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2000 Abstracts

March 9, 2000 Meeting Abstracts

Following are the abstract presentations from the 11th Annual Meeting of the American Dermatitis Society, held on March 9, 2000 in San Francisco. Congratulation the award recipients under the Awards and Grants page.

Table of Contents

M. Al-Ghareeb An Unusual Explanation for "Angry Back"
M. Khanna Contact Sensitization to Tea Tree Oil with Erythema
Multiforme -Like ID-Reaction
A. Ehrlich Metal Allergies- The Role of Body Piercing
H. Majamaa Patch Testing Enhances Identification of Cereal Allergy in Infants
H. Loffler Evaluation of Irritant Skin Reactions in Mice Ears
I. Al-Aradi An Interesting Case of Allergic Contact Dermatitis to a
Prosthetic Limb
B. Andrea Delayed Type Hypersensitivity in Patients with Anogenital Complaints
J. Moore Patch Testing Practices: ACDS Members
L. Horev Gold Allergy in Israeli Contact Dermatitis Patients
L. A. Scalf Dental Metal Allergy in Subjects with Oral, Cutaneous, and Genital Lichenoid Reactions
T. N. Salam Balsam-Related Systemic Contact Dermatitis
M. Saxena Eyelid Allergic Contact Dermatitis (ACD) to Black Iron Oxide
C. Zachariae Cucumber Contact Dermatitis
S. Beck Plant and Pesticide Allergens in a Photopatch Testing Series
S. L. Jacobs Use of Topical Tacrolimus in Chronic Actinic Dermatitis
M. L. Bennett Contact Allergy to Corticosteroids in Patients Who Have Used Inhaled or Intranasal Corticosteroids
L. Kanerva Occupational Allergic Contact Dermatitis from Preimpregnated Epoxy Products (Prepregs)
L. Kanerva Nickel, Cobalt, Chromium, Lead and Aresenic in Eye-Shadows
M. C. Pires Actinic Reticuloid
R. Quinby Sensible Formulations of Sensitive Skin Products
M. C. Thelmo Effect of Potassium Hydroxide and Trichloroacetic Acid Induced Skin Irritation on In Vitro Percutaneous Penetration of Estradiol
J. M. Fernandez-
Reliability of T.R.U.E. Test
S. J. Bashir Barrier Disruption By Three Commercial Adhesive Tapes: A Difference
J. S. Taylor Donald J. Birmingham and Occupational Dermatology in the U.S. Public Health Service
P. Elsner The Occupational Skin Disease Prevention Project in the Food Processing Industry
R. Wolford Efficacy of Buffering Solution as a Protectant for Workers Using Alkalies
P. Susitaival Occupational Skin Diseases in Finnish Dental Nurses
D. V. Belsito ACD to Glutaraldehyde in Health Care Workers
L. Kanerva Permeation of Methacrylates (2-HEMA, TREGDMA) Through Disposable Protective Gloves
K. E. Andersen Immersion Oil Contact Allergy, An Unsuspected Source of Epoxy Allergy
K. E. Andersen Time/Dose Relationships in Elicitation of Isoeugenol Contact Allergy
E. Warshaw U.S. Dermatologists' Approach to Patch Testing 22
J. G. Marks, Jr. North American Contact Dermatitis Group Patch Test Results 1996-1998
C. M. Mowad Is Routine Testing for Primula Obconica Useful in the United States
P. D. Shenefelt Relevance of the Pareto Principle, Lorenz Curves, and Gini Coefficients to Patch Testing
J. A. Yiannias A New Method to Facilitate Successful Antigen Avoidance: Database Generated Guide of Skin Care Products Free of the Patient's Allergens
B. Bjarnason Pigment of Patch-Test Substances May Mask Detection of Perfusion and Affect Perfusion Assessments Made with the Laser Doppler Imaging Technique (LDIT)
E. M. Jackson Pediculicide Contact Dermatitis
M. Isaksson Stability of Corticosteroid Patch Test Preparations
T. Agner Allergic Contact Dermatitis from IPBC
D. Sasseville Brominated Swimming Pool Water: Chlorine-Sensitive BEWARE!
S. Nedorost Urticarial and Eczematous Reaction to Benzophenone in
Finished Plastic
R. L. Nixon Hazardous Holidays-Severe Allergic Contact Dermatitis from Paint-on Tattoos in Bali
M. S. Chapman Chemical Leukoderma Due to Buspirone Patches
M. J. Rapaport Steroid Addiction-Steroid Withdrawal Syndrome

An Unusual Explanation for "Angry Back"
Meshal Al-Ghareeb, M.D.
March 9 - 8:10 am


Dr. Meshal AI-Ghareeb and Dr. Melanie Pratt Ottawa Hospital - University of Ottawa, Canada

Objective: To clarify the cause of multiple positive patch test reactions.

Methods: We present the very unusual case of a 72 year old woman who originally presented with an acute eczematous dermatitis after wearing various brands of support stockings. Past treatments for her venous stasis dermatitis included a Unna boot, duoderm regular, topical antibiotic and corticosteroid creams as well as OTC products.

A. In July, 1999, she was originally patch tested using Finn Chambers to:

1. NACDG Standard Series
2. Medicament Series

Results 96 hrs: revealed strong positives at all patch test sites

B. In October 1999, re-patch tested to NACDG Standard Series

- open aluminium chloride hexahydrate 2% pet

Results 96 hrs: revealed all sites very positive and blank sites reacted most strongly. Aluminium chloride hexahydrate 2% pet = 3+

C. To be retested in January 2000 using plastics disc. Results will be discussed.

Conclusion: Although rare, aluminium ACD does exist and can be the cause of a false 'Angry Back". The clinical differences are outlined.

Contact Sensitization to Tea Tree Oil with Erythema Multiform-Like ID-Reaction
Manish Khanna, M.D.
March 9 - 8:20 am


Manish Khanna, MD, Kholoud Qasem, MD and Denis Sasseville, MD. Royal Victoria Hospital, Montreal, QC, CANADA

Objective: To describe the progression of an acute allergic contact dermatitis caused by the topical use of tea tree oil into a widespread id-reaction with features of erythema multiforme.

Case report: A 46-year-old man applied pure tea tree oil ("T36-C7" Melaleuca Inc.) to a superficial abrasion on his left leg. Within a few days, the treated area became red and itchy. Applications of tea tree oil were stopped but the eruption became generalized, with urticarial plaques and atypical targets. A skin biopsy from a target-like lesion showed a spongiotic dermatitis. The patient then developed a dermatitis under the Elastoplast(R) dressing used on the biopsy site. The lesions cleared with oral prednisone.

Five months later, patch tests were done with the North American standard series, tea tree oil, abitol, abietic acid and turpentine peroxides (Chemotechnique, Malmo Sweden). The patient was also tested to a drop of his own, old tea tree oil. At day 4, the patient reacted to both tea tree oil samples, with a stronger reaction to his own than to the fresh preparation. Positive reactions to colophony, abitol and Balsam of Peru were also noted.

Conclusion: Erythema multiforme (EM) secondary to allergic contact dermatitis is a rare but well characterized phenomenon. Strong allergens such as poison ivy, exotic woods, Primula obconica, sesquiterpene lactones, epoxy resin, topical antibiotics have triggered this reaction, which may appear together with or after the initial dermatitis. Urticarial plaques, classic or atypical targets, bullae and purpura appear near the site of the dermatitis, then spread at a distance. A skin biopsy may show classic EM with vacuolation of the basal layer and necrotic keratinocytes, or an eczematous, spongiotic dermatitis, as in our case.

Other interesting features of our case include: a) concomitant positive reactions to colophony, abitol, and Balsam of Peru, which probably share mono-, di- and sesquiterpenes with tea tree oil, and, b) a stronger reaction to oxidized than to fresh tea tree oil, in accordance with Hausen et al.

Metal Allergies- The Role of Body Piercing
Alison Ehrfich, M.D.
March 9 - 8:30 am


Alison Ehrlich, M.D., Michael Kucenic, M.D., and Donald V. Belsito, M.D., Dermatology, University of Kansas Medical Center, Kansas City, Kansas 66160

Metal allergies have been epidemiologically linked to body piercing, hence the greater prevalence in females. We sought (1) to determine the incidence of metal allergies in males with (n=100) and without (n=50) piercing; (2) to assess whether the incidence of metal allergies differs between males with one site (n=50) versus multiple sites (n=50) pierced; and, (3) to evaluate the coreactivity between Nickel/Cobalt and Nickel/PaIladium.

