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Annale Italiano 2011, anno 65, numero 1, Gennaio-Aprile

Cheiliti da contatto: allergia o irritazione?

Monica Corazza, Stefania Zauli, Michela Ricci, Giulia Toni, Alessandro Borghi

Obiettivo: valutare la frequenza di sensibilizzazione da contatto in un gruppo selezionato di pazienti affetti da cheilite ed individuare gli allergeni più frequentemente coinvolti.Materiali e metodi: è stata condotta un?analisi retrospettiva su 33 pazienti afferiti con diagnosi clinica di cheilite. Tutti i pazienti sono stati sottoposti a patch test con la serie standard SIDAPA (Società Italiana di Dermatologia Allergologica Professionale ed Ambientale) ed eventuali serie integrative. Risultati: sono state riscontrate complessivamente 29 positività, ma sono state valutate rilevanti solo 12 di queste (alcoli della lanolina, profumi mix, aldeide formica, propolis, balsamo del Perù, Kathon CG®, carvone, isoeugenolo, propil gallato, butil-idrossitoluene e butil-idrossianisolo). Conclusioni: la maggior parte delle cheiliti eczematose è risultata di natura irritativa. Le cheiliti allergiche da contatto rappresentavano il 24,2% delle cheiliti esaminate ed erano più frequenti nel sesso femminile. I patch test rappresentano un esame fondamentale per distinguere queste due forme.

Contact cheilitis: allergy or irritation?

Background: Eczematous cheilitis is an inflammatory condition of the lips that is due to endogenous factors (atopic cheilitis) or exogenous factors such as cosmetics, pharmaceuticals, food and dental materials. The cheilitis due to exogenous factor can be divided into irritant and allergic contact cheilitis. The diagnosis of eczematous cheilitis is based on a careful history, physical examination and patch testing performed with conventional allergens, additional series and personal products in appropriate concentrations and vehicle. Objectives: the aim of this study is to assess the frequency of contact sensitivity in a selected group of patients with cheilitis and identify the allergens more frequently involved. Materials and methods: 33 patients with cheilitis referred to the Dermatology Section of the University of Ferrara. 14 patients presented an unspecified cheilitis, 9 presented a desquamative cheilitis, 2 a chronic cheilitis, 1 a dystrophic cheilitis and 1 a vesicular-crusted cheilitis. In 4 patients, cheilitis was associated with a perioral dermatitis, whereas in 2 patients the eczematous dermatitis involved all the face. All patients were patch tested with the allergens of SIDAPA (Società Italiana di Dermatologia Allergologica Professionale ed Ambientale) standard series and some additional series suspected of having contributed to patient cheilitis. In particular, Fragrance series was tested in 30 patients, Antimicrobials-Preservatives series in 18 patients and Emulsifiers series in 16 patients. The Odontotechnics series was tested in 9 patients, because of a history suggesting a relationship between cheilitis and odontoiatric procedures. Results: 33 patients (28 females and 5 males) with a mean age of 49 years (range 23-91) were enrolled in the study. The mean duration of cheilitis was 12.8 months; it was longer in males (15 months) that in females (12.4 months). A personal history of atopy was recorded in 6 patients (all females). Allergic contact cheilitis was diagnosed in 8 patients (7 females and 1 male) (24.2%); 3 females had a personal history of atopy. Positive reactions to lanolin alcohols, fragrance mix, formaldehyde, propolis, Myroxylon pereirae resin (balsam of Peru), Kathon CG ® , carvone, isoeugenol, propyl gallate, butylhydroxytoluene and butylhydroxyanisol were considered relevant. Conclusions: the major part of eczematous cheilitis is irritant. Allergic contact cheilitis represents about 24% of eczematous cheilitis. They are more common in females, probably in relation to a widespread use of cosmetics. A history of atopy was commonly found in patients with cheilitis, suggesting a predisposition in atopic subjects to develop allergic cheilitis. Allergens more frequently involved are components of cosmetic products such as lanolin, perfumes, natural substances such as propolis and preservatives such as Kathon CG®. Patch test is of primary importance in performing the diagnosis and differentiating irritant contact cheilitis from allergic ones.

