Chronic actinic dermatitis. Therapy with systemic PUVA and mycophenolate mofetil

A 66-year-old man was diagnosed with psoriasis in 2001 and treated accordingly; in 2007, the diagnosis was switched to atopic dermatitis and the therapy modified. Initially he improved with fumarates and methotrexate, but then experienced recurrent exacerbations with erythroderma and severe superinfection requiring hospitalization. Based on the modified clinical picture with striking accentuation on the head and back of the hands, we diagnosed chronic actinic dermatitis. In September 2008 immunosuppressive therapy with mycophenolate mophetil (2×500?mg/d) was started. Since the response was modest, photo-hardening with systemic photochemotherapy (PUVA) was added, producing close to complete recovery within 6 months.     

Persistent post-occupational dermatitis: report of five cases

Persistent post-occupational dermatitis is a phenomenon that is well-recognized by occupational dermatologists, but there have been few studies on it. In view of this, we proposed to assess the prevalence of this phenomenon in an English setting and ascertain the characteristics of the patients affected. Using modified criteria adapted from previous studies, details of 1100 patients seen in a contact dermatitis clinic were screened. Persistent post-occupational dermatitis was diagnosed in 5 patients out of 1100 seen over a 35-month period in a contact clinic (4 women, 1 man; age of onset 19-52 years). All had hand dermatitis that persisted despite removal of the apparent causative agents. Four patients were nickel-allergic on patch testing, though nickel was thought to be a potential causative agent in only one case and 2 patients were allergic to thiuram-mix on patch testing, and in both thiuram had a possible causative role. In all 5 cases, irritant exposure seemed important, with allergic factors contributing in 3 cases. Two patients had had eczema in childhood. Persistent post-occupational dermatitis is uncommon, affecting less than 0.5% of patients seen in a contact dermatitis clinic, but when diagnosed it has major implications for the future employment prospects of the individuals concerned.     

Azathioprine in the treatment of Partheniumdermatitis

Background Parthenium dermatitis is a chronic disorder whose management is extremely difficult. Allergen avoidance is almost impossible, topical corticosteroid therapy provides only partial relief, and prolonged systemic corticosteroid therapy has unacceptable side-effects.
Methods Twenty patients with chronic Parthenium dermatitis, with relative contraindications to systemic corticosteroids or their side-effects, were treated with oral azathioprine (100–150 mg daily). The severity of dermatitis was assessed at 0, 1, 3, 6, and 12 months using a modified PASI scoring system.
Results The mean age of the patients was 54 years (range, 40–72 years) and the mean duration of dermatitis was 7.6 years (range, 3 months to 36 years). The mean initial score was 18.9 (range, 3.3–42), which decreased to 8.8 (range, 1.6–18.2) at 3 months, 4.8 (range, 0.6–14.6) at 6 months, and 0.7 (range, 0.2–1.4) at 12 months. Of the 15 patients evaluated at 6 months, all but one showed a response. Ten (66.6%) patients showed near-total clearance, i.e. reduction in score by more than 90%, and three patients (20%) showed more than 50% reduction in score. No significant side-effects were noted.
Conclusions Azathioprine is an effective and safe alternative to corticosteroid therapy in the treatment of chronic Parthenium dermatitis. It is especially useful in patients with side-effects or contraindications to corticosteroid therapy.     

Therapieresistente granulomatöse rosazeaähnliche Dermatitis bei einem 9-jährigen Mädchen

A 9-year-old female developed facial papules and pustules since four years. Clinically, perioral dermatitis was suspected. Different topical therapy regimens and systemic anibiotics had been unsuccessful and a skin biopsy showed granulomatous (lupoid) rosacea. Only systemic antibiotic treatment with minocyclin led to healing of the skin lesions. While granulomatous rosacea-like dermatitis is more frequently diagnosed in adults, it is only rarely encountered in children where, in most of the cases, it represents a therapeutic challenge.     