To date, 108 males ranging from 18-43 years (mean 25.1 years) have been patch tested to: cobalt chloride 1%, nickel sulfate 2.5%, gold sodium thiosulfate 0.5%, and palladium chloride 1% utilizing the standard NACDG protocol. 2 of 45 non-pierced males (4.4%) had at least one positive patch test reaction; 2 of 25 (8.0%) "one site pierced" males had at least one positive reaction; and 5 of 38 (13.5%) "multi-site pierced" males had at least one positive reaction. This data suggest that body piercing may increase the incidence of metal allergy in males. There is a trend in the predicted direction [linear X2(1), p=0.078].

Allergic reactions were noted to gold (3 subjects), nickel (6 subjects), cobalt (4 subjects), and palladium (1 subject). 4 of 6 Ni allergic patients also were Co allergic. There were no Ni/Pd coreactions, although one subject did react only to Pd.

Patch Testing Enhances Identification of Cereal Allergy in
Heli Majamaa, M.D.
March 9 - 8:40 am


Maiamaa Heli1 Holm Kati2 Turjanmaa Kristiina1
Departments of Dermatology1 and Paediatrics2, Tampere University Hospital, Tampere, Finland

Objective: To study the relevance of patch testing, skin prick tests and the concentration of wheat-specific IgE antibodies in relation to oral wheat challenge in infants with suspected wheat allergy. Specifically we aimed to determine whether patch testing could enhance the diagnostic accuracy in detecting wheat allergy.

Methods: The study material comprised 39 infants under 2 years of age. The patients were subjected to wheat challenge. Wheat-specific IgE was measured, and skin prick and patch tests were performed.

Results: Of the 39 wheat challenges, 22 (56%) were positive. Of the positive reactions, 5 involved immediate-type skin reactions and in 17 patients, delayed-onset reactions of eczematous or gastrointestinal type appeared. Of the infants with challenge-proven wheat allergy, 20% showed elevated IgE concentrations to wheat, 23% had a positive skin prick test and 86% had a positive patch test for wheat.

Conclusion: Our study demonstrated that patch testing with cereals will significantly increase the probability of early detection of cereal allergy in infants with atopic eczema.

Evaluation of Irritant Skin Reactions in Mice Ears
Harald Loffler, M.D.
March 9 - 8:50 am


Loffler, Harald; Effendy, Isaak
Dept. of Dermatology, Phillipp-University of Marburg, Germany

Objective: The ear swelling technique is the standard method for evaluating allergic skin reaction in mice. However, in experimental irritant contact dermatitis, the epidermal barrier disruption, which represents a predominant effect of irritants, cannot be assayed by this method. An appropriate method to evaluate the barrier disruption is the measurement of transepidermal water loss (TEWL) but this was so far only possible on the trunk of nude or shaved mice. We therefore developed a new technique to measure the TEWL of mice ears (murine auricular TEWL: MATEWL).

Material and Methods: We lengthened the cylinder of an evaporimeter probe, so that we could place a whole ear of a mice in the cylinder. We measured the TEWL of a whole ear before and after application of an irritant (sodium lauryl sulphate, SLS) and an contact allergen (2,4-dinitro-flurobenzene, DNFB). We compared the results with the measurement of ear swelling.

Results: The ear thickness was remarkably higher (three to five times higher) in DNFB than in SLS treated ears. The increase of MATEWL, however, was three times higher in SLS than in DNFB treated ears.

Conclusion: We conclude that for the evaluation of irritant induced epidermal barrier disruption in mice, MATEWL measurement provides a novel approach that is superior to the ear swelling method.

An Interesting Case of Allergic Contact Dermatitis to a
Prosthetic Limb
Ibrahim Al-Aradi, M.D.
March 9 - 9:00 am


Dr. Ibrahim Al-Radi and Dr. Melanie Pratt

Objective: To find possible sources of contact allergy and irritancy in this patient with a prosthetic limb.

Method: We present a case of an 87 year old gentleman with a congenital birth defect of the right leg which necessitated an amputation in February, 1999. The patient had three successive prosthesis over 10 months to which he developed an eczematous dermatitis and secondary infection. Treatment included betamethasone valerate cream, bactroban, uremol HC, myclo cream, halog unq. and oral cipro.
He was patch tested November, 1999 to:

1. NACDG Standard Series
2. Plastic and Glue Series
3. Steroid Series
4. Own topical medicaments

Results at 96 hrs:

1+ = imidazolidinyl urea
2+ = diazolidinyl urea
3+ + paratertiarybutyl phenol formaldehyde resin
3+ = uremol HC cream
1 + = fragrance
1 + = balsam of Peru

Dec/99 - The patient was patch tested to own components of all prosthesis past, present and future. (12 things)

Results 96 hrs:

1+"Quick Sil" = (silicone material)
2+ "resin" (impregnated with nylon and fiberglass)
3+ fitting putty made of silicone used to shape stump
1+ duraplex (a plastic material)

Conclusions: The patent had a combination of allergic and irritant contact dermatitis plus infection to account for his stump problems. The relevance and sources of these positive allergens are discussed and alternatives are suggested.

Delayed Type Hypersensitivity in Patients with Anogenital
Bauer Andrea, M.D.
March 9 - 9:10 am


Bauer Andrea, MD, Elsner Peter, MD
Department of Dermatology, Friedrich-Schiller-University Jena Allergic contact dermatitis is common in the anogenital area. The results of patch testing performed in 1008 patients, evaluated for allergic anogenital contact dermatitis from 21 dermatological departments of the Information Network of Departments of Dermatology (IVDK), from 1992 to 1997 were analysed.

The final diagnosis of allergic contact dermatitis was made in 351 patients (34.8%). The allergen spectrum of patients with anogenital complaints resembles that of all patients (n=54.000) tested from 1992 to 1997. However, it is remarkable that dibucaine HCI ranks fourth among contact allergens in the study population. Positive reactions to chloromethylisothazolinone (CMI/Ml) and to benzocaine --were observed more frequently among patients with anogenital complaints compared to the total IVDK population (3.7% vs. 2.5% and 2.7% vs 1.5 %). In general active agents of topical medicaments and popular remedies, preservatives, and ointment bases appeared to cause allergic reactions most frequently.

As a consequence of our analysis, we recommend for patch testing in patients with anogenital eczema to use the standard series, dibucaine HCI, propolis, bufexamac, and further ingredients of topical preparations according to the patient's history.

Patch Testing Practices: ACDS Members
Jane Moore, M.D.
March 9 - 9:20 am


Jane Moore, MD, and Erin Warshaw, MD, University of Minnesota, VAMC, Minneapolis, MN

The objective of this study was to evaluate patch testing practices of American Contact Dermatitis Society (ACDS) members. An independent, voluntary, nonproprietary questionnaire was sent to all 322 ACDS members. Returned questionnaires (46%) were computer scanned and analyzed. The majority of respondents were male (61 %) and had practiced for 11 -20 years (35%) in a Northeast U.S. (22%) private practice (36%). Most patch tested 6-10 patients monthly (30%). Twenty-two percent of responders used TRUE Test, most commonly because it was less time-consuming (37%). Most (35%) applied an average of 26-50 patches and 96% applied personal items. The most prevalent patch test reading schedule was 48, 96 hours (51 %) although 14% performed only one reading at either 48 or 72 hours. The most common "standard" trays utilized were European standard (26%) and TRUE Test (27%). Sixty-five percent of respondents photopatch tested. Seventy percent evaluated patients for latex allergy, and 39% performed latex prick testing. Cosmetic allergy was the most common (39%) subspecialty interest. Sixty percent stated they were not satisfied with reimbursements. This study was supported by the Minneapolis Veterans Affairs Medical Center.

Gold Allergy in Israeli Contact Dermatitis Patients
Liran Horev, M.D.
March 9 - 9:30 am


Liran Horev1, Francis Afflo1, Abraham Zlotogorski1, Shabtay Dikstein2 and Arieh Ingham1.
1Department of Dermatology, Hadassah University Hospital, Jerusalem, Israel.
2 School of Pharmacy, Unit of Cell Pharmacology, Hebrew University, Jerusalem, Israel.

Background: Gold allergy is a controversial subject. Given the high frequency of usage of gold in jewelry and in dentistry and in implants there are surprisingly fewer than expected reports of gold allergy. The relevance of positive patch tests reactions to gold, is also not always clear.

Objective: The purpose of this study was to elucidate the frequency of positive reactions to gold in patch tests among Israeli contact dermatitis patients and its clinical relevance.

