Most Common Allergic Diseases: Historical Reflections in Understanding Bergmann K-C, Ring J (eds): History of Allergy. Chem Immunol Allergy. Basel, Karger, 2014, vol 100, pp 97–100 DOI: 10.1159/000358608
Allergic Contact Dermatitis Ali Alikhan a · Howard I. Maibach b
2
a
Department of Dermatology, Mayo Clinic, Rochester, Minn., and b Department of Dermatology, University of California at San Francisco School of Medicine, San Francisco, Calif., USA
Allergic contact dermatitis is one of the most important dermatologic disorders worldwide – it can cause significant morbidity and decreased quality of life, as well as having major economic implications and loss of vocational productivity. Patch testing is the most important discovery in allergic contact dermatitis and the best diagnostic modality to date; the thin-layer rapiduse epicutaneous (TRUE) test is a more recent patch test development which has improved the convenience and feasibility of the test. The future of allergic contact dermatitis is bright as we continue to learn more about the science of the disorder, as well as ways to improve diagnosis and patient care. Furthermore, it is important to remember, in this global age, that cooperation between health care providers worldwide is essential. © 2014 S. Karger AG, Basel
Awareness of contact dermatitis has been present since ancient Greek and ancient Egyptian times, as evidenced by the writings of Hippocrates and Pliny the Younger [1, 2]. Knowledge of the disorder grew
rapidly during the 19th century, with Ferdinand von Hebra demonstrating that croton oil could provoke eczematous dermatitis on normal human skin [1].
Patch Testing – Jadassohn and Bloch The standard diagnostic test in allergic contact dermatitis is the patch test, the discovery of which is credited to Josef Jadassohn. Jadassohn was the first dermatologist ‘to apply objective experimental methods to the study of cutaneous immunology’ [3]. In 1895, while professor of dermatology at Breslau University, he developed the contact test (‘funktionelle Hautprüfung’) in order to objectively diagnose a patient who had developed an eczematous reaction to mercury plasters, which had been prescribed for pediculi pubis [2, 4]. In doing so, he recognized the potential for certain chemicals (when placed on the skin) to cause eczematous reactions in sensitized individuals. Bruno Bloch, a student of Jadassohn and a professor at Basel and Zurich Universities, expanded the work of Jadassohn, increasing the knowledge base of contact dermatitis immunology [3, 4]. He Downloaded by: Univ. of California San Diego 132.239.1.231 - 12/10/2016 1:18:34 AM
Abstract
further described the patch test methodology and grading of skin reactions, postulated the idea of cross-reactivity, described the first cases of systemic contact dermatitis and, with Paul Karrer, synthesized primin [2], the specific chemical in Primula obconica that is responsible for allergic contact dermatitis [5]. Perhaps most importantly, he developed and promoted a primitive standard series for patch testing [5]. Among his influential disciples are Marion Sulzberger, who brought patch testing to America, and Paul Bonnevie. Between 1895 and the 1960s, patch testing was used in certain European clinics, but ignored by others [4]. No consensus was reached regarding material, allergen concentrations, reading times or reading scores. Additionally, differentiating between allergic and irritant dermatitis, as well as understanding the significance of a positive patch test, was unclear.
Important Early Basic Science Discoveries Important discoveries in basic immunology as it relates to allergic contact dermatitis have been reviewed extensively by Krueger and Stingl [6]. Some of these scientists and their discoveries include: (1) Landsteiner and Jacobs – their experiments underlined the relationships between chemical structure and allergenicity [7, 8]; (2) Sulzberger and Baer – demonstrated in man a relationship between the in vitro reactivity of a chemical and its ability to produce allergic contact dermatitis [9]; (3) Landsteiner and Chase – using guinea pig modeling, they found that allergic contact hypersensitivity could be transferred to naïve recipients by live lymphoid cells from affected donors [10].
dard allergen series and published it in his famous textbook of environmental medicine [4, 5]. Bonnevie’s [11] twenty-one allergen series is considered the predecessor to the current standard series utilized by various countries and continents. It was employed for several decades in Copenhagen, allowing Marcussen [12] to publish a large epidemiological survey on contact allergies in 1962. Later, it was modified and updated by the fledgling International Contact Dermatitis Research Group (ICDRG).
