Letters to the Editor Contact Dermatitis 1988;18:76‑80. 9. Roller JA. Contact allergy to clotrimazole. Br Med J 1978;2:737. 10. Erdmann S, Hertl M, Merk HF. Contact dermatitis from clotrimazole with positive patch‑test reactions also to croconazole and itraconazole. Contact Dermatitis 1999;40:47‑8. 11. Valsecchi R, Pansera B, di Landro A, Cainelli T. Connubial contact sensitization to clotrimazole. Contact Dermatitis 1994;30:248. 12. Balato N, Lembo G, Nappa P, Ayala F. Contact dermatitis from clotrimazole. Contact Dermatitis 1985;12:110. 13. Kalb RE, Grossman ME. Contact dermatitis to clotrimazole. Cutis 1985;36:240‑2. 14. Imafuku S, Nakayama J. Contact allergy to ketoconazole cross‑sensitive to miconazole. Clin Exp Dermatol 2009;34:411‑2. 15. Goday JJ, Yanguas I, Aguirre A, Ilardia R, Soloeta R. Allergic contact dermatitis from sertaconazole with cross‑sensitivity to miconazole and econazole. Contact Dermatitis 1995;32:370‑1. 16. Baes H. Contact sensitivity to miconazole with ortho‑chloro cross‑sensitivity to other imidazoles. Contact Dermatitis 1991;24:89‑93.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148592 PMID: *****
Allergic contact dermatitis to Parthenium hysterophorus mimicking actinic prurigo Sir, Allergic contact dermatitis to Parthenium hysterophorus has a wide spectrum of clinical presentations and can mimic various eczematous and photosensitive eruptions.[1,2] We present a case with an actinic prurigo-like presentation that responded very well to thalidomide. A 28‑year‑old unmarried woman presented with a 10‑year history of itchy papules and nodules over her extremities and nape of neck. Initially, there were summer exacerbations but then disease became persistent for the last 3 years. She also gave history of episodic, redness of eyes, eyelid pruritus and swelling along with mild facial edema. There was no personal or family history of atopy. Cutaneous examination revealed a predominantly monomorphic, symmetrical eruption of 4‑8 mm sized hyperpigmented, dome shaped firm papules involving the nape of the neck and upper back, and the dorsal aspect below knee and elbow, and the ‘V’ area of chest. The face, 82
flexures, conjunctiva and oral mucosa were spared. A provisional clinical diagnosis of actinic prurigo was considered. A skin biopsy from a papule showed features of a subacute spongiotic tissue reaction. The baseline hematological and biochemical parameters and anti‑nuclear antibody test (ANA) were within normal limits. A patch test using modified Indian Standard Series (ISS) and parthenium antigen showed 3+ positivity to P. hysterophorus aqueous extract in 1:100 dilution [Figure 1]. Photo‑patch testing done using the same antigens with ultraviolet A (UVA) at 10J/ cm2 was negative (2+ positive on both irradiated and non‑irradiated sides). Phototesting with narrow band UVB (NbUVB) showed a minimal erythema dose (MED) of 0.8 J/cm2 and with UVA was negative at 12J/cm2. On repeat interviewing, the patient reported lesional exacerbation when visiting her farm to fetch fodder for cattle, especially during summers. She also added that Parthenium was abundant in her surroundings. Hence, a final diagnosis of Parthenium dermatitis presenting with actinic prurigo-like lesions was made. She was started on prednisolone 40 mg/day in tapering doses, but due to minimal response after 3 weeks, it was substituted with thalidomide 100 mg thrice daily after appropriate consent, precautions and counseling. The patient started responding to treatment within 2 weeks and had about 75% improvement after 6 weeks. The lesions flattened completely within 16 weeks and thalidomide was gradually tapered and stopped over the next 6 weeks. It had to be restarted at 100 mg twice daily due to a moderate relapse. The patient had near complete relief with mild
