Humoral and cellular immunity in sarcoidosis

The Kveim reaction was studied in vivo in 50 patients with sarcoidosis. Commonwealth Serum Laboratories Kveim material and a new Danish Kveim material gave 14 and 8 positive reactions respectively, as well as 6 and 8 equivocal reactions. Forty-six of the patients were also tested in vitro for cell mediated immunity to the Danish Kveim material, using both the leucocyte migration agarose technique and the capillary technique. No significant migration inhibition or stimulation were found. A tuberculin skin test was performed in 49 of the patients, and in 45 a dinitrochlorobenzene sensitivity titer was determined. Both tests revealed a depression of the cell mediated immunity. The serum levels of immunoglobulins IgG, IgA, IgM, IgD, and IgE were determined. The serum of each patient was also examined to determine if organ-non-specific and granulocyte-specific antinuclear factors of IgG class, antibodies against native DNA, rheumatoid factor, mitochondrial antibodies, antibodies against thyroid cytoplasm, and parietal cell antibodies were present. IgG levels were above normal in 28 patients; IgE was above normal in 10 patients, 4 of whom were atopics or had an atopic disposition. Organ-non-specific antinuclear factors were present in 17 patients.

Estimation of lymphocyte subpopulations in the peripheral blood of patients with sarcoidosis

Lymphocyte subpopulations in the peripheral blood of 36 sarcoidosis patients and 36 age- and sex-matched controls were determined, using the sheep erythrocyte rosette (SRBC-R) technique and immunofluorescence staining with whole rabbit anti-human immunoglobulin antisera. In the patient group the total number of lymphocytes, SRBC-R lymphocytes, and IgM-positive lymphocytes was reduced in comparison to in the control group. In the patient group no correlation could be found between any of the lymphocyte subpopulations and disease stage, cutaneous involvement of the disease, or cutaneous reactivity to purified protein derivative and dinitrochlorobenzene.

Severity of hand eczema assessed by patients and dermatologist using a photographic guide

BACKGROUND

The severity of hand eczema is of interest in epidemiological studies. Ideally, as no validated methods of self-assessment exist, a dermatologist should examine all subjects. However, this is very resource intensive.

OBJECTIVES

To examine if severity grading performed by patients with hand eczema using a self-administered photographic guide was in agreement with the assessment performed by a trained dermatologist. Furthermore, to measure the correlation between the severity of hand eczema expressed on a visual analogue scale (VAS) and the clinical severity assessment, using the photographic guide.

METHODS

Fifty-three consecutive outpatients with hand eczema were included, a number based on a prestudy statistical calculation. The patients were asked to grade current severity of their hand eczema by choosing one of four groups of photographs representing differing severities of hand eczema. On the same day all patients were examined by an experienced dermatologist, who graded the severity using the same photographic guide. The photographic guide was a modified version of a validated guide for use by physicians. In addition, the patients rated the severity of their hand eczema on a VAS.

RESULTS

Fifty-one of the respondents completed the full questionnaire. For 37 of the 51 patients (73%) the clinical severity assessments of patient and dermatologist were identical. The measure of agreement, Cohen's kappa coefficient, was 0.61, indicating good inter-rater agreement. The correlation between the dermatologist-rated severity and the corresponding score by the patients on the VAS was only moderate (Spearman's rank correlation coefficient rho = 0.52).

CONCLUSIONS

The photographic guide for the self-assessment of hand eczema is an easy instrument to use, and for research purposes can be a reliable tool for patients with hand eczema to grade severity. A VAS can only be considered as a mediocre tool for estimation of the dermatologist-rated clinical severity, but should be validated as an independent instrument to assess severity of hand eczema.

Treatment of hand eczema

Hand eczema is a common skin disease that tends to become chronic and may interfere with many types of work. Emollients have been shown to be useful in reducing eczema activity and in the primary prevention of hand eczema. Protection of the hands is very important for the prevention of hand eczema and is a fundamental aspect of the treatment of hand eczema. Although topical corticosteroids are the mainstay of treatment, few studies of their rational use, efficacy and side-effects have been conducted. A combination of tacrolimus and topical corticosteroids may reduce the risk of steroid-associated side-effects. Systemic treatment with immunosuppressants such as cyclosporine and methotrexate show promising results, and acitretin may suppress keratotic hand eczema. Botulinum toxin has been used with success in the treatment of dyshidrotic hand eczema. PUVA is effective as a systemic treatment. Bath-PUVA treatment, UVB and Grenz rays can also suppress hand eczema.