Contact Dermatitis and Public Health – Ramazzini and Prosser White The fields of contact dermatitis and public health are inextricably linked. Bernardo Ramazzini (1633– 1714), the author of A Treatise of the Disease of Tradesmen, is considered the father of occupational medicine – he ‘emphasized the connection of many diseases with the occupations of patients and urged that medical students study ways to protect workers’ [2]. He described hand dermatitis in laundry women and soapworkers, attributing their condition to direct contact with substances. Two-hundred years later, Robert Prosser White would expand the field of occupational dermatology. Prosser White saw and diagnosed thousands of work-related skin disorders in Wigan, UK, a large industrial town in the heart of Lancashire [1, 13]. He published and lectured extensively on occupational dermatoses, holding various international positions and receiving numerous honors. His textbook Occupational Affections of the Skin was considered the definitive reference for occupational skin disease [1, 13].
Contact Dermatitis Societies
Understanding that most clinical cases of allergic contact dermatitis are caused by a relatively small number of chemicals, Paul Bonnevie, a student of Bruno Bloch and professor of occupational medicine in Copenhagen, expanded Bloch’s limited stan-
98
The first contact dermatitis society, the Scandinavian Committee for Standardization of Routine Patch Testing, was created in 1962. In 1967, this committee enlarged and joined with various national or European groups interested in contact dermatitis to form the ICDRG, whose tasks were to standardize (at an international level) the patch testing
Alikhan · Maibach
Downloaded by: Univ. of California San Diego 132.239.1.231 - 12/10/2016 1:18:34 AM
Standard Series – Bonnevie
Improving Convenience – The TRUE Test The thin-layer rapid-use epicutaneous (TRUE) test was developed by Fischer and Maibach in 1985 [17]. It is a standardized, ready-to-apply patch test system requiring no pre-mixing or preparation time, and contains 29 common allergens. The allergens are incorporated in hydrophilic gels, coated on a water-impermeable sheet of polyester, and dried to a thin film. The coated polyester sheet is cut into squared patches that are mounted on non-woven cellulose tape with acrylic adhesive, covered with siliconized plastic (a protect sheet), and packed in an airtight and light-impermeable envelope [18]. When the test strip is taped on the skin, perspiration hy-
Allergic Contact Dermatitis
drates the film and transforms it to a gel, causing the allergen to be released. The TRUE test has been demonstrated to be accurate and safe, and allows for greater consistency in terms of allergen distribution, quantity, stability and location. Unfortunately, development costs and regulatory hurdles have limited its expansion to the much larger baseline series of today.
Moving into the Computer Age – The CARD Database
2
First developed at the Mayo Clinic in 1998, the Contact Allergen Replacement Database (CARD) is an internet database which enables clinicians to find suitable skin care products for their patients with contact allergies; it contains over 8,100 known ingredients catalogued in over 5,500 commercially available skin care products [19]. By entering allergens that the patient should avoid (based on patch test positivity and clinical relevance), the program creates a list of safe products for the patient to use. This innovative use of technology has enhanced patient care as allergen avoidance education can be quite overwhelming given complexly named allergens as well as avoidance of allergen cross-reactors. The Contact Allergen Management Program (CAMP), which is similar to the CARD, has been developed by the ACDS.
The Future of Allergic Contact Dermatitis While the study of allergic contact dermatitis has blossomed since Jadassohn developed the patch test over 100 years ago, further improvements will significantly strengthen the field. Alikhan and Maibach [20] suggest various strategies to enhance our understanding of allergic contact dermatitis and our practice of patch testing. Categories for improvement include: understanding allergen stability, identifying true allergens, expanding and refining the TRUE test, separating irritant reactions from allergic reactions, investigating patch wearing and application periods, developing patch test banks, approaching false-negative patch test results, re-examining the
99
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procedure (e.g. allergen vehicles, allergen concentrations, etc.), encourage cooperative research among different countries, and promote interest by dermatologists in allergic and environmental skin disorders [1, 5]. Founding members included H.J. Bandmann, C.D. Calnan, E. Cronin, S. Fregert, N. Hjorth, B. Magnusson, H.I. Maibach, K.E. Malten, C. Meneghini, V. Pirilä, and D.S. Wilkinson. The first international standard series was published in 1997 by the ICDRG [14], with an updated revision in 2011 [14]. Niels Hjorth was the first chairman of the ICDRG and organized the first international symposium on contact dermatitis in 1974. This symposium was followed by many others, which elevated the stature of contact dermatitis throughout the world and resulted in the establishment of numerous national and continental contact dermatitis groups [5, 15]. Among these groups are the European Environmental and Contact Dermatitis Research Group (EECDRG), the European Society of Contact Dermatitis (ESCD), which is responsible for the journal Contact Dermatitis, the North American Contact Dermatitis Group (NACDG), and the American Contact Dermatitis Society (ACDS), which is responsible for the journal Dermatitis [1]. Many of these groups have their own standard allergen series, allergen concentrations, and patch testing methodology and techniques (e.g. when to read the tests, use of Finn chambers, etc.) [16].
