Cases for Diagnosis
Treatment-Resistant Adult Atopic Dermatitis
Dermatitis atópica del adulto de evolución tórpida
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Despite sequential treatment with oral corticosteroids and antihistamines, ciclosporin, and methotrexate combined with systemic corticosteroids, the symptoms worsened.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient had been working as a chef for 8 years. She reported partial improvement of lesions during holiday periods and worsening on return to work. She also had oral allergy syndrome symptoms triggered by certain foods.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical Examination</span><p id="par0020" class="elsevierStylePara elsevierViewall">Physical examination revealed pruritic, lichenified, erythematous-eczematous plaques on the face, the neck, the back of the hands, the forearms, and the cleavage area (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Additional Tests</span><p id="par0025" class="elsevierStylePara elsevierViewall">Total immunoglobulin (Ig) E was 11.198 IU/mL and there was elevated specific IgE against latex and various airborne allergens and foods.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patch tests performed with the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) were all negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Prick-to-prick tests conducted with food brought in by the patient that she said caused her to itch were positive for baby squid, cuttlefish, whiting, tomato, wheat flour, and egg yolk (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is your diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Protein contact dermatitis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Course and Treatment</span><p id="par0050" class="elsevierStylePara elsevierViewall">The patient left her job and avoided contact with all foods to which she was sensitized at home. The only treatment administered was tacrolimus ointment 0.1%. At the follow-up visit 8 weeks later, the patient was free of lesions for the first time in 5 years.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0055" class="elsevierStylePara elsevierViewall">Protein contact dermatitis, which was first described in 1976 by Hjorth and Roed-Petersen, is an immediate contact reaction caused by sensitization to high-molecular-weight proteins mostly found in food.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinically, it is characterized by pruritus and acute eczematous lesions that appear 10 to 30 minutes after contact with the allergen. If exposure continues, the patient develops typical symptoms of subacute chronic dermatitis, with symptoms worsening with each exposure.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Protein contact dermatitis mainly affects the hands, the forearms, or both. Diffuse eczema of the volar surfaces is the most common clinical manifestation. There have also been reports of localized pulpitis and chronic paronychia.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Eczema may also affect the face, as occurred in our patient, in the case of airborne allergens or when there is indirect contact via the hands.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Some patients, like ours, may report symptoms of oral allergy syndrome following the ingestion of a food to which they are sensitized, but there have been no reports of digestive allergy symptoms, generalized urticaria, or anaphylaxis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Protein contact dermatitis is primarily an occupational skin disease, and has been described in chefs, slaughterhouse workers, veterinarians, and food handlers in general; it has, however, also been described in amateur anglers who use worms as bait.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">According to the literature, there is an association between protein contact dermatitis and atopic disease in up to 50% of patients. There have also been reports of an association with pre-existing dermatitis. It seems clear that impaired skin barrier function has an important role in the development of protein contact dermatitis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The pathophysiology of the disease remains uncertain. It is an immediate, IgE-mediated contact dermatitis, and in this respect, is similar to immunologic contact urticaria, although the clinical manifestations differ.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Skin tests are the main diagnostic tool.