Treatment of hyperkeratotic dermatitis of the palms (eczema keratoticum) with oral acitretin. A single-blind placebo-controlled study

Hyperkeratotic dermatitis of the palms--also called eczema keratoticum--is a chronic, sometimes disabling condition in middle-aged persons. We carried out a single-blind, placebo-controlled study using acitretin in 29 patients. Fourteen patients received active therapy (30mg acitretin daily) and 15 placebo. All had hyperkeratotic changes of the palms with painful fissures and most had involvement of the volar aspects of their fingers. Approximately half of the patients had similar plantar changes. A semi-quantitative score of six parameters was used: hyperkeratosis, fissuring, scaling, itch, redness and vesicle count. After 4 weeks of treatment, a 51% reduction of all symptoms was observed among patients receiving acitretin (p < 0.01) compared with a 9% reduction in the placebo group (p>0.05). No further improvement was seen over another 4 weeks of treatment. There were no changes in blood biochemistry, including serum lipids. No patients discontinued therapy because of side effects. We conclude that 30 mg of acitretin is efficacious and safe to use in patients with hyperkeratotic dermatitis of the palms.

Reduced nickel sensitivity in young Danish women following regulation of nickel exposure

In most western countries, nickel is the most common contact allergen among young women. In 1991, Denmark implemented a statutory order calling for the reduction of exposure to nickel in nickel-plated items in close contact with the skin. In a retrospective analysis, a comparison is made of the number of positive patch tests to nickel seen in a private practice of dermatology before and after this statutory order was implemented. From 1 January 1986 to 31 December 1989, 35 of 1135 (3.1%) men patch tested and 628 of 3024 (20.8%) women patch tested had positive reactions to nickel. From 1 January 1996 to 31 December 1999, 48 of 1104 (4.3%) men and 424 of 2193 (19.3%) women had positive patch tests to nickel. During the 1st period, 155 of 702 women under the age of 20 (22.1%) had positive patch tests to nickel, compared to 54 of 324 (16.7%) during the second period (p<0.05). The most likely explanations of this decrease in nickel sensitivity are reduced exposure to nickel and increased public awareness of the risk of nickel sensitization.

Brachioradial pruritus

Twenty-one patients seen in a temperate climate who had a clinical diagnosis of brachioradial pruritus are presented. The history and clinical manifestations of the patients indicate that the symptoms were neuralgiform and caused by cumulative sun exposure.

[Keratin diseases]

The rapid development in human genome research has resulted in a tremendous increase in our understanding of the molecular basis of many genetic skin diseases. One outstanding example of this is diseases caused by mutations in keratin genes, which comprise several disorders of the epidermis, as for example the different types of epidermolysis bullosa simplex. In this respect, the most important questions have been to 1. Define the molecular defect. 2. Unravel the pathophysiological mechanisms that lead to the characteristic phenotype and 3. Design of new therapeutic strategies. Molecular research has contributed significantly to the first two issues whereas a therapeutic break-through has yet to appear.

[Epidermolysis bullosa simplex: genotype-phenotype correlation in Danish patients]

Epidermolysis bullosa simplex (EBS) is a group of autosomal dominant inherited skin disorders caused by mutations in the keratin genes K5 or K14. We examined five Danish families with EBS-Weber-Cockayne (WC) or EBS-Koebner (K) and two sporadic cases of EBS-Dowling-Meara (DM) in order to investigate the mutational spectrum and evaluate the genotype-phenotype correlation in Danish patients. Three new K14 mutations, one new and one previously described K5 mutation were identified by DNA sequence analysis. The positions of the EBS-DM mutations were consistent with previous studies, whereas the EBS-WC and EBS-K mutations were found in regions of the keratin genes not typically associated with this type of EBS mutations. In conclusion, we found a strict genotype-phenotype correlation. Furthermore, we found that the position of the mutation in the keratin gene is not the only determinant for severity of the disease; the nature of the amino acid substitution should also be considered when predicting the severity of the EBS disorder.