utility of intradermal testing, understanding the significance of positive patch testing, developing contact allergy certifications and fellowships, increasing discussion of chemical identification of allergens in publications, improving international collaboration between worldwide contact dermatitis groups, and improving technology (e.g. utilization and refinement of skin bioengineering tools, in vitro diagnostic methods and use of a patient’s genetic code).
Conclusion This brief overview omits many important contributors and contributions. Lachapelle’s [21] Giant Steps in Patch Testing: A Historical Memoir provides extensive detail and is highly recommended.
References 1 Smith DR: The continuing rise of contact dermatitis. 1. The academic discipline. Contact Dermatitis 2009;61:189–193. 2 Wright RC, Goldman L: Contact dermatitis: a historical perspective. Int J Dermatol 1979;18:665–668. 3 Crissey JT, Parish LC, Holubar K: Historical Atlas of Dermatology and Dermatologists. Boca Raton, Parthenon, 2002. 4 Lachapelle J-M, Maibach HI: Patch Testing and Prick Testing: A Practical Guide – Official Publication of the ICDRG. Berlin, Springer, 2009. 5 Rycroft RJG: Textbook of Contact Dermatitis. Berlin, Springer, 2001. 6 Krueger GG, Stingl G: Immunology/inflammation of the skin – a 50-year perspective. J Invest Dermatol 1989;92:32S–51S. 7 Landsteiner K, Jacobs J: Studies on the sensitization of animals with simple chemical compounds. J Exp Med 1935;61:643–656. 8 Landsteiner K, Jacobs J: Studies on the sensitization of animals with simple chemical compounds. II. J Exp Med 1936; 64: 625– 639.
9 Sulzberger MB, Baer RL: Sensitization to simple chemicals. 3. Relationship between chemical structure and porperties, and sensitizing capacities in the production of eczematous sensitivity in man. J Invest Dermatol 1938;1:45–58. 10 Landsteiner K, Chase MW: Experiments on transfer of cutaneous sensitivity to simple chemical compounds. Proc Soc Exp Biol Med 1942;49:688–690. 11 Bonnevie P: Aetiologie und Pathogenese der Ekzemkrankheiten. Klinische Studien über die Ursachen der Ekzeme unter besonderer Berücksichtigung des diagnostischen Wertes der Ekzemproben. Copenhagen, Busch, 1939. 12 Marcussen PV: Variations in the incidence of contact hypersensitivities. Trans St Johns Hosp Dermatol Soc 1962;48:40–48. 13 Ashworth J: Robert Prosser White (1855– 1934). Clin Exp Dermatol 1994;19:186–187. 14 Lachapelle JM, Ale SI, Freeman S, Frosch PJ, Goh CL, Hannuksela M, et al: Proposal for a revised international standard series of patch tests. Contact Dermatitis 1997; 36: 121–123.
15 Cheng LS, Alikhan A, Maibach HI: Compilation of international standards for patch testing methodology and allergens. Dermatitis 2009;20:257–260. 16 Cheng LS, Alikhan A, Maibach HI: Creating an electronic collaboration between international contact dermatitis groups. Contact Dermatitis 2009;61:59–60. 17 Fischer TI, Maibach HI: The thin layer rapid use epicutaneous test (TRUE-test), a new patch test method with high accuracy. Br J Dermatol 1985;112:63–68. 18 Fischer T, Maibach HI: Easier patch testing with TRUE Test. J Am Acad Dermatol 1989; 20:447–453. 19 Yiannias JA, Miller R, Kist JM: Creation, history, and future of the Contact Allergen Replacement Database (CARD). Dermatitis 2009;20:322–326. 20 Alikhan A, Maibach HI: Allergic contact dermatitis: the future. Dermatitis 2009; 20: 327–333. 21 Lachapelle JM: Giant Steps in Patch Testing: A Historical Memoir. Phoenix, SmartPractice, 2010.
