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Patch Test By H.Eshaghi M.D IRRITANT CONTACT DEMATITIS  Non-immunologic inflammatory reaction of the skin due to an external agent  Varied morphology.

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Presentation on theme: "Patch Test By H.Eshaghi M.D IRRITANT CONTACT DEMATITIS  Non-immunologic inflammatory reaction of the skin due to an external agent  Varied morphology."— Presentation transcript:

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2 Patch Test By H.Eshaghi M.D

3 IRRITANT CONTACT DEMATITIS  Non-immunologic inflammatory reaction of the skin due to an external agent  Varied morphology  Clinical types  Chemical burns  Irritant reactions  Acute irritant contact dermatitis  Chronic irritant contact dermatitis

4  Irritant Contact dermatitis : Acute irritant dermatitis → severe eczematous reaction  Single overwhelming exposure  Few brief exposures to strong irritants or a caustic agent Chronic (cumulative) irritant dermatitis → eczematous changes that develop upon repeated exposure to weaker irritants: water, soaps, detergents, solvents, weak acids or alkalis, low humidity, heat, air, and dusts

5 Allergic Contact Dermatitis  Delayed type IV hypersensitivity reaction  SENSITIZER: chemical agent with low molecular weight which is able to sensitize certain individuals and induce cell mediated immune reaction that end with dermatitis only in previously sensitized persons.  Pathogenesis:  Induction (sensitization) phase: days  Elicitation phase: 2-4 days  Antigen binds Langerhan’s cells in the epidermis or macrophages in the dermis  Interaction with CD4+ T lymphyocytes at the regional lymph nodes causes release of inflammatory cytokines

6 Mechanism  Specific immune phenomenon that is the result of a T cell mediated immune response to a defined allergen resulting in eczema or the exacerbation of a pre-existing dermatitis

7 Common allergens  Chromate  Rubber chemicals  Preservatives  Nickel  Fragrances  Epoxy resins  Phenol-formaldehyde resins

8  Contact dermatitis of the hands in a dental technician  Patch testing to be allergic to the Thiuram chemicals (accelerator in gloves)

9 Theoretical basis of patch testing  Patch test was first devised by Jadassohn(1895) and described in practical detail by Bloch (1929) immunological basis of the patch test is the type IV.

10 1. Type I Hypersensitivity 2. Type II Hypersensitivity 3. Type III Hypersensitivity 4. Type IV Hypersensitivity

11 Components and cells in Type I hypersensitivity  Allergen : pollen 、 dust mite 、 insects, etc selectively activate CD4+Th2 cells and B cells  Allergen ( IgE ) and its production IgE : mainly produced by mucosal B cells in the lamina prapria special affinity to the same cell IL-4 is essential to switch B cells to IgE production  High affinity receptor of the IgE on mast cell and basophil

12 Type I hypersensitivity

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14  Skin allergy  Systemic anaphylaxis: 1) Anaphylactic drug allergy : penicillin 2) Anaphylactic serum allergy :  Respiratory allergic diseases : 1) Allergic asthma  2) Allergic rhinitis  Gastrointestinal allergic diseases : The lack of Serum IgA protein hydrolase Undigested protein Allergen Common disease of type I hypersensitivity

15 Allergen Stimulate Antibody A. Opsonic phagocytosis D. ADCC of NK C. Effect of complement Combined opsonic activities Cell injury ways of type II hypersensitivity Cell

16 Antigen or hapten on cell Antibody (IgG, IgM) Activate complement Lyse target cell Opsonic phagocytosis NK, phagocyteStimulate / block Destroy target cellADCC Target cell injury Change the function ofTarget cell Mechanism of Type II hypersensitivity

17 Mechanism of type III hypersensitivity  Formation of the intermediate immune complex  Deposition of the intermediate immune complex  Tissue injury by the immune complex

18 common disease of type III hypersensitivity 1. Local immune complex disease Arthus reaction : Experimental local reaction, Necrotic vasculitis Ulcer Human local reaction: insulin-dependent diabetes mellitus (IDDM) 2. Acute systemic immune complex disease serum sickness Anti-serum → Ab+Ag → systemic tissue injury,fever, arthritis, skin rash Pinicillin 、 Sulfanilamide Acute immune complex glomerulonephritis : Streptococcus infection 3. Chronic immune complex disease: SLE Rheumatoid arthritis : RF+IgG → Deposit on synovial membrane

19 Type IV hypersensitivity  characteristics of type IV hepersensitivity  mechanism of type IV hepersensitivity  common diseases of type IV hepersensitivity

