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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 5-year-old girl with atopic dermatitis &#40;onset at 6 months of age&#41; and no known history of allergy was assessed for the presence of erythematous scaly plaques and edema affecting the face&#44; trunk&#44; and skin folds that appeared after exposure to sunlight and application of several sunscreens &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical picture had been diagnosed as &#8220;sun allergy&#8221; by her pediatrician&#44; leading her to avoid exposure to sunlight&#46; This affected her quality of life considerably&#44; as she was unable to take part in normal activities for her age&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Her clinical history indicated allergic or photoallergic contact dermatitis possibly associated with the use of sunscreens&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Patch testing was performed with the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group &#40;T&#46;R&#46;U&#46;E&#46; Test&#44; SmartPractice&#44; extended with allergens from Chemotechnique Diagnostics&#41; and photopatches with the sunscreen series &#40;Chemotechnique Diagnostics&#41;&#46; Patch testing was also performed with her own products&#44; which were mainly sunscreens&#46; The study had to be carried out over several weeks owing to poor collaboration on the part of the patient&#44; who ripped the patches off completely on several occasions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patch test results were read according to the recommendations of the International Contact Dermatitis Research Group&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The results for the Spanish standard series were negative&#46; With the patient&#39;s own products &#40;3 different sunscreens&#41;&#44; positive results were recorded only for the Carreras ultra 80 children&#39;s sun cream&#46; The photopatch reading at 96<span class="elsevierStyleHsp" style=""></span>hours with duplicate sunscreens and UV-A &#40;5<span class="elsevierStyleHsp" style=""></span>J&#47;m<span class="elsevierStyleSup">2</span>&#41; at 48<span class="elsevierStyleHsp" style=""></span>hours revealed weak positive results for isoamyl p-methoxycinnamate in half&#46; This allergen was present in the Carreras sunscreen&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was diagnosed with photoaggravated allergic contact dermatitis caused by isoamyl p-methoxycinnamate with present relevance&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment consisted of avoidance of the sunscreen involved&#46; The patient experienced no further skin lesions associated with sun exposure and was able to live a normal life&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">UV absorbers are classified as physical &#40;inorganic&#41; and chemical &#40;organic&#41;&#46; The latter&#44; together with topical nonsteroidal anti-inflammatory drugs&#44; are the group of substances that most frequently cause photoallergic reactions&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Consequently&#44; many are recommended in the standard series for photopatch testing in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A 2012 European multicenter study<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> revealed that the absorbers that most commonly caused photoallergic contact dermatitis were octocrylene&#44; benzophenone-3&#44; and butyl methoxydibenzoylmethane&#46; Allergic contact dermatitis was less frequent than photoallergic contact dermatitis&#44; with the most common absorbers being methylene bis-benzotriazolyl tetramethylbutylphenol &#40;Tinosorb M&#41;&#44; octocrylene&#44; and benzophenone-3&#46; Methylene bis-benzotriazolyl tetramethylbutylphenol is solubilized in a surfactant known as decyl glucoside&#44; which could be the causative allergen in some cases and must be patch tested&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the case we report&#44; the patient was diagnosed with photoaggravated allergic contact dermatitis with present relevance caused by isoamyl p-methoxycinnamate&#46; The compound belongs to the cinnamate group&#46; Sunscreens containing this substance absorb UV-B radiation and are chemically associated with cinnamon-related flavoring agents and aroma compounds&#44; with which they can cross-react&#46; Balsam of Peru and fragrance mix I contain cinnamic alcohol and cinnamic aldehyde&#44; which could cross-react with isoamyl p-methoxycinnamate&#46; However&#44; patch testing with these substances was negative in the present case&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Isoamyl p-methoxycinnamate has been approved in Europe and Asia&#44; but not in the United States of America&#46; It is used mainly in sunscreens labeled as &#8220;waterproof&#8221; owing to its low solubility in water&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Photoallergy has been reported more frequently than contact allergy&#44; and there has also been a report of a case of contact urticaria&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Isoamyl p-methoxycinnamate 10&#37; pet is one of the allergens included in the European standard photopatch test&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the present case&#44; the positive result on contact between the patch and this substance increased from weak to moderate with UV-A light&#46; Therefore&#44; it was interpreted as photoaggravated or photoaugmented contact allergy&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Management of these reactions basically involves identification and avoidance of the causative allergen&#46; If patch testing is not available but suspicion is high&#44; physical sunscreens can be recommended directly&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Symptoms can be treated with topical or systemic corticosteroids&#44; topical calcineurin inhibitors&#44; and immunosuppressants&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Given the difficulty involved in diagnosing photoaggravated allergic contact dermatitis&#44; prevalence is probably underestimated&#46; The absence of a clear photodistributed pattern can complicate identification of this condition&#46; Cases of photoaggravated allergic contact dermatitis caused by isoamyl p-methoxycinnamate are very rare&#44; and reporting these findings is very important for updating and standardization of allergens in the basic photopatch series&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The case we report also demonstrates the difficulty involved in performing patch testing in children&#44; whose unwillingness to cooperate necessarily requires more time for testing&#46; In addition&#44; the small area of a child&#39;s back necessitates accurate selection of the allergens to be tested&#46; The collaboration of trained nurses and parents is a key aspect of this process&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letter
Photoaggravated Allergic Contact Dermatitis Due to Isoamyl p-Methoxycinnamate in a Pediatric Patient
Dermatitis de contacto alérgica fotoagravada a isoamil p-metoxicinamato en paciente pediátrico