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Alikhan · Maibach
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Dr. Ali Alikhan Department of Dermatology, Mayo Clinic 200 First Street SW Rochester, MN 55905 (USA) E-Mail alikhan.mirza @ mayo.edu
Allergic Contact Dermatitis Ali Alikhan a · Howard I. Maibach b
2
a
Department of Dermatology, Mayo Clinic, Rochester, Minn., and b Department of Dermatology, University of California at San Francisco School of Medicine, San Francisco, Calif., USA
Allergic contact dermatitis is one of the most important dermatologic disorders worldwide – it can cause significant morbidity and decreased quality of life, as well as having major economic implications and loss of vocational productivity. Patch testing is the most important discovery in allergic contact dermatitis and the best diagnostic modality to date; the thin-layer rapiduse epicutaneous (TRUE) test is a more recent patch test development which has improved the convenience and feasibility of the test. The future of allergic contact dermatitis is bright as we continue to learn more about the science of the disorder, as well as ways to improve diagnosis and patient care. Furthermore, it is important to remember, in this global age, that cooperation between health care providers worldwide is essential. © 2014 S. Karger AG, Basel
Awareness of contact dermatitis has been present since ancient Greek and ancient Egyptian times, as evidenced by the writings of Hippocrates and Pliny the Younger [1, 2]. Knowledge of the disorder grew
rapidly during the 19th century, with Ferdinand von Hebra demonstrating that croton oil could provoke eczematous dermatitis on normal human skin [1].
Patch Testing – Jadassohn and Bloch The standard diagnostic test in allergic contact dermatitis is the patch test, the discovery of which is credited to Josef Jadassohn. Jadassohn was the first dermatologist ‘to apply objective experimental methods to the study of cutaneous immunology’ [3]. In 1895, while professor of dermatology at Breslau University, he developed the contact test (‘funktionelle Hautprüfung’) in order to objectively diagnose a patient who had developed an eczematous reaction to mercury plasters, which had been prescribed for pediculi pubis [2, 4]. In doing so, he recognized the potential for certain chemicals (when placed on the skin) to cause eczematous reactions in sensitized individuals. Bruno Bloch, a student of Jadassohn and a professor at Basel and Zurich Universities, expanded the work of Jadassohn, increasing the knowledge base of contact dermatitis immunology [3, 4]. He Downloaded by: Univ. of California San Diego 132.239.1.231 - 12/10/2016 1:18:34 AM
Abstract
further described the patch test methodology and grading of skin reactions, postulated the idea of cross-reactivity, described the first cases of systemic contact dermatitis and, with Paul Karrer, synthesized primin [2], the specific chemical in Primula obconica that is responsible for allergic contact dermatitis [5]. Perhaps most importantly, he developed and promoted a primitive standard series for patch testing [5]. Among his influential disciples are Marion Sulzberger, who brought patch testing to America, and Paul Bonnevie. Between 1895 and the 1960s, patch testing was used in certain European clinics, but ignored by others [4]. No consensus was reached regarding material, allergen concentrations, reading times or reading scores. Additionally, differentiating between allergic and irritant dermatitis, as well as understanding the significance of a positive patch test, was unclear.
Important Early Basic Science Discoveries Important discoveries in basic immunology as it relates to allergic contact dermatitis have been reviewed extensively by Krueger and Stingl [6]. Some of these scientists and their discoveries include: (1) Landsteiner and Jacobs – their experiments underlined the relationships between chemical structure and allergenicity [7, 8]; (2) Sulzberger and Baer – demonstrated in man a relationship between the in vitro reactivity of a chemical and its ability to produce allergic contact dermatitis [9]; (3) Landsteiner and Chase – using guinea pig modeling, they found that allergic contact hypersensitivity could be transferred to naïve recipients by live lymphoid cells from affected donors [10].
dard allergen series and published it in his famous textbook of environmental medicine [4, 5]. Bonnevie’s [11] twenty-one allergen series is considered the predecessor to the current standard series utilized by various countries and continents. It was employed for several decades in Copenhagen, allowing Marcussen [12] to publish a large epidemiological survey on contact allergies in 1962. Later, it was modified and updated by the fledgling International Contact Dermatitis Research Group (ICDRG).