20 Characteristics Interaction of primed T cells and associated antigen Infiltration of Mononuclear Cells, Inflammatory response

21 Mechanism of type IV hypersensitivity  Formation of effector and memory T cells  Inflammation and cytotoxicity caused by effector T cells 1) Inflammation and tissue injury mediated by CD4+Th1 Release chemokines and cytokines Immune injury mainly caused by infiltration of mononuclear cells and lymphocytes 2) Cytotoxicity of CD8+

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23 Common disease of type IV hypersensitivity  Infectious delayed type hypersensitivity OT( Old Tuberculin ) test  Contact dermatitis  Acute rejection of allogenic transplantation Same disease (SLE), multiple immune injury,hypersensitivity involved Same drug (penicillin), several types of hypersensitivity

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25  Sensitized T lymphocytes have secondary contact with the antigen (hapten)  conjugated with a protein and presented on the surface of an antigen presenting cell (APC).  APCs are the Langerhans’ cells  Presentation of the antigen by :Langerhans’ cell to CD4+ Th-1 type T lymphocyte  Release of cytokines that produces T cell activation and the recruitment of other non-antigen specific T cells and macrophages to the site

26  inflammatory reaction : peak at 72 hours  clinically patch test reaction: localised area of eczema  After 3–4 days, immunological mechanisms downgrade the reaction and it gradually fades away.

27 Standard series  All patients are patch tested to a standard of allergens, such as the International, European, North  American, or British Contact Dermatitis Group (BCDG) standard series

28 British Contact Dermatitis Group recommended standard series Neomycin sulfate Thiuram mix 1 Paraphenylenediamine Cobalt chloride Formaldehyde Rosin Quinoline mix Balsam of Peru Isopropyl PPD Wool alcohols Mercapto mix Epoxy resin Paraben mix PTBPF resin Fragrance mix Quaternium Nickel sulfate Methylchloroisothiazolinone Methylisothiazolinone Mercaptobenzothiazole Primin Sesquiterpene lactone mix Chlorocresol Bronopol Cetearyl alcoho Fucidic aci Tixocortol pivalate Budesonide Imidazolidinyl urea Diazolidinyl urea Methyldibromoglutaronitrile Ethylenediamine dihydrochl

29 Contact dermatitis Allergens hazards in selected occupations  Bakers:Flavouring, oil, antioxidant  Building trade workers:Cement (Cr, Co), rubber,resin, wood  Caterers, cooks : fruit, veg,Veg/fruit, cutlery (Ni),rubber glove  Cleaners: Rubber glove, nickel,  Dental personnel : acrylate, Rubber, acrylate mercury  Electronics assemblers: Cr, Co, Ni

30 Patch Test: Materials  Finn chambers (shallow aluminium discs to hold allergens) Hypoallergenic acrylate tape.  Allergens (diluted in various vehicles like petrolatum, water, ethanol, acetone, olive oil, etc.)  India Indian Standard Battery approved by CODFI [Contact and Occupational Dermatoses Forum of India] is usually employed Marker pen

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35 Indications of Patch Test  Allergic Contact Dermatitis Syndrome (ACDS)  Atopic dermatitis  Nummular dermatitis (nummular eczema)  Seborrheic dermatitis presenting episodes of acute inflammation)  Asteatotic eczema  Stasis dermatitis  Eczematous lesions around leg ulcer  Pompholyx and/or dyshidrotic eczema  Lichenification

36 Taking a history  past and present occupation (possible contact with industria allergenor irritants)  Hobbies (plants,animals)  cosmetics, and current and previous treatments(potential medicamental hydrocortisone).

37 Selection of Patients 1. Taking less : 15 mg of oral steroid) topical steroid 2. Not applying topical steroid on back for at least 1 week active or flared-up 3. Not having active or flared-up dermatitis sunburned on back 4. Not have been sunburned on back within last 2 weeks antihistamine 5. Oral antihistamine can be continued during the process.

38 follow during the patch test procedure  Not to take bath or wash or wet the back  To avoid tight underclothes  To avoid exercise or activity causing sweating  To avoid friction/scratching  avoid strong sun exposure.

