Nickel is the major cause of allergic contact dermatitis. It is a widely spread metal, being therefore very difficult to avoid. Nickel cutaneous allergy can occur in occupa-tional and non-occupational contexts and can result from direct cutaneous contact, systemic as well as airborne exposure. Such allergy can manifest with typical lesions of allergic con-tact dermatitis or with peculiar features such as follicular erythemato-micropapular-vescicular lesions. Diagnosis of allergic contact dermatitis to nickel is based on patch test-ing, employing nickel sulfate 5% in petroleum jelly. Reactions to patch test have to be assessed at 48-72 hours, and up to 6 days. Nickel contact dermatitis can be managed with the traditional therapeutic approach used in allergic contact dermatitis. As of today, hyposensitization therapy with oral nickel represents to be the only treatment acting on the pathogenetic mechanisms of nickel allergy.

Although sunscreens are widely used by an increasing number of people, they rarely cause adverse reactions such as allergic and photoallergic contact dermatitis. Benzophenone and octocrylene are the sun filters that most commonly cause allergic reactions, however other filters may sometimes play a role as sensitizers. We report a case of an allergic contact dermatitis to tinosorb M®, an organic compound with physical and chemical sun filter features. It contains methylene bis-benzotriazolyl-tetramethylbutylphenol (its active component), water, propylen glycol, xanthan gum and decyl glucoside. This latter is a surfactant that is added to stabilize the compound. Commonly well-tolerated, tinosorb M® has been recently described as sensitizer. It may cause allergic and photoallergic contact dermatitis caused by the filter itself or by decyl glucoside. Due to such sensitizing proprieties, and to the cross-reactivity of decyl glucoside with other glucosides present in several cosmetics, recently a new kind of tinosorb M glucosyde-free has been introduced to the market.

Mycobacterium marinum is a non-tuberculous photochromogenic mycobacterium, commonly responsible for fish and amphibious infections world-wide. Contagion in humans typically follows minor hand trauma from aquarium keeping and manifests as a granulomatous infection of the skin. Dissemination is rare and almost exclusive to immunosuppressed hosts. 15 cases of M. marinum fish tank related infection are hereby reported. The site of infection was the upper limbs in all cases. 3 patients presented a single papulo-verrucous lesion, while the remaining 12 showed a sporotrichoid clinical pattern. Diagnosis was reached by history and clinical examination and further supported by one or more of the following criteria: histology, culture, acid fast bacilli identification from histologic specimen and PCR. 2 to 3 months minocycline treatment showed efficacy in 13 individuals, another case was treated with rifampicin-isoniazid association, yet another showed spontaneous regression over a 3 month period.

BACKGROUND: data on epidemiological impact and clinical characteristics of chronic hand eczema in Southern Europe are lacking. OBJECTIVES: to estimate prevalence of chronic hand eczema and its different stages of severity and refractoriness to standard therapy among patients accessing Italian dermatological reference centers, and to evaluate socio-demographic and clinical factors associated with each different stage. METHODS: A cross-sectional multicenter study was conducted. Adult hand eczema patients, consecutively accessing 14 centers through a 6-month period, were enrolled. Patients were classified according to disease duration, severity and response to standard therapy with potent topical corticosteroids. Logistic regression analyses were performed to investigate relationship between socio-demographic and clinical data with different stages of eczema. RESULTS: 981 patients participated. Hand eczema was chronic in 83.5% of patients. Among them, 21.3% were severe, 62% of these patients being refractory to standard therapy. Food processing and related works, health professions, craft and related trades works (builders, plumbers, electricians), hairdressers/beauticians and handicraft works were the jobs most frequently associated with having chronic hand eczema. Severe chronic hand eczema was more likely to be among men, older patients and those with lower education. Severe and refractory hand eczema was also more likely among unemployed and patients with allergic rhinitis and/or atopic dermatitis. CONCLUSIONS: Chronic hand eczema is frequent among hand eczema patients accessing dermatology centers. Many patients were severe and refractory to standard therapy. The appropriate identification of hand eczema is a first step necessary to implement effective and efficient treatments. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Background Little is known about the socio-economic burden of severe chronic hand eczema in patients refractory to treatment with potent corticosteroids. Objectives To estimate the socio-economic burden of severe chronic hand eczema refractory to potent topical corticosteroids, and to establish an algorithm for the estimation of the health-related quality of life EuroQol five-dimensional (EQ-5D) utility index from the Dermatology Life Quality Index (DLQI) summary score. Methods A multicentre cost of illness study was conducted, adopting the societal perspective. Adult patients with severe and refractory chronic hand eczema were enrolled. Direct (e.g. drug treatment and travel) and indirect (i.e. loss of productivity) mean costs/patient-month were estimated. Health-related quality of life was assessed with the EQ-5D and DLQI questionnaires. An ordinary least square regression model was used to investigate relationships between health-related quality of life scores. Results One hundred and four valid patients (mean age 44.5 years, 39.4% male) participated. Overall mean costs were €418.3/patient-month: loss of productivity contributed 43.7%, followed by hospitalization (16.1%) and travel (10.3%). Health-related quality of life scores were, on average, 0.50 (EQ-5D utility) and 11.3 (DLQI). Utility and DLQI summary were significantly related to each other. Conclusions Wellbeing and loss of productivity are the most important consequences in these patients. Appropriate treatment is necessary to improve patient health and productivity, which will contribute to reducing societal costs.

