Sensitization to thimerosal (Merthiolate) is still present today

The results on thimerosal (Merthiolate) hypersensitivity of a retrospective study, together with the relevant data on thimerosal hypersensitivity referred to in the literature up to 1993, are presented. Positive patch test reactions to thimerosal (0.1% pet.) were observed in 32 (1.3%) of 2461 adult patients with suspected contact allergy examined in the period 1987-1992. 20 (0.8%) patients had a solitary positive patch test to thimerosal. The observed incidence is low. Clinical symptoms related to thimerosal hypersensitivity were observed in only 3 patients. The collected results are discussed with emphasis on the clinical implications of sensitization to thimerosal. It appears that a positive patch test to thimerosal is frequently clinically irrelevant.

Cyclosporin in atopic dermatitis: a multicentre placebo-controlled study

The efficacy of cyclosporin (Sandimmun) given in a daily dose of 5 mg/kg for 6 weeks in severe atopic dermatitis was confirmed in this double-blind, placebo-controlled, short-term study. Of the 46 patients included in the study, 23 were randomized to receive cyclosporin and 23 to receive placebo. Four of the 23 patients (17%) on cyclosporin, and 14 of the 23 patients (61%) who received placebo, discontinued the trial because of inefficacy. All patients who discontinued the trial were assessed following the principle of 'intention to treat'. Compared with the baseline, the mean scores for disease severity [6-area, total body severity assessment (TBSA)] improved by 55%, and the mean scores for extent of disease [rule-of-nines area assessment (RoNAA)] improved by 40%, in patients treated with cyclosporin. Nine of the patients who received cyclosporin and completed the study (n = 14) had an individual reduction of disease severity (TBSA) of 75% or more, and in three patients this reduction was nearly 100%. In the placebo group, a mean worsening of disease severity (4%) and of extent of the disease (25%), compared with the baseline, was observed at week 6. Patients' and investigators' mean scores for the overall efficacy were similar, and showed a statistically significant difference in favour of cyclosporin. Two patients on cyclosporin developed hypertension during therapy, and one of these withdrew from the study. At the end of the trial, no statistically significant differences in the systolic or diastolic blood pressures were observed between the two groups. In the cyclosporin group, the increases in the values of serum creatinine and bilirubin at week 6, compared with the respective values at the baseline, were statistically significantly different from those in the placebo group, but all values normalized in the post-treatment period. Cyclosporin can be a safe and very effective treatment in episodes of severe atopic dermatitis, provided that the recommended guidelines for its administration are strictly observed.

Oral manifestations of gold allergy

BACKGROUND

Sensitization to gold in a large group of patients suspected of clinical allergy to this metal has not been reported.

OBJECTIVE

Two hundred patients with symptoms of persistent oral mucosal or cutaneous lesions that were possibly related to allergy to constituents of gold alloys or gold jewelry were patch tested to determine the frequency of sensitization.

METHODS

Patch testing was performed with the European standard series and a series of dental materials including three different salts of gold. A persistent papular reaction to gold-(tri)chloride was considered a positive reaction.

RESULTS

In 17 patients (8.5%, all women, mean age 50.2 years) persistent papular patch test reactions to both 0.5% and 1.0% gold(tri)chloride were observed. In five of seven patients with oral lichen planus (OLP) and in one of six patients with the burning mouth syndrome, gold in the dentures was replaced. Particularly in patients with OLP, a significant but variable improvement was observed. In all cases in which gold was replaced and improvement occurred, the patients were sensitized to 0.5% gold(tri)chloride. One patient with allergic contact stomatitis and one patient with allergic contact dermatitis healed completely after gold had been replaced.

CONCLUSION

Sensitization to gold should be considered as a possible cause of allergic contact dermatitis and allergic contact stomatitis as well as a pathogenic or triggering factor in OLP.

[Amalgam. VI. Allergy to mercury in dental materials; oral and systemic reactions]

Allergy for mercury in dental alloys can be responsible for the induction of allergic contact stomatitis. Evidence is also available for a role of mercury sensitization in the pathogenicity of oral lichen planus in particular. Aspects related to the development of allergic processes in the oral cavity are summarized. Allergy for mercury as the cause of oral mucosal reactions is rather rare in spite of the frequent use in dental amalgam, but probably underestimation of the incidence should be considered. Recent views with respect to the role of mercury as allergen in allergic contact stomatitis, oral lichen planus, the so-called Burning mouth syndrome and in systemic allergic reactions are summarized. Immunologic aspects in the pathogenesis are briefly discussed. Especially in cases in which the site or oral lesions is opposite to the dental alloy it is important to establish sensitization for mercury by use of epicutaneous path testing. When a positive test to mercury is obtained replacement of mercury containing alloys should be considered.