Figure 1: Patch test with Indian Standard Series showing 3+ positivity to Parthenium aqueous extract in 1:100 dilution (Patch no.2) and 2+ positivity in 1:200 dilution (Patch no.3)
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
Letters to the Editor
a
b Figure 2: Composite clinical photographs showing response to thalidomide. (a) Left side showing baseline image with discrete excoriated papules over extensors of both hands, forearms and ‘V’ area of chest. Right half showing significant improvement seen
scarring and hyperpigmentation [Figure 2a and b]. She was then maintained on thalidomide 100 mg/day for another 10 weeks. The patient did not experience any therapy related adverse effects after 8 months of thalidomide intake. Low dose azathioprine was planned as a maintenance therapy for her but she was lost to follow up. Parthenium dermatitis in India most commonly presents in a classical airborne contact dermatitis pattern. Other reported presentations include chronic actinic dermatitis, mixed pattern (airborne and photosensitive pattern), exfoliative dermatitis, prurigo nodularis-like eruption and photosensitive lichenoid eruption among others.[1,2] We were unable to find any previous reports of an actinic prurigo‑like presentation due to parthenium dermatitis. We diagnosed our patient as actinic prurigo in view of the prominent photodistribution of infiltrated, discrete papules and nodules of teenage. In addition, dramatic response to thalidomide has been considered
after 6 months of thalidomide use. (b) Left side showing baseline image with dome shaped discrete excoriated papules over dorsae of hands and feet. Right half showing near complete clearance after 8 months of thalidomide use
as an indicator of actinic prurigo in the literature.[3] Furthermore, parthenium dermatitis is rare in teenagers and children.[1] However, a strongly positive patch test in the setting of exposure to parthenium in our case suggested parthenium dermatitis. The absence of photopatch test positivity does not refute our clinical diagnosis since parthenium causes enhanced photosensitivity but true photocontact allergy is rare.[1] The MED value in our patient was 800 mJ/cm2 which is in the normal range for North Indian skin (skin types 3, 4 and 5).[4] Polymorphous light eruption was not considered as a possibility in the current case as it is characterized by grouped shiny patches, micropapules, papules and plaques on sun‑exposed sites. The spongiotic dermatitis on histopathology also favored prurigo over polymorphous light eruption. Akhtar et al. showed that patients with parthenium dermatitis had significantly elevated levels of TNF‑α,
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
83
Letters to the Editor
IL‑6, IL‑8 ad IL‑17.[5] Thalidomide is known to inhibit TNF‑α and IL‑8, and also causes alteration of lymphocytic response from Th1 to Th2.[6] These mechanisms may help in other allergic contact dermatitis (ACD) patients as well and suggests a role for thalidomide in cases which are either refractory to systemic glucocorticoids and immunosuppressants or where avoidance of such agents is desired, provided that its benefits outweigh the risk of serious side effects.
