[Use and adverse reactions of local antibiotics and disinfectants on the skin]

The local antibiotics are an important addition to the treatment of moderately severe skin infections. Development of contact allergy and bacterial resistance, however, are some of the adverse reactions that may occur. Fusidic acid and tetracycline are the most suitable products for the treatment of superficial primary infections of the skin caused by Gram-positive cocci and secondary infected dermatoses. In case of insufficient effect mupirocin may be tried. Mupirocin is an effective antibiotic in the treatment of nasal carriage of Staphylococcus aureus in cases of increased risk of infection (haemodialysis, continuous peritoneal dialysis, after thoracic surgery). Besides it is an important local antibiotic in the treatment of meticillin-resistant staphylococci in the nose. In order to prevent development of bacterial resistance its further use has to be restricted. Silver sulfadiazine is a good option for the local treatment of infections by Pseudomonas aeruginosa and other Gram-negative bacteria. Erythromycin and clindamycin are useful local antibiotics for the treatment of mild acne vulgaris. Disinfectants are mainly suitable for the use on the intact skin.

[Contact allergy to eyedrops containing beta-blockers]

In six patients (4 women aged 80, 62, 43 and 52 years and 2 men aged 58 and 51 years), who used eyedrops containing beta-blockers for the treatment of glaucoma, allergic contact dermatitis of the eyelids was diagnosed. Three were allergic to metipranolol, 2 to levobunolol and 1 to timolol. In literature, less than 50 cases of hypersensitivity to beta-blockers in eye medication have been reported. There are, however, reasons to assume that sensitization is more frequent: (a) not all patients are referred by the ophthalmologist to the dermatologist; (b) false-negative reactions to patch tests with the commercial preparations and with beta-blockers are not infrequent; (c) they are not routinely tested because beta-blockers are difficult to obtain in pure form; (d) cross-reactions with other beta-blockers are infrequent, and changing to another preparation therefore usually solves the clinical problem. Nevertheless it is advisable to test a battery of beta-blockers (befunolol, levobunolol, metipranolol, timolol) in allergic patients. A test preparation of 2% in water or 3%-10% in petrolatum may be suitable. Control testing in non-exposed individuals is necessary to exclude irritation reactions.

Methyldibromoglutaronitrile is an important contact allergen in The Netherlands

From 15 May to 15 December 1994, 2943 patients suspected of having contact dermatitis (1955 women, 988 men) were patch tested with methyldibromoglutaronitrile 0.3%, 0.1% and 0.05% pet. 119 patients (4.0%; women 4.1%, men 3.8%) proved to be allergic. 71% of the reactions were considered to be relevant. In 2/3 of the patients, causative products were cosmetics, in 1/3 moistened toilet tissues. Testing with methyldibromoglutaronitrile at lower concentrations (0.05% and 0.1%) and with commercial allergens (Euxyl K 400 and methyldibromoglutaronitrile, both containing methyldibromoglutaronitrile 0.1%), resulted in a number of false-negative reactions. All preservatives in the European standard series had lower scores than the 4% positive reactions to methyldibromoglutaronitrile (formaldehyde 2.0%, MCI/MI (Kathon CG) 3.2%, parabens 1.0%, quaternium-15 1.3%). It is concluded that methyldibromoglutaronitrile (present in the commercial preservative Euxyl K 400) is an important contact allergen in the Netherlands in cosmetics and moistened toilet tissues. It should be added to cosmetics series and to proctological series. The optimal test concentration is unknow, but may be 0.3% pet. The concentration of 0.1% methyldibromoglutaronitrile in the currently available commercial allergens appears to be too low, resulting in a number of false-negative reactions.

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.

Jessner's lymphocytic infiltration of the skin. A clinical study of 100 patients

Jessner's lymphocytic infiltration of the skin is a well-known but poorly understood disorder. Some doubt still exists about whether it is a single entity or a heterogeneous group that can pass into polymorphous light eruption, discoid lupus erythematosus, or even malignant lymphoma. Therefore, a large number of patients with lymphocytic infiltration of the skin (N = 100; 46 male, 54 female) were examined to elucidate these questions. We conclude that lymphocytic infiltration of the skin is a single entity. Progression into polymorphous light eruption, discoid lupus erythematosus, or lymphoma was not observed. However, this study shows that lymphocytic infiltration of the skin and polymorphous light eruption cases occur simultaneously in 1 patient. In this study the cases of 10 patients with this combination are reported. An effective but harmless therapy is yet unknown. Intermittent use of topical steroids can be useful but is not effective in many patients.

Contact allergy to a reaction product in Hirudoid cream: an example of compound allergy

We have investigated patients with a contact allergy to Hirudoid cream. The hypersensitivity reactions appeared to be due to an allergy to the cream base, but the separate ingredients did not give rise to positive patch test reactions. The hypersensitivity proved to be due to an allergy to a reaction product, and the simultaneous presence of the preservatives 1,3,5-trihydroxyethylhexahydrotriazine and thymol was found to be necessary for the occurrence of a positive patch test reaction. A new allergen was found to be formed by the reaction between thymol and the degradation products of the triazine derivative. This allergen was identified by nuclear magnetic resonance spectroscopy and infrared spectroscopy as 3-(hydroxyethyl)-5-methyl-8-(2-methylethyl)-3,4-dihydro-2H-1,3-benzoxazi ne.

Nodular prurigo-like eruptions induced by etretinate

We report two patients treated with etretinate (Tigason) who developed a nodular prurigo-like eruption. We consider this to be an unusual side-effect of the drug.