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The tests of choice are prick-to-prick tests with fresh food, which may be brought in by the patient. Other options are scratch and rub tests, but these only give positive results if performed on affected or previously affected skin; this is one of the characteristics that distinguishes protein contact dermatitis from contact urticaria. Elevated specific IgE levels in serum can also point to a diagnosis of protein contact dermatitis. Patch tests tend to be either negative or irrelevant.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The differential diagnosis should include causes of chronic eczema of the hands—whether of irritant, allergic, or endogenous etiology—and, as occurred in our case, adult atopic dermatitis.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion, protein contact dermatitis should be suspected in any food handler who develops chronic eczema of the hands, the forearms, or the face. Diagnosis hinges on taking a careful history and performing skin allergy tests. Avoidance of contact with offending allergens can help to achieve complete healing.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course and Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Esteve-Martínez A, et al. Dermatitis atópica del adulto de evolución tórpida. Actas Dermosifiliogr.2011;102:821-822.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 493 "Ancho" => 740 "Tamanyo" => 58713 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 462 "Ancho" => 697 "Tamanyo" => 61473 ] ] ] 2 => array:6 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 763 "Ancho" => 572 "Tamanyo" => 66027 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Occupational contact urticaria and protein contact dermatitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Doutre" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur J dermatol" "fecha" => "2005" "volumen" => "15" "paginaInicial" => "419" "paginaFinal" => "424" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16280292" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatitis de contacto proteicas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. De la Cuadra Oyanguren" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Piel" "fecha" => "2003" "volumen" => "18" "paginaInicial" => "118" "paginaFinal" => "126" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermatitis de contacto por alimentos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Amado" 1 => "S.E. Jacob" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2007" "volumen" => "98" "paginaInicial" => "452" "paginaFinal" => "458" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17669298" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immediate contact skin reactions: an update on contact urticaria, contact urticaria syndrom and protein contact dermatitis-“a never ending history”" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Gimenez–Arnau" 1 => "M. Maurer" 2 => "J. De la Cuadra" 3 => "M. Maibach" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1684/ejd.2010.1049" "Revista" => array:7 [ "tituloSerie" => "Eur J Dermatol" "fecha" => "2010" "volumen" => "20" "paginaInicial" => "552" "paginaFinal" => "562" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20732848" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0161642009012822" "estado" => "S300" "issn" => "01616420" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La técnica del <span class="elsevierStyleItalic">prick</span> test en la consulta de dermatología" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Rodriguez-Serna" 1 => "J. De la Cuadra Oyanguren" 2 => "L. Conde Salazar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Piel" "fecha" => "2004" "volumen" => "19" "paginaInicial" => "276" "paginaFinal" => "280" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immunological occupational contact urticaria and contact dermatitis from proteins: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Amaro" 1 => "Goossens A" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0536.2007.01267.x" "Revista" => array:6 [ "tituloSerie" => "Contact dermatitis" "fecha" => "2008" "volumen" => "58" "paginaInicial" => "67" "paginaFinal" => "75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18186738" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010200000010/v1_201304241244/S157821901200025X/v1_201304241244/en/main.assets" "Apartado" => array:4 [ "identificador" => "6171" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cases for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010200000010/v1_201304241244/S157821901200025X/v1_201304241244/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901200025X?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 9 | 14 |