Long-term, intermittent treatment of chronic hand eczema with mometasone furoate

Chronic hand eczema can be incapacitating, and there is little knowledge of the efficacy and safety of long-term treatment with topical corticosteroids. We compared the efficacy and safety of two different schedules for the treatment of chronic hand eczema with a potent topical corticosteroid, mometasone furoate. In a prospective, open, randomized trial, 120 patients with chronic hand eczema were treated daily with mometasone furoate fatty cream until the dermatitis cleared or for a maximum of 9 weeks. Those who cleared were randomized to treatment for up to 36 weeks with mometasone furoate on Sunday, Tuesday and Thursday (group A), mometasone furoate on Saturday and Sunday (group B) or no further corticosteroid treatment (group C). In the event of relapse, patients were permitted daily treatment with mometasone furoate for 3 weeks on two separate occasions. For 50 of 106 randomized patients, daily treatment for 3 weeks controlled their dermatitis; 29 needed 6 weeks and 27 needed 9 weeks of treatment. During the maintenance phase, 29 of 35 (83%) in group A, 25 of 37 (68%) in group B and nine of 34 (26%) in group C had no recurrences (P = 0.001, chi2-test). Side-effects were minimal. It is concluded that long-term, intermittent treatment of chronic hand eczema with mometasone furoate fatty cream is effective and safe.

Identification of novel and known mutations in the genes for keratin 5 and 14 in Danish patients with epidermolysis bullosa simplex: correlation between genotype and phenotype

Epidermolysis bullosa simplex (EBS) is a group of autosomal dominant inherited skin diseases caused by mutations in either the keratin 5 (K5) or the keratin 14 (K14) genes and characterized by development of intraepidermal skin blisters. The three major subtypes of EBS are Weber-Cockayne, Koebner, and Dowling-Meara, of which the Dowling-Meara form is the most severe. We have investigated five large Danish families with EBS and two sporadic patients with the Dowling-Meara form of EBS. In the sporadic Dowling-Meara EBS patients, a novel K14 mutation (N123S) and a previously published K5 mutation (N176S) were identified, respectively. A novel K14 mutation (K116N) was found in three seemingly unrelated families, whereas another family harbored a different novel K14 mutation (L143P). The last family harbored a novel K5 mutation (L325P). The identified mutations were not present in more than 100 normal chromosomes. Six polymorphisms were identified in the K14 gene and their frequencies were determined in normal controls. These polymorphisms were used to show that the K14 K116N mutation was located in chromosomes with the same haplotype in all three families, suggesting a common ancestor. We observed a strict genotype-phenotype correlation in the investigated patients as the same mutation always resulted in a similar phenotype in all individuals with the mutation, but our results also show that it is not possible to predict the EBS phenotype merely by the location (i.e., head, rod, or linker domains) of a mutation. The nature of the amino acid substitution must also be taken into account.

The clinician's choice of antibiotics in the treatment of bacterial skin infection

The development of modern antibiotics has vastly improved the therapy of cutaneous bacterial infections, particularly those caused by Staphylococcus aureus. This organism and beta-haemolytic streptococci are the most common cutaneous pathogens. A growing body of evidence suggests that proteins from S. aureus and some strains of streptococci can act as superantigens and cause polyclonal T-cell activation by binding directly to antigen-presenting cells. This process is a likely explanation of Kawasaki's syndrome as well as staphylococcal and streptococcal toxic shock syndrome. Sudden aggravation of atopic dermatitis, contact dermatitis and some cases of psoriasis can be similarly explained. Bacterial toxins can precipitate the staphylococcal scalded skin syndrome. Specific and effective eradication of bacteria and programmes to prevent recurrences are important, particularly in immune suppressed persons. Topical antibiotics used primarily for superficial infections of limited extent and for the prevention of recurrences in carriers of S. aureus should be combined with the use of topical disinfectants. The treatment of selected bacterial skin infections based on clinical examples will be discussed. These include secondarily infected dermatoses, cellulitis and streptococcal carriage in the ano-genital region and staphylococcal folliculitis and nasal carriage.

Once daily treatment of psoriasis with tacalcitol compared with twice daily treatment with calcipotriol. A double-blind trial

Once daily topical treatment of psoriasis with tacalcitol ointment (4 micrograms/g) was compared with twice daily treatment with calcipotriol ointment (50 micrograms/g) in a double-blind, randomized study over a treatment period of 8 weeks. The severity of pruritus, erythema, infiltration and scaling was scored on a scale from 0 to 4. These features were scored at the initiation of treatment, after 2, 4, 6 and 8 weeks of treatment, and at 4 weeks after discontinuation of treatment. The sum score was the total score for erythema, infiltration and scaling. Serum levels of calcium, phosphate, ionized calcium and intact parathyroid hormone were used as safety parameters. Two hundred and eighty-seven adults with stable plaque psoriasis participated and were treated at least once. Both tacalcitol and calcipotriol ointments effectively reduced the severity of psoriasis. The mean reduction in the sum score in the intention-to-treat population of 287 patients was 4.03 in the group treated with tacalcitol compared with 5.05 in the group treated with calcipotriol. The mean baseline sum scores were 7.64 and 7.15, respectively. The acceptability of both ointments was excellent, and none of the patients had adverse effects in terms of increased serum calcium or other alterations in calcium metabolism. Although less effective than calcipotriol ointment used twice daily, tacalcitol ointment is an effective and useful once daily treatment of chronic plaque psoriasis.

