Fabrizio Guarneri, Caterina Trifirò e Serafinella Patrizia Cannavò
Iniziata negli anni ?70 con dispositivi a scopo ludico e tuttora inarrestabilmente in crescita, causa e motore di una rivoluzione sociale e culturale che investe ogni aspetto del quotidiano, l?informatizzazione ?di massa? rappresenta uno straordinario progresso umano ma anche un elemento di rischio per la salute, attraverso la genesi di ?nuove? patologie e/o la ?riproposizione? di alcune già note, in forme inedite o incon- suete. Le ?malattie da progresso tecnologico? in ambito dermatologico sono schematicamente classificabili in sei categorie: patologie da pressione/trauma/frizione, allergie da contatto, eritema ab igne, dermatite da videoterminali, cell phone dermatitis, patologie degli addetti alla produzione. Viene presentata una rassegna della letteratura, dalla quale si evince la necessità di una più stretta collaborazione fra i due mondi, spesso non comunicanti, della medicina e dell?informatica, per un progresso tecnologico realmente a favore ed in funzione dell?uomo.
The generalized diffusion of informatic tech- nology started in the 1970s, when the first video gaming consoles were put on the market of home appliances. Since then, a long and apparently unstoppable trend of growth has led informatics to become an integral part of almost any daily activity, particularly in high-income countries. While current digital devices bring remarkable and, not long ago, unthinkable advantages and opportunities, they are not devoid of potential risks for human health: indeed, medical literature reports that modern technology can induce new or unusual clinical presentation of known diseases, making diagnosis difficult, or even generate new diseases, strictly linked to the technology itself. Dermatological interest is more recent than in other branches of medicine, as first reports date back to mid-1990s; however, a rapid increase has been observed in the 2000s, and literature is now quite abundant and varied. Cutaneous diseases related to technological development of informatic devices can be schematically divided in six groups: diseases caused by pressure, trauma or friction, allergic contact dermatitis, erythema ab igne, screen dermatitis, cell phone dermatitis, diseases affecting workers of the electronics industry (similar to some diseases affecting users, but caused by occupational contact with internal components or materials, to which average users normally have no direct access). The first group includes diseases caused by computer accessories such as the keyboard, computer mouse and mousepad, by controllers of video gaming consoles and by mobile communication devices and personal digital assistants. Clinical manifestations range from classical irritant contact dermatitis to lichenified dermatosis, from painful edema to blisters, from subcorneal post-traumatic hemorrhages to traumatic nail dystrophy. Allergic contact dermatitis from keyboards or the computer mouse can be induced by several haptens contained in plastic materials or synthetic rubbers, such as phthalates, neoprene, thiourea, resorcinol monobenzoate, but also the much more common cobalt. Computer-induced erythema ab igne is caused by the high temperatures that portable computers can reach when inappropriately kept on thighs, thus disturbing optimal air flow through the cooling unit, for prolonged times. Screen dermatitis is a debated nosological entity, which includes a wide spectrum of signs and symptoms reported to occur more frequently in subjects occupationally exposed to video display units than in non-exposed controls. Cell phone dermatitis is a peculiar form of allergic con- tact dermatitis, caused by metals (usually nickel, but chromium can also be involved) contained in external parts of cell phones which come in contact with skin, typically during conversations. Occupational diseases reported in workers of the computer industry are few, probably mainly because of the almost complete au- tomation of computer production cycles. A summary of literature concerning cutaneous diseases linked to informatic devices is presented, pointing out the emerging need of a more strict collaboration between two often non-communicating worlds, medicine and informatics, to achieve technological progress which really improves life.
Leonardo Bianchi, Francesco Lanza, Diletta Neve, Paolo Lisi
Le reazioni avverse a farmaci sistemici, anche se raramente, possono essere causate da componenti del veicolo, quali conservanti, coloranti e antiossidanti. Viene riportato il caso di una donna di 44 anni affetta da pustolosi localizzata su mento, collo e scollo, esordita dopo 2 giorni di terapia intramuscolare con diclofenac sodico. I test cutanei allergodiagnostici hanno mostrato reazione positiva al farmaco come tale e a sodio metabisolfto. Questo antiossidante è utilizzato soprattutto nell?industria alimentare, ma è presente pure in alcuni farmaci parenterali, quali anestetici locali addizionati ad adrenalina, diclofenac e corticosteroidi.