Anogenitaldermatosen – allergische und irritative Auslösefaktoren Analyse von Daten des IVDK1 und Literaturübersicht

Background: Anogenital dermatoses (AGD) are common and often very distressing. Clinically it is often unclear if allergic contact dermatitis or irritant dermatitis is involved. In order to optimize therapy and prophylaxis, it is essential to identify relevant allergens or irritants. Patients and Methods: Data of the Information Network of Departments of Dermatology (IVDK, data center in Göttingen) collected between 1999 and 2003 were analyzed. The anogenital area was involved in 1 168 patients with suspected allergic contact dermatitis. Clinical variables and patch test results were statistically compared with the remaining IVDK patch test population, the latter standardized for age and sex. Results: Allergic contact dermatitis had been suspected prior to patch testing in 39.5 %, while in 24.6 % this diagnosis was eventually confirmed. Irritant contact dermatitis was diagnosed in 11.8 %. Other diagnoses, included balanitis, lichen sclerosus et atrophicus and herpes genitalis. Positive reactions to cinchocaine (6.6 %), bufexamac (3.5 %) and benzocaine (2.4 %) were observed significantly more often among patients with anogenital dermatitis. Among those in whom co‐factors were considered important (n = 422), wetness (38.4 %), occlusion (30.3 %), mechanical strain (4.7 %) and heat (3.6 %) were mentioned as irritation factors. Conclusion: Because of the significantly higher frequency of sensitization to cinchocaine, benzocaine and bufexamac in patients with anogenital dermatitis, these ingredients should be used only with caution. According to the literature, ingredients of toiletries, cosmetics and contraceptives of any kind seem to cause allergic contact dermatitis rarely although there are several case reports. Comprehensive patch test including the standard series plus major sensitizers such as cinchocaine, benzocaine and bufexamac, and in particular patients' own skin care products, is recommended.     

Validez de una encuesta telefónica para determinar la prevalencia y la estacionalidad de la dermatitis atópica en España

BackgroundAtopic dermatitis is a eczematous disease of the skin with onset during childhood and subsequent flares. The UK Working Party (UKWP) defined the diagnostic criteria normally used for atopic dermatitis. The objective of this study was to assess the prevalence of atopic dermatitis according to these criteria.MethodsThis was a 2-phase cross-sectional, epidemiologic computer-assisted telephone survey. Parents of children aged 14 years or less participated in the first phase to determine the prevalence of atopic dermatitis in Spain. In the second phase, 6 months later, parents of children with diagnosis of atopic dermatitis according to the UKWP diagnostic criteria in phase 1 were interviewed to assess seasonal variations in disease activity between the 2 phases.ResultsIn total, 1979 parents participated; 8.6 % of the children (95 % confidence interval, 7.4 %-9.8 %) were diagnosed with atopic dermatitis by telephone. Of these, 49.2 % had a family history of atopy and 41.3 % had been diagnosed with atopic dermatitis by a physician. Diagnosis by the physician and that made by interview agreed in 75.3 % of these cases. Of the factors associated with atopic dermatitis, it was found that increased body temperature, periods of stress, dust, use of/contact with wool or fiber clothes, and use of certain soaps and hygiene products showed seasonal variations.ConclusionsThe estimated prevalence of atopic dermatitis in children between 0 and 14 years old in Spain was 8.6 %. Certain factors associated with disease flares showed seasonal variations.     