Method: Gold sodium thiosulfate 0.5% in pet. Was included in our standard patch test series and applied on the backs of 150 consecutive contact dermatitis patients. The tests were evaluated in accordance with the ICDRG guidelines at day 2 and 4. A questionnaire on gold exposure and gold sensitivity was answered by all the 150 tested patients.

Results: A positive reactions to gold was found in 12 patients (8.0%) of the tested patients. None of the patients received gold therapy. 56 out of 150 patients (37.3%) responded that their ears were pierced. Of these 8 (14.3%) had positive reaction to gold. 69 of 150 patients (46%) had had direct skin contact with gold but only 13 (18.8%) had had skin symptoms on contact with gold . 10 of 150 (6.7%) thought they were hypersensitive to gold. Only 13 (18.8%) had dental gold , 8 (5.3%) had oral symptoms.

Conclusion: In routine patch tests of Israeli Contact dermatitis patients the frequency of positive reactions to gold is relatively high. The relevance is low except for ear piercing.

Dental Metal Allergy in Subjects with Oral, Cutaneous, and Genital Lichenoid Reactions
Leigh Ann Scalf, B.S.
March 9 - 9:40 am


Joseph F. Fowler, Jr., M.D., Leigh Ann Scalf, B.S., Kelli W. Morgan, M.D., Stephen W. Looney, Ph.D; Division of Dermatology and Department of Family and Community Medicine, University of Louisville, Kentucky Background: The subject of lichen planus (LP) and dental metal allergy has long been debated. An overwhelming majority of the existing literature focuses on mercury and gold salts in relation to oral lichen planus. Objective: Our objective was to expand current knowledge regarding LP and lichenoid lesions (at) and dental metal allergy (1) by investigating more dental metals, and (2) by investigating cutaneous and genital disease in addition to oral disease. Methods: Fifty-one patients with known LP or LL were patch tested to a series of dental metals. Results: Thirty-eight of 51 patients (74.51%) had at least one positive reaction. Twenty-five of 51 patients (49.0%) showed sensitivity to at least one mercurial allergen. Prevalence data for patients patch tested by the North American Contact Dermatitis Group (NACDG) from 1994-1996 was available for: chromate, cobalt, nickel, and thimerosal. The prevalence of positive reactions was higher in our group than in the NACDG group for all four of these allergens and statistical significance was achieved for chromate (p = 0.007) and thimerosal (p = 0.004). Conclusion: Sensitization to dental metals is more common among LP and LL patients than in routinely tested patients, and may be an etiologic or triggering factor in oral, cutaneous and genital LP and LL.

Balsam-Related Systemic Contact Dermatitis
Tamara N. Salam, M.D.
March 9 - 9:50 am


Tamara N. Salam, MD; Joseph F. Fowler, Jr., MD
University of Louisville, Division of Dermatology, Louisville, KY

Background. Positive patch tests to balsam of Peru (BOP) or fragrance mix (FM) may suggest the possibility of systemic contact dermatitis from balsam-related foods and spices.

Objective: A retrospective study to determine if avoidance of balsam-related foods results in an improvement of dermatitis in these patients.

Methods. A review of the records of all patients seen from July 1st to December 31st, 1998 with positive patch tests to BOP, FM, cinnamic aldehyde, and/or balsam of tolu was performed 9 to 14 months after their evaluation in a tertiary dermatology center. All patients were contacted via telephone to assess the status of their dermatitis and if they were able to note any specific balsam-related food allergies.

Results: 75 patients were identified, and 71 could be contacted. Fourteen were only allergic to BOP and/or FM on testing; 31 were positive to BOP/FM and other allergens with presumed relevance to BOP/FM; 26 were positive to BOP/FM and others with other allergens felt to be responsible for the dermatitis and were not placed on a BOP diet. Excluding this last group, 21 of 45 (47%) had complete or significant improvement that they related to dietary modification. 10 did not modify their diet with 8 reporting no improvement. 8 improved with fragrance or other allergen avoidance only, and 6 modified their diet unsuccessfully. Most commonly implicated foods include tomatoes, citrus, and spices.

Conclusion: Almost half of subjects with positive patch tests to BOP and/or FM, who followed a BOP reduction diet, reported complete/significant improvement of their dermatitis.

Eyelid Allergic Contact Dermatitis (ACD) to Black Iron
Malinee Saxena, M.D.
March 9 - 10:00 am


Saxena.Malinee, University of Minnesota, Minneapolis, MN; Warshaw, Erin, VA Medical Center; Ahmed, Debra, Mayo Medical Center, Rochester, MN

Eye cosmetics contain a variety of pigments, fragrances, resins, preservatives and vehicles. Mascara is one of the most commonly used eye cosmetics and can cause irritant and allergic eyelid dermatitis.

We present a case of eyelid ACD to black iron oxide. A 44-year-old woman presented with a 10-month history of periorbital and eyelid dermatitis while using eye cosmetics from a specific manufacturer. In spite of transient response to prednisone and topical steroids, the eruption persisted. Epicutaneous patch testing to T.R.U.E. Test, cosmetic, preservative, vehicle and steroid series, and personal products yielded a marked reaction to her black mascara. Subsequent patch testing to the mascara components provided by the manufacturer revealed a severe reaction only to 5% black iron oxide. This black iron oxide was further tested on 10 normal controls with no reactions.

There is one previous report of ACD to iron oxide, also presenting as eyelid dermatitis and found in eye cosmetics. In summary, iron oxide should be considered an uncommon yet potentially important allergen related to cosmetic eyelid ACD.

Cucumber Contact Dermatitis
Claus Zachariae, M.D.
March 9 - 10:10 am


Claus Zachariae, Department of Dermatology, Gentofte Hospital, University of Copenhagen, Niels Andersen's Vej 65, DK-2900 Hellerup, Denmark.

Cucumber seldom causes allergic reactions. So far only oral contact urticaria, stornatitis and food allergy have been described. Cucumber has not been reported to cause delayed hypersensitivity reactions. We will here present a case of possible allergic contact dermatitis to cucumber in a greenhouse worker.

Cucumber (cucurnis sativus) belongs to a family of cucurbitaceae vegetables also including watermelon and melon. As well as causing irritant reactions they can all cause type I allergies especially amongst catering workers. Irritant hairs on the surface of the plants enhance the penetration of the antigen in to the skin.

A 42-year-old male greenhouse worker was referred to our department as he had developed a severe eczematous reaction localized to the forearms, the lower extremities and to a lesser degree the back. The first symptoms came approximately 5 month after he had started working as a greenhouse farmer. His job consisted of planting and pruning cucumber plants as well as plucking cucumbers. His eczema was clearly work related as it started clearing during the weekends. Patch test showed a ++ reaction at 3 and 7 days towards Formaldehyde, a ++ reaction at 2,3 and 7 days towards dibrorndicyanobutane and a ++ reaction at 2,3 and 7 days towards cucumber leaf as well as a + reaction at day 7 towards cucumber stem.

Plant and Pesticide Allergens in a Photopatch Testing Series
Samuel Beck, MD
March 9 - 10:20 am - 10:45 am


Beck, Samuel MD; Cohen, David E. MD, MPH; Soter, Nicholas A. MD.
The Ronald 0. Perelman Department of Dermatology, New York University School of Medicine, New York, NY.

Sunscreens, fragrances and biocides have classically been described as allergens responsible for photo-allergic dermatitis. Reports of newer photoallergens not included in standard allergen series have been described.

The purpose of this study is to evaluate the change in the etiology of photo-allergic dermatitis over a thirteen year period, from 1986-1999. The impact of including plant and pesticide allergens on the overall epidemiology of photo-allergic dermatitis is described.

The results of photo-patch testing between December 1993 and December 1999 were compared to those tested between June 1986 and October 1993.

Between 1993 and 1999, 33 patents were photo-patch tested with the WU Skin and Cancer Unit's standard photo-allergen series, which included plant and pesticide allergens. Thirteen patients had positive tests, accounting for 37 positive photo-patch test reactions. Fifteen (41%) positive tests were to sunscreens, 5 (13.5%) to fragrances, 8 (22%) to therapeutic agents, 6 (16%) to plants, and 3 (8%) to pesticides. Between 1986 and 1993, 138 patients were photo-patch tested. Fifty-three patients tested positive accounting for 77 positive photo-patch test reactions. Forty-four (57%) positive tests were to sunscreens, 14 (18%) to fragrances, 10 (13%) to therapeutic agents and 9 (120/6) to other agents.

The results indicate that plant and pesticide allergens account for a substantial proportion of positive photo-patch tests and should be included in a standard photo-patch test allergen series. It appears that such an inclusion may increase the sensitivity of photo-patch testing in those suspected of having photo-allergic contact dermatitis. The inclusion of plants and pesticides increases the positive yield of photo-patch testing.