Adverse reactions to systemic drugs rarely may be due to vehicle components, such as preservatives, colorants and antioxidants. We report the case of a 44-year-old woman affected by localized pustulosis of the chin, neck and V of the chest, appeared after 2 days of intramuscular therapy with diclofenac. The patch test showed positive reaction to the drug as it and to sodium metabisulphite (5% pet). Sodium metabisulphite is an antioxidant mainly used in the food industry. However, it is present in some parenteral drugs, such as local anesthetics with adrenaline, diclofenac, and corticosteroids
Luca Stingeni, Stefano Caraffini, Veronica Bellini, Diletta Neve, Paolo Lisi
Viene riportato il caso di una donna di 49 anni che ha più volte presentato anafilassi (caratterizzata da eruzione eritemato-edematosa, tosse stizzosa e perdita di coscienza) dopo assunzione di numerosi farmaci, per lo più antibiotici. Dopo accurate indagini allergodiagnostiche (patch test, prick test e test intradermico con farmaci incriminati e alternativi, test di tolleranza orale con farmaci e con placebo) e dopo attento esame della composizione dei preparati farmaceutici che avevano causato recidiva della sintomatologia, è stato precisato il ruolo eziologico di magnesio stearato. Si tratta di un eccipiente impiegato per l?allestimento di numerosi prodotti farmaceutici sotto forma di compresse, capsule e bustine; il suo impiego consente di aumentarne la scorrevolezza e di ridurne la capacità aderente, così come di favorire il progressivo assorbimento del principio attivo e la sua cessione protratta. Non ci risultano altri casi di anafilassi da magnesio stearato segnalati in letteratura
A case of a 49-year-old non atopic woman who suffered from anaphylaxis characterized by erythematous-oedematous rash, cough and loss of awareness after oral therapy with ciprofloxacin and others drugs, mostly antibiotics, is reported. Allergodiagnostic in vivo investigations (patch test, prick test and intradermal testing with incriminated and alternative drugs, oral and intramuscular challenge tests with alternative drugs and placebo) were done: multiple anaphylactic reactions were observed but only when the patient was orally administered drugs containing magnesium stearate as excipient. This is a chemical widely used in the pharmaceutic industry for its excellent anti-binder properties. It is used for the preparation of numerous drugs in tablets, capsules, and sachets increasing the flowability, reducing the adherent ability, facilitating the progressive absorption of the active principle and its sustained release. To our knowledge, this is the first case report of anaphylaxis induced by magnesium stearate
Cataldo Patruno, Dario Bianca, Teresa Lopez, Nicola Balato
Una paziente di 34 anni ha presentato angioedema del volto e della lingua in seguito alla assunzione orale di prednisone (5 mg) o di betametasone disodio fosfato (1 mg). Il prick test e il test di esposizione con deflazacort soluzione orale fino a 6 mg sono risultati negativi. Le reazioni da ipersensibilità immediata nei confronti dei corticosteroidi (CS) sistemici sono una evenienza rara ma con importanti implicazioni cliniche per l?ampia utilizzazione di tali farmaci. In questi pazienti è pertanto necessario individuare molecole, nell?ambito della stessa categoria farmaceutica, che non inducano tale effetto collaterale. Deflazacort, per la sua peculiare struttura chimica, è considerato una valida alternativa in pazienti con ipersensibilità immediata nei confronti di alcuni CS sistemici, quali gli esteri succinici di idrocortisone e metilprednisolone. Il nostro caso suggerisce la possibilità dell?utilizzo di deflazacort anche in pazienti con ipersensibilità nei confronti di prednisone e betametasone disodio fosfato.