Environmental contact factors in eczema and the results of patch testing Chinese patients with a modified European standard series of allergens

Environmental contact factors in eczema were investigated in China by clinical questionnaire and patch testing patients with a modified European standard series of allergens. 217 consecutive eczema patients were studied. Contact dermatitis (CD) was clinically diagnosed in 30% of the patients. Among the patients patch tested, 46 patients had clinically diagnosed allergic CD (ACD), 20 patients clinically had non-ACD (NACD) (including 16 cases of irritant contact dermatitis, 1 case of phototoxic contact reaction and 3 cases of asteatotic eczema) and 115 patients had clinically suspected ACD. 45 patients (98%) in the ACD group went on to have relevant patch test results. The most common ACD was from metals, fragrance materials, cosmetics and rubber materials. The most common contact allergens identified were nickel, fragrance mix, para-phenylenediamine (PPD), carba mix and thimerosal. No adverse reactions were observed to patch testing, except for pruritus in patch-test-positive patients. The positive rate of patch testing in ACD was much higher than that in NACD (98% versus 15%, P < 0.05, chi(2)-test). 60 (28%) patients had facial dermatitis (FD). Among these, 20 (33%) were confirmed as having ACD. 48 (22%) patients had hand dermatitis (HD). Among these, 7 (15%) were confirmed as having ACD. Fewer patients were confirmed as having ACD in the HD group than in the FD (15% versus 33%, P < 0.05, chi(2)-test). Although the difference was not significant, the total positivity rate in the HD group (55%) was lower than in the other groups. 65 (30%) patients had unclassified endogenous eczema (UEE). The total positive rate of patch testing in the UEE group (56%) was no different from that in the FD or HD groups. However, the relevance of positive patch tests was hard to determine in UEE. These results indicate that CD is common in eczema; relatively more patients with FD have ACD, while other factors, such as irritation, may play more of a role in HD. The total positive rate of patch testing in the UEE group was no different from that in the FD or HD groups, suggesting that patch testing should be stressed in UEE and the relevance of positive patch test results in UEE should be studied further. It is effective and safe to patch eczema patients with a modified European standard series of allergens in China.     

PUVA THERAPY OF CHRONIC ACTINIC DERMATITIS

A modified PUVA regime was used to treat five men with long-standing chronic actinic dermatitis. They are all now symptom free on monthly maintenance PUVA therapy and no longer react abnormally to ultra-violet radiation, with consequent improvement of their quality of life.     

The role of microorganisms in diaper dermatitis.

A quantitative microbiological survey of multiple sites in the diaper area in 40 normal infants and 100 infants with various forms of diaper dermatitis showed (1) no significant differences between normal infants and those with common chafing form of diaper dermatitis except for a low number of Staphylococcus aureus organisms in 50% of those with chafing dermatitis compared to no S aureus in normals; (2) S aureus occurred in high numbers in every case of atopic dermatitis and was frequently found at much lower levels in psoriasis, seborrheic dermatitis, and chafing dermatitis; (3) Candida albicans occurred in 80% of cases clinically diagnosed as moniliasis localized to the diaper area and in 33% of those suspected of Candida infection with dissemination beyond the diaper area, while C albicans was found in only five of 145 culture sites in 40 normal infants.     

A newer approach in the treatment of seborrheic dermatitis with QR678® and QR678 Neo®—A prospective pilot study

Background

Seborrheic dermatitis is a common chronic inflammatory skin disorder that affects the scalp and is characterized by erythema and oily scales. It could perhaps be difficult to control and could seriously degrade one's quality of life. The study's objective is to assess the effectiveness of intradermal administrations of QR678 Neo® hair growth factor therapy for the treatment of scalp seborrheic dermatitis in both men and women.

Method

Forty male and female patients with clinically diagnosed seborrheic dermatitis of the scalp in the age 18–45 years, not satisfactorily responding to standard therapy for at least 6 months, were included. 1 mL solution of QR678 Neo® was administered in the scalp skin of all patients at 3-week interval till eight sessions. Patients were advised to continue with antifungal shampoo and topical antifungal solution with steroid combination which they had been on during the treatment. Assessment of disease severity, dermoscopic evaluation, and self-assessment were done at baseline and at the end of the fourth and the eighth sessions.