Contact Dermatitis and Public Health – Ramazzini and Prosser White The fields of contact dermatitis and public health are inextricably linked. Bernardo Ramazzini (1633– 1714), the author of A Treatise of the Disease of Tradesmen, is considered the father of occupational medicine – he ‘emphasized the connection of many diseases with the occupations of patients and urged that medical students study ways to protect workers’ [2]. He described hand dermatitis in laundry women and soapworkers, attributing their condition to direct contact with substances. Two-hundred years later, Robert Prosser White would expand the field of occupational dermatology. Prosser White saw and diagnosed thousands of work-related skin disorders in Wigan, UK, a large industrial town in the heart of Lancashire [1, 13]. He published and lectured extensively on occupational dermatoses, holding various international positions and receiving numerous honors. His textbook Occupational Affections of the Skin was considered the definitive reference for occupational skin disease [1, 13].
Contact Dermatitis Societies
Understanding that most clinical cases of allergic contact dermatitis are caused by a relatively small number of chemicals, Paul Bonnevie, a student of Bruno Bloch and professor of occupational medicine in Copenhagen, expanded Bloch’s limited stan-
98
The first contact dermatitis society, the Scandinavian Committee for Standardization of Routine Patch Testing, was created in 1962. In 1967, this committee enlarged and joined with various national or European groups interested in contact dermatitis to form the ICDRG, whose tasks were to standardize (at an international level) the patch testing
Alikhan · Maibach
Downloaded by: Univ. of California San Diego 132.239.1.231 - 12/10/2016 1:18:34 AM
Standard Series – Bonnevie
Improving Convenience – The TRUE Test The thin-layer rapid-use epicutaneous (TRUE) test was developed by Fischer and Maibach in 1985 [17]. It is a standardized, ready-to-apply patch test system requiring no pre-mixing or preparation time, and contains 29 common allergens. The allergens are incorporated in hydrophilic gels, coated on a water-impermeable sheet of polyester, and dried to a thin film. The coated polyester sheet is cut into squared patches that are mounted on non-woven cellulose tape with acrylic adhesive, covered with siliconized plastic (a protect sheet), and packed in an airtight and light-impermeable envelope [18]. When the test strip is taped on the skin, perspiration hy-
Allergic Contact Dermatitis
drates the film and transforms it to a gel, causing the allergen to be released. The TRUE test has been demonstrated to be accurate and safe, and allows for greater consistency in terms of allergen distribution, quantity, stability and location. Unfortunately, development costs and regulatory hurdles have limited its expansion to the much larger baseline series of today.
Moving into the Computer Age – The CARD Database
2
First developed at the Mayo Clinic in 1998, the Contact Allergen Replacement Database (CARD) is an internet database which enables clinicians to find suitable skin care products for their patients with contact allergies; it contains over 8,100 known ingredients catalogued in over 5,500 commercially available skin care products [19]. By entering allergens that the patient should avoid (based on patch test positivity and clinical relevance), the program creates a list of safe products for the patient to use. This innovative use of technology has enhanced patient care as allergen avoidance education can be quite overwhelming given complexly named allergens as well as avoidance of allergen cross-reactors. The Contact Allergen Management Program (CAMP), which is similar to the CARD, has been developed by the ACDS.
The Future of Allergic Contact Dermatitis While the study of allergic contact dermatitis has blossomed since Jadassohn developed the patch test over 100 years ago, further improvements will significantly strengthen the field. Alikhan and Maibach [20] suggest various strategies to enhance our understanding of allergic contact dermatitis and our practice of patch testing. Categories for improvement include: understanding allergen stability, identifying true allergens, expanding and refining the TRUE test, separating irritant reactions from allergic reactions, investigating patch wearing and application periods, developing patch test banks, approaching false-negative patch test results, re-examining the
99
Downloaded by: Univ. of California San Diego 132.239.1.231 - 12/10/2016 1:18:34 AM
procedure (e.g. allergen vehicles, allergen concentrations, etc.), encourage cooperative research among different countries, and promote interest by dermatologists in allergic and environmental skin disorders [1, 5]. Founding members included H.J. Bandmann, C.D. Calnan, E. Cronin, S. Fregert, N. Hjorth, B. Magnusson, H.I. Maibach, K.E. Malten, C. Meneghini, V. Pirilä, and D.S. Wilkinson. The first international standard series was published in 1997 by the ICDRG [14], with an updated revision in 2011 [14]. Niels Hjorth was the first chairman of the ICDRG and organized the first international symposium on contact dermatitis in 1974. This symposium was followed by many others, which elevated the stature of contact dermatitis throughout the world and resulted in the establishment of numerous national and continental contact dermatitis groups [5, 15]. Among these groups are the European Environmental and Contact Dermatitis Research Group (EECDRG), the European Society of Contact Dermatitis (ESCD), which is responsible for the journal Contact Dermatitis, the North American Contact Dermatitis Group (NACDG), and the American Contact Dermatitis Society (ACDS), which is responsible for the journal Dermatitis [1]. Many of these groups have their own standard allergen series, allergen concentrations, and patch testing methodology and techniques (e.g. when to read the tests, use of Finn chambers, etc.) [16].