[Milker's nodules]

Milker's nodule is a parapox virus infection seen mostly on the hands of dairy farmers. We saw 15 cases over a period of two years in the County of North Jutland. Clinically, milker's nodule goes through a papular, a nodular and a crusted stage. Most patients were seen when the infection was in the nodular stage, an often painful condition requiring treatment. Three patients developed an erythema multiformelike secondary eruption. Lesions from nine patients were removed for histological examination. The histology of all lesions was consistent with milker's nodule. In three of seven patients parapox virus was demonstrated by electron microscopy. Treatment was commonly curettage followed by cauterization.

Oral terbinafine in toenail dermatophytosis. A double-blind, placebo-controlled multicenter study with 12 months' follow-up

The treatment of onychomycosis has previously often been protracted and unsuccessful. Terbinafine has been shown to be effective in short-term regimens. In this double-blind, placebo-controlled study, 148 patients with toenail dermatophytosis were randomized to treatment with either 250 mg terbinafine daily or placebo for 3 months. An additional treatment was given for 3 months to patients whose infection had not responded. The patients were followed clinically and mycologically through 12 months. After 3 months 82% of the terbinafine-treated group, versus 5% of the placebo group, showed significant improvement, i.e. negative culture and growth of unaffected nail more than 2 mm (p = < 0.0001). After 12 months clinical and mycological cure was seen in 40% of the patients treated with terbinafine for 3 or 6 months, while 67-81% were clinically cured, but with positive microscopy. Side-effects occurred in 13.5% of the terbinafine group, versus 5.4% of the placebo group, and were mild. 250 mg terbinafine daily for 3 months was significantly more effective than placebo. The efficacy did not appear to improve with additional treatment for 3 months.

[Results of treatment of non-melanoma skin cancer in a dermatologic practice. A prospective study]

The study was carried out to determine the results of treatment of a cohort of patients with histologically verified non-melanoma skin cancer diagnosed and followed prospectively for two years in a private practice of dermatology. Throughout the follow-up period, any new non-melanoma skin cancers among this cohort were recorded. Six hundred and forty-six consecutive patients seen in the Dermatology Clinic, Vesterbro 99, Aalborg, Denmark, from July 1, 1990, to June 30, 1993, had a total of 768 tumours that were histologically verified as basal cell carcinoma, squamous cell carcinoma or Bowen's disease. Six hundred and twenty-eight tumours in 526 patients were treated in our clinic, 91% of these with curettage followed by electrocautery. Hundred and twenty patients with a total of 140 tumours were referred to a local hospital for treatment. Thirty-six of the 508 basal cell carcinomas treated in the clinic recurred during the follow-up period, and one mixed tumour (basal cell and squamous cell carcinoma) recurred. During the follow-up period, 151 new non-melanoma skin cancers were detected. In addition, 10 patients each developed 10 or more new tumours.

Atopic dermatitis may be linked to whether a child is first- or second-born and/or the age of the mother

Five hundred and thirty families with at least 1 child who had been referred to a dermatologist with atopic dermatitis were interviewed in an effort to determine whether factors such as the age of the mother when a child is born and/or birth rank can contribute to the development of atopic dermatitis. The families interviewed had a total of 1,084 children, or an average of 2 children per family. Sixty per cent of the children with atopic dermatitis were under 5 years of age. Ninety-one per cent of them had developed the disease before the age of 3; those most severely affected had developed the disease during the first year of life. In families with 2 children, but only 1 child with atopic dermatitis, the odds ratio for the second child to develop atopic dermatitis was 1.379 (0.025 < p < 0.05). The average maternal age was 24.8 to 25.2 years when giving birth to the first child and 28 years when giving birth to the second child, irrespective of the status of the child. Thus, atopic dermatitis can be related to birth rank or to the age of the mother.

Can oral challenge with balsam of Peru predict possible benefit from a low-balsam diet?