Results

Improvement was observed in adherent scalp flaking score after eighth session (mean = 12) compared to baseline (mean = 60). The dermoscopic evaluation showed a noticeable difference from baseline (mean = 11) in erythema and scaling with the Seborrheic Dermatitis Scalp Severity Index tool at the end of treatment (mean = 2). A high satisfaction score was given for the efficiency in the self-assessment questionnaire.

Conclusion

Our study proved that treatment with QR678 Neo® led to an improvement in the overall scalp condition by the resolution of flaking and inflammation.     

Urticarial vasculitis with blister formation: bullous (vesicular) urticarial vasculitis

A 37-year-old woman developed blistering on urticarial erythematous lesions. She had multiple joint pain, subfever, alopecia, high antinuclear factor, and hypocomplementemia. She was diagnosed as having SLE. Her SLE symptoms responded well to steroid therapy, whereas her urticarial lesions responded to DDS but not to steroid. Histology of her skin lesions resembled that of dermatitis herpetiformis. We suggested the term “bullous (Vesicular) urticarial vasculitis” to distinguish such a case with peculiar manifestations in urticarial vasculitis.     

Skin diseases in Greek and immigrant children in Athens

Objectives This study aimed to characterize the spectrum of skin diseases affecting children in Greece. Methods We retrospectively studied data for 4071 children, aged 0–12 years, who were examined and diagnosed with dermatoses at the outpatient clinic of a university dermatological hospital between December 2005 and August 2007. To evaluate changes in disease patterns, these data were compared with data for a cohort of 12,700 children diagnosed with skin diseases at the same clinic two to three decades earlier (in 1977, 1980, and 1983). Results The most frequent disease was dermatitis/eczema (34.7%), with atopic dermatitis found in 20.7% of children, contact dermatitis in 6.9%, pityriasis alba in 2.1%, and seborrheic dermatitis in 1.8%. Infections (19.3%), nevi (5.6%), scabies (4.8%), and insect bites (4.3%) followed. More viral (12%) than bacterial (3.7%) and fungal (3.6%) infections were noted. Warts constituted 53.2% of viral infections. Immigrants had an increased risk for bacterial infections and scabies. Conclusions Children diagnosed with skin diseases 24–30 years earlier were younger; exhibited lower prevalences of dermatitis/eczema (P = 0.01), viral infections (P < 0.001) and nevi (P < 0.001); higher prevalences of bacterial and fungal infections (P < 0.001) and insect bites (P < 0.01); and similar rates of scabies (P = 0.17). This study documents the high prevalence of atopic dermatitis in the region, the increasing incidence of viral infections and nevi, and the continuing problem of scabies, especially in immigrants.     

Adult-onset atopic dermatitis

Atopic dermatitis beginning in adult life is not mentioned in the medical literature. In a review of 2604 patients attending a contact dermatitis clinic, 243 patients (9%) were diagnosed with atopic dermatitis which began for the first time at 20 years of age or older with no contact factors present. This compares with 213 patients (8%) who had atopic dermatitis and contact dermatitis. Patients with purely atopic dermatitis had negative patch testing to relevant allergens and the diagnosis was based on a personal or family history of atopy as well as elevated IgE levels and multiple positive skin prick tests. A broad range of age of onset was found, as well as a female preponderance. The commonest sites of dermatitis were generalized involvement, dermatitis of the hands or eczema involving the face.     

Cutaneous reactions to surgical preparations and dressings

A prospective study of 100 surgical patients was undertaken to identify causes of contact dermatitis. Patch testing with the North American Contact Dermatitis Standard Series and additional agents used in the surgical preparation and dressing was performed in 11 patients with post-operative dermatitis or a history of tape allergy. 12 patients were diagnosed as having irritant (mechanical) contact dermatitis. One patient had allergic contact dermatitis to benzoin postoperatively; another patient with a history of an adhesive tape reaction had a positive patch test to thiuram mix, rubber accelerators formerly present in adhesive tapes. Our findings indicate that irritant contact dermatitis is a common problem in the surgical patient. Allergic contact dermatitis is less common, occurring in 2 of the 100 patients.     