Use of Topical Tacrolimus in Chronic Actinic Dermatitis
Stacy L. Jacobs, MD
March 9 - 10:20 am - 10:45 am


Stacy L. Jacobs and David E. Cohen, M.D., MPH , Department of Dermatology New York University Medical Center, New York, NY

A case of chronic actinic dermatitis in a 70 year old is reported. He had a a two-year history of generalized pruritic eruption on his head, neck, trunk and extremities. Treatment with systemic corticosteroids resulted in transient improvement while treatment with plaquenil and topical and intralesional steroids provided no relief. Use of topical tacrolimus resulted in a marked decrease in erythematous lichenified hyperpigmented plaques on sun-exposed areas. Phototests showed a reduced minimal erythema dose response to UVA, a normal minimal erythema dose to UVB, and no response to visible light. Photopatch tests were negative with negative corresponding non-irradiated patch test sites.

Contact Allergy to Corticosteroids in Patients Who Have
Used Inhaled or Intranasal Corticosteroids
Michelle L. Bennett, MD
March 9 - 10:20 am - 10:45 am


Michelle L. Bennett, M.D. and Elizabeth F. Sherertz, M.D. Wake Forest University/Baptist Medical Center Winston-Salem, NC, USA

The purpose of this investigation is to determine if skin allergy to corticosteroids is a common occurrence in patients with allergic rhinitis or asthma who use inhaled or intranasal corticosteroids. Several case reports describe this phenomenon, but no controlled epicutaneous patch test study has been performed to determine the prevalence of corticosteroid allergy.

Evaluation of thirty subjects with asthma or allergic rhinitis will include pertinent history and physical examination as well as patch testing using all available inhaled and intranasal corticosteroid preparations as well as four common screening steroids, the vehicle propylene glycol and the preservative benzalkonium chloride.

We will report our findings, including the percentage of subjects with positive patch test results, providing information as to the prevalence of corticosteroid allergy in this patient population. A literature review will also be performed, and prior case reports as well as studies using intradermal testing will be summarized.

Via this descriptive pilot study, we expect to demonstrate that contact allergy to corticosteroids in intranasal and inhaled preparations is an uncommon occurrence.

Occupational Allergic Contact Dermatitis from
Preimpregnated Epoxy Products (Prepregs)
Lasse Kanerva, MD
March 9 - 10:20 am - 10:45 am


Kanerva L, Estlander T, Jolanki R, Henriks-Eckerman M-L, Tarvainen K. Finnish Institute of Occupational Health, Helsinki, Finland
Objective: To describe a patient with occupational allergic contact dermatitis from preimpregnated epoxy products (prepregs).
Case Report and Methods: The patient was a 30-year-old laminator in an aircraft plant. He assembled aircraft parts and was occupationally exposed to preimpregnated carbon fiber and fiberglass sheets (prepregs) and epoxy tapes. Standard epoxy (DGEBA-ER) provoked a -+ patch test reaction. In the next patch test session triglycidyl-paminophenol (TGPAP; 1%-0.25%, 2+; 0.05%, 1+) and tetraglycidyl-4,4'-methylenedianiline (TGMDA; 1%, 3+; 0.5%-0.05% 2+) provoked allergic patch test reactions, whereas o-diglycidylhexahydrophthalate was negative (1%- 0.05% pet). Six prepreg products used by the patient were extracted by ultrasound sonification for 5 min, 10% w/v and tested in dilution series in acetone. They all provoked allergic patch test reactions. The products were also analyzed for their TGPAP, TGMDA and DGEBA content with gas and liquid chromatographic methods, showing up to 10% of TGPAP, 19% of TGMDA and 5% of DGEBA-ER in the prepregs.
Conclusion: The patient had been occupationally sensitized to TGPAP and TGMDA from prepregs and tapes. He was not able to continue in his previous job but continued as an inspector at his work-place. Even in this new task he had several relapses of dermatitis on his face because he worked close to work-sites where epoxies were used. This face dermatitis indicated airborne allergic contact dermatitis from epoxies. TGPAP and TGMDA need to be used when patch testing patients exposed to prepregs.

Nickel, Cobalt, Chromium, Lead and Arsenic in Eye
Lasse Kanerva, MD
March 9 - 10:20 am - 10:45 am


Kanerva L (1), Jolanki R (1), Hakala E (2), Sainio E-L (3) (1) Section of Dermatology, Finnish Institute of Occupational Health, 00250 Helsinki (2) Oulu Regional Institute of Occupational Health, 90220 Oulu (3) Consumer Agency and Ombudsman, Product Safety, 00530 Helsinki, Finland

Background and Objectives: The regulations relating to cosmetic products give no limit values for toxic elements such as metals or arsenic (As) occurring as impurities in cosmetic products. It has been proposed that the levels of nickel (Ni) or cobalt (Co) should not exceed 5 ppm and should preferably be below 1 ppm. The levels of As and lead (Pb) should not exceed 5 and 20 ppm, respectively, and the level of water-soluble chromium (Cr) should preferably be less than 2 ppm.

Material and Methods: Pb, Co, Ni, Cr and As in eye-shadows in 88 colors of 25 brands and 49 products were analyzed by electrothermal atomic absorption spectroscopy using Zeeman background correction, matrix modification and pyrolytic tubes with wall or platform atornization.

Results: 66 out of 88 (75%) of the colors contained more than 5 ppm of at least one of the elements, and all 49 products contained more than one 1 ppm. of at least one of the elements. In one color the amount of all elements was less than I ppm The highest levels of Co and Ni were 41 and 49 ppm, respectively. These levels were high enough to cause allergic symptoms in those previously sensitized. Furthermore, long-term exposure to such levels may probably sensitize. The concentrations of As were extremely low, 2.3 ppm at most. The level of Pb was less than 20 ppm in all products. Accordingly, the concentrations of As and Pb seemed to be safe. 9 colors had concentrations of water-soluble chromium exceeding 2 ppm, and a very high level, 318 ppm, was encountered in one case.

Conclusion: The results indicate that eye-shadows have no significant systemic toxicological effects. The group at greatest risk are those already sensitized to the allergenic elements. Such consumers will have difficulties in choosing suitable products, since these elements in the form of impurities are not declared in the list of ingredients. Manufacturers should demand certification that the raw materials they buy contain no toxic elements.

Actinic Reticuloid
Mario Cezar Pires, MD
March 9 - 10:20 am - 10:45 am


Authors: Pires MC; Oliveira NRA; Lopes LF; Andretta N; Landman G.

Institution: Complexo Hospitalar Padre Bento de Guarulhos

Country: Brazil

The term "Actinic Reticuloid" was joined by Hawk and Magnus in 1979. This is a photodermatosis related to UVA, UVB and visible light. It is more common in men and atopic patients. Frequently the patients show a chronic contact dermatitis due allergens such as: nickel, cobalt, potassium dichromate and others. Nowadays, the actinic reticuloid is classified in the group of the actinic chronic dermatitis.

We present a case of a male, 59 years old, machine technique who showed erythematous and scaling lesions in the arm, neck and face. The patient told a history of chronic contact dermatitis that worsens with the sun. Nowadays he is retired but the dermatosis persists.

The patch test was positive to 9 allergens. Then we suspected the excited skin syndrome and we repeated the test with these substances separated and all were positive again.

The patient was treated with azathioprin 150 mg by day and improved after 16 weeks.

Sensible Formulations of Sensitive Skin Products
Rachel Quinby, MD
March 9 - 10:20 am - 10:45 am


Rachel Quinby, M.D. Andrew Scheman, M.D.
Northwestern University Medical Center Chicago, IL

This presentation reviews the existing literature on ingredients known to aggravate sensitive skin. The focus is then shifted to a rational approach for designing products which will be optimally tolerated by individuals with sensitive skin and to a list of preferred ingredients serving various functions in such products.

Effect of Potassium Hydroxide and Trichloroacetic Acid
Induced Skin Irritation on In Vitro Percutaneous
Penetration of Estradiol
Marylou C. Thelmo, MD, MPH
March 9 - 10:20 am - 10:45 am


Marylou C. Thelmo, M.D., M.P.H., Hanafi Tanojo, Ph.D.,
Leanne L. Zhang, and Howard I. Maibach, M.D.
Department of Dermatology, University of California,
San Francisco, CA 94143-0989

Objective: To study the change in the in vitro percutaneous penetration of estradiol on excised skin pre-treated with two irritants.

