Erythema multiforme reaction to patch testing

S3 Guidelines: Epicutaneous patch testing with contact allergens and drugs - Short version, Part 2

Epicutaneous patch testing is the diagnostic standard for the detection of allergic contact dermatitis. The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology and allergology as well as other medical specialties involved in establishing the indication for patch testing and its execution in patients with contact dermatitis and other forms of delayed-type hypersensitivity. The target audience also includes other health care providers and insurance funds. Based on a systematic literature search and a formal consensus process (S3), the guidelines were developed by dermatologists in collaboration with pediatricians, occupational medicine physicians, nursing staff as well as patient representatives. The systematic methodological approach and appraisal of evidence upon which the recommendations are based are outlined in a separate method report that also contains evidence tables. The guidelines address general aspects of patch testing as well as medicolegal issues. The recommendations given relate to topics such as the indication for patch testing, informed patient consent, as well as the choice of test substances, test chambers and test site, duration of exposure, reading times and interpretation of test reactions. Furthermore, recommendations are provided with respect to endogenous and exogenous factors, specific patient groups (children, pregnant women, immunosuppressed individuals) as well as possible risks and adverse events associated with patch testing using contact allergens.

Vesicular erythema multiforme-like reaction to para-phenylenediamine in a henna tattoo

Allergic contact dermatitis reaction to topical "black henna" tattoo is usually described secondary to the organic dye para-phenylenediamine, a derivative of analine. Allergic contact dermatitis reactions to para-phenylenediamine are well recognized and most commonly involve an eczematous reaction that may become generalized and an acute angio-edema. Only four previous instances have been reported of an erythema multiforme-like reaction to para-phenylenediamine and its derivatives, including only one mild reaction to a tattoo. A vesicular erythema multiforme-like reaction has not been reported. An erythema multiforme-like reaction to contact allergens is usually caused by potent allergens including plant quinolones in Compositae and sesquiterpene lactones in exotic woods, and it is also reported to topical drugs, epoxy resin, metals (particularly nickel), and various chemicals. A generalized vesicular erythema multiforme-like reaction is unusual, and rarely reported. We describe a 6-year-old boy who developed a localized, eczematous and severe generalized vesicular erythema multiforme-like contact allergy to para-phenylenediamine secondary to a henna tattoo. As henna tattoos are becoming increasingly popular, one should be aware of the possibility of such a reaction. This presentation also highlights the call to ban the use of para-phenylenediamine and its derivatives in dyes.

Erythema multiforme due to contact with laurel oil

Erythema multiforme is a relatively common skin disorder. The best known cause is herpes simplex virus infection. We report the first case of erythema multiforme due to contact with laurel oil. The diagnosis was confirmed by the positive patch test to laurel oil, the histopathological studies of the lesions and the histopathological studies of the positive patch test to laurel oil.

Delayed hypersensitivity to hydroxychloroquine manifested by two different types of cutaneous eruptions in the same patient

Hydroxychloroquine (HXQ) sulphate is a synthetic antimalaria drug that is widely used in rheumatology due to its immunosuppressive properties. Delayed-type sensitization to this drug is rare. A 47-year-old woman diagnosed with HLA B27 ankylosing spondylitis was treated with HXQ for 22 days and had to discontinue the drug due to gastric intolerance. Five days later the patient developed erythema multiforme (EM) with an extensive and unusual distribution. Patch test with 10% HXQ in DMSO were positive at 48 hours. Eight days later a generalized pruriginous erythematous papular exanthema developed, and a skin biopsy was obtained. The first reaction was EM. Patch-testing elicited systemic eczematous contact dermatitis. We report two different clinical patterns of delayed hypersensitivity in the same patient and with the same drug.

Pemphigus foliaceus with epidermal detachment: adverse events from patch testing

Uncommon adverse reactions to patch testing have been reported, but few cases have shown patch testing to be a potential contraindication. We report a patient with known pemphigus foliaceus who had significant epidermal detachment of normal skin during the removal of patch-testing tape.

