Intolerance and contact allergy to tar and dithranol in psoriasis.
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Biomedical subjects
Publications and source records attributed to M H Beck.
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We have studied, immunohistochemically, hypersensitivity reactions to corticosteroids and compared them with allergic contact dermatitis from nickel and appropriate controls. We could find no qualitative differences between nickel and corticosteroid contact reactions, providing further evidence that hypersensitivity to corticosteroids is an immunologically mediated reaction.
Over a 12-month period, nine patients were seen in a contact dermatitis clinic with an inflammatory dermatosis localized predominantly to the external auditory canal. Of these patients, four were found to have an allergic contact dermatitis which was exacerbating their dermatitis. All were allergic to one or more corticosteroids and topical antibiotics used in the treatment of their dermatitis. We would suggest that hypersensitivity to topical corticosteroids and other medicaments be considered in patients with otitis externa which fails to respond to treatment.
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Topical corticosteroids are increasingly recognized as relatively common contact sensitizers. Between July 1988 and December 1991 2687 patients undergoing routine patch testing were also tested with tixocortol pivalate (TP). Over the same time period 528 patients were selected for testing with a series of 18 steroids. One-hundred and thirty-one cases (4.9%) of corticosteroid hypersensitivity were detected and 119 (90.8%) of these cases were positive to TP. Thirty-seven patients reacted to one or more steroids in the steroid series, the most frequent sensitizers being hydrocortisone, budesonide (3.6%) and hydrocortisone 17-butyrate (2.5%). Of these 37 cases, 20 (54%) reacted to more than one steroid simultaneously, but the patterns of cross-reaction were not consistent with previously suggested groupings. Screening for steroid allergy should be performed as part of standard patch testing. The value of TP as a marker of corticosteroid hypersensitivity is reinforced by this study, but no satisfactory marker was found for the 9.2% of cases not detected by TP. There remains a need for further markers of corticosteroid hypersensitivity. A prevalence of 4.9% of corticosteroid allergy amongst our patients suggests that the frequency of this finding is generally underestimated.
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A case of a psoriatic patient allergic to dithranol and coal tar is described. It is suggested that dithranol 0.001% pet. is a suitable concentration to test for dithranol allergy, as higher concentrations may produce irritant reactions. The literature on dithranol allergy is reviewed and the frequent simultaneous reactions to dithranol and coal tar discussed.
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Computer data on 4721 consecutive patients patch tested with an extended standard series were analysed for the frequency of allergic reactions to each substance. Particular attention was given to the negative first reading at day 2 (D2) which later became positive at day 4 (D4). A total of 4210 allergic reactions were recorded. 993 of which were negative on D2 (24%). The most frequent positive reactions were to nickel sulphate (18%), fragrance-mix (8%), colophony (6%), neomycin (6%), cobalt chloride (6%), thiuram-mix (4%) and potassium dichromate (3%). The frequency of negative D2, positive D4 readings was sizeable for all but one substance, primin, with a range of 14% for fragrance-mix to 64% for neomycin. All of 21 positive reactions to primin were recorded on D2. In our opinion, it is unjustified to perform D2-only patch test readings.
The use of a lymphocyte transformation test (LTT) to confirm allergic contact dermatitis from thiurams has been investigated. The responses of peripheral blood mononuclear cells (PBMC) from thiuram-sensitive and non-sensitive individuals following culture with dimethylcarbamoyl-protein (human serum albumin; HSA) and dimethylthiocarbamoyl-HSA conjugates has been compared. Only PBMC from those patients who were patch-test-positive with thiuram-mix and sensitized to tetramethylthiuram monosulphide (TMTM) or TMTM and tetramethylthiuram disulphide (TMTD) exhibited significant proliferative responses to these conjugates. Thiuram-patch-test-negative patients and control donors with no history of allergic contact dermatitis failed to mount a significant response to any concentration of either conjugate. Two of the thiuram-sensitive patients were also nickel-patch-test-positive, and PBMC isolated from these donors, but not from nickel-patch-test-negative patients, proved positive in a nickel LTT. The data reveal that relevant hapten-protein conjugates are capable of provoking specific human lymphocyte proliferative responses in vitro, and that, using this technique, the LTT can, in principle, be used for the investigation and/or diagnosis of skin sensitization to lipophilic contact allergens.
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