Methods: Pretreatment of fresh human skin with various concentrations of potassium hydroxide (KOH) for 2 hours and of trichloroacetic acid (TCA) for 24 hours. Penetration of [14C]-estradiol through the pre-treated skin was monitored using in vitro diffusion cells. Untreated skin was used as control.

Results: There was a significant decrease in skin permeability to estradiol on KOH pre-treated skins compared to control. Comparisons between 0.05%, 0.1%, and 0.2% KOH were significant. Skin permeability of estradiol decreased significantly after 7.5% TCA pre-treatment compared to control, 20%, and 30% TCA.

Conclusion: KOH and TCA damage the skin barrier property thus blocking the permeation of lipophilic compounds. The damage is dose-dependent. However, there may be more than one mechanism involved.

Acknowledgement: This work was supported by a research fellowship (MCT) from the American Contact Dermatitis Society.

Reliability of T.R.U.E. Test
J.M. Femandez-Vozmediano, MD
March 9 - 10:20 am - 10:45 am


Fernandez Vozmediano JM, Armario Hita JC
Dermatology Service. University Hospital of Puerto Real. University of Cadiz.Spain

INTRODUCTION. There are numerous studies which compare the reliability of TRUE test (TT) with Finn Chamber (FC). We present a comparative study carried out on our population.

MATERIAL AND METHOD. Epicutaneous tests were carried out on 168 patients simultaneously with TT and FC, the readings were made after 48 and 96 hours.

RESULTS. The patients had an average age of 33.41± , they were 60% female. 68% presented eczema on the hands, 35% were housewives. The most frequent allergens were nickel sulphate (46%), cobalt dichloride (14%) and potassium dichromate (9%). The total concordance was of 68%. For the total of the tests, sensitivity of TT compared to FC was of 69% and specificity was of 99%. For some allergens, relative sensitivity was even lower.

CONCLUSIONS. The proportion of false negatives of TT compared to FC is very high, this fact leads to a lower number of diagnosis. Protocoled epicutaneous tests carried out with FC present higher sensitivity as a screening ACD test compared to TT.

Barrier Disruption By Three Commercial Adhesive Tapes:
A Difference
Saqib J. Bashir, MD
March 9 - 10:20 am - 10:45 am


S. J. Bash A. L. Chew, A. Anigbogu, F. Dreher & H.I. Maibach Department of Dermatology, University of California, San Francisco

Background: Tape stripping of the stratum corneurn (SC) has been performed to measure stratum corneum, barrier function, drug reservoir and percutaneous penetration.

Objective: Quantification of SC tape stripping and water kinetic parameters utilizing three types of adhesive tapes.

Methods: SC was tape stripped and the mass of SC removed by each tape quantified utilizing a protein assay. Transepidermal water loss was measured, barrier disruption and SC water kinetics calculated. Three common acrylate adhesive tapes were utilized and a comparison made between them.

Results: Each tape successfully stripped the SC, but the rayon tape did not induce barrier disruption. Neither tape type nor site significantly influenced the mass of SC removed. Water kinetics did not differ significantly. Individual variation in barrier disruption to water following tape stripping was demonstrated.

Conclusions: The tapes removed a similar amount of SC. but have a different propensity to cause barrier disruption. Some individuals do not demonstrate increased TEWL despite an equivalent mass of SC being removed compared to those who do show a response.

Donald J. Birmingham and Occupational Dermatology in the U.S. Public Health Service
James S. Taylor, M.D.
March 9 - 10:50 am


James S. Taylor MD(1), Boris D. Lushniak MD(2), Earl J. Rudner MD(3), and Marcus M. Key MD(4): Cleveland Clinic, Cleveland OH(l); National Institute for Occupational Safety and Health, Cincinnati, OH(2); Henry Ford Hospital, Detroit MI(3); and University of Texas, Houston TX(4).

Donald J Birmingham MD (1911-1998), ACDS honorary member, was a major contributor to occupational dermatology in the United States. He served in the US Public Health Service (USPHS) for 23 years and directed its occupational dermatology activities from 1951-1964. Later he was chair of the departments of Occupational and Environmental Health and Dermatology at Wayne State University. During his career Birmingham made seminal contributions to our present understanding of occupational skin disease through his clinical reports, as well as through his research, educational and public policy work.

In the USPHS he continued a program begun in 1928 by Dr Louis Schwartz at the National Institutes of Health. Field and laboratory investigations included studies in the munitions, aircraft, machine tool, pesticide, agricultural, food processing, mining, petroleum and plastics industries. This work included major descriptions of cashew nut shell oil, chromium, printing ink, and epoxy, polyester and formaldehyde resin contact dermatitis, as well as dermatitis among TNT and tetryl workers, oil acne, chloracne, arsenical dermatoses and phototoxicity from pink rot celery. He was the major contributor to the 3rd edition of Schwartz, Tulipan and Birmingham's Occupational Skin Diseases in 1957, and directed a number of seminars including a month long didactic and field work course in May 1967. He was a member of the AMA Committee which wrote the first edition of the Guides to the Evaluation of Permanent Impairment and was chair of the committee on the skin. Honors included the USPHS Meritorius Service Medal and election as vice-president of the American Academy of Dermatology. He never fully retired and continued to serve as a consultant to industry and government. Donald Birmingham's career was characterized by scholarship, mentorship, and major achievement with quiet reserve, humor, modesty, honesty, and devotion to his family.

The Occupational Skin Disease Prevention Project in the
Food Processing Industry
Peter Elsner, M.D.
March 9 - 11:00 am


Bauer Andrea, MD, Kelterer Daniela, MD, *Stadeler Martina, MD, *Schneider Wolfgang, MD, *Kleesz Peter, MD, Elsner Peter, MD Department of Dermatology Friedrich-Schiller-University Jena, *Research Center for Applied System Safety and Industrial Medicine Erfurt, Germany

Statistical reports of occupational diseases show high incidences of occupational skin diseases in employees in the food processing industry. Since January 1999 23 employees were included in an interdisciplinary skin disease prevention program. After the analysis of the occupational exposure and the personal occupational disease history, diagnosis and therapy were re-evaluated and supplemented if necessary. Individual skin care and protection regimes will be demonstrated and practised. Since January 1999 16 employees were examined in the occupational clinic. 75% of the employees had an irritant contact dermatitis. The preliminary results showed that most of the occupational skin diseases are due to no, wrong or misplaced skin care and protection habits. 7 (44%) employees were followed up till now. In 43% skin condition improved and/or healed. Moreover in 43% the skin condition was stable although they stayed at work. These first results are promising. More employees will be included and the program will be expanded.

Efficacy of Buffering Solution as a Protectant for Workers
Using Alkalies
Rodney Wolford
March 9 - 11:10 am


Marilyn Larson, Rodney Wolford, FOF Communications, Washington, DC

Alkaline pH has been shown to impede barrier recovery while acidification of the SC enhances ft. Thus, workers using alkalies may benefit from buffering rinses.

OBJECTIVE: To assess the efficacy of a pH 5.5 buffering rinse to improve the condition of skin occupationally exposed to alkalies, compared with water washing, moisturizers, and gloves.

METHOD: Pre/post treatment surveys 30 days apart of 30 concrete truck drivers. Workers reported daily on use of the four treatments. Workers were grouped by treatment compliance (high/low). Relative risk for skin improvement was estimated between compliance groups (Chi-Square).

RESULTS: Workers using buffering rinse were 7.8 times more likely than workers not using ft to report improvement (Cl: 1.2, 50.8; p=.001 ). No differences were seen between workers using and not using water washes (p=.276), moisturizers (p=.311), or gloves (p=.122). No difference in reported frequency of symptoms was seen between compliance groups for any treatment (N.S.).

CONCLUSION: Skin exposed to alkalies may benefit from pH 5.5 buffering rinses. This conclusion is consistent with a requirement for acidic pH in restoration of normal barrier recovery.

Occupational Skin Diseases in Finnish Dental Nurses
Paivikki Susitaival, M.D.
March 9 - 11:20 am


Alanko K, Susitalval P, Estlander T, Jolanki R, and Kanerva L.
Finnish Institute of Occupational Health, Helsinki, Finland

Objectives: Causes of occupational skin diseases (OSD) were studied in a population of dental nurses. Material and methods: A telephone interview, using a modified Tuohilampi questionnaire, was done to 799/923 female dental nurses. 327 nurses (41%) reporting work-related hand or facial dermatitis were invited to a medical interview and 245 nurses participated. 26 nurses had been previously diagnosed as having OSD. 119 met the criteria for suspected undiagnosed OSD and were selected for further clinical examinations with skin prick and patch testing. Results: Among the 105 nurses examined, 21 new cases of OSD were diagnosed. Among the 47 OSD cases, there were 27 diagnoses of allergic contact dermatitis (ACD), 14 of contact urticaria (CU), and 10 nurses with irritant contact dermatitis alone. Causes of ACID included (meth)acrylates (10), rubber chemicals (10), and Ampholyte 103G (7). The cause of CU was natural rubber latex (NRL) in 13 cases. Among the 19 examined with latex-related Immediate complaints only none were diagnosed with CU. Conclusions: Components of protective gloves and dental (met)acrylates were the most common causes of allergy. 84% of the interviewed nurses handled dental restorative plastics daily. 90% of the nurses used protective gloves regularly. One fourth of the interviewed population complained about latex-glove related skin problems but very few cases of latex-CU were diagnosed.