Fitodermatiti da contatto: rilievi diagnostici

Domenico Bonamonte, Caterina Foti, Gianni Angelini

Lo studio delle fitodermatiti da contatto (FDC) presenta varie difficoltà: notevole numero di specie, moltitudine di antigeni, peraltro diversi nelle varie porzioni della pianta, e possibilità di contatto con diverse piante nella stessa occasione. Nel determinismo delle stesse dermatiti intervengono inoltre fattori ambientali (stagione, clima, radiazioni ultraviolette) e costituzionali (sudorazione). Da considerare anche il fatto che la dermatite può insorgere, oltre che per contatto con le piante come tali, anche per contatto con prodotti industriali da esse derivati (cosmetici, medicamenti topici) e con alimenti e loro additivi. Il rischio di contrarre una fitodermatite da contatto è a nostro avviso molto elevato e dipende dall?occupazione del paziente e dal suo stile di vita, incluse le attività del tempo libero. Lo scopo del presente lavoro è quello di fornire alcuni sintetici suggerimenti utili per la diagnosi clinica ed eziologica delle FDC. Le reazioni cutanee da piante comprendono vari quadri clinici con meccanismi patogenetici diversi: irritazione e allergia da contatto, fotoirritazione e fotoallergia da contatto, orticaria da contatto immunologica e non immunologica, reazioni granulomatose ed ipercromie primitive (berloque dermatitis da coinvolgimento melanocitario e iperpigmentazione chinone-dipendente da contatto, per esempio, con henné o noci). Per ciascuno di questi pattern clinici vengono considerate le possibilità di diagnosi differenziale. Quando si sospetta una pianta come causa della dermatite, bisogna provvedere innanzitutto all?identificazione della stessa, prima di procedere con i test cutanei. I campioni per i test devono essere ottenuti da tutte le porzioni delle piante (fiori, foglie, steli, radici, frutti), incluse quelle considerate ?selvagge?. Ogni campione deve essere suddiviso in tre parti, una per l?identificazione, una per l?estrazione dell?antigene e l?altra per ulteriori eventuali studi chimici. Una volta identificata la pianta, bisogna consultare la letteratura per le notizie sugli antigeni, comprese le loro diluizioni e i veicoli di estrazione. Il dermatologo può quindi testare il paziente con ogni singola porzione della pianta come tale o con gli estratti opportunamente preparati. Non è necessario testare le piante notoriamente irritanti. E? obbligatorio testare con ogni parte della pianta 20 soggetti sani di controllo, allo scopo di evidenziare eventuali reazioni di tipo irritativo.

Diagnostic criteria in plant contact dermatitis.

The study of plant contact dermatitis presents many difficulties, such as the number of plant species, the multitude of antigens (different in the various portions of the plant), the fact that the patient may have been exposed to several plants, and the participation to the pathogenetic mechanism of environmental (climate, season) and constitutional (sweating) factors. On the other hand, the plant dermatitis may arise not only for contact with the plant itself, but also for contact to the derivatives found in industrial and cosmetic products (perfumes). The risk of contracting dermatitis, in our opinion very frequent, depends on the patient?s occupation and life style, including leisure activities. The aim of the present paper is to give some synthetic and schematic suggestions useful for the clinical and aethiological diagnosis of phytocontact dermatitis. Cutaneous reactions to plant material include various types of contact reaction, such as irritant and allergic contact dermatitis, airborne toxic and allergic contact dermatitis, phototoxic and photoallergic reactions, immunologic and non immunologic contact urticaria, granulomatous reactions, and primitive hyperchromic pictures (melanocytic-mediated berloque dermatitis, and quinone-dependent hyperpigmentation from lawsone or juglone). For each one of these clinical patterns, the various differential diagnostic features are considered. When a plant has been suspected in causing contact dermatitis, it is necessary to proceed, obviously before testing the patient, to the botanical investigation (sources: botanists of herbariums, Universities, Department of Agriculture). Samples must be obtained of all the portions of the plant (flowers, leaves, stems, roots, and fruits) to which the exposure may have occurred, including those considered ?weeds?. Each sample must be divided into three parts, one used for identification, one for making extract dilutions and another one preserved in freezer for chemical study. After the identification of the plant and the information on its antigens, the dermatologist may proceed to test the patient with the various portions of plant itself or with the extracts, properly prepared. It is useless to patch test with irritant plants. It is mandatory to test with the various parts of the plant 20 control individuals in order to identify eventual irritant reactions.