Background. Nickel contact allergy remains common in Western countries, and the dermatitis may require prolonged treatment. The development of new strategies aimed at improving the quality of life of affected individuals is needed. Objectives. To investigate the efficacy of oral hyposensitization in nickel-allergic individuals and how this affects in vitro T cell responsiveness to the metal. Methods. Twenty-eight nickel-allergic patients received a daily dose of 50 μg of elemental nickel (given as NiSO 4·6H 2O) in cellulose capsules for 3 months. Severity of clinical manifestations, in vivo nickel responsiveness and in vitro T cell responses to the metal were assessed after 1 and 3 months. Results. Twenty-six patients finished the study. In these patients, oral hyposensitization ameliorated clinical manifestations despite continued nickel exposures, and increased the threshold of skin responsiveness to nickel. The 12 enrolled patients in the immunological study showed decreased in vitro T lymphocyte responsiveness to the metal, in terms of both cell proliferation and cytokine release. In the 1-year follow-up, 50% of the patients experienced relapses of the clinical manifestations at sites of topical exposure to nickel. Conclusions. Our study suggested therapeutic efficacy of oral hyposensitization in allergic individuals. Placebo-controlled studies are required to confirm the results and determine the optimal therapeutic regimen for prolonged beneficial effects.

Skin infections represent an important public health issue and cost-driver. Additionally, chronic skin lesions are sometimes colonized by Gram-negative species. Topical therapies are a key component in the management of mild-to-moderate skin infections. In such cases, topical antibiotics may be preferable to systemic treatment, since they maximize the effective doses at the site of infection while minimizing the systemic side effects of the drugs. However, the prevalence of resistant strains is steadily increasing and cases of sensitization are not uncommon. As a consequence, the ideal topical antibiotic should be selective (thus, minimizing cross-resistance), have weak sensitization potential, penetrate the skin efficiently, reach adequate local doses at the site of infection, and finally be available in different formulations matching patients' preferences and needs. Fusidic acid (FA) is a selective antibiotic available in several topical formulations. Pharmacokinetic and pharmacodynamic studies have shown that, contrary to other topical antibiotics such as gentamicin or mupirocin, FA reaches high antimicrobial concentration at deep skin layers after topical application either on intact or damaged epidermis. Several randomized controlled trials demonstrated that FA, in its various topical formulations, is very effective in treating skin infections, given its high bactericidal activity against S. aureus (including strains resistant to penicillin, methicillin, ampicillin, cloxacillin), S. epidermidis, Streptococcus pyogenes, Propionibacterium acnes, Corinebatteria, Clostridia. Additionally, FA presents a low risk of resistance even in methicillin-resistant S. aureus strains, a common pathogen implied in the etiology of skin infections and infected atopic eczema. Such feature makes FA particularly useful in the management of these medical conditions. Finally, possibly due to its large steric effect, FA has proved a very low risk of contact sensitization. Overall, data on FA efficacy, safety, sensitization potential, resistance profile and spectrum selectivity make it a first-choice option in the treatment of primary and secondary skin infection.