ACD to Glutaraldehyde in Health Care Workers
Donald V. Belsito, M.D.
March 9 - 11:30 am


Matthew P. Shaffer, B.A. and Donald V. Belsito, M.D., Dermatology, University of Kansas Medical Center, Kansas City, KS 66160

In a five-year study, 468 patients were patch tested to glutaraldehyde (1% and 0.2% in pet [1994-1996], 1% and 0.5% in pet [1996-1998] or 1% in pet [1998-1999]). In addition, all patients were tested to the NACDG's Standard Tray, which included formaldehyde (1% aq). A comparison of results was made between health-care workers (HCWs) and those who were not. HCWs allergic to glutaraldehyde were subsequently questioned about their dermatitis, disease course following diagnosis, occupational changes, glove usage and safety training while using glutaraldehyde.

HCWs were more likely to be allergic to glutaraldehyde than nonhealth-care workers (NHCWs): 17.6% vs 1.9% (p < 0.001). Statistically significant differences between HCWs and NHCWs were also seen in their reactivity to thimerosal (p 0.002), benzalkonium chloride (p = 0.046), and methyl methacrylate (p 0.003). Using a chi-square test with Yate's correction, a higher than expected co-reactivity to formaldehyde was also noted among HCWs and NHCWs allergic to glutaraldehyde (expected co-reactivity, 1.53; observed co-reactivity, 7 [p < 0.001]), which cannot fully be explained by concomitant exposure.

In our study, ACD to glutaraldehyde often caused persistent occupational dermatitis, which forced 3/6 workers to leave their jobs. In 3 workers who remained in health-care, 2 had persistent dermatitis despite precautions. Three workers were unavailable to follow-up, 2 of the 3 because of pending litigation. Although NIOSH has published guidelines for safe handling of glutaraldehyde, sensitized workers in our study were unaware of these guidelines. It is essential that workers exposed to glutaraldehyde heighten occupational safety standards and improve barrier protection. The potential cross-sensitization to the more ubiquitous formaldehyde molecule accentuates the need for adherence to prescribed safety standards.

Permeation of Methacrylates (2-HEMA, TREGDMA) ThroughDisposable Protective Gloves Lasse Kanerva, M.D.
March 9 - 11:40 am


Kanerva L, Makela EA, Vaananen V, Jolanki R, Estlander T, Alanko, K
Finnish Institute of Occupational Health, FIN-00250, Helsinki, Finland

Objective: Methacrylate (MA) allergy is an increasing problem, especially for dental personnel. Gloves are important in avoiding skin contact with MAs, but usually gloves are not certified for chemical protection against MAs.

Methods: A 50% mixture of 2-HEMA and TREGDMA was used as a test chemical. The study was carried out according to the European standard EN 374-3 with the open loop method, using purified water as collection medium and detecting the chemical with an HPLC/UV-detector. Ten different types of disposable gloves were studied. Some analyses were made with 2 glove samples on top of each other (double gloving).

Results: The breakthrough times (BTT) of the MA mixture through glove materials varied from 3.5 min to >8 h: methylethyl MA gloves (3.5 min), PVC gloves (8.2-10 min), natural rubber latex (NRL) gloves (9.4 -16 min), nitrile gloves (14 -72 min) and polychlorophene/ copolymer gloves (62 min). The BTTs of double gloving were 1.2 - 2 fold compared to the sum of the BTT of single gloves, e.g. the BTT time of polyethene glove (PE) combined with NRL glove was > 8h.

Conclusions: Some disposable glove materials, e.g. nitrile gloves, can be used as barriers to MAs. Double-gloving seems to be beneficial in reducing skin exposure; adding a simple PE glove under another glove improves the protection considerably. Manufacturers should be required to type-test gloves before marketing them for special purposes, e.g. dentistry.

Immersion Oil Contact Allergy, An Unsuspected Source of
Epoxy Allergy
Klaus E. Andersen, M.D.
March 9 - 11:50 am


Klaus.E. Andersen*, Ole.J. Clemmensen#, *Department of Dermatology and #Department of Pathology, Odense University Hospital, Odense, Denmark.

Three of four laboratory technicians working at the chromosome laboratory at the department of pathology developed recurrent dermatitis on hands, face and neck during the fall of 1998. The dermatitis was strictly work related with aggravation on workdays, improvement in weekends and complete clearing during longer holidays and vacation. A new immersion oil was introduced in the laboratory in February 1998. The label did not contain any warning or information about the components of the oil. Standard battery patch testing revealed an unexpected positive reaction to epoxy resin in 3 of the 4 laboratory technicians. Use-test and patch testing with the oil was strongly positive and the dermatitis cleared completely after removal of the oil. Subsequent information on the oil revealed that it contained epoxy resin. In the literature publications appeared describing an epidemic of occupational contact dermatitis from an immersion oil for microscopy. According to a recent publication (Le Coz and coworkers. Contact Dermatitis 1999; 40: 77-83) the newly formulated immersion oil had been withdrawn from the market. Unfortunately, the company marketing the oil had not taken the necessary steps to inform laboratories using the oil about the epoxy problem.

Time/Dose Relationships in Elicitation of lsoeugenol
Contact Allergy
Klaus E Andersen, M.D.
March 9 - 2:00 pm


Klaus E. Andersen*, Department of Dermatology, Odense University Hospital, Denmark.
*Presenting author on behalf of the European perfume allergy group
J. Duus-Johansen, T. Menne, S. Rastogi; Denmark; M. Bruze, Sweden; P. Frosch, Germany; A. Goossens, Belgium; I. White, UK; J.-P. Lepoittevin, France

A total of 27 isoeugenol sensitive patients and 7 controls underwent serial dilution patch testing with isoeugenol in ethanol and subsequently Repeated Open Application Test (ROAT) with isoeugenol in ethanol in 2 concentrations: 0.2% and 0.05%. The ROAT was performed blindly and the participants applied the test solutions to the right and left arm twice daily until a visible reaction appeared or for a maximum of 28 days. The ROAT sites were evaluated and the amount of isoeugenol solution used was measured once a week. 16/27 (59%) (Fisher test, p=0.0085) showed a positive ROAT to isoeugenol 0.2% and 10/27 (37%) (Fisher test, p=0.055) had positive ROAT to 0.05%. The controls were negative. There was a significant linear dose response relationship between the patch test reactivity and the number of days until the ROAT became positive for both concentrations of isoeugenol. The total amount of isoeugenol solution 0.2% used in the ROAT among those developing dermatitis varied between 0.11 g and 1.54 g. Those with a negative ROAT used a total of 1.76 g (25% and 75% fractiles: 1.24 g and 2.23g).

U.S. Dermatologists' Approach to Patch Testing
Erin Warshaw, M.D.
March 9 - 2:10 pm


Erin Warshaw MD, University of Minnesota and Veterans Affairs Medical Center, Minneapolis, MN

One-third (3,215) of all American Academy of Dermatology Fellows with U.S. addresses were systematically sampled using a written questionnaire on patch testing practices. Forty-three percent (1,372) of surveys were returned, computer scanned (Teleform software), and tabulated (Microsoft Access software). Eighty-three percent of responding dermatologists patch tested and most (83%) patch tested five or fewer patients per month. The most common reason given for not patch testing was poor reimbursement. While the majority of dermatologists (52%) employed a 48-hour, 96-hour patch test reading schedule, 26% only performed a single reading at 48 or 72 hours. The majority of dermatologists (74%) used TRUE Test and most (44%) did so because it was less time-consuming for staff. Many dermatologists (46%) felt that they were patch testing more patients now than when TRUE Test was not available. Only 11 % of dermatologists performed photopatch testing although 24% said that allergic contact dermatitis was one of their special interests and 80% had at least one specialty book on contact dermatitis. This independent, non-proprietary study was supported by the Minneapolis Veterans Affairs Medical Center.