BACKGROUND

Previous studies have shown that some patients sensitive to balsams and/or fragrances obtain long-term benefits by following a low-balsam diet, whereas others do not.

OBJECTIVE

This study was performed to determine whether a low-balsam diet was a helpful long-term treatment for selected patients sensitive to balsam of Peru and/or a perfume mixture and to determine whether oral challenge with balsam of Peru could predict which balsam-sensitive patients might benefit from a reduction in balsam intake.

METHODS

Questionnaires were sent to 46 patients with positive patch test results to balsam of Peru and/or a perfume mixture and chronic dermatitis of a morphology consistent with endogenous dermatitis who had experienced improvement after 1 to 2 months on a diet intended to reduce the intake of balsams. The questionnaires were mailed 1 to 3 years after the initiation of the diet treatment to inquire about a possible long-term benefit of the diet.

RESULTS

Twenty-eight of the 46 patients stated in the questionnaire that they had long-term benefits from the diet treatment. These included 16 of 22 patients who had reacted to a placebo-controlled oral challenge with 1 g balsam of Peru, 3 of 10 who had no reaction or a placebo reaction to the oral challenge, and 9 of 14 who had not been challenged orally. The efficacy of the diet treatment was not correlated to whether the patient had patch test reactivity to either balsam of Peru, the perfume mixture, or both substances. Food items most commonly mentioned by patients as causing aggravation of their symptoms on at least three different occasions were wine, candy, chocolate, cinnamon, curry, citrus fruit, and flavorings.

CONCLUSIONS

In its present form, the oral challenge procedure with balsam of Peru offers only limited assistance in selecting patients who are likely to benefit from diet treatment.

Chromate-allergic patients challenged orally with potassium dichromate

30 patients who had positive patch tests to potassium dichromate participated in a placebo-controlled oral challenge with 2.5 mg chromium given as potassium dichromate. 17 reacted to chromate but not to the placebo, 2 reacted to both chromate and the placebo, and 4 reacted to the placebo but not chromate. 7 patients had no reaction. A specific reaction to chromate was most common among patients with dermatitis of the hands and/or feet.

Plantar Trichophyton rubrum infections may cause dermatophytids on the hands

Over a 2-year period, we saw 37 patients with a diagnosis of dermatophytid on the hands based on 1) culture-proven dermatophytosis on one or both feet; 2) symmetrical, secondary vesicular eruptions on the fingers and/or palmar aspects of the hands; and 3) a resolution in both areas of involvement after treatment of the dermatophytosis on the foot. During the study period, 128 patients had culture-proven dermatophytosis of the feet caused by Trichophyton rubrum. Nine of these (7%) developed dermatophytid. Seventy-eight patients had dermatophytosis of the feet caused by Trichophyton mentagrophytes. Twenty-seven of these (35%) developed dermatophytid. One of 6 patients infected on the feet with Epidermophyton floccosum developed dermatophytid.

Stomatitis or systemically-induced contact dermatitis from metal wire in orthodontic materials

5 patients with dermatitis or stomatitis related to the use of orthodontic appliances are described. All the patients were patch tested with the European standard series. One had a ++ reaction to potassium dichromate, one a ++ reaction to nickel, and the remaining 3 no positive patch tests. 3 of the patients had recurrent vesicular hand eczema, which flared after oral challenge with 1 of the metals used in their orthodontic appliances. 2 of these 3 patients had negative patch tests. The dermatitis of 4 of the 5 patients cleared completely upon the removal of their metal orthodontic appliances or their replacement with appliances made of acrylics.

Nickel sensitivity and occupational skin disease

One of the earth's most common metals, nickel, is present in items ranging from uniform buttons to semiconductors. Nickel also represents the most frequently occurring contact allergen. This chapter describes numerous ways that nickel is used industrially and details the clinical features, diagnosis, and prevention of this sensitivity.

Low nickel diet: an open, prospective trial

BACKGROUND

Nickel-sensitive patients may experience persistent dermatitis even if they avoid cutaneous contact with nickel-plated items.

OBJECTIVE

The purpose of the study was to determine whether reduced nickel intake in food reduces the activity of dermatitis in selected nickel-sensitive persons.

METHODS

Ninety nickel-sensitive patients who had a flare of dermatitis after oral challenge with 2.5 mg of nickel but had no reaction to a placebo were instructed to adhere to a low-nickel diet.