R. Linares Navarro
Autor para correspondencia
, I. Ruiz González, C.C. Olmos Nieva, M.Á. Rodríguez Prieto
Servicio de Dermatología, Complejo Asistencial Universitario de León, León, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 5-year-old girl with atopic dermatitis &#40;onset at 6 months of age&#41; and no known history of allergy was assessed for the presence of erythematous scaly plaques and edema affecting the face&#44; trunk&#44; and skin folds that appeared after exposure to sunlight and application of several sunscreens &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical picture had been diagnosed as &#8220;sun allergy&#8221; by her pediatrician&#44; leading her to avoid exposure to sunlight&#46; This affected her quality of life considerably&#44; as she was unable to take part in normal activities for her age&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Her clinical history indicated allergic or photoallergic contact dermatitis possibly associated with the use of sunscreens&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Patch testing was performed with the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group &#40;T&#46;R&#46;U&#46;E&#46; Test&#44; SmartPractice&#44; extended with allergens from Chemotechnique Diagnostics&#41; and photopatches with the sunscreen series &#40;Chemotechnique Diagnostics&#41;&#46; Patch testing was also performed with her own products&#44; which were mainly sunscreens&#46; The study had to be carried out over several weeks owing to poor collaboration on the part of the patient&#44; who ripped the patches off completely on several occasions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patch test results were read according to the recommendations of the International Contact Dermatitis Research Group&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The results for the Spanish standard series were negative&#46; With the patient&#39;s own products &#40;3 different sunscreens&#41;&#44; positive results were recorded only for the Carreras ultra 80 children&#39;s sun cream&#46; The photopatch reading at 96<span class="elsevierStyleHsp" style=""></span>hours with duplicate sunscreens and UV-A &#40;5<span class="elsevierStyleHsp" style=""></span>J&#47;m<span class="elsevierStyleSup">2</span>&#41; at 48<span class="elsevierStyleHsp" style=""></span>hours revealed weak positive results for isoamyl p-methoxycinnamate in half&#46; This allergen was present in the Carreras sunscreen&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was diagnosed with photoaggravated allergic contact dermatitis caused by isoamyl p-methoxycinnamate with present relevance&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment consisted of avoidance of the sunscreen involved&#46; The patient experienced no further skin lesions associated with sun exposure and was able to live a normal life&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">UV absorbers are classified as physical &#40;inorganic&#41; and chemical &#40;organic&#41;&#46; The latter&#44; together with topical nonsteroidal anti-inflammatory drugs&#44; are the group of substances that most frequently cause photoallergic reactions&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Consequently&#44; many are recommended in the standard series for photopatch testing in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A 2012 European multicenter study<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> revealed that the absorbers that most commonly caused photoallergic contact dermatitis were octocrylene&#44; benzophenone-3&#44; and butyl methoxydibenzoylmethane&#46; Allergic contact dermatitis was less frequent than photoallergic contact dermatitis&#44; with the most common absorbers being methylene bis-benzotriazolyl tetramethylbutylphenol &#40;Tinosorb M&#41;&#44; octocrylene&#44; and benzophenone-3&#46; Methylene bis-benzotriazolyl tetramethylbutylphenol is solubilized in a surfactant known as decyl glucoside&#44; which could be the causative allergen in some cases and must be patch tested&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the case we report&#44; the patient was diagnosed with photoaggravated allergic contact dermatitis with present relevance caused by isoamyl p-methoxycinnamate&#46; The compound belongs to the cinnamate group&#46; Sunscreens containing this substance absorb UV-B radiation and are chemically associated with cinnamon-related flavoring agents and aroma compounds&#44; with which they can cross-react&#46; Balsam of Peru and fragrance mix I contain cinnamic alcohol and cinnamic aldehyde&#44; which could cross-react with isoamyl p-methoxycinnamate&#46; However&#44; patch testing with these substances was negative in the present case&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Isoamyl p-methoxycinnamate has been approved in Europe and Asia&#44; but not in the United States of America&#46; It is used mainly in sunscreens labeled as &#8220;waterproof&#8221; owing to its low solubility in water&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Photoallergy has been reported more frequently than contact allergy&#44; and there has also been a report of a case of contact urticaria&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Isoamyl p-methoxycinnamate 10&#37; pet is one of the allergens included in the European standard photopatch test&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the present case&#44; the positive result on contact between the patch and this substance increased from weak to moderate with UV-A light&#46; Therefore&#44; it was interpreted as photoaggravated or photoaugmented contact allergy&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Management of these reactions basically involves identification and avoidance of the causative allergen&#46; If patch testing is not available but suspicion is high&#44; physical sunscreens can be recommended directly&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Symptoms can be treated with topical or systemic corticosteroids&#44; topical calcineurin inhibitors&#44; and immunosuppressants&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Given the difficulty involved in diagnosing photoaggravated allergic contact dermatitis&#44; prevalence is probably underestimated&#46; The absence of a clear photodistributed pattern can complicate identification of this condition&#46; Cases of photoaggravated allergic contact dermatitis caused by isoamyl p-methoxycinnamate are very rare&#44; and reporting these findings is very important for updating and standardization of allergens in the basic photopatch series&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The case we report also demonstrates the difficulty involved in performing patch testing in children&#44; whose unwillingness to cooperate necessarily requires more time for testing&#46; In addition&#44; the small area of a child&#39;s back necessitates accurate selection of the allergens to be tested&#46; The collaboration of trained nurses and parents is a key aspect of this process&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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