North American Contact Dermatitis Group Patch Test
Results 1996-1998
James G. Marks, Jr., M.D.
March 9 - 2:20 pm


James G. Marks, Jr. -M.D. The Milton S. Hershey Medical Center,
Hershey,PA, Donald V. Belsito, M.D., Kansas University Medical
Center, Kansas City, KS, Vincent A. DeLeo, M.D., St.
Lukes/Roosevelt Hospital Center, New York, NY, et al

Objective: We report patch testing results from July 1, 1996 to June 30, 1998 on over 3,400 patients with suspected allergic contact dermatitis.

Method: The patients were evaluated and then patch tested by 12 North American Contact Dermatitis Group (NACDG) dermatologists with a screening series of 50 allergens using a standardized technique.

Results: The patients' age in the 1996-98 study ranged from 3 to 96 years. 70.8% had at least one positive allergic patch test reaction. The most frequent primary diagnosis was allergic contact dermatitis (48.5%) followed by irritant contact dermatitis (15%), other dermatitis (13.4%), other dermatoses (9.8%), and atopic dermatitis (6.6%). The new allergens tested in the 1996-98 series were sodium gold thiosulfate, methyldibromo glutaronitrile/phenoxyethanol, and oxybenzone.

Conclusions: Patch testing remains a worthwhile diagnostic tool in evaluation of patients with suspected allergic contact dermatitis. The screening series will evolve over time based on experience with previously tested antigens and the introduction of new ones.

Is Routine Testing for Primula Obconica Useful in the
United States
Christen M. Mowad, M.D.
March 9 - 2:30 pm


Christen M. Mowad MD
Geisinger Medical Center, Danville, PA 17821

Background: Primula obconica is a known sensitizer. However, reports of allergic contact dermatitis to this allergen are higher in Europe than in the United States. The incidence of allergy to Primula obconica in the United States is hard to access because no series of routine testing to this allergen has been performed. Method:

This study evaluated 567 consecutive patients for sensitivity to this allergen as part of a standard screening. Patients were tested to primin 0.01 % in petrolatum (Trolab). Patches were applied in a standard fashion, applied to the upper back and left in place for 48 hours. All patients underwent two separate readings.

Results: One positive reaction was identified. This patient also had an expanded plant series tested and these were all negative.

Conclusion: Although not always apparent and therefore, difficult to diagnose, the frequency of primin allergy in this series was too low to do routine testing to this allergen. These findings do not support the use of routine testing to Primula obconica in the United States.

Relevance of the Pareto Principle, Lorenz Curves, and Gini Coefficients to Patch Testing
Philip D. Shenefelt, M.D.
March 9 - 2:40 pm


Philip D. Shenefelt, M.D., University of South Florida, Tampa, Florida, USA

Some delayed contact allergens are much more frequent problems in a given population than are others. Of the roughly 3000 known delayed contact sensitizers, only a small proportion account for most of the cases of allergic contact dermatitis.

The purpose of this study is to describe and illustrate concepts for examining the concentration of cases within categories and their relevance to patch testing.

Three methods of describing concentrations of cases within a category were borrowed from economics theory and applied to the results of two recent reports of the frequency of specific patch test positivity.

The Pareto Principle was found to provide a rough rule of thumb concerning the concentration of specific patch test antigen positive results in the study groups of patients. The Lorenz curve was shown to provide a graphic illustration of this concentration of cases of specific allergen positivity. The Gini coefficient was found to provide a numerical indicator of the degree of concentration of the results.

The Pareto Principle, Lorenz curves, and Gini coefficient are useful descriptors for examining the concentration of cases with respect to specific patch test allergens.

A New Method to Facilitate Successful Antigen Avoidance: Database Generated Guide of Skin Care Products Free of the Patients' Allergens
James A. Yiannias, M.D.
March 9 - 2:50 pm


James A. Yiannias, M.D., Assistant Professor of Dermatology, Mayo Clinic Scottsdale

Rokea A. el-Azhary, M.D., Associate Professor of Dermatology, Mayo Clinic Rochester

Commercial availability of patch testing has allowed dermatologists the ability to more readily diagnose contact allergy. However, antigen avoidance compliance is commonly difficult in part because of the complexity of antigen names and the consequent difficulty in finding appropriate skin care products.

Traditionally, following patch testing "negative" antigen avoidance methods are utilized. This approach lists the sources of the allergen and the general methods of avoidance. We have developed a "positive" approach that utilizes a database of nationally available skin care products. The physician or medical staff enters the name of the identified antigen(s), and the database generates an extensive list of commercially available soaps/shampoos, moisturizers, sunscreens, make-ups, and other skin care products that are free of the designated allergen.

This interactive database will be demonstrated as an evolving educational tool to facilitate the successful avoidance of contact allergens.

Pigment of Patch-Test Substances May Mask Detection of Perfusion and Affect Perfusion Assessments Made with the Laser Doppler Imaging Technique (LDIT)
Bolli Bjamason, M.D.
March 9 - 3:00 pm


Bolli Biarnason 1, Ellen Flosadottir2 and Torkel Fischer3

1 Department of Dermatology, Karolinska Hospital, Stockholm, 2 Faculty of Odontology, Karolinska Institute, Stockholm, 3 National Institute for Working Life, Solna, Sweden.

Objective: To investigate effect of pigmented patch-test substances on assessment of perfusion made with the LDIT.

Materials: Subjects allergic to balsam of Peru were retested with variably pigmented balsam of Peru test substances applied with transparent polyester patches and directly in a petrolatum vehicle with transparent foils. Readings were performed with the LDIT prior to and following detachment of the foils with an instrument set-up that we have suggested for non-pigmented substances on white skin.

Results: Results show that pigment remnants following detachment of tests may mask detection of perfusion and affect perfusion assessments.

Conclusion: Pigment of patch-test substances may affect perfusion assessments with the instrument set-up suggested for non-pigmented substances.

Acknowledgments: The Swedish Foundation for Health Care and Allergy Research, the Welander-Finsen Foundation.

Pediculicide Contact Dermatitis
Edward M. Jackson, PhD
March 9 - 3:10 pm


Edward M. Jackson, Ph.D.

Jackson Research Associates, Inc. Sumner, WA

INTRODUCTION Pediculicides have been limited to naturally occurring pyrethrum and its chemically synthesized analogs, the permethrins, in topical over-the-counter drugs. In June, 1999 malathion was re-introduced as a topical prescription drug pediculicide.

In 1998 Florida began a malathion spraying program to control the Mediterranean fruit fly. This program was similar to the California infestation control program.

METHODS The contact dermatitis potential of malathion presented by a complete review of the contact dermatitis literature, the Center for Disease Control Florida spraying surveillance program results as published in the MORIBIDITY AND MORTALITY REPORT will be reviewed. The content of two Internet sites, one of which presents uninformed opinion and the other scientifically and medically based facts, will also be summarized.

CONCLUSION Dermatologists should be informed on the safety of malathion to be able to answer patient questions and prescribe safe and effective remedies.

Stability of Corticosteroid Patch Test Preparations
Marlene Isaksson, M.D.
March 9 - 3:40 pm


Marlene Isaksson, Birgitta Gruvberger, Lena Persson, Magnus Bruze
Department of Occupational and Environmental Dermatology, Malmo University Hospital, Malmo, Sweden

Object: To chemically investigate the stability of 3 corticosteroid patch test markers, tixocortol pivalate, budesonide, and hydrocortisone-17-butyrate (Hc-17-B) in petrolatum preparations and in ethanolic solutions.

Method: Petrolatum preparations and ethanolic solutions containing each corticosteroid as well as mixtures of the 3 corticosteroids were made up and kept at room temperature, refrigerated and deep frozen. To check the stability high performance liquid chromatography analyses were carried out repeatedly for 1 year. A decrease of -<20% of the value at time 0 was used as the threshold for stability.

Results: All preparations with the corticosteroids in petrolatum and tixocortol pivalate and budesonide in ethanol were stable during the investigative period, irrespective of storage conditions. Hc-17-B in ethanol was stable during the whole investigative period only when kept deep frozen.

Conclusions: All investigated petrolatum preparations were stable at least during 1 year, irrespective of storage conditions. The chemical stability of Hc-17-B in ethanol was dependent of concentration and storage conditions.

Allergic Contact Dermatitis from IPBC
Tove Agner, M.D., PhD
March 9 -3:50 pm


Agner T, Bryld LE and Menne T
Department of Dermatology, Gentofte University Hospital, DK-2900 Hellerup, Denmark.