The aetiology of eyelid dermatitis: a 10-year retrospective analysis

Few studies have examined the aetiology of eyelid dermatitis across broad demographics. The objectives of this study were (i) to compare the diagnoses of patients with isolated eyelid dermatitis to the diagnoses of patients with additional sites of involvement and (ii) to determine the relevant allergens among patients with allergic eyelid dermatitis. A retrospective analysis of 1215 patients patch tested over 10 years was conducted in this study. Compared to patients without eyelid dermatitis, patients with this entity were more often female. Of the 105 patients with eyelid dermatitis, 43.8% had allergic contact dermatitis (ACD), 36.2% seborrhoeic dermatitis, 11.4% other dermatitis/dermatoses, 7.6% irritant contact dermatitis, 3.8% psoriasis, and 2.9% atopic eczema. With isolated eyelid dermatitis, seborrhoeic dermatitis was the most frequent diagnosis (46.3%) followed by ACD (35.2%). Allergens commonly causing allergic eyelid dermatitis consisted of fragrances, metals, neomycin, oleamidopropyl dimethylamine, tosylamide formaldehyde resin, benzalkonium chloride, and other preservatives. When evaluated according to sites of involvement, seborrhoeic dermatitis was diagnosed most often in patients with isolated eyelid dermatitis, but when dermatitis was distributed to facial or other sites, ACD was the most frequent diagnosis. A majority of the causative allergens for eyelid dermatitis are not present on the Food and Drug Administration-approved panels available in the USA.     

Infantile Seborrheic Dermatitis: Seven-Year Follow-up and Some Prognostic Criteria

Based on clinical features, infantile seborrheic dermatitis (ISD) can be classified as follows: true seborrheic dermatitis (SD), psoriasiform seborrheic dermatitis (Psor SD), and erythrodermic seborrheic dermatitis. We reviewed the records of 72 children who had been affected by ISD several years earlier to investigate the evolution of disease, to evaluate the patients for the presence of new skin lesions, and to study family histories with respect to these conditions. In addition, we attempted to determine if there is any connection among the initial features of ISD and the types of skin lesions, and atopy or psoriasis. On reexamination, our patients previously diagnosed as having SD showed a larger variety of new skin lesions than those who had Psor SD, and 15% had developed atopic dermatitis. Atopic dermatitis was not present at follow-up in the children with previously diagnosed Psor SD. Psoriatic lesions were present in similar percentages in both groups at the time of reevaluation. Investigation of family history was not useful in predicting later development of psoriasis or atopic dermatitis. We conclude that the initial clinical features of ISD may be of prognostic value, and that SD and Psor SD are probably two different clinical entities.     

Suppressive effect of ultraviolet (UVB and PUVA) radiation on superantigen production by Staphylococcus aureus

It is well known that Staphylococcus aureus (S. aureus) proliferates on the moist skin lesion of atopic dermatitis. Reduction of bacteria colonization from skin lesions by antibiotics has been reported to be effective for the treatment of atopic dermatitis. S. aureus produces superantigens which can activate T cells and possibly enhance the inflammatory reaction. Photo(chemo)therapy has been successfully used for the treatment of severe cases of atopic dermatitis. We have previously reported that photo(chemo)therapy had bacteriostatic effect on S. aureus. Now we examined the effect of UVB and psoralen plus UVA (PUVA) on superantigen production from S. aureus. We isolated S. aureus from six atopic dermatitis patients. S. aureus was irradiated in vitro with UVB (0, 5, 10 mJ/cm²) or PUVA (0.001% psoralen plus 0, 5, 10 mJ/cm² UVA) and incubated 4 h with 100 strokes per min. After incubation, the amounts of superantigens in the supernatant were measured using ELISA kit. The production of superantigens decreased in an ultraviolet dose-dependent manner. The suppressive effects of UV radiation on superantigen production may be involved in the therapeutic efficacy of photo(chemo)therapy for atopic dermatitis.     