Frequency of false-negative reactions to the fragrance mix

To estimate the frequency of false-negative reactions to the fragrance mix, the 8 constituents of the mix in concentrations of 5% (2% for cinnamic aldehyde) were added to the European standard series for routine testing. Patients with positive reactions to individual ingredients in the absence of a reaction to the mix were retested with serial dilutions. In a 4-month period, 677 patients were tested. 61 (9%) reacted to the mix and to 1 or more of the ingredients. 4 patients (0.6% of all patients tested and 6.2% of the patients allergic to fragrances) had false-negative reactions to the mix. They were allergic to cinnamic alcohol, geraniol, isoeugenol and oak moss (1 reaction each), in the absence of a reaction to the fragrance mix. It is concluded that the currently used concentration of the mix (8 x 1%) not infrequently results in false-negative reactions, and that further research should be done to overcome this problem.

Secondary erythermalgia in systemic lupus erythematosus; [comment]

Secondary erythermalgia, as a symptom of an underlying illness, is characterized by burning pain in the extremities together with local erythema and warmth. The onset and clinical symptomatology of secondary erythermalgia in a woman with a 20 year history of systemic lupus erythematosus (SLE) is described. Histopathologic examination of affected skin areas revealed an inflammatory process compatible with vasculitis. These findings completely differ from the histopathology in erythromelalgia and in primary erythermalgia. The erythermalgic symptoms completely resolved by treatment with prednisone. We conclude that secondary erythermalgia in SLE in our patient was associated with cutaneous vasculitis.

Cyclosporine in atopic dermatitis. Modulation in the expression of immunologic markers in lesional skin

BACKGROUND

In previous studies, oral cyclosporine was highly effective in the treatment of patients with severe atopic dermatitis. In this study seven patients with severe and therapy-resistant atopic dermatitis underwent therapy with cyclosporine, 5 mg/kg/day, for 6 weeks.

OBJECTIVE

The effect of cyclosporine on the expression of cytokines, which probably play a role in this disease, was examined.

METHODS

The study was performed with a panel of antibodies as markers of inflammatory cells, adhesion molecules, and cytokines (interferon-gamma [IFN-gamma], tumor necrosis factor-alpha [TNF-alpha] and interleukins 1 alpha, 1 beta, and 8 [IL-1 alpha, IL-1 beta, and IL-8, respectively]). They were visualized by indirect immunoperoxidase techniques.

RESULTS

After 2 weeks of cyclosporine therapy, a reduction of 60% in the disease (severity and extent) was observed. This reduction was 89% after 4 weeks and 90% after 6 weeks of therapy. Results of indirect immunoperoxidase stains performed on lesional skin sections after 2 weeks of treatment showed statistically significant reduced numbers of CD14+, CD25 (IL-2R+) and IL-8+ inflammatory cells in the dermis and CD36(OKM5)+ cells in both the epidermis and dermis. The number of cells expressing IFN-gamma and TNF-alpha, assumed to be the products of the helper T-cell (TH)1 subset, was unaltered despite the impressive clinical benefit observed. Keratinocytes in lesional atopic skin did not express intercellular adhesion molecule type 1 (ICAM-1). The expression of the adhesion molecules ICAM-1, lymphocyte function-associated (LFA) type 1, and LFA-3 on inflammatory cells also remained unaffected by cyclosporine treatment.

CONCLUSION

A statistically significant reduction in the number of activated T cells and in the number of cells expressing the IL-2 receptor (CD25) paralleled a marked improvement in the disease and supports the view that atopic dermatitis is based on a T-cell-mediated immune inflammation.

Sensitization to azo dyes: negative patch tests to yellow and red azo dyes in printed paper

An over 2 x fold increase in para-aminoazobenzene allergy was observed in patients with allergic contact dermatitis during the years 1990-1991. Presuming that an increase in colour-printed newspapers might be a new unrecognized source of clinical allergy to azo dyes, patch tests were performed in 32 patients with an established p-aminoazobenzene allergy using a series of important azo dyes used in offset printing ink (Pigment Yellow 12, Pigment Yellow 13, Pigment Red 53, Pigment Red 57), as well as with dye-containing inks and specimens of colour-printed newspaper containing these azo dyes. In 25 out of the 32 patients (78%), positive patch tests were seen to textile azo dyes, in particular to Disperse Orange 3 (24 patients). In none of the 32 patients were reactions observed to the azo dyes used in printing ink, to the inks used or to the colour-printed paper specimens, indicating that these products were apparently not a cause of contact dermatitis in our group of patients with azo dye sensitization.

Burning mouth syndrome: a possible etiologic role for local contact hypersensitivity

BACKGROUND

The pathogenesis of the burning mouth syndrome (BMS) is not yet understood. Apart from psychologic factors, several etiologic "somatic" factors have been reported.

OBJECTIVE

In 22 patients (19 women, 3 men, mean age 56 years) classified with BMS, clinical and laboratory investigations were performed, with particular emphasis on the role of contact hypersensitivity. Twenty of the 22 patients wore a complete or partial denture.

METHODS

Besides clinical and laboratory investigations patch testing was performed with a standard routine series and a standardized denture-dental (acrylate and metal) series.