A 34-year-old woman was referred to us for the occurrence of angioedema of the face and tongue. Angioedema appeared soon after the oral administration of prednisone (5 mg) or betamethasone disodium phosphate (1 mg). Skin prick test and incremental oral challenge test with deflazacort drops (0.06 mg, 0.6 mg, 1.5 mg, 3.0 mg, 6.0 mg) given at hourly intervals (total dose: 11.16 mg) were negative. Immediate hypersensitivity reactions to systemic corticosteroids (CS) are a rare occurrence. Since CS are drugs of widespread use with many indications, investigating for a well-tolerated different type of systemic CS is of the outmost importance in these patients. For this purpose, skin test and oral challenge with an alternative CS are suggested. Due to its molecular structure, deflazacort is reported as a safe molecule in patients with immediate hypersensitivity to some CS, such as succinate esters of hydrocortisone and methylprednisolone. In our case no reaction was seen after skin test and oral challenge with deflazacort, thus suggesting its safe use also in patients with immediate adverse reactions to prednisone and betamethasone disodium phosphate.
Colombina Vincenzi, Aurora Maria Alessandrini, Michela Starace, Francesca Bruni, Bianca Maria Piraccini
Negli ultimi anni molti studi hanno ricercato una diretta correlazione tra allergia ai metalli e rigetto di un impianto dentale metallico. Riportiamo il caso di una donna di 53 anni, con una precedente diagnosi di allergia da contatto a nichel e cobalto, che ha manifestato bolle e vescicole a livello gengivale dopo l?installazione di due impianti dentali. La paziente è risultata positiva anche a titanio biossido, principale componente dell?impianto stesso. Questo caso sottolinea l?importanza di sottoporre a patch test il paziente che debba ricevere un dispositivo dentale, soprattutto se già allergico ai metalli.
Recently, studies have tried to collocate the direct correlation between allergy to metals and failure of dental metal implants. We report the case of a 53 years old woman, with a previous diagnosis of contact allergy to nickel and cobalt, which showed blisters and vesicles at the gum after the installation of two dental implants. The patient was positive also to titanium bioxide, the main component of the implant itself. This report emphasizes the importance of patch testing every patient who is undergoing a dental implant, especially if allergic to metals before the dental procedure.
Monica Corazza, Stefania Zauli, Antonella Pagnoni, Alessandro Borghi, Lucia Mantovani, Annarosa Virgili
Si presenta il caso di una dermatite eritemato-edematosa coinvolgente i quadranti interni di entrambe le mammelle e la regione pre-sternale insorta in seguito a contatti prolungati e ripetuti con una pietra ametista. La paziente, naturopata, aveva applicato l?ametista in tale sede, corrispondente all?area del IV chakra, a scopo purificatorio. Sono state effettuate indagini allergodiagnostiche e analisi chimiche (spettroscopia ad assorbimento atomico e analisi del pH di una soluzione simile al sudore contenente polvere di ametista) allo scopo di chiarire l?eziologia della dermatite. Dal momento che tutte le indagini effettuate sono risultate negative, è stata posta diagnosi di dermatite da contatto irritante.
The authors report the case of an erythemato-oedematous dermatitis involving the inner side of both breasts and the pre-sternal region. The dermatitis appeared after prolonged and repeated contacts (several hours a day) with a voluminous amethyst. The patient, a naturopath, applied the amethyst in these sites, which correspond to the area of IV chakra, to purify. Allergodiagnostic investigations and chemical analysis (atomic absorption spectroscopy and pH analysis of a solution similar to sweat, containing amethyst dust) were performed in order to clarify the etiology of the dermatitis. As all these investigations resulted negative, a diagnosis of irritant contact dermatitis was done.