Bicentre experience in the treatment of severe generalised atopic dermatitis with extracorporeal photochemotherapy

Pilot studies have shown an improvement of atopic dermatitis in approximately 65% of patients during extracorporeal photopheresis (ExP) therapy. The purpose of the present clinical trial was to investigate the response to ExP by controlling clinical and laboratory parameters during short term ExP therapy in patients with severe generalised atopic dermatitis. Thirty-five patients with severe, therapy-resistant atopic dermatitis were treated with ExP in an open clinical trial at two week intervals over a period of 6 to 10 cycles. Disease activity was measured before each cycle by SCORAD index together with a standardized protocol for blood samples. ExP led to a significant decrease (p < 0.05) in SCORAD from 74.4 +/- 15.5 before to 36.8 +/- 16.8 after ExP therapy (mean 10 cycles). Approximately 70% (24/33 patients = responder) of patients had a favourable response to ExP requiring at least 6 cycles. The decrease in SCORAD was accompanied by a significant decrease of eosinophil cationic protein (27%), sE-selectin (37%) and sIL-2R (53%) levels in serum (p < 0.05). No significant correlation between a decrease in these levels and values of blood eosinophils or lymphocytes was found (p > 0.05). In comparison to responders, most non-responders were characterised by very high levels of total IgE before and during therapy (p < 0.05). The present clinical trial confirms that short term ExP is an effective treatment for certain patients with severe atopic dermatitis based on anti-inflammatory mechanisms. Total IgE could be a predictor of outcome in ExP treatment.     

Retrospective survey of patch testing at department of dermatology and venerology, zagreb university hospital center in zagreb, croatia

Epicutaneous (patch) test is a standard test to confirm contact allergy. During a six-year period (1998-2003), contact allergic dermatitis was diagnosed in 4132 (65%) of 6341 patients using standard patch test with a Croatian series of allergens according to the International Contact Dermatitis Research Group (ICDRG). The most common clinical diagnoses related to contact allergy (male; female) were contact allergic dermatitis (65.4%; 72.2%); atopic dermatitis (15.9%; 11.7%); contact irritant dermatitis (7.0%; 6.6%) and nummular eczematoid dermatitis (4.2%; 2.4%). According to occupation, positive patch test reaction was most commonly observed in workers, whereas 65% of patients showed positive reactions to one or more substances. There was an increased frequency of positive patch test reactions to potassium dichromate, nickel sulfate, thimerosal and neomycine sulfate, along with a significant decrease in the frequency of positive patch test reactions to cobalt chloride, carba mix, wood tars, detergents, parabens mixture, urushiol and rubber mixture. We strongly recommend keeping up-to-date with the epidemiology of contact allergy in Croatia.     

Discoid lupus erythematosus exacerbated by contact dermatitis caused by use of squaric acid dibutylester for topical immunotherapy in a patient with alopecia areata

A 57-year-old Japanese male patient with an 18-year history of discoid lupus erythematosus (DLE) presented with alopecia on his scalp, and was clinically diagnosed to have alopecia areata. He was started on topical immunotherapy with squaric acid dibutylester (SADBE) for the treatment of alopecia areata. The patient was first sensitized with the application of 2% SADBE on the right upper arm, followed subsequently by re-exposure to a low concentration of SADBE to provoke contact dermatitis on the scalp as treatment. Approximately 2 months later, he developed multiple red scaly lesions on his scalp and face, which were diagnosed histopathologically as DLE. DLE is known to be exacerbated by a variety of factors, including sunlight, X-rays, tattoos, burns, and some forms of cutaneous trauma, including dermatitis. However, to the best of our knowledge, there have only been two reported cases of DLE exacerbated by contact dermatitis.