RESULTS

Folate, iron, pyridoxine deficiency, and Candida infections were found, but correction of the deficiency or treatment of the infection was of no benefit. Contact allergy to allergens used in the production of acrylate-based dentures was observed in six (27%) of the cases (all wore a denture); positive reactions were seen to N,N,-dimethyl-4-toluidine (3 cases), to 4-tolyldiethanolamine (2 cases), to benzoylperoxide (2 cases), and to oligotriacrylate (1 case). In six cases (27%) a possible relevant sensitization was seen to dental metals and in particular to gold chloride (four cases).

CONCLUSION

The possible role of local hypersensitivity reactions to denture or dental components as etiologic factors in BMS must be considered.

Differential role of lymphocyte function-associated antigens in the activation of nickel-specific peripheral blood T lymphocytes

The possible role(s) of the adhesion molecules LFA-1 alpha (CD11a), LFA-1 beta(CD18), ICAM-1 (CD54), CD2 (T11, LFA-2), and LFA-3 (CD58) in the in vitro activation of nickel-specific peripheral blood (PB) T lymphocytes was studied. For this purpose, monoclonal antibodies (MoAb) to these markers were used. Both LFA-2 and LFA-3 appeared to be consistently involved, whereas LFA-1 was inconsistently involved. In studies using antigen-presenting cells (APC) isolated from peripheral blood to present nickel, anti-LFA-1 alpha and/or LFA-1 beta MoAb partially inhibited the in vitro activation of nickel-specific T lymphocytes in nine of 42 patients allergic to nickel. In the other 33 patients variable results, ranging from a slight increase or inhibition of proliferation to no inhibition at all, was observed, in particular when different anti-LFA-1 alpha MoAb were added to the cultures. In those patients who showed no inhibition when anti-LFA-1 (alpha and beta) MoAb were added, no inhibition was also observed when a mixture of anti-LFA-1 (alpha and beta) and ICAM-1 MoAb were added to the cultures. Similar results were also obtained using epidermal APC. In control experiments the various anti-LFA-1 (alpha and beta) MoAb effectively inhibited the tetanus toxoid and Con-A induced T-lymphocyte proliferation as well as the spontaneous aggregation of the JY cell line. Anti-CD2 and anti-LFA-3 MoAb strongly inhibited the proliferative responses of nickel-specific peripheral blood T lymphocytes from all 42 patients. These results indicated that the receptor-ligand interaction between CD2 and LFA-3 is essential for in vitro activation of nickel-specific peripheral blood T lymphocytes. This activation, however, does not regularly involve LFA-1 molecules on T lymphocytes. The involvement of LFA-1 in the activation of nickel-specific T lymphocytes correlated positively with high patch test scores to nickel and the disease activity in contact dermatitis patients.

The autologous mixed epidermal cell-T lymphocyte reaction is elevated in psoriasis: a crucial role for epidermal HLA-DR+/CD1a- antigen-presenting cells

The objective of this study was to determine whether epidermal cells (EC) from psoriasis lesions and uninvolved skin could stimulate autologous T lymphocytes in the in vitro autologous mixed epidermal cell-T lymphocyte reaction (autologous MECLR). The functional role of antigen-presenting cell (APC) subsets was concurrently determined in this reaction. Mononuclear cells and purified T lymphocytes from peripheral blood of psoriasis patients showed a clear proliferative response to autologous unpurified epidermal cells from involved as well as uninvolved skin. The autologous mixed leukocyte reaction (MLR) was not elevated in psoriasis patients. In healthy controls and contact allergy patients, T-lymphocyte proliferation was not observed either in the autologous MECLR or in the autologous MLR. The level of proliferation in the autologous MECLR from psoriasis patients correlated to the number of epidermal cells that were added. To exclude the possibility that the observed proliferation in the autologous MECLR in psoriasis was due to the presence of epidermal T lymphocytes that were being stimulated and expanded in vitro, the stimulator EC were gamma irradiated (30 Gy) in some experiments. Preincubation of EC with cyclosporin A (CsA) significantly inhibited the autologous MECLR. The CsA-induced inhibition could be neutralized by the addition of fresh untreated EC to these cultures. This indicated that one of the modes of action of CsA in resolving psoriasis is, as some investigators have already shown, via inhibition of epidermal accessory cell function. In the autologous MECLR, APC from psoriasis skin could initiate this reaction, whereas APC from peripheral blood could not. This occurred in an MHC class II restricted fashion. Depletion experiments showed that Langerhans cells (HLA-DR+/CD1a+) were not the principal stimulators of autologous T lymphocytes in the MECLR. These results indicated that mainly HLA-DR+/CD1a- epidermal cells from psoriasis patients could stimulate autologous peripheral blood T lymphocytes in an MHC class II-restricted fashion.

Bullous pemphigoid in children. Report of three cases with special emphasis on therapy

Three children aged 4 months, 7 years, and 12 years, had bullous pemphigoid (BP). Two children suffered from disseminated BP and one (12 years) from vulvar localized BP. This last form has been described only once before in a girl. The various forms of pemphigoid in childhood are rare and reported in only about 40 instances. Bullous pemphigoid in childhood does not differ clearly from the adult counterpart, although lesions of the mucous membranes seem more common in childhood.