Fotoinvecchiamento e tanoressia

Domenico Bonamonte

L?incidenza delle neoplasie cutanee tende ad aumentare nonostante gli sforzi della campagna educazionale sui danni da eccessiva fotoesposizione e sull?impiego di schermanti solari. Un motivo di insuccesso della campagna potrebbe essere quello dell?esistenza di soggetti con particolari caratteristiche demografiche (adolescenti e giovani adulti, in particolare di sesso femminile), che non solo si espongono continuamente al sole senza alcuna protezione, ma fanno uso continuo anche di mezzi di abbronzatura ?indoor?. Questa dipendenza dall?abbronzatura, detta anche tanoressia, potrebbe essere legata a complesse motivazioni, psicologiche, sociali o organiche. Nell?attesa che il meccanismo dell?insorgenza della tanoressia venga chiarito, è auspicabile, oltre all?educazione sull?impiego di schermanti solari, una normativa che regoli modalità di impiego e di manutenzione di lampade, docce e lettini di abbronzatura; l?uso di questi apparecchi dovrebbe essere vietato prima dei 18 anni.

Photoaging and tanorexia

With age, the skin undergoes a number of changes that have profound effect on function of this organ. The most important changes involve loss of elasticity, failure of protective barrier function of the skin and predisposition to cutaneous cancer. The effects of aging does not only affect the elderly, but it can start from the age of 30-40 years. The majority of the changes in fact are due to cumulative, excessive exposition to the sun during the life time. The clinical features of photodamaged skin differ depending on the skin type: obviously, the gross appearance of the photoaging is evident in subjects with fair skin, who show atrophic skin changes, dysplastic lesions and epidermal malignancies. Recently, the media attention concerns the rising of incidence of skin cancers despite the extensive educational efforts for decreasing the exposure to sun and non solar UV light (UVL). Numerous studies have in fact shown that knowledge about the harmfull effects of UVL often fails to alter tanning behavior: particularly young adults continue to use any skin photoprotection strategies either in case of sun exposure or the use of tanning salons. A possible mechanism for tanning dependence (?tanorexia?) could be the release of endogenous opioids during the UVR exposure. However, although some authors found increased plasma levels of endorphins during UVR exposure, others have failed to demonstrate the same effect. Apart from the biopsychological reasons of tanning dependence, in addition to the promotion of sunscreens, legal government restrictions are mandatory for the use of indoor tanning, in particular with regard to children and teenagers.

Il ritorno del carbonchio? Casistica personale e revisione della letteratura

Domenico Bonamonte, Annarita Antelmi, Paolo Greco, Gianni Angelini

Il carbonchio è un?infezione acuta che colpisce primitivamente animali erbivori (in genere pecore, capre, ovini e cavalli). L?uomo acquisisce la malattia per contagio, prevalentemente professionale, da animali o loro prodotti infetti (pelli, lana, setole, ossa). L?agente eziologico del carbonchio, Bacillus anthracis, è un germe voluminoso, non mobile, capsulato, aerobio, Gram-positivo e capace di dare origine a spore altamente resistenti, potendo sopravvivere nel terreno anche per decadi. Sebbene ben controllato, il carbonchio continua ad osservarsi nei paesi industrializzati, sia pure in forma di modesti e isolati focolai. A causa della loro particolare resistenza, le spore potrebbero essere usate come arma biologica. Al riguardo, gli episodi di bioterrorismo del 2001 negli Stati Uniti hanno causato 11 casi di antrace polmonare, 5 dei quali ad esito letale. Al fine di evitare un possibile ritorno del carbonchio in forma endemica, tenuto conto delle recenti segnalazioni sia pure di casi sporadici in Europa e in Italia in particolare, si rendono obbligatorie appropriate misure di prevenzione, in particolare ambientali e terapeutiche.

