MSB Review
SULZBERGER AND THE PATCH TEST: A WINNING COMBINATION ERNST EPSTEIN, M.D. AND HOWARD MAIBACH, M.D. Erom the Department of Dermatology, University of California Schoof of Medicine, San Erancisco, California
In 1928 when Marion Sulzberger imported the patch test into the United States,' he recognized in this seemingly simple test a powerful tool for furthering our understanding of the variety of eczematous disorders labelled as "dermatitis" and "eczema." His perceptive scientific studies and continuing educational efforts have led to widespread awareness of the uses—and the limitations—of the patch test. When one considers the many current excellent books on contact dermatitis, as well as manuals of patch testing, it is hard to realize that for more than 2 decades Sulzberger's classic monograph, Dermatofogic Allergy,^ published in 1940, was the only English-language text in which the technique, use and interpretation of patch tests was discussed. In reviewing Sulzberger's decades-long romance with the patch test, we are struck with the changing relationship between physician and patch test. Early studies often dealt with basics. Eor example, in reporting on a patient with ragweed dermatitis,^ Sulzberger pointed out that scratch and intradermal tests were negative, but patch tests were positive. In other studies, he also stressed that patch tests are necessary for the diagnosis 360
of contact allergy, and that scratch and immediate-type intradermal tests are useless. What is now common knowledge was then a matter of controversy. Sulzberger explored the usefulness of the patch test in explaining a variety of disorders—for example, describing in 1930^ that patch tests demonstrate hypersensitivity to trichophytin in patients with dermatophytosis of the feet and accompanying " i d " reactions on the hands. Like other investigators using the patch test, he had his share of blind alleys and erroneous interpretations. It is clear that Sulzberger hoped to use the "contact test"— as the patch test was sometimes called in those days—to predict which patients were likely to develop the distressing dermatitis that not infrequently accompanied arsphenamine treatment of syphilis. These efforts^ failed, and we still lack a test for allergy to systemically administered medicaments. In reading Sulzberger's studies, we are impressed by his persistent questioning and innovative approaches—the characteristics of the successful medical investigator. Phenomena, no matter how curious or hard to explain, are carefully noted and the whys are systematically probed. Sulzberger used the patch test on 2 fronts: to aid in the management of patients, and as a tool to increase our understanding of allergic skin disorders. In association with others, notably Adolph Rostenberg, Jr. and Rudolph Baer, the re-
No. 5
SULZBERGER PATCH TEST
suits of patch testing in large series of patients were tabulated and evaluated.'^' Practical advice was given to the clinician as to "proper" patch test concentrations of a wide variety of materials.'' The use of routine or battery testing of patients with suspected contact dermatitis was stressed, and specific recommendations as to routine tests to be used were made.-"* Parallel to his interest In the patch test as a tool for patient management was Sulzberger's effective use of the patch test In studying the allergic reactivity of the skin. With his colleagues at New York University, he published studies on experimental sensitization, spanning many years. In 1939, together with Rostenberg** he reported on the experimental sensitizations of humans to dinitrochlorobenzene, and 23 years later with a different team described the establishment of contact type of sensitivity to methylcholanthrene in guinea pigs.'" Perhaps most important was his contribution to establishing the usefulness of patch testing as a clinical tool. For many years, his institution was the only North American university training its residents in the use of patch testing and providing patch test facilities for the systematic examination of patients. His writings stressed that with the proper use of patch testing certain patients could be rescued from the wastebasket diagnosis of "chronic eczema," and provided with a specific diagnosis as a guide to effective treatment. Some of his papers, as well as much of his textbook writings, were sorely needed missionary efforts to spread the gospel that there was a way of testing for contact dermatitis, and that it worked!
•
Epstein and Maibach
361
The stimulus provided by Sulzberger lives on in the numerous patch test clinics now active in North American dermatologic teaching centers, the North American Contact Dermatitis Group (which he helped found) and the everincreasing awareness of the role of contact allergens as a cause of skin disease. We dermatologists, and many of our patients, have benefitted immeasurably from Sulzberger's long-standing "affair" with the patch test! References 1. Sulzberger, M. B., and Wise, F.: The contact or patch test: Its uses, advantages, and limitations. Arch. Dermatol. Syphilol. 23:519, 1931. 2. Sulzberger, M. B.: Dermatologic Allergy. Springfield, Charles C Thomas, 1940. 3. Sulzberger, M. B., and Wise, F.: Ragweed dermatitis: With sensitization and desensitization phenomena. JAMA 94:93, 1930. 4. Sulzberger, M. B., and Lewis, C. M.: Trichophytin hypersensitiveness demonstrated by contact tests. Arch. Dermatol. Syphilol. 22: 410, 1930. 5. Chargin, L., Sulzberger, M. B., and Crowley, D. F.: Hypersensitiveness of the skin to arsphenamine as determined by the contact test. Arch. Dermatol. Syphilol. 22:237, 1930. 5. Rostenberg, A., Jr., and Sulzberger, M. B.: Some results of patch tests. Arch. Dermatol. Syphilol. 35:433, 1937. 7. Rostenberg, A., Jr., and Sulzberger, M. B.: A list of substances for patch-testing and the concentrations to be employed. |. Invest. Dermatol. 2:93, 1939. 8. Coodman, |., and Sulzberger, M.B.: Patch tests with therapeutic agents. Arch. Dermatol. Syphilol. 35:944, 1937. 9. Sulzberger, M. B., and Rostenberg, A., jr.: Acquired specific supersensitivity (allergy) to simple chemicals. J. Immunol. 36:17, 1939. 10. Sulzberger, M. B., Sherwin, R. W., Herrman, F.: Delayed contact-type sensitization to methylcholanthrene in guinea-pigs. J. Invest. Dermatol. 39:179, 1962.