Background: Only few occurrences of allergic contact dermatitis to IPBC (3-iodo-2-propynyl-butylearbainate) have been recorded to date. While the first cases reported were seen in men with an occupational or unknown exposure (1), a cosmetics-associated case of allergic contact dermatitis due to IPBC has recently been published (2).

Methods: We review our experience with three and half years of consecutive testing with IPBC in a hospital clinic. All patients referred to patch testing were additionally tested with IPBC preservative in a concentration of 0. % in pet. Where appropriate, an additional dilution series and a blinded ROAT (repeated open application test) was performed.

Results: From 1996 to 1/12000 a total of 3147 persons (2077 women and 1070 men) referred to the clinic for contact dermatitis were patch tested with IPBC as part. Besides the three male cases previously published (1), four more persons with IPBC contact allergy were found. Two persons had a confirmed exposure history to an IPBC-containing skin lotion, and two persons, who had multiple allergies, had possible exposure to IPBC-containing cosmetics products. The latter four persons were all diagnosed in 1999, and all were women. The number of persons patch tested per year in 1996-99 was alike, but no persons with IPBC allergy were found in 1997 or 1998.

Conclusion: IPBC, a biocide originally used for wood or paint preservation, has in recent years been introduced as a preservative in cosmetics. Our experience suggests that the introduction of IPBC into everyday cosmetics may probably result in an increased number of cases with cosmetically induced allergic contact allergy due to IPBC.


1. Bryld LE, Agner T, Rastogi SC, Menne T lodopropynly butylcarbamate: a new contact allergen. Contact Dermatitis 1997, 36: 156-158.

2. Pazzaglia M, Tosti A. Allergic contact dermatitis from 3-iodo-2-propynylbutylcarbamate in a cosmetic cream. Contact Dermatitis 1999, 41: 290.

Brominated Swimming Pool Water: Chlorine-Sensitive
Denis Sasseville, M.D.
March 9 - 4:00 pm


D. Sasseville, MD, Royal Victoria Hospital, Montreal, QC, CANADA

Objective: to report a case of allergic contact dermatitis to 1-bromno-3-chloro-5,5-dimethylhydantoin in a patient sensitized to sodium hypochlorite.

Case report: A 40-year-old woman had previous episodes of hand eczema after contact with sodium hypochlorite bleach, and generalized dermatitis within days of swimming in chlorinated pools. Due to her intolerance to chlorine, she was advised to brominate her own pool with DiHalo ® tablets. After a week of daily swims, she broke out in a pruritic eruption on her trunk, arms and thighs, with relative sparing of the areas covered by her swimsuit.

Patch tests were done with the standard series, the products used to sanitize the pool, some of their ingredients and various chlorinated substances. At day 4, there were positive reactions to DiHalo® 1% aq., NaOCI 1% aq. and LiOCl 1% aq. Chloramine-T and DMDM Hydantoin gave negative results.

Conclusion: Allergic contact dermatitis or urticaria to sodium hypochlorite occur rarely. In 1983, an epidemic of dermatoses was seen in the U.K. among users of swimming pools disinfected with DiHalo ®. All patients had negative patch tests, suggesting an irritant mechanism. Sold as "bromine tablets", 1 bromo-3-cNoro-5, 5-dimethylhydantoin (DiHalo®, Halobrome®, Aquabrome®) releases both bromine and chlorine. In 1995, 3 patients had positive patch tests to Halobrome® while negative to chlorine compounds.

Pool sanitation relies almost exclusively on chlorinated products. Alternative systems such as ionizers, oxygen generators, UV devices and oxidative catalysts have low or unproven efficacy. My patient was able to sanitize her pool with polyhexamethylene biguanide (PHMB), a chlorine-free compound sold In the U.S.A. as Bacquacil® or Softswim®.


1 . Sasseville D, Geoffrion G, Lowry RN. Allergic contact dermatitis to chlorinated swimming pool water. Contact Dermatitis 1999:41:347-8.

2. Rycroft RJG, Penny PT. Dermatoses associated with brominated swimming pools. Br Med J 1983:287;462.

3. Fitzpatrick DA, Wilkinson SM, Bhaggoe R, et al. Spa pool dermatitis. Contact Dermatitis 1995:33;53.

Urticarial and Eczematous Reaction to Benzophenone in
Finished Plastic
Susan Nedorost, M.D.
March 9 - 4:10 pm


Susan Nedorost M.D.a, Richard Averitte Jr., M.D.a, Nihal Ahmad PhD.a, James Arnold M.D. b, Kevin Cooper M.D.a Depts. of Dermatologya and Otolaryngologyb, University Hospitals of Cleveland and Case Western Reserve University, Cleveland, OH

A five-year-old girl was referred by her otolaryngologist. Her mother reported a history of a red rash beginning within hours of exposure to plastic sipper cup lids, disposable diapers, and outdoor playground equipment. The rash would last for several days. She previously had plastic myringostomy tubes with constant ear drainage until these were removed and replaced with metal tubes and then had no further difficulty. Examination revealed urticarial and eczematous dermatitis around her mouth and on her right index finger and thumb where she held her sipper cup.

Patch testing revealed a 1+ reaction to benzophenone-3. The patient's sipper cup lid was the most recent and problematic exposure. The manufacturer denied the presence of any UV absorber in the cup lid. However, high-pressure liquid chromatography performed in our department revealed benzophenone in the plastic lid.

Benzophenone is used as a stabilizer in many plastic and rubber products. Both contact urticaria and dermatitis have previously been reported. When this child required tonsillectomy, only metal devices were used for surgery and anesthesia and she experienced no problems.

Acknowledgments: Sally Kline PhD. PolyBlend Technologies

Hazardous Holidays-Severe Allergic Contact Dermatitis from Paint-on Tattoos in Bali
Rosemary L. Nixon, M.D.
March 9 - 4:20 pm


Rosemary L. Nixon and Matheen Mohamed
Dermatology Unit Monash Medical Centre and Monash University Department of Medicine, Melbourne Australia

Bali is a favoured holiday destination for Australians. We report three holiday makers who experienced more than they bargained for. They developed severe allergic reactions to "paint-on tattoos" where the primary eruption at the tattoo site was followed within days by a generalised eruption requiring treatment with oral steroids.

Traditionally, henna has been used for skin painting. However there have been an increasing number of reports of tattoo reactions from Bali, India and Africa where paraphenylene diamine (PPD) has been applied to the skin. In our cases it appeared that PPD was mixed with a solvent, such as kerosene, to aid skin penetration.

PPD is an extremely strong sensitiser as evidenced in vitro guinea pig sensitisation tests. Not only did our patients develop this widespread rash, described variously as an id or autosensitization or conditional hyperirritability response, they also developed severe allergic reactions to PPD on patch testing, characterised by +++ blistering reaction. Even diluting the standard PPD to 10% made little difference. All patients developed a large number of cross reactions relating to hair dyes, black rubber and textile dyes.

The development of such severe allergy to PPD could have enormous implications in those who are occupationally exposed, such as hairdressers.

Chemical Leukoderma Due to Buspirone Patches
M. Shane Chapman, M.D.
March 9 - 4:30 pm


M.Shane Chapman, MD, Kathryn A. Zug, MD and Jose Peraza, MD Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire

Hydroquinones and certain phenolic compounds are well known causes of contact or chemical leukoderma. Most reported cases of contact leukoderma occur in occupational settings with contactants known to cause this entity, however, a number of consumer products have also been reported to cause contact leukoderma. Although transdermal patch delivery systems are known to cause local irritation and allergic contact dermatitis, none have been previously reported to cause leukoderma. We describe a case of contact leukoderma due to buspirone patches. Histologically these areas revealed an absence of melanocytes and minimal inflammation. Patch test results and the mechanics of testing will be discussed along with a review of contact leukoderma. Based on our review of the literature, this is the first case of contact leukoderma caused by a transdermal drug delivery system.

Steroid Addiction-Steroid Withdrawal Syndrome
Marvin J. Rapaport, M.D.
March 9 - 4:40 pm


Marvin J. Rapaport, M.D., Vicki Rapaport, M.D. UCLA, Los Angeles, California 90095

A large series of patients with the "red scrotum syndrome," vulvodynia, "status cosmeticus," photosensitive eczema, intractable eczema and perianal atrophoderma will be presented. Some additional examples of facial problems will also be shown.

All of these patients had been applying increasingly more potent topical corticosteroids and some had used systemic corticosteroids for many years. Patch testing and modes of therapy will be demonstrated and described. Most of the patients cleared with the cessation of corticosteroid usage. The relationship of all of the above syndromes was that the patients were addicted to corticosteroid usage.

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