Parabens were introduced in the 30s and currently represent the most common preservatives in cosmetics, in topical as well as systemic drugs and in alimentary products. Chemically, they are p-hydroxybenzoic acid alkylesters. Methyl, ethyl, propyl and butylparaben are frequently used, the former two especially. Their great popularity results from a series of useful properties: they are inexpensive, odorless, tasteless, colorless and show an ample anti-bacterial spectrum. Parabens have always been cause of argument, first because of their sensitizing capacities, and recently given their alleged mammary cancerogenic potential and hormonal interferences. From an allergological perspective, parabens constitute weak sensitizers. As a matter of fact, contact allergy incidence to these substances has always been low, and today reaches negligible levels, given their banning from most cosmetic products. Contact allergy highest percentages used to be associated to topical parabens containing drugs which were applied on lesional skin (wounds, ulcers, preexisting contact dermatitis). Percentages have conversely always been low following use of cosmetic products on healthy skin. A recent literature review ruled out parabens responsibility (as contained in antiperspirants) in mammary cancer determinism. These compounds have also been suspected to interfere with sexual hormones. At recommended doses, however, methyl and ethylparaben do not show any hormonal effects in humans. Further studies concerning propyl and butylparaben are advisable, given their possible fertility impairing effect in males which were exposed during their childhood. Key words: breast cancer, contact allergy, cosmetics, hormones, estrogens, parabens, percutaneous absorbtion, p-hydroxibenzoic acid.

CONTEXT: Alkyl glucosides and alkyl poly-glucosides are widely used as wetting agents, surfactants and emulsifiers in several industrial and cosmetic products. They are known as well-tolerated and are usually added to the primary surfactants in order to reduce the irritating potential of the main foaming agents. OBJECTIVE: Recently, some authors suggested that allergic contact dermatitis to alkyl glucosides might be more frequent than suspected. On the other hand, the chemical structures of glucosides do not show potentially allergenic chemical groups or strongly polarized structures. The aim of our study is to investigate alkyl glucosides carrying out a detailed chemical analysis on samples of raw materials to identify potentially allergenic impurities or by-products contained in commercial samples of alkyl glucosides. MATERIALS AND METHODS: We chemically analyzed samples of cocoyl glucoside, decyl glucoside and lauryl glucoside by three different analytical methods, in order to identify any undesired or polluting substances. RESULT: In each of the three samples, we detected the presence of isobornyl acrylate. Its approximate content in the tested samples is 500 ng/g of the product. DISCUSSION: Isobornyl acrylate is not used in the synthesis of alkyl glucosides, but as a plasticizer in many plastic materials. It can be easily released to materials flowing over these surfaces when they have high extraction power, as glucosides. CONCLUSION: Isobornyl acrylate may play a role as hidden allergen, in the form of an impurity collected during the industrial process, explaining some cases of allergic reaction to alkyl glucosides.