RESULTS

Fifty-eight of the 90 patients benefited in the short term from the diet, whereas 15 others had possible benefit. Seventeen patients did not benefit in the short term. Fifty-five patients who adhered to the diet for at least 4 weeks, and whose dermatitis had cleared or improved at the end of this time, responded to a questionnaire follow-up 1 to 2 years later. Forty of these patients had long-term improvement of their dermatitis. Patients with strongly positive patch tests to nickel had less benefit from the diet than patients with moderately positive patch tests.

CONCLUSION

Reduction of the dietary intake of nickel may benefit some nickel-sensitive patients.

Eruptive syringoma mimicking urticaria pigmentosa. A case report

A case of eruptive syringoma with the clinical features of urticaria pigmentosa is described. A histological specimen revealed a syringoma with an increased number of mast cells in the connective tissue.

[Aluminum allergy caused by DTP vaccine]

All children referred to two private dermatological practices from 1 Jan. 1985 to 31 Dec. 1990 who had pruritus and subcutaneous infiltrates in the areas of immunization with Di-Te-Pol vaccine were patch tested with a Finn Chamber or with 2% aqueous aluminium chloride. Di-Te-Pol vaccine contains aluminium hydroxide. Contact allergy to aluminium was demonstrated in 32 children (20 girls and 12 boys). Of the three patch test methods used, testing with 2% AlCl3 occluded with a Finn Chamber proved to be the most sensitive. Immunization of children who have been shown to be allergic to aluminium should be carried out with vaccines which do not contain aluminium.

Vaccination granulomas and aluminium allergy: course and prognostic factors

21 children who had cutaneous granulomas following immunization with a vaccine containing aluminium hydroxide, and who had positive patch tests to aqueous aluminium chloride and/or to a Finn Chamber, were followed for 1 to 8 years. During the period of observation, the symptoms cleared in 5 children, improved in 11, and remained unchanged in 5. The course of the granulomas could not be correlated with sex or atopy, nor with intensity of the initial aluminium patch test. 4 children were patch tested again with aluminium.

Contact sensitization to 5-chloro-2-methyl-4-isothiazolin-3-one and 2-methyl-4-isothiazolin-3-one (MCI/MI). A European multicentre study

The frequency of positive reactions to 5-chloro-2-methyl-4-isothiazolin-3-one and 2-methyl-4-isothiazolin-3-one (MCI/MI) were studied at 22 European contact dermatitis clinics over a period of 1 year. A total of 4713 patients participated. All the patients were patch tested with nickel sulphate, formaldehyde, paraben-mix, and MCI/MI. 19.4% of the patients had positive patch tests to nickel, making this the most common allergen. 3% of the patients reacted to 100 ppm MCI/MI, while 2.6% reacted to formaldehyde and 1.1% to parabens. There was great variation in the frequency of MCI/MI sensitivity among the 22 centres. MCI/MI contact allergy was most common among women and in patients with facial dermatitis, while it was rarely seen in patients with dermatitis on the lower legs. There were no fluctuations in the number of positive patch tests to MCI/MI on a monthly basis when the results from all centres were combined. 117 of the 141 MCI/MI sensitized patients included in the study were retested. 88% had positive patch tests when retested. 101 of the MCI/MI-sensitive patients participated in a double-blind, placebo-controlled product use test. This test showed that 31% of the MCI/MI-sensitive patients had a positive reaction to a MCI/MI-preserved product. Only a few patients reacted to a control product. It is concluded that the preservative MCI/MI is an important new contact allergen.

Topical metronidazole in the treatment of perioral dermatitis

The twice-daily topical application of 1% metroindazole cream was compared with 250 mg oral tetracycline, taken twice daily, in the treatment of perioral dermatitis in a prospective, double-blind, double-dummy, randomized, multicenter trial. One hundred eight patients were treated for 8 weeks. At the end of this time the median number of papules in the metronidazole-treated group was reduced to 8% of the initial number, and the median number in the group treated with tetracycline was reduced to 0% of the initial number. Although both treatments were effective, oral tetracycline was significantly more effective than topical metronidazole.

Nickel contact allergy and a nickel-restricted diet

More than half of nickel-allergic patients develop secondary eruptions, that is, dermatitis in areas of the skin that are not in obvious contact with nickel-plated items. Similar eruptions occur after placebo-controlled oral challenge with inorganic nickel salts. The possible relationship between ingestion of nickel in food and secondary eruptions in nickel-sensitive patients is discussed, making reference to the available literature. Recommendations are given for the management of patients suspected to have nickel dermatitis aggravated by nickel in food.