Saurabh Singh, Sujay Khandpur, Vinod Kumar Sharma Department of Dermatology and Venereology, All India Institute of Medical Sciences (AIIMS), New Delhi, India Address for correspondence: Dr. Sujay Khandpur, Department of Dermatology, Venereology, and Leprology, All India Institute of Medical Sciences, New Delhi - 110 029, India. E‑mail: [email protected]
REFERENCES 1. Sharma VK, Sethraman G. Parthenium dermatitis. Dermatitis 2007;18:183‑90. 2. Verma KK, Sirka CS, Ramam M, Sharma VK. Parthenium dermatitis presenting as photosensitive lichenoid eruption: A new clinical variant. Contact Dermatitis 2002;46:286‑9. 3. Ross G, Foley P, Baker C. Actinic prurigo. Photodermatol Photoimmunol Photomed 2008;24:272‑5. 4. Tejasvi T, Sharma VK, Kaur J. Determination of minimal erythema dose for narrow band UVB radiation in north Indian patients: Comparison of visual and dermaspectrometer® readings. Indian J Dermatol Venereol Leprol 2007;73:97‑9. 5. Akhtar N, Verma KK, Sharma A. Study of pro‑ and anti‑inflammatory cytokine profile in the patients with parthenim dermatitis. Contact Dermatitis 2010;63:203‑8. 6. Wu JJ, Huang DB, Pang KR, Hsu H, Tyring SK. Thalidomide: Dermatological indications, mechanisms of action and side effects. Br J Dermatol 2005;153:254‑73. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148594
cases with unusual presentations of contact allergy to benzocaine, a commonly prescribed anesthetic gel for relief from pain in various mucosal conditions. A 52‑year‑old lady presented with a highly pruritic erythematous rash on her lips and perioral area, with predominant involvement of the angles of mouth since 2 weeks. She also had similar lesions on her right index finger and the lateral aspect of her right middle finger since 1 week. She had extreme burning and stinging in her oral cavity, in spite of regular application of benzocaine 20% gel and triamcinolone acetonide 0.1% paste for oral lichen planus. Her past records revealed drug allergies to sulphasalazine and dapsone with which she had developed acute generalized exanthematous pustulosis and generalized maculopapular rash, respectively around 1 year back. She denied any other drug intake known to cause orodynia such as angiotensin‑converting enzyme inhibitors, anticoagulants, antipsychotics, antidepressants or anti‑retroviral drugs. The patient was otherwise well and in good mental health. On examination, multiple erythematous papules coalescing to form ill‑defined plaques were present on the lips, perioral area and right index and middle fingers. Desquamation occurred particularly over lips, angles of mouth and web space of the second finger [Figure 1a]. On the contrary, oral mucosa was relatively normal with no clinical signs of inflammation except subsiding lesions of oral lichen planus [Figure 1b]. An eczematous eruption temporally correlating with the application of medicaments suggested a diagnosis of contact dermatitis to the local application(s). To confirm our suspicion, we performed patch tests with Indian Standard Series (ISS) and corticosteroid series (both from Chemotechnique DiagnosticsR), using aluminium chambers premounted on hypo‑allergenic adhesive tape. Readings were taken at 48 and 96 hours by the same clinician according to the International Contact Dermatitis Research Group grading. Benzocaine
PMID: *****
Does contact allergy to benzocaine cause orodynia? Sir, Contact dermatitis to topical anesthetics is a well‑known entity and manifests as a wide spectrum of irritant and allergic reactions. Herein, we report two 84
a
b
Figure 1: (a) Erythematous rash on lips, angles of mouth and perioral area with similar involvement of right index finger and lateral aspect of right middle finger; (b) oral mucosa showing no evidence of erythema or erosions
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148592 PMID: *****
Allergic contact dermatitis to Parthenium hysterophorus mimicking actinic prurigo Sir, Allergic contact dermatitis to Parthenium hysterophorus has a wide spectrum of clinical presentations and can mimic various eczematous and photosensitive eruptions.[1,2] We present a case with an actinic prurigo-like presentation that responded very well to thalidomide. A 28‑year‑old unmarried woman presented with a 10‑year history of itchy papules and nodules over her extremities and nape of neck. Initially, there were summer exacerbations but then disease became persistent for the last 3 years. She also gave history of episodic, redness of eyes, eyelid pruritus and swelling along with mild facial edema. There was no personal or family history of atopy. Cutaneous examination revealed a predominantly monomorphic, symmetrical eruption of 4‑8 mm sized hyperpigmented, dome shaped firm papules involving the nape of the neck and upper back, and the dorsal aspect below knee and elbow, and the ‘V’ area of chest. The face, 82