Background: A non-steroidal, anti-inflammatory moisturizing cream containing rhamnosoft, ceramides, and L-isoleucine (ILE) (pro-AMP cream) has been recently developed for the specific treatment of atopic eczema (AE) of the face. In this trial, we evaluated the clinical efficacy and tolerability of pro-AMP cream in the treatment of facial AE in children in comparison with an emollient cream. Methods: In a randomized, prospective, assessor-blinded, parallel groups (2:1) controlled trial, 107 children (72 allocated to pro-AMP cream and 35 allocated to control group) with mild-to-moderate chronic AE of the face were enrolled. Treatments were applied twice daily for a 6-week period. Facial Eczema Severity Score (ESS) was evaluated at baseline, week 3, and week 6, by an assessor unaware of treatment allocation. Investigator's Global Assessment (IGA) score was assessed at week 3 and at week 6. Tolerability was evaluated at week 3 and at week 6 using a 4-point score (from 0: low tolerability to 3: very good tolerability). Results: At baseline ESS, mean (SD) was 6.1 (2.4) in the pro-AMP cream group and 5.3 (3) in the control group. In the pro-AMP group, in comparison with baseline, ESS was significantly reduced to 2.5 (-59%) after 3 wks and to 1.0 (-84%) at week 6 (p = 0.0001). In the control group, ESS was reduced to 3 (-42%) at week 2 and to 2.6 (-50%) at week 6. At week 6, ESS in pro-AMP cream was significantly lower than the control group (1.0 vs. 2.6; p = 0.001). Both products were well tolerated. Conclusion: Pro-AMP cream has shown to be effective in the treatment of mild-to-moderate chronic lesion of AE of the face. Clinical efficacy was greater in comparison with an emollient cream.

BACKGROUND: Etiopathogenesis of nummular eczema is obscure; many causative factors have been proposed. Only a few studies investigated the relevance of contact allergy. OBJECTIVE: This retrospective study aimed to investigate the role of contact allergy in the underlying mechanism of nummular eczema. METHODS: From the 29,323 consecutive patients, we patch-tested for eczematous dermatitis of various type, 1022 (3.5%) with nummular eczema were enrolled. Data were collected for each patient, including age, sex, occupation, symptoms onset and duration, onset and spread sites, and clinical evidence or history of atopy. Histological analyses of acute phase lesions were carried out in some patients. RESULTS: Peak incidence of age at disease onset was found in the third decade of life. Predominant sites of lesions were upper (75.8%) and lower (64.5%) limbs, followed by trunk, dorsum of the hands, and face and neck. Three hundred thirty-two (32.5%) of 1022 patients showed positive reactions to 1 or more allergens. Highest sensitization rates were found with nickel sulfate (10.2%), potassium dichromate (7.3%), and cobalt chloride (6.1%). Histopathology showed less pronounced spongiosis in atopic subjects and the elderly. CONCLUSIONS: Because this study demonstrates that contact allergy is common with nummular eczema, patch testing is strongly advisable in every patient with persistent nummular dermatitis.

BACKGROUND: Photocontact dermatitis to Ficus carica is induced by furocoumarins present in sap. These substances are generally considered to cause phototoxic reactions. OBJECTIVES: We conducted a patch test and histopathological study of patients with phytophoto contact dermatitis from the fig tree to evaluate the mechanism underlying the photoreaction. PATIENTS AND METHODS: Patch and photopatch testing with serial dilutions of two natural furocoumarins [5-methoxypsoralen and 8-methoxypsoralen (8-MOP)] contained in plant sap were performed in 47 patients. A synthetic furocoumarin, 4,5',8-trimethylpsoralen, was also tested. Histopathological analyses were made of some positive photoreactions. RESULTS: Positive photopatch tests reactions to 8-MOP were obtained in 12 of 47 patients, in 4 of them down to a concentration of 0.0001%. Patch tests and photopatch tests to the other two furocoumarins were negative. Histopathological findings on biopsies from positive photopatch tests to 8-MOP showed a dermatitis. CONCLUSIONS: Allergic photoreactions induced by contact with plants containing coumarins are generally regarded as chance findings. This study has demonstrated that phytophoto allergic contact dermatitis resulting from furocoumarins is not an exceptional finding, and should be suspected in subjects with diffuse clinical manifestations in photo-exposed but also non-exposed sites. To differentiate allergic from toxic photoreactions, patch tests need to be performed with serial dilutions of furocoumarins. Histological analysis of a biopsy sample from a positive test site will reveal alterations compatible with a photoallergic contact dermatitis.

