphous, small, papular eruptions around the mouth, nose and eyes that histopathologically show a granulomatous pattern. It affects prepubescent children of both sexes and typically persists for several months but resolved without scarring. We report a 9 year-old girl with multiple, discrete, monomorphic, papular eruptions of 2-months duration on the perioral and periocular areas. Histopathological examination demonstrated upper dermal and perifollicular granulomatous infiltrate.