Luisa Di Costanzo, Nicola Balato, Cataldo Patruno, Serena La Bella, Fabio Ayala
Tumor necrosis factor alfa (TNFα) è una citochina proinfiammatoria che gioca un ruolo centrale nella patogenesi di alcune patologie infiammatorie. Gli inibitori di TNFα(TNFα-I) sono farmaci biologici utilizzati con successo nel trattamento di tali disordini. Sono descritte diverse reazioni avverse da TNFα-I; quelle cutanee sono le più frequenti. L?utilizzo del patch test per la diagnosi di tali reazioni è controverso. Abbiamo pertanto praticato test epicutanei (patch test e scratch-patch test) con serie standard SIDAPA e con i farmaci come tali in 6 pazienti con reazioni avverse da TNFα-I (orticaria in 3, eruzione eczematosa in 2, eruzione psoriasiforme in 1). I risultati ottenuti non sembrerebbero raccomandare l?uso di tali metodiche per la diagnosi eziologica delle reazioni avverse cutanee da TNFα-I
Tumor necrosis factor alpha (TNFα) is a proinflammatory cytokine produced by different cell types (T-lymphocytes, keratinocytes, and Langerhans cells) which plays an important role in immune system regulation. TNFα-inhibitors (TNFα-Is) are successfully used in the treatment of a large variety of chronic autoimmune disorders, such as rheumatoid arthritis, ankylosing spondylitis, Crohn disease, and psoriasis. Severe adverse events are uncommon and include lymphomas, opportunistic infections like tuberculosis, and demyelinating disorders. Literature analysis reveals that a wide variety of undesirable cutaneous reactions can be associated with TNFα-Is. These include eczematous eruptions, cutaneous lymphomas, herpes simplex, bacterial infections, lichenoid or psoriasiform eruptions, erythema multiforme, lupus erythematosus, and acute generalized exanthematous pustulosis. In literature, patch testing is a debated method to diagnose some cutaneous adverse reaction. In order to evaluate if patch testing could be a suitable method to screen these patients, we enrolled 6 patients with skin adverse reactions to biologic drugs. Three of them experienced urticaria, two eczematous eruption, and one psoriasiform eruption. Another 21 psoriatic patients treated with TNFα-Is with no side effects and 25 healthy subjects were enrolled as controls. All the subjects were tested with the commercial preparation of 3 TNFα-Is (adalimumab, etanercept, and infliximab) as is. In addition, a scratch-patch test was performed to enhance penetration of the drugs into the skin because of their high molecular weight (~ 150,000 Da). The tests were read at 30 mins, 48 and 72 hrs, and at day 7. The method was made by causing mechanical injury to the epidermis with a sterile skin prick lancet in order to compromise the stratum corneum, thus also big substances may penetrate the skin. In all cases patch and scratch-patch tests were negative. One patient who experienced generalized acute urticaria during the treatment with infliximab did not react to this drug, but a late, persistent, slight reaction to scratch patch test with etanercept was registered, probably due to an irritative reaction. In conclusion, our data seem to suggest that both conventional patch test and scratch-patch test with TNFα-Is are not reliable methods for the diagnosis of urticarial, eczematous, or psoriasiform eruptions presumably due to these drugs when commercial solutions are used for testing. Moreover, false positive reactions may be seen when scratch patch test is performed to enhance skin penetration
Veronica Bellini, Stefano Fiorucci, Barbara Renga, Simona Pelliccia, Leonardo Bianchi1, Paolo Lisi
Introduzione:i toll-like receptors (TLRs) sono coinvolti nelle risposte immuni e possono presentare geneticamente SNPs (Single Nucleotide Polymorphisms) in grado di alterarne la funzionalità . Tra questi, TLR9 può avere una mutazione a carico del suo SNP C-1237T che sembra essere correlata con patologie disimmuni. Obiettivi: verificare l?incidenza di SNP C-1237T di TLR9 in una popolazione di pazienti con eruzione eritemato-papulo-pustolosa (EEPP) indotta da farmaci inibitori dei recettori del fattore di crescita epidermico (EGF) e la correlazione delle sue varianti genotipiche con il sesso, la gravità dell?eruzione e la sede di localizzazione della neoplasia. Materiali e metodi: 26 pazienti con EEPP da farmaci inibitori dei recettori di EGF sono stati sottoposti a sequenziamento del DNA da sangue periferico per la ricerca della mutazione di SNP C-1237T di TLR9. La gravità dell?eruzione cutanea è stata quantificata utilizzando EGFRISTI (Epidermal Growth Factor Receptor Inhibitor-related Skin Toxicity Index). Risultati: la mutazione a carico di SNP C-1237T di TLR9 è stata trovata nel 30,8% dei pazienti e pertanto in una percentuale superiore a quella riportata nella popolazione caucasica (12%). Il suo riscontro era correlato con la gravità dell?eruzione (0% nelle eruzioni lievi, 26,7% in quelle moderate, 57,1% in quelle gravi) e con la sede di localizzazione della neoplasia (7/15 neoplasie del polmone, 1/9 neoplasie del colon-retto, 0/2 neoplasie del distretto testa-collo). Conclusioni: i dati, se confermati su casistica più ampia, potrebbero consentire lo screening dei pazienti da trattare con gli inibitori dei recettori di EGF, in quanto le EEPP più gravi sono indicative di migliore risposta oncologica al trattamento.