SULZBERGER AND THE PATCH TEST: A WINNING COMBINATION ERNST EPSTEIN, M.D. AND HOWARD MAIBACH, M.D. Erom the Department of Dermatology, University of California Schoof of Medicine, San Erancisco, California
In 1928 when Marion Sulzberger imported the patch test into the United States,' he recognized in this seemingly simple test a powerful tool for furthering our understanding of the variety of eczematous disorders labelled as "dermatitis" and "eczema." His perceptive scientific studies and continuing educational efforts have led to widespread awareness of the uses—and the limitations—of the patch test. When one considers the many current excellent books on contact dermatitis, as well as manuals of patch testing, it is hard to realize that for more than 2 decades Sulzberger's classic monograph, Dermatofogic Allergy,^ published in 1940, was the only English-language text in which the technique, use and interpretation of patch tests was discussed. In reviewing Sulzberger's decades-long romance with the patch test, we are struck with the changing relationship between physician and patch test. Early studies often dealt with basics. Eor example, in reporting on a patient with ragweed dermatitis,^ Sulzberger pointed out that scratch and intradermal tests were negative, but patch tests were positive. In other studies, he also stressed that patch tests are necessary for the diagnosis 360
of contact allergy, and that scratch and immediate-type intradermal tests are useless. What is now common knowledge was then a matter of controversy. Sulzberger explored the usefulness of the patch test in explaining a variety of disorders—for example, describing in 1930^ that patch tests demonstrate hypersensitivity to trichophytin in patients with dermatophytosis of the feet and accompanying " i d " reactions on the hands. Like other investigators using the patch test, he had his share of blind alleys and erroneous interpretations. It is clear that Sulzberger hoped to use the "contact test"— as the patch test was sometimes called in those days—to predict which patients were likely to develop the distressing dermatitis that not infrequently accompanied arsphenamine treatment of syphilis. These efforts^ failed, and we still lack a test for allergy to systemically administered medicaments. In reading Sulzberger's studies, we are impressed by his persistent questioning and innovative approaches—the characteristics of the successful medical investigator. Phenomena, no matter how curious or hard to explain, are carefully noted and the whys are systematically probed. Sulzberger used the patch test on 2 fronts: to aid in the management of patients, and as a tool to increase our understanding of allergic skin disorders. In association with others, notably Adolph Rostenberg, Jr. and Rudolph Baer, the re-
No. 5
SULZBERGER PATCH TEST
suits of patch testing in large series of patients were tabulated and evaluated.'^' Practical advice was given to the clinician as to "proper" patch test concentrations of a wide variety of materials.'' The use of routine or battery testing of patients with suspected contact dermatitis was stressed, and specific recommendations as to routine tests to be used were made.-"* Parallel to his interest In the patch test as a tool for patient management was Sulzberger's effective use of the patch test In studying the allergic reactivity of the skin. With his colleagues at New York University, he published studies on experimental sensitization, spanning many years. In 1939, together with Rostenberg** he reported on the experimental sensitizations of humans to dinitrochlorobenzene, and 23 years later with a different team described the establishment of contact type of sensitivity to methylcholanthrene in guinea pigs.'" Perhaps most important was his contribution to establishing the usefulness of patch testing as a clinical tool. For many years, his institution was the only North American university training its residents in the use of patch testing and providing patch test facilities for the systematic examination of patients. His writings stressed that with the proper use of patch testing certain patients could be rescued from the wastebasket diagnosis of "chronic eczema," and provided with a specific diagnosis as a guide to effective treatment. Some of his papers, as well as much of his textbook writings, were sorely needed missionary efforts to spread the gospel that there was a way of testing for contact dermatitis, and that it worked!
•
Epstein and Maibach
361
The stimulus provided by Sulzberger lives on in the numerous patch test clinics now active in North American dermatologic teaching centers, the North American Contact Dermatitis Group (which he helped found) and the everincreasing awareness of the role of contact allergens as a cause of skin disease. We dermatologists, and many of our patients, have benefitted immeasurably from Sulzberger's long-standing "affair" with the patch test! References 1. Sulzberger, M. B., and Wise, F.: The contact or patch test: Its uses, advantages, and limitations. Arch. Dermatol. Syphilol. 23:519, 1931. 2. Sulzberger, M. B.: Dermatologic Allergy. Springfield, Charles C Thomas, 1940. 3. Sulzberger, M. B., and Wise, F.: Ragweed dermatitis: With sensitization and desensitization phenomena. JAMA 94:93, 1930. 4. Sulzberger, M. B., and Lewis, C. M.: Trichophytin hypersensitiveness demonstrated by contact tests. Arch. Dermatol. Syphilol. 22: 410, 1930. 5. Chargin, L., Sulzberger, M. B., and Crowley, D. F.: Hypersensitiveness of the skin to arsphenamine as determined by the contact test. Arch. Dermatol. Syphilol. 22:237, 1930. 5. Rostenberg, A., Jr., and Sulzberger, M. B.: Some results of patch tests. Arch. Dermatol. Syphilol. 35:433, 1937. 7. Rostenberg, A., Jr., and Sulzberger, M. B.: A list of substances for patch-testing and the concentrations to be employed. |. Invest. Dermatol. 2:93, 1939. 8. Coodman, |., and Sulzberger, M.B.: Patch tests with therapeutic agents. Arch. Dermatol. Syphilol. 35:944, 1937. 9. Sulzberger, M. B., and Rostenberg, A., jr.: Acquired specific supersensitivity (allergy) to simple chemicals. J. Immunol. 36:17, 1939. 10. Sulzberger, M. B., Sherwin, R. W., Herrman, F.: Delayed contact-type sensitization to methylcholanthrene in guinea-pigs. J. Invest. Dermatol. 39:179, 1962.