The return of anthrax? Personal experience and literature review

Anthrax is an acute disease primarily of domestic herbivorous animals (usually sheeps, cows, horses, goats), but humans can acquire the disease if they are occupationally exposed to infected animals or animal products (hair, hides, bones, skin wool). The causative organism of anthrax is Bacillus (B.) anthracis, a large, non-mobile, aerobic, Gram-positive rod, with the capacity to make heat- and dry-resistant spores under various conditions. Spores may survive for decades in topsoil and resist high temperatures. The organism may be identified by Gram staining of liquid aspirated from a lesion and grows rapidly on simple media; the edge of the colonies is likened ?Medusa?s head?. Virulence of the bacillus is conferred by a capsule which inhibits phagocytosis and a complex exotoxin which consists of ?oedema? and ?lethal? factors together with a ?protective antigen? determinant. The organism may be transmitted also by insects, including house flies. Anthrax infection occurs in humans by 3 routes: cutaneous, inhalational, and gastrointestinal. The most frequent clinical manifestation is the cutaneous disease (?malignant pustule?), occurring in more than 95% of cases. The lesion is most often localized on exposed areas, such as upper extremities, neck, head, and begins as a papule that evolves into a vesicle or bulla with surrounding oedema. The lesion becomes then hemorrhagic and necrotic and may be surrounded by small satellite vesicles. The involved area is rarely painful; regional lymph nodes may be enlarged and tender. The disease may rarely manifest as pulmonary anthrax, a very serious and often deadly infection due to inhalation of spores from contaminated animal products, or gastrointestinal anthrax (common in Africa) from ingestion of a large numbers of vegetative bacilli from infected meat. Penicillin remains the proven drug of choice and is best given intravenously in high doses. Otherwise other antibiotics (amoxicillin) appear to be satisfactory. In case of strains resistant to penicillin the drug of choice is ciprofloxacin. Although well controlled in the developed countries, anthrax remains of a global concern because B. anthracisspores can potentially be used as a biological weapon. In this regard, the anthrax attacks of September 2011 in USA, associated with spores delivered by mail, resulted in 11 cases of inhalational anthrax, 5 of whom died. On the other hand, some local anthrax outbreaks have been recorded in the last decade also in many western European countries (Scotland, England, Italy, etc.). In the light of these current events, several and mandatory preventive measures are to be taken, by mean of procedures useful both for outbreaks of illness due to biological terrorism and for anthrax outbreaks occurring naturally or by accident. In the last case, the appropriate control of the occupational hazard for workers who handle animals or their products is obviously necessary. Carcasses and infected meat must be deeply buried or cremated. Cremation is a proper postmortem procedure also for humans. All related instruments and material for care of the patients must be autoclaved or incinerated. Any imported animal products (skin, bones, wool, etc.) should be properly disinfected before the importation, while a careful ventilation is necessary for at risk working environment.

Le correlazioni clinico-anamnestiche e i risultati dei test cutanei allergodiagnostici nelle reazioni avverse cutaneo-mucose ad antibatterici sistemici

Luca Stingeni, Francesca Raponi, Katharina Hansel, Daniela Agostinelli, Paolo Lisi