Background:erythematous and papulo-pustular eruption (EPPE) is the most common cutaneous adverse reaction induced by Epidermal Growth Factor Receptor inhibitors (EGFRI). This rash greatly worsens the quality of life of patients. Tolllike receptors (TLRs) are a family of receptors involved in immune responses which may present genetic Single Nucleotide Polymorphisms (SNPs) able to alter the gene functionality. A role of some TLRs in the pathogenesis of inflammatory diseases and cancers was recently suggested. It has been reported that TLR9 presents a mutation in its C-1237T SNP which seems to be correlated with several autoimmune diseases, such as atopic dermatitis and asthma. Furthermore, it is possible that some synthetic agonists of TLR9, called CpG-oligodeoxynucleotides, are able to stimulate the antitumoral innate immune response. Objectives:to assess the incidence of TLR9 C-1237T SNP in patients with EPPE induced by EGFRI and the correlations of genotypic variations of TLR9 C-1237T SNP with gender, EPPE and tumor site. Materials and methods:blood sampling for DNA extraction and sequencing to search the TLR9 C-1237T SNP mutation were carried out in 26 patients with EPPE induced by erlotinib in 14, cetuximab in 11, and tovok in 1. The eruption severity was quantified using EGFRISTI (Epidermal Growth Factor Receptor Inhibitor-related Skin Toxicity Index). The rash was considered mild, moderate, or severe if EGFRISTI value was < 20, between 20 and 40, or > 40, respectively. Results:TLR9 C-1237T SNP mutation was found in 30.8% of patients. This percentage is higher than that reported in the literature for Caucasian population (12%). The presence of mutation was correlated with the eruption severity (0% in mild, 26.7% in moderate, 57.1% in severe) and the cancer site (7/15 lung cancers, 1/9 colon/rectum cancers, 0/2 head/neck cancers). Conclusions:the data, if confirmed in a wider number of cases, could allow the screening of patients to be treated with EGFRI because the most serious EPPEs are indicative of better response to cancer treatment
Fabrizio Guarneri, Caterina Trifirò e Serafinella Patrizia Cannavò
Iniziata negli anni ?70 con dispositivi a scopo ludico e tuttora inarrestabilmente in crescita, causa e motore di una rivoluzione sociale e culturale che investe ogni aspetto del quotidiano, l?informatizzazione ?di massa? rappresenta uno straordinario progresso umano ma anche un elemento di rischio per la salute, attraverso la genesi di ?nuove? patologie e/o la ?riproposizione? di alcune già note, in forme inedite o inconsuete. Le ?malattie da progresso tecnologico? in ambito dermatologico sono schematicamente classificabili in sei categorie: patologie da pressione/trauma/frizione, allergie da contatto, eritema ab igne, dermatite da videoterminali, cell phone dermatitis, patologie degli addetti alla produzione. Viene presentata una rassegna della letteratura, dalla quale si evince la necessità di una più stretta collaborazione fra i due mondi, spesso non comunicanti, della medicina e dell?informatica, per un progresso tecnologico realmente a favore ed in funzione dell?uomo.