utility of intradermal testing, understanding the significance of positive patch testing, developing contact allergy certifications and fellowships, increasing discussion of chemical identification of allergens in publications, improving international collaboration between worldwide contact dermatitis groups, and improving technology (e.g. utilization and refinement of skin bioengineering tools, in vitro diagnostic methods and use of a patient’s genetic code).
Conclusion This brief overview omits many important contributors and contributions. Lachapelle’s [21] Giant Steps in Patch Testing: A Historical Memoir provides extensive detail and is highly recommended.
References 1 Smith DR: The continuing rise of contact dermatitis. 1. The academic discipline. Contact Dermatitis 2009;61:189–193. 2 Wright RC, Goldman L: Contact dermatitis: a historical perspective. Int J Dermatol 1979;18:665–668. 3 Crissey JT, Parish LC, Holubar K: Historical Atlas of Dermatology and Dermatologists. Boca Raton, Parthenon, 2002. 4 Lachapelle J-M, Maibach HI: Patch Testing and Prick Testing: A Practical Guide – Official Publication of the ICDRG. Berlin, Springer, 2009. 5 Rycroft RJG: Textbook of Contact Dermatitis. Berlin, Springer, 2001. 6 Krueger GG, Stingl G: Immunology/inflammation of the skin – a 50-year perspective. J Invest Dermatol 1989;92:32S–51S. 7 Landsteiner K, Jacobs J: Studies on the sensitization of animals with simple chemical compounds. J Exp Med 1935;61:643–656. 8 Landsteiner K, Jacobs J: Studies on the sensitization of animals with simple chemical compounds. II. J Exp Med 1936; 64: 625– 639.
9 Sulzberger MB, Baer RL: Sensitization to simple chemicals. 3. Relationship between chemical structure and porperties, and sensitizing capacities in the production of eczematous sensitivity in man. J Invest Dermatol 1938;1:45–58. 10 Landsteiner K, Chase MW: Experiments on transfer of cutaneous sensitivity to simple chemical compounds. Proc Soc Exp Biol Med 1942;49:688–690. 11 Bonnevie P: Aetiologie und Pathogenese der Ekzemkrankheiten. Klinische Studien über die Ursachen der Ekzeme unter besonderer Berücksichtigung des diagnostischen Wertes der Ekzemproben. Copenhagen, Busch, 1939. 12 Marcussen PV: Variations in the incidence of contact hypersensitivities. Trans St Johns Hosp Dermatol Soc 1962;48:40–48. 13 Ashworth J: Robert Prosser White (1855– 1934). Clin Exp Dermatol 1994;19:186–187. 14 Lachapelle JM, Ale SI, Freeman S, Frosch PJ, Goh CL, Hannuksela M, et al: Proposal for a revised international standard series of patch tests. Contact Dermatitis 1997; 36: 121–123.
15 Cheng LS, Alikhan A, Maibach HI: Compilation of international standards for patch testing methodology and allergens. Dermatitis 2009;20:257–260. 16 Cheng LS, Alikhan A, Maibach HI: Creating an electronic collaboration between international contact dermatitis groups. Contact Dermatitis 2009;61:59–60. 17 Fischer TI, Maibach HI: The thin layer rapid use epicutaneous test (TRUE-test), a new patch test method with high accuracy. Br J Dermatol 1985;112:63–68. 18 Fischer T, Maibach HI: Easier patch testing with TRUE Test. J Am Acad Dermatol 1989; 20:447–453. 19 Yiannias JA, Miller R, Kist JM: Creation, history, and future of the Contact Allergen Replacement Database (CARD). Dermatitis 2009;20:322–326. 20 Alikhan A, Maibach HI: Allergic contact dermatitis: the future. Dermatitis 2009; 20: 327–333. 21 Lachapelle JM: Giant Steps in Patch Testing: A Historical Memoir. Phoenix, SmartPractice, 2010.
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Dr. Ali Alikhan Department of Dermatology, Mayo Clinic 200 First Street SW Rochester, MN 55905 (USA) E-Mail alikhan.mirza @ mayo.edu