| 2024 October | 71 | 48 | 119 |
| 2024 September | 62 | 31 | 93 |
| 2024 August | 82 | 53 | 135 |
| 2024 July | 83 | 47 | 130 |
| 2024 June | 74 | 25 | 99 |
| 2024 May | 63 | 33 | 96 |
| 2024 April | 80 | 28 | 108 |
| 2024 March | 65 | 27 | 92 |
| 2024 February | 61 | 24 | 85 |
| 2024 January | 59 | 38 | 97 |
| 2023 December | 64 | 25 | 89 |
| 2023 November | 50 | 18 | 68 |
| 2023 October | 62 | 28 | 90 |
| 2023 September | 48 | 25 | 73 |
| 2023 August | 39 | 11 | 50 |
| 2023 July | 41 | 27 | 68 |
| 2023 June | 50 | 20 | 70 |
| 2023 May | 64 | 21 | 85 |
| 2023 April | 47 | 15 | 62 |
| 2023 March | 53 | 22 | 75 |
| 2023 February | 46 | 19 | 65 |
| 2023 January | 41 | 25 | 66 |
| 2022 December | 56 | 43 | 99 |
| 2022 November | 21 | 26 | 47 |
| 2022 October | 20 | 30 | 50 |
| 2022 September | 15 | 61 | 76 |
| 2022 August | 24 | 29 | 53 |
| 2022 July | 22 | 23 | 45 |
| 2022 June | 29 | 23 | 52 |
| 2022 May | 41 | 38 | 79 |
| 2022 April | 43 | 31 | 74 |
| 2022 March | 48 | 54 | 102 |
| 2022 February | 35 | 31 | 66 |
| 2022 January | 30 | 37 | 67 |
| 2021 December | 29 | 44 | 73 |
| 2021 November | 31 | 39 | 70 |
| 2021 October | 40 | 51 | 91 |
| 2021 September | 32 | 36 | 68 |
| 2021 August | 22 | 47 | 69 |
| 2021 July | 18 | 30 | 48 |
| 2021 June | 29 | 45 | 74 |
| 2021 May | 29 | 47 | 76 |
| 2021 April | 68 | 41 | 109 |
| 2021 March | 62 | 38 | 100 |
| 2021 February | 47 | 30 | 77 |
| 2021 January | 44 | 26 | 70 |
| 2020 December | 32 | 27 | 59 |
| 2020 November | 27 | 20 | 47 |
| 2020 October | 33 | 16 | 49 |
| 2020 September | 39 | 17 | 56 |
| 2020 August | 19 | 19 | 38 |
| 2020 July | 31 | 18 | 49 |
| 2020 June | 19 | 32 | 51 |
| 2020 May | 20 | 23 | 43 |
| 2020 April | 33 | 14 | 47 |
| 2020 March | 20 | 23 | 43 |
| 2020 February | 5 | 0 | 5 |
| 2020 January | 4 | 3 | 7 |
| 2019 December | 8 | 1 | 9 |
| 2019 November | 4 | 1 | 5 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 8 | 1 | 9 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 2 | 0 | 2 |
| 2019 June | 6 | 11 | 17 |
| 2019 May | 1 | 24 | 25 |
| 2019 April | 0 | 11 | 11 |
| 2019 March | 2 | 11 | 13 |
| 2019 February | 0 | 1 | 1 |
| 2019 January | 1 | 1 | 2 |
| 2018 December | 4 | 1 | 5 |
| 2018 November | 0 | 5 | 5 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 4 | 0 | 4 |
| 2018 February | 40 | 1 | 41 |
| 2018 January | 52 | 5 | 57 |
| 2017 December | 49 | 4 | 53 |
| 2017 November | 54 | 3 | 57 |
| 2017 October | 38 | 9 | 47 |
| 2017 September | 56 | 9 | 65 |
| 2017 August | 105 | 4 | 109 |
| 2017 July | 77 | 6 | 83 |
| 2017 June | 95 | 8 | 103 |
| 2017 May | 79 | 3 | 82 |
| 2017 April | 72 | 13 | 85 |
| 2017 March | 54 | 12 | 66 |
| 2017 February | 38 | 7 | 45 |
| 2017 January | 23 | 8 | 31 |
| 2016 December | 48 | 7 | 55 |
| 2016 November | 56 | 8 | 64 |
| 2016 October | 69 | 6 | 75 |
| 2016 September | 50 | 2 | 52 |
| 2016 August | 59 | 9 | 68 |
| 2016 July | 58 | 6 | 64 |
| 2016 June | 8 | 1 | 9 |
| 2016 May | 6 | 5 | 11 |
| 2016 April | 4 | 1 | 5 |
| 2016 March | 8 | 1 | 9 |
| 2016 February | 6 | 2 | 8 |
| 2016 January | 9 | 2 | 11 |
| 2015 December | 8 | 3 | 11 |
| 2015 November | 12 | 1 | 13 |
| 2015 October | 10 | 3 | 13 |
| 2015 September | 5 | 1 | 6 |
| 2015 August | 14 | 4 | 18 |
| 2015 July | 49 | 3 | 52 |
| 2015 June | 45 | 9 | 54 |
| 2015 May | 65 | 23 | 88 |
| 2015 April | 45 | 11 | 56 |
| 2015 March | 36 | 9 | 45 |
| 2015 February | 34 | 5 | 39 |
| 2015 January | 31 | 16 | 47 |
| 2014 December | 45 | 22 | 67 |
| 2014 November | 30 | 14 | 44 |
| 2014 October | 44 | 11 | 55 |
| 2014 September | 43 | 8 | 51 |
| 2014 August | 49 | 15 | 64 |
| 2014 July | 59 | 24 | 83 |
| 2014 June | 62 | 17 | 79 |
| 2014 May | 70 | 12 | 82 |
| 2014 April | 67 | 7 | 74 |
| 2014 March | 65 | 15 | 80 |
| 2014 February | 55 | 9 | 64 |
| 2014 January | 60 | 16 | 76 |
| 2013 December | 60 | 20 | 80 |
| 2013 November | 21 | 4 | 25 |
| 2013 October | 18 | 2 | 20 |
| 2013 September | 40 | 9 | 49 |
| 2013 August | 15 | 9 | 24 |
| 2013 July | 9 | 18 | 27 |
| 2013 June | 7 | 16 | 23 |
| 2013 May | 18 | 15 | 33 |
| 2013 April | 9 | 20 | 29 |
| 2013 March | 18 | 16 | 34 |
| 2013 February | 33 | 7 | 40 |
| 2013 January | 32 | 6 | 38 |
| 2012 December | 18 | 5 | 23 |
| 2012 November | 3 | 2 | 5 |
| 2012 October | 1 | 1 | 2 |
| 2012 July | 1 | 0 | 1 |
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