The generalized diffusion of informatic technology started in the 1970s, when the first video gaming consoles were put on the market of home appliances. Since then, a long and apparently unstoppable trend of growth has led informatics to become an integral part of almost any daily activity, particularly in high-income countries. While current digital devices bring remarkable and, not long ago, unthinkable advantages and opportunities, they are not devoid of potential risks for human health: indeed, medical literature reports that modern technology can induce new or unusual clinical presentation of known diseases, making diagnosis difficult, or even generate new diseases, strictly linked to the technology itself. Dermatological interest is more recent than in other branches of medicine, as first reports date back to mid-1990s; however, a rapid increase has been observed in the 2000s, and literature is now quite abundant and varied. Cutaneous diseases related to technological development of informatic devices can be schematically divided in six groups: diseases caused by pressure, trauma or friction, allergic contact dermatitis, erythema ab igne, screen dermatitis, cell phone dermatitis, diseases affecting workers of the electronics industry (similar to some diseases affecting users, but caused by occupational contact with internal components or materials, to which average users normally have no direct access). The first group includes diseases caused by computer accessories such as the keyboard, computer mouse and mousepad, by controllers of video gaming consoles and by mobile communication devices and personal digital assistants. Clinical manifestations range from classical irritant contact dermatitis to lichenified dermatosis, from painful edema to blisters, from subcorneal post-traumatic hemorrhages to traumatic nail dystrophy. Allergic contact dermatitis from keyboards or the computer mouse can be induced by several haptens contained in plastic materials or synthetic rubbers, such as phthalates, neoprene, thiourea, resorcinol monobenzoate, but also the much more common cobalt. Computer-induced erythema ab igne is caused by the high temperatures that portable computers can reach when inappropriately kept on thighs, thus disturbing optimal air flow through the cooling unit, for prolonged times. Screen dermatitis is a debated nosological entity, which includes a wide spectrum of signs and symptoms reported to occur more frequently in subjects occupationally exposed to video display units than in non-exposed controls. Cell phone dermatitis is a peculiar form of allergic contact dermatitis, caused by metals (usually nickel, but chromium can also be involved) contained in external parts of cell phones which come in contact with skin, typically during conversations. Occupational diseases reported in workers of the computer industry are few, probably mainly because of the almost complete automation of computer production cycles. A summary of literature concerning cutaneous diseases linked to informatic devices is presented, pointing out the emerging need of a more strict collaboration between two often non-communicating worlds, medicine and informatics, to achieve technological progress which really improves life.
Lucia Mantovani, Stefania Zauli, Alessandro Borghi, Sara Minghetti, Monica Corazza, Annarosa Virgili
Paederusè un insetto che produce un liquido vescicante, la pederina, in grado di causare lesioni vescico-bollose sulla superficie cutanea 24 ore dopo il contatto. La dermatite da Paederusè caratterizzata da un?evoluzione attraverso fasi successive, un?obiettività clinica sproporzionata rispetto alla sintomatologia, dalla presenza di lesioni ?a bacio? e dal decorso autorisolutivo. Alcuni elementi, come la distribuzione lineare delle lesioni, il coinvolgimento di altri membri della famiglia, l?insorgenza durante la notte e la stagionalità possono essere di aiuto nella diagnosi. Viene descritto uno caso di dermatite che per il suo aspetto clinico ed il decorso autorisolutivo ci ha fatto sospettare una dermatite da Paederus
Paederusis an insect which produces a vesicant liquid, the pederin, inducing vesico-bullous lesions on the skin, 24 hours after contact. Paederusdermatitis is characterized by an evolution through different stages, the presence of "kissing lesions", and a spontaneous resolution. Some features, such as the linear distribution of the lesions, involvement of other family members, onset during the night, and the season can be helpful in diagnosis, which is generally based on clinical criteria. The authors describe a case of dermatitis which for its clinical appearance and spontaneous resolution, suggested a diagnosis of Paederusdermatitis.