BACKGROUND: Inherited epidermolysis bullosa (EB) is a group of skin diseases characterized by blistering of the skin and mucous membranes.There are four major types of EB (EB simplex, junctional EB, dystrophic EB and Kindler syndrome) caused by different gene mutations. Dystrophic EB is derived from mutations in the type VII collagen gene (COL7A1), encoding a protein which is the predominant component of the anchoring fibrils at the dermal-epidermal junction.For the first time in literature, we have evaluated the presence of anti-skin autoantibodies in a wider cohort of patients suffering from inherited EB and ascertained whether they may be a marker of disease activity. METHODS: Sera from patients with inherited EB, 17 with recessive dystrophic EB (RDEB), 10 with EB simplex (EBS) were analysed. As much as 20 patients with pemphigus vulgaris, 21 patients with bullous pemphigoid and 20 healthy subjects were used as controls.Anti-skin autoantibodies were tested in all samples with the Indirect Immunofluorescence (IIF) method and the currently available ELISA method in order to detect anti-type VII collagen, anti-BP180 and anti-BP230 autoantibodies. RESULTS: The mean concentrations of anti-type VII collagen autoantibodies titres, anti-BP180 and anti-BP230 autoantibodies were statistically higher in RDEB patients than in EBS patients.The sensitivity and specificity of the anti-type VII collagen ELISA test were 88.2% and 96.7%. The Birmingham Epidermolysis Bullosa Severity score, which is used to evaluate the severity of the disease, correlated with anti-skin autoantibodies titres. CONCLUSIONS: The precise pathogenic role of circulating anti-skin autoantibodies in RDEB is unclear. There is a higher prevalence of both anti-type VII collagen and other autoantibodies in patients with RDEB, but their presence can be interpreted as an epiphenomenon.

Ultraviolet (UV) radiation is an etiologic cause for non-melanoma skin cancer (basalcell carcinoma and squamouscell carcinoma) and malignant melanoma, but the spectral range promoting the tumor induction is still to be explained. It follows that it is mandatory the complete photoprotection from sunscreens towards the whole UV range. In the European Union, sunscreens are tested on their effectiveness by means of 4 indicators: SPF (Sun Protection Factor), UVA-PF (Protection Factor), SPF/PF-UVA ratio, and critical wave length. However, SPF can confirm that sunscreen products protect us from sunburn under good condition of use. In order to achieve a whole protection, instead, it is also interesting to calculate other indicators to assess protection against non-melanoma skin cancers and to quantify the effectiveness of the product against UVA1 and UVA2. Photostability of sunscreens represents a further significant problem concerning photoprotection. It has been clearly demonstrated that not all UVA and UVB absorbers are sufficiently photostable. Within UV exposure, in fact, some of them may change spectral performance. High SPF value implies the long-lasting photoprotection, but this is only guaranteed when UV filters remain stable throughout the entire period of sun exposure. Thus, the production of photostable products is extremely important. But, most sunscreens on the market do not have a photostability label. Therefore, there is a need for a global uniform claim on UV photoprotection.

Transdermal therapeutic systems (TTS) have become a popular method of drug delivery because they allow drugs to be delivered in a rate-controlled manner, avoiding first-pass metabolism and the fluctuating plasma concentrations encountered with oral medications. Moreover, applying TTS is easy, does not require any assistance as intramuscular or intravenous administration, and provokes fewer side effects than there are with the oral delivery of drugs. Drugs most commonly delivered through TTS are scopolamine, estradiol, nitroglycerin, and clonidine. Unfortunately, TTS may provoke adverse skin reaction as irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD). TTS seems to be ideally suited to produce sensitization because they cause occlusion, irritation, and repeated placement of the allergen at the same skin location. Since TTS consist of an adhesive, an active pharmaceutical drug and enhancing agents, sensitization may develop owing to one of these 3 components. The purpose of this manuscript is to review known responsible allergens of ACD to TTS. We describe also a case report about ACD to TTS caused by rivastigmine in a patient affected by Alzheimer's dementia. Rivastigmine is one of the latest drugs indicated as a known culprit allergen of ACD to TTS.

Scalp hair heterochromia presenting in tufts with no underlying skin changes is rare and can be a sign of somatic mosaicism. We describe the case of a healthy 5-year-old boy with this condition.

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