il percorso diagnostico delle reazioni avverse a farmaci (RAF) non è agevole e il corretto approccio clinico-anamnestico ne rappresenta l?indispensabile fase iniziale. Questo, infatti, consente di prospettare il nesso di causalità tra il farmaco assunto e le manifestazioni cutaneo-mucose da esso indotte. Al fine di ottimizzare tale approccio recentemente abbiamo proposto sei classi di correlazioni cliniche-anamnestiche (CCA): ?certa?, ?molto probabile?, ?probabile?, ?dubbia?, ?non correlazioni?, ?non precisabile?. La seconda fase del percorso diagnostico prevede l?esecuzione dei test cutanei allergodiagnosici (TCA) (patch test, prick test e test intradermico), anche se la loro attendibilità è spesso condizionata da fattori tecnici. Obiettivi: i) validare i criteri proposti per definire le classi di CCA mediante i risultati dei TCA eseguiti in soggetti con RAF cutaneo-mucose da antibatterici sistemici; ii) individuare le eventuali correlazioni tra le reazioni positive ai TCA e la morfologia clinica delle RAF o il tipo di farmaco in causa. Materiali e metodi: sono stati esaminati retrospettivamente i dati clinico-anamnestici e i risultati dei TCA eseguiti in 451 soggetti (292 F, 159 M) con RAF cutaneo-mucose verificatesi in corso di terapia con antibatterici sistemici. I pazienti sono stati distribuiti nelle 6 classi di CCA e, all?interno di ciascuna di esse, sono state individuate le reazioni positive ai TCA. Queste, inoltre, sono state distribuite in relazione alla morfologia delle RAF e al tipo di farmaco in causa. Risultati: nel 32,2% dei casi è stata identificata una delle prime 3 CCA e soprattutto quella ?molto probabile? (26,8%). Nei rimanenti pazienti la CCA più frequente (53,2%) era quella ?non precisabile?. Il 18,1% dei soggetti ha presentato reazioni positive ai TCA; il test più frequentemente positivo è stato il test intradermico (65,9%). Le CCA con maggiore prevalenza di reazioni positive erano quella ?certa? (29,4%) e quella ?molto probabile? (24,8%), con significatività statistica rispetto a quanto osservato nelle altre CCA (p=0,01). Le reazioni positive ai TCA avevano prevalenza maggiore nelle RAF a patogenesi IgE-mediata, specie quando causate dai betalattamici, rispetto a quelle a patogenesi ritardata. Conclusioni: i dati di questo studio sembrano validare i criteri da noi proposti per definire le CCA nelle RAF cutaneo-mucose da antibatterici. L?elevato numero dei soggetti inseriti nella CCA ?non precisabile? conferma le difficoltà dell?approccio clinico-anamnestico specie quando si debbano inquadrare RAF fortemente retrodatate.

Clinical anamnestic correlations and skin test results in skin adverse drug reactions to systemic antibacterials.

Background:diagnosis of adverse drug reactions (ADR) is not easy and the correct clinical anamnestic approach represents the first step. This allows you to define the imputability criterion, iethe causal link between the drug and the skin manifestations induced by it. In order to optimize this approach, six classes of clinico-anamnestic correlations (CAC) were recently identified by us: "certain" "very likely," "likely," "dubious," "no correlation", "indeterminable". The second diagnostic step includes the perfor-mance of allergogical skin tests (AST) (patch test, prick test and intradermal test), although their reliability is influenced by technical factors. Objectives: i) to validate the proposed criteria to define CAC classes through AST performed in patients with skin ADR from systemic antibacterials; ii) to determine possible correlations between positive reactions to AST, ADR clinical morphology and drug involved. Materials and methods: we retrospectively examined clinical data, medical history and AST results performed in 451 subjects (292 F, 159 M) with skin ADR arised during therapy with systemic antibacterials. Patients were distributed in the six classes of CAC; positive reactions to AST within each of classes were identified. Finally AST positive reactions in relation to ADR morphology and type of drug involved were analyzed. Results: in 32.2% of cases were identified 1 of the 3 first CAC, especially "very likely" (26.8%). In the remaining patients the most frequent CAC was "indeterminable" (53.2%). 18.1% of the subjects had positive reactions to AST; the most frequent positive AST was the intradermal test (65.9%). CAC with higher prevalence of positive reactions were "certain" (29.4%) and "very likely" (24.8%), with statistical significance compared to that observed in other CAC (p=0.01). Positive reactions to AST were more frequent in ADR with IgE-mediated pathogenesis and caused by betalactams than in cell-mediated ADR. Conclusions: our data seem to validate the criteria proposed by us to define the CAC in skin ADR induced by antibacterials. The large number of subjects included in the CAC ?indeterminable? confirms the difficulty to clinical anamnestic approach in such patients, especially in cases of long lasting past ADR.