flexures, conjunctiva and oral mucosa were spared. A provisional clinical diagnosis of actinic prurigo was considered. A skin biopsy from a papule showed features of a subacute spongiotic tissue reaction. The baseline hematological and biochemical parameters and anti‑nuclear antibody test (ANA) were within normal limits. A patch test using modified Indian Standard Series (ISS) and parthenium antigen showed 3+ positivity to P. hysterophorus aqueous extract in 1:100 dilution [Figure 1]. Photo‑patch testing done using the same antigens with ultraviolet A (UVA) at 10J/ cm2 was negative (2+ positive on both irradiated and non‑irradiated sides). Phototesting with narrow band UVB (NbUVB) showed a minimal erythema dose (MED) of 0.8 J/cm2 and with UVA was negative at 12J/cm2. On repeat interviewing, the patient reported lesional exacerbation when visiting her farm to fetch fodder for cattle, especially during summers. She also added that Parthenium was abundant in her surroundings. Hence, a final diagnosis of Parthenium dermatitis presenting with actinic prurigo-like lesions was made. She was started on prednisolone 40 mg/day in tapering doses, but due to minimal response after 3 weeks, it was substituted with thalidomide 100 mg thrice daily after appropriate consent, precautions and counseling. The patient started responding to treatment within 2 weeks and had about 75% improvement after 6 weeks. The lesions flattened completely within 16 weeks and thalidomide was gradually tapered and stopped over the next 6 weeks. It had to be restarted at 100 mg twice daily due to a moderate relapse. The patient had near complete relief with mild
Figure 1: Patch test with Indian Standard Series showing 3+ positivity to Parthenium aqueous extract in 1:100 dilution (Patch no.2) and 2+ positivity in 1:200 dilution (Patch no.3)
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
Letters to the Editor
a
b Figure 2: Composite clinical photographs showing response to thalidomide. (a) Left side showing baseline image with discrete excoriated papules over extensors of both hands, forearms and ‘V’ area of chest. Right half showing significant improvement seen
scarring and hyperpigmentation [Figure 2a and b]. She was then maintained on thalidomide 100 mg/day for another 10 weeks. The patient did not experience any therapy related adverse effects after 8 months of thalidomide intake. Low dose azathioprine was planned as a maintenance therapy for her but she was lost to follow up. Parthenium dermatitis in India most commonly presents in a classical airborne contact dermatitis pattern. Other reported presentations include chronic actinic dermatitis, mixed pattern (airborne and photosensitive pattern), exfoliative dermatitis, prurigo nodularis-like eruption and photosensitive lichenoid eruption among others.[1,2] We were unable to find any previous reports of an actinic prurigo‑like presentation due to parthenium dermatitis. We diagnosed our patient as actinic prurigo in view of the prominent photodistribution of infiltrated, discrete papules and nodules of teenage. In addition, dramatic response to thalidomide has been considered
after 6 months of thalidomide use. (b) Left side showing baseline image with dome shaped discrete excoriated papules over dorsae of hands and feet. Right half showing near complete clearance after 8 months of thalidomide use
as an indicator of actinic prurigo in the literature.[3] Furthermore, parthenium dermatitis is rare in teenagers and children.[1] However, a strongly positive patch test in the setting of exposure to parthenium in our case suggested parthenium dermatitis. The absence of photopatch test positivity does not refute our clinical diagnosis since parthenium causes enhanced photosensitivity but true photocontact allergy is rare.[1] The MED value in our patient was 800 mJ/cm2 which is in the normal range for North Indian skin (skin types 3, 4 and 5).[4] Polymorphous light eruption was not considered as a possibility in the current case as it is characterized by grouped shiny patches, micropapules, papules and plaques on sun‑exposed sites. The spongiotic dermatitis on histopathology also favored prurigo over polymorphous light eruption. Akhtar et al. showed that patients with parthenium dermatitis had significantly elevated levels of TNF‑α,
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
83
Letters to the Editor
IL‑6, IL‑8 ad IL‑17.[5] Thalidomide is known to inhibit TNF‑α and IL‑8, and also causes alteration of lymphocytic response from Th1 to Th2.[6] These mechanisms may help in other allergic contact dermatitis (ACD) patients as well and suggests a role for thalidomide in cases which are either refractory to systemic glucocorticoids and immunosuppressants or where avoidance of such agents is desired, provided that its benefits outweigh the risk of serious side effects.