Erythema multiforme due to contact with weeds: a recurrence after patch testing

Erythema multiforme (EM) as a complication of patch testing (PT) is rare. A 52-year-old woman with a 13-year history of episodes of EM, after contact with weeds during home gardening, had had no recent history of herpes simplex, other infection, drug ingestion or vaccination. On examination, EM lesions were distributed on the exposed skin. 5 weeks after complete resolution, PT and photopatch testing (PPT) were done with fresh plants she brought in. She was PT with a standard series and the Hermal-Trolab plants, woods, tars, balsams and flavors series. Intradermal testing, with a 3 + reaction to mixed weed pollens, was done 3 weeks later. Specific IgE to weed pollens class 1 (CAP-Pharmacia) was detected. Eczematous PT reactions were obtained with fresh leaves: common chickweed (Stellaria media Caryophyllaceae), dandelion (Taraxacum officinale Compositae), field-milk thistle (Sonchus arvensis Compositae) and white clover (Trifolium repens Leguminosae). Photoaggravation was seen to common chickweed and dandelion. Positive PT was also seen with alantolactone. By the 4-day reading, a typical EM had commenced, coming up to quite the same extent as seen on admission. There was no photosensitivity (UV skin tester, K. Waldmann). In the essential oil obtained from common chickweed, thin layer chromatography (TLC) revealed the well-known contact allergens borneol, menthol, linalool, 1,8-cineole, and other terpenes such as epoxy-dehydro-caryophyllene, monoterpene alcohol-ester and caryophyllene. Up to now, no data on essential oil in Stellaria media (common chickweed) have been reported. It can be concluded that EM developed due to contact with weeds, and recurred after patch testing. Neither blistering nor eczematous lesions have been seen on her skin, making this case very unusual. As far as the world literature is concerned, this is only the 4th report of EM developing in association with patch testing.

(Un)usual effects of patch testing?

BACKGROUND

Little information is available concerning subjective complaints associated with patch testing.

OBJECTIVES

To gather information about the frequency and the nature of such complaints, and to evaluate, if possible, whether the complaints were really caused by patch testing.

PATIENTS/METHODS

Four hundred and thirty-three patients took part in a questionnaire study between December 1996 and October 1997. Complaints of itch and other subjective complaints, such as tiredness and feeling unwell, were recorded.

RESULTS

From the total group of 433 patients, 379 patients (87%) recorded one or more complaints on day 0. By day 2 this number was 383 patients (88%), with a significant reduction to 326 patients (75%) by days 3-4. Most complaints concerned itch on the back, and to a lesser extent tiredness. Fifty-four patients (54 of 433; 12%) did not report itch or other subjective complaints on day 0; of this group, 36 patients (66%) developed complaints by day 2. By days 3-4, 24 patients (44%) reported complaints: 20 patients from the day 2 group (37%) and four patients (7%) from days 3-4. Again the largest increase in complaints was found for itch on the back, but other complaints were also found to have increased, mainly tiredness, feeling unwell, headache, shakiness and light-headedness.

CONCLUSIONS

We conclude that patch testing can, in addition to local skin reaction and itch, also cause other subjective complaints in a number of patients.

Allergy testing in serious cutaneous drug reactions--harmful or beneficial?

We report on 3 cases of adverse cutaneous drug reactions of erythema multiforme type. Despite the serious previous clinical conditions, patch tests with the possible causative drugs have been performed in all our patients, because of multiple candidate drugs and the need of the patients for further treatment with at least some of the agents. We demonstrate that patch tests are a good and safe approach to initial evaluation of the nature of a cutaneous drug reaction. In the case of a positive patch test reaction to one of the substances, re-exposure to the non-reactants in a clinical setting is recommended. If a one-side-blinded placebo-controlled challenge test is well tolerated, then the clinician should be able to reintroduce drugs previously suspected as causing the allergy.