Contact dermatitis from polyacrylate in TENS electrode

INTRODUCTION: Transcutaneous electric nerve stimulation (TENS) is useful for many chronic pains. It induces few serious side effects, but skin reactions are not rare. We report on two cases of contact dermatitis due to TENS electrodes by sensitization to the acrylate in TENS conductive gel. CASE REPORTS: A 50 year-old man suffered from post-traumatic lumbar pair. He developed eczematous lesions on the sites where the TENS electrodes were applied. Patch tests were positive with the TENS gel, with ethylene glycol dimethylacrylate (2 p. 100 petrolatum) and ethyl-acrylate (2 p. 100 petrolatum) on day 2 and 4 readings. A 54 Year-old man had a paralysis of the foot elevator following rupture of an aneurysm. After 2 months, he had an eczema on the sites where the TENS electrodes were applied. Patch tests were negative with the TENS electrodes but positive with 2-hydroxyethyl acrylate (0.1 p. 100 petrolatum), triethyleneglycol diacrylate (0.1 p. 100 petrolatum), 2-hydroxyethyl methacrylate (2 p. 100 petrolatum) and 2-hydroxypropyl methacrylate (2 p. 100 petrolatum) on day 2 and 4 readings. DISCUSSION: TENS transmits small electrical currents through the skin that induce the depolarization of the affected sensory nerve endings. They have few serious side effects but skin reactions such as irritation, burns or allergy to propylene glycol in the electrode gel, to the rubber of the electrodes (mercaptobenzothiazole) or to the metallic part of the electrodes, i.e. nickel, are not uncommon. To our knowledge, only one case of an allergy to the polyacrylates of TENS electrode gel has been previously reported in the literature. We emphasize that acrylate could be the main sensitizer in the more recently commercialized TENS electrodes and will propose alternative ways of treating patients sensitized to acrylate and who require treatment with TENS.     

Cutaneous delayed hypersensitivity reactions to heparins and heparinoids

INTRODUCTION: Due to cross-reactions between unfractionated heparins, low-molecular-weight heparins and sometimes heparinoids, cutaneous delayed hypersensitivity reactions might be a problem for the choice of therapeutic alternative. We report on two cases of sensitization to heparins and heparinoids. OBSERVATIONS: One woman developed localized skin reaction to a low-molecular-weight heparin, then a generalized maculopapular rash when an intravenous injection of unfractionated heparins was performed. The second patient had a localized then extended reaction to a low-molecular-weight heparin and was referred for the choice of a well tolerated method to obtain anticoagulation during a pulmonary surgery. METHODS: Patch tests, prick tests, intradermal and subcutaneous tests were performed with several unfractionated heparins, low-molecular-weight heparins, danaparoid and lepirudin in both cases. RESULTS: In the first case, tests performed with both heparins and heparinoid were positive and the use of lepirudin was proposed if anticoagulation was necessary. In the second case the subcutaneous danaparoid injection induced a localized reaction on the injection site. Danaparoid injections were continued associated with localized applications of dermocorticoids without any side effect. DISCUSSION: Cutaneous delayed hypersensitivity reactions occur on the injection site but can also be generalised. Cross reactions might be unexpected therefore skin-tests are necessary to guide the choice of a therapeutic alternative. In case of intolerance to both heparins and heparinoids various solutions may be proposed such as the application of topical corticosteroids on the injection site or the administration of hirudins. There is no cross sensitization between heparins and hirudins, but the use of hirudins is restricted and requires specific monitoring.     

Ultra-late metastasis of melanoma with secondary dissemination along the venous stripping line

BACKGROUND: A woman was cured of a melanoma of the leg. She presented an ultra late recurrence 17 years later, then rapid and extensive recurrence immediately after venous stripping. CASE REPORT: In 1977, a 38-year-old woman was operated for a SSM melanoma of the calf. She was then given chemotherapy and BCGtherapy for 2 years. In 1994, she presented a nodular recurrence which was treated surgically. In March 1997, she underwent a stripping of the leg. One month later, a nodular recurrence was discovered along the stripping line. DISCUSSION: The ultra late recurrence (> 15 years) in this case is highly exceptional and, to our knowledge, this is the first case of a recurrence along a vascular course. We discuss metastatic dissemination of SSM melanoma and the role played by stripping in this case of recurrence.     

Contact dermatitis due to ethyl alcohol: how to perform patch tests?