39 Patch Test: Methods  upper back (excluding vertebra and scapular angle)  deltoid area (for small number of allergens)  Site should be gently cleansed (with water and alcohol) and dried  The top of patch test unit is marked and the protective foil removed and they are kept with aluminium chambers faced up  The protective foil is fixed longitudinally along the edge of the patch test unit to facilitate handling

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41 Reading the patch test reactions  fixed on the upper back ; left on for two days.  removed, marked, read with another reading at four days  problem in reading patch tests: differentiate irritantreactions (which have no diagnostic value) from allergic ones

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44 Recording Patch test (la dou) 1 +=Weakreaction, nonvesicular,erythema,mild infiltration 2 + =Strongreaction, erythema, edema,vesicles 3 + =Extreme reaction, spreading,bullous,ulcerative 4 =Doubtful, faint erythema only 5 = Irritant reaction 6 =Negative 7 =Excited skin reaction 8 =Not tested

45 Recording patch test (0D) +/− doubtful: faint erythema only + weak: erythema, maybe papules ++ strong: vesicles, infiltration +++ extreme: bullous

46 Patch Testing

47 variety of substances found both in the industrial allergen  Acrylates Adhesives  Chromate Cement  Cobalt Pigment  Epoxy resins  Paints/resins  Ethylenediamine  Formaldehyde Preservatives  Detergents  Nickel Electroplating  jewellery manufacture  Paraphenylenediamine  Phenol formaldehyde

48 The possible side effects are explained  irritation on the back from the presence of the patches,  the production of an excessive reaction  worsening of the dermatitis in a number of cases, and actually sensitised by the process of testing

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56  develop a “late” reaction—for example 1–3 weeks after( Gold salts cause this)  late reaction develops, often re-patch test after a suitable period (for example, four weeks)

57  The management of contact dermatitis is often difficult: overlapping factors  testing helps identify the allergens involved  useful in dermatitis of the hands, face, feet

58  Most cases of occupational contact dermatitis: mixed etiology  Elimination of an allergen may not produce full resolution → often irritant /endogenous factors at play as well.  Difficult to eliminate fully all contact with ubiquitous allergens such as nickel or colophony

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60 Prick test

61 Diagnosis of allergic disease  most important History taking Physical examination Evaluation of causative allergen Skin test : prick, intradermal, patch Serum specific IgE :RAST specific allergen provocation test :nasal, bronchial, oral

62 Focus of Allergy diagnosis  Is the patient atopic?  Does allergy contribute to patient’s symptom?  What are the clinical relevant allergens? →allergen avoidance → environmental control →immunotherapy, desensitization

63 Allergy History Taking  Main dominant symptoms  Associated symptoms  Frequency and severity of symptoms, impact on lifestyle  Seasonal or perennial ?  Triggering factors : allergic or non-allergic factor  Occupation, hobbies  Food, drug consumption history  Possible allergen exposure in home  Personal or family history of allergic disease  Prior treatment response, side-effects

64 Skin test Purpose identification of causative allergens standardization of allergens : allergenic potency Advantages easy to perform, fast not expensive high sensitivity

65 Skin test : method Prick test Intradermal test Scratch test

66 Skin prick test clean the test skin surface(back, forearm volar surface) with cotton moistened with 75% alcohol and dry up place a small drop of each test extract and positive/negative control solution 3-5cm apart prick with 25 or 26G needle and lift gently needle tip upward read the wheal and flare reaction 15min later-read

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68 Skin prick test

69 Intradermal test clean the test skin surface(back, forearm volar surface) with 75% alcohol and dry up intradermal injection of allergen extract with 1ml syringe and 26G needle (approximately 2-4mm diameter bleb, 0.02ml injection) perform with positive/negative control solution read the wheal and flare reaction 15min later

70 Controls  false positive -dermographism -needle irritation  false negative -medication (e.g. antihistamine) -underlying disease -technical error

71 Factors affecting skin test Allergen extract Area of body -back >> arm -upper back >> lower back -ulnar side of arm >> radial side of arm Age -significant wheal detect in infants -increase from infancy to adulthood -decline after age of 50 Sex, Race Seasonal variation

72 Drugs affecting skin test H1 antihistamine Imipramies, Phenothiazines: > 10days Systemic steroid short-term(=1wk) : no effect long-term : possible effect H2 blocker, leukotriene antagonist, theophylline, beta- agonist: no clinical significance

73 Positive criteria Size of wheal and erythema(flare)  prick test: wheal size =3mm flare=10mm → regarded as clinically significant allergy  intradermal test : wheal size =5mm

74 Interpretation  Clinical relevancy positive skin test ≠clinical allergic disease consider asymptomatic sensitization, insignificant cross-reaction (sensitization rate: 30-40% of general population)  Correlation with other allergy diagnostic test  Diagnostic value of skin test: inhalant : most cheapest and effective method for respiratory allergy food : low sensitivity drug : variable, low sensitivity except penicillin


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