Saurabh Singh, Sujay Khandpur, Vinod Kumar Sharma Department of Dermatology and Venereology, All India Institute of Medical Sciences (AIIMS), New Delhi, India Address for correspondence: Dr. Sujay Khandpur, Department of Dermatology, Venereology, and Leprology, All India Institute of Medical Sciences, New Delhi - 110 029, India. E‑mail: [email protected]
REFERENCES 1. Sharma VK, Sethraman G. Parthenium dermatitis. Dermatitis 2007;18:183‑90. 2. Verma KK, Sirka CS, Ramam M, Sharma VK. Parthenium dermatitis presenting as photosensitive lichenoid eruption: A new clinical variant. Contact Dermatitis 2002;46:286‑9. 3. Ross G, Foley P, Baker C. Actinic prurigo. Photodermatol Photoimmunol Photomed 2008;24:272‑5. 4. Tejasvi T, Sharma VK, Kaur J. Determination of minimal erythema dose for narrow band UVB radiation in north Indian patients: Comparison of visual and dermaspectrometer® readings. Indian J Dermatol Venereol Leprol 2007;73:97‑9. 5. Akhtar N, Verma KK, Sharma A. Study of pro‑ and anti‑inflammatory cytokine profile in the patients with parthenim dermatitis. Contact Dermatitis 2010;63:203‑8. 6. Wu JJ, Huang DB, Pang KR, Hsu H, Tyring SK. Thalidomide: Dermatological indications, mechanisms of action and side effects. Br J Dermatol 2005;153:254‑73. Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.148594
cases with unusual presentations of contact allergy to benzocaine, a commonly prescribed anesthetic gel for relief from pain in various mucosal conditions. A 52‑year‑old lady presented with a highly pruritic erythematous rash on her lips and perioral area, with predominant involvement of the angles of mouth since 2 weeks. She also had similar lesions on her right index finger and the lateral aspect of her right middle finger since 1 week. She had extreme burning and stinging in her oral cavity, in spite of regular application of benzocaine 20% gel and triamcinolone acetonide 0.1% paste for oral lichen planus. Her past records revealed drug allergies to sulphasalazine and dapsone with which she had developed acute generalized exanthematous pustulosis and generalized maculopapular rash, respectively around 1 year back. She denied any other drug intake known to cause orodynia such as angiotensin‑converting enzyme inhibitors, anticoagulants, antipsychotics, antidepressants or anti‑retroviral drugs. The patient was otherwise well and in good mental health. On examination, multiple erythematous papules coalescing to form ill‑defined plaques were present on the lips, perioral area and right index and middle fingers. Desquamation occurred particularly over lips, angles of mouth and web space of the second finger [Figure 1a]. On the contrary, oral mucosa was relatively normal with no clinical signs of inflammation except subsiding lesions of oral lichen planus [Figure 1b]. An eczematous eruption temporally correlating with the application of medicaments suggested a diagnosis of contact dermatitis to the local application(s). To confirm our suspicion, we performed patch tests with Indian Standard Series (ISS) and corticosteroid series (both from Chemotechnique DiagnosticsR), using aluminium chambers premounted on hypo‑allergenic adhesive tape. Readings were taken at 48 and 96 hours by the same clinician according to the International Contact Dermatitis Research Group grading. Benzocaine
PMID: *****
Does contact allergy to benzocaine cause orodynia? Sir, Contact dermatitis to topical anesthetics is a well‑known entity and manifests as a wide spectrum of irritant and allergic reactions. Herein, we report two 84
a
b
Figure 1: (a) Erythematous rash on lips, angles of mouth and perioral area with similar involvement of right index finger and lateral aspect of right middle finger; (b) oral mucosa showing no evidence of erythema or erosions
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2015 | Vol 81 | Issue 1
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