INTRODUCTION: Ethyl alcohol sensitization is rare and can induce immediate contact urticaria or delayed eczema. Patch tests performed with ethanol can provoke an irritative reaction and are not well codified. CASE-REPORTS: We report on 4 cases of contact dermatitis due to alcohol in 4 women. Eczema was due to alcohol contained in the reservoir of a transdermal transfer system with estrogens in 2 cases and related to the application of alcoholized antiseptic lotions in the other 2 cases. In 2/4 cases we observed a co-sensitization with corticosteroids. METHODS: Patch tests were performed with alcohol at 95 degrees diluted at 70 p. 100 and at 10 p. 100 in water and read after 20 minutes then on day 2 and day 4. RESULTS: Positive results were obtained in 4/4 cases when alcohol was tested diluted at 70 p. 100 in water and in 3/4 cases when diluted at 10 p. 100 in water. No irritant reaction was observed in 140 negative controls. DISCUSSION: Immediate after 20 minutes and delayed readings of patch tests performed with ethyl alcohol diluted at 70 p. 100 seem to be convenient in diagnosing cutaneous delayed hypersensitivity to alcohol. Co-sensitization between corticosteroids and alcohol could be due to an aldehyde deshydrogenase deficiency.     

Radiodermatitis afer heart catheterization

INCREASING INCIDENCE: The development of new interventional techniques in radiology, particularly angioplasty of the coronary arteries, has lead to a rise in the incidence of radioderimitis. Clinical presentations vary from skin rash to necrosis and chronic ulceration. Telangiectasic atrophy and poikilodermitis are also observed. CASE REPORTS IN THE LITERATURE: Twenty-three cases of radiodermitis after cardiac catheterism have been reported in the literature. Mean delay to onset after the first radiology examination varies from 15 days to 10 years. TO REDUCE THE RISK: The main risk factor is a long duration of scopy using the same incidence. Use of older non-digitalized radiology machines also increases the risk. Physicians performing endovascular procedures should be aware of the risk of radiodermitis after angioplasy and implement radioprotective measures. RETROSPECTIVE DIAGNOSIS: Patients who develop localized pigmentation disorders and/or telangiectasies should be questioned concerning prior, often forgotten, radiology examinations.     

Sensitization to resorcinol in a prescription verrucide preparation: unusual systemic clinical features and prevalence]

BACKGROUND: Resorcinol is a rare sensitizer. In Lorraine, where it is used in high concentrations in an anti-wart ointment, this molecule has induced many cases of allergy. The purpose of this study was to describe clinical features in patients sensitized to resorcinol, to determine the incidence of sensitization in Lorraine and ascertain the occurrence of cross reactions with other phenolic pro-haptens.PATIENTS AND METHODS: The files of all patients sensitized to resorcinol were studied from 1992 to 1999. Over a 20-month period, 983 consecutive patients underwent our standard patch tests where we included resorcinol (1 p. 100 in petrolatum). Co-sensitization with other pro-haptens was studied in all sensitized patients.RESULTS: Sensitization to resorcinol was observed in 0.5 p. 100 of the 983 consecutively tested patients. Contact sensitization was found in 24 patients, who all but one had previously used the anti-wart ointment containing resorcinol. All developed contact eczema on the site of application of the ointment, with generalized urticaria (4 cases), pompholyx (1 case), and generalized papulo-vesicular rash with pompholyx (6 cases). Positive patch tests were observed with resorcinol monobenzoate (15/19 cases), pyrocatechol (7/14 cases), pyrogallol (9/19 cases), salicylaldehyde (2/17 cases), and hydroquinone (6/17 cases). Negative patch tests were observed with phenysalicylate, hexylresorcinol, or fluoresceine.CONCLUSION: Resorcinol should not be applied in high concentrations as it can provoke generalized sensitization and co-sensitization with other pro-haptens.     

The use of skin testing in the investigation of cutaneous adverse drug reactions

Skin testing with the suspected compound has been reported to be helpful in determining the cause of cutaneous adverse drug reactions (ADRs), but the value and specificity of these tests need to be determined. In this study, 72 patients with presumed drug eruptions (27 maculopapular, 18 urticarial, seven erythrodermic, nine eczematous, four photosensitivity, three fixed drug eruptions, three with pruritus and one with acute generalized exanthematous pustulosis) were assessed. All had drug patch tests; 46 also had prick tests and 30 had intradermal tests (performed on hospitalized patients using a sterile solution of the suspected drug, diluted sequentially) with immediate and delayed readings. Among these patients, 52 (72%) had a positive skin test reaction, 43%, 24% and 67% in patch, prick and intradermal skin tests, respectively. The results of skin tests varied with the drug tested and with the clinical type of cutaneous ADR, as a significantly higher number of positive patch tests was observed in maculopapular rashes than in urticarial reactions ( P =  0.001). This study supports the value of careful sequential drug skin testing in establishing the cause of cutaneous ADR. Guidelines are proposed for performing these tests, and these include the use of appropriate negative control patients to avoid false-positive results.     

An unusual form of Stevens-Johnson syndrome with subcorneal pustules associated with Mycoplasma pneumoniae infection

We report a 10-year-old girl in whom Stevens-Johnson syndrome (SJS) (with acute gingivostomatitis and conjunctivitis) was associated with a pustular eruption clinically and histologically similar to Sneddon-Wilkinson subcorneal pustulosis. This is a very rare form of SJS, the true incidence of which is probably underestimated.