Effect of short-contact anthralin therapy on ultraviolet B irradiation of psoriasis

The influence of short-contact anthralin on the therapeutic effect of ultraviolet B irradiation (Sylvania UV-21 tubes) was investigated with the half-body comparison method in fifteen outpatients with plaque-type psoriasis. The lesions on the right or left half of the body were exposed to one of the topically applied compounds (either anthralin and 2% salicylic acid in petrolatum or 2% salicylic acid in petrolatum alone) for 10 to 30 minutes daily. Of the fifteen patients, five (Group I) were given 0.3% anthralin and five (Group II) received increasing concentrations of anthralin (0.3, 1, 3%); the other five (Group III) were patients who had failed to respond to ultraviolet B therapy alone, and for them a new clearing treatment was started with the addition of anthralin in increasing concentrations (0.3%, 1%, 3%). Only two patients in Group I, one patient in Group II, and one in Group III showed a moderately better clearance of psoriasis on the short-contact anthralin side. Irritation of nonaffected skin by anthralin was common only during the first week of the treatment. Staining of clothes and bedding occurred.

Effect of photochemotherapy on the cardiovascular system

The effect of PUVA therapy on the cardiovascular system was studied in 2 groups of patients. The first group consisted of 9 otherwise healthy patients, who were treated without airconditioning. The second group was formed by 15 otherwise healthy psoriasis patients, who were treated with photochemotherapy, using airconditioning. In both groups the cabinet-skin and rectal temperature rose significantly. The most marked finding however was the rise in heart rate. By applying airconditioning, significantly smaller increases in the measured parameters occurred. In none of the patients changes in the electrocardiograms were observed. The effects on the cardiovascular system can evidently be limited by applying airconditioning and by keeping the time of light exposure as short as possible.

In-111 leukocyte scanning and partial functional asplenia in a patient with Sézary syndrome

Functional asplenia is described in the case report of an 80-year-old woman who was admitted with Sézary syndrome. The spleen could not be visualized by a Tc-99m tin colloid (SnC) liver and spleen scan, but was visualized by a Tc-99m sulfur colloid (SC) scan, suggesting a different mechanism in accumulation of SnC and SC in the spleen. In-111 oxine labeled Sézary cells could be found in the spleen, bone marrow, and lymph nodes.

Serum vitamin A levels and pruritus in patients on hemodialysis

35 patients attending a hospital dialysis unit were questioned for the presence and severity of pruritus. Attention was given to skin anomalies and loss of hair. In all patients the serum vitamin A level was determined. Although all of them showed an increased serum vitamin A level, no correlation could be found between the vitamin A content and the presence of pruritus.

Plane xanthomata associated with multiple myeloma and hyperlipoproteinaemia

A case of plane xanthomatosis associated with multiple myeloma and hyperlipoproteinaemia in a 62-year-old woman is reported. The patient had IgG type lambda paraproteinaemia and type II A hyperlipoproteinaemia. The IgG paraprotein showed binding activity against high-density lipoprotein. It could not be demonstrated that these paraprotein-lipoprotein complexes were responsible for the hyperlipidaemia. Microchemical analysis of pathological skin demonstrated a high content of triglycerides, similar to that in eruptive xanthomata. No correlation was found between the lipid composition of the xanthomatous skin and the serum lipid composition. The results obtained with an in vitro culture method showed that the paraprotein present in the patient's serum was synthesized in the bone marrow but not in the normal or pathological skin.

Influence of local triamcinolone acetonide on patch test reactions to nickel sulfate

The influence of local application of triamcinolone acetonide on patch test reactions was investigated in patients with a contact allergy to nickel sulfate. In 15 patients the reaction to patch tests with a mixture of 5% nickel sulfate and 0.1% triamcinolone acetonide in petrolatum was compared with the reaction to 5% nickel sulfate in petrolatum. In eight patients the test area on the skin was infiltrated with triamcinolone acetonide or saline solution after which test were performed with nickel sulfate. In eight patients the test area was pretreated with 0.1% triamcinolone acetonide cream or the cream base alone before the patch tests with nickel sulfate were done. In general, all three methods gave partial suppression of the size of the reaction.

Contact allergy to bufexamac

A 44-year-old woman developed an allergic contact eczema due to bufexamac (Droxaryl cream) after the use of this cream for a circumscribed neurodermatitis of the vulva. Patch tests with 5% bufexamac in petrolatum and 1% in acetone were positive. In 20 control persons, the same agents did not cause any skin reaction. The meaning of these findings is discussed.

Allergic vasculitis with atypical localisation

A 42-year-old man with recurrent attacks of blue-black haemorrhages predominantly on the palms and soles is described. Histology of a lesion revealed typical signs of allergic vasculitis. Direct immunofluorescence showed IgG and complement depositions in the vessel walls.

Allergic contact eczema due to chloracetamide

In the period from August, 1969, to December, 1970, 27 patients with a contact allergy to Hirudoid ointment have been seen. In 17 of these patients, it could be demonstrated, that this allergy was due to the presence of the preservative CA 24, containing chloracetamide. Therefore, the use of chloracetamide in creams and ointments for medical use has to be omitted.

On the origin of urocanic acid in the horny layer

In 4 volunteers samples of skin scrapings taken at various depths on the fore-arms were collected for determination of the urocanic acid, amino-nitrogen, and sodium content. The percentage of urocanic acid in the samples from deeper levels was higher than in the superficial material. The ratio between the amounts of urocanic acid and amino-nitrogen was the same in all layers. It is therefore concluded that the urocanic acid in the human stratum corneum is of epidermal origin and is not derived from sweat.