A recent survey of the European Academy of Allergy and Clinical Immunology (EAACI) Drug Allergy Interest Group (DAIG) on how European allergy specialists deal with beta‐lactam (BL) hypersensitivity ...demonstrated a significant heterogeneity in current practice, suggesting the need to review and update existing EAACI guidelines in order to make the diagnostic procedures as safe and accurate, but also as cost‐effective, as possible. For this purpose, a bibliographic search on large studies regarding BL hypersensitivity diagnosis was performed by an EAACI task force, which reviewed and evaluated the literature data using the GRADE system for quality of evidence and strength of recommendation. The updated guidelines provide a risk stratification in BL hypersensitivity according to index reaction(s), as well as an algorithmic approach, based on cross‐reactivity studies, in patients with a suspicion of BL hypersensitivity and an immediate need for antibiotic therapy, when referral to an allergist is not feasible. Furthermore, the update addresses availability and concentrations of skin test (ST) reagents, ST and drug provocation test (DPT) protocols, and diagnostic algorithms and administration of alternative BL in allergic subjects. Specifically, distinct diagnostic algorithms are suggested depending on risk stratification of the patient into high and low risk based on the morphology and chronology of the reaction, immediate (ie, occurring within 1‐6 hours after the last administered dose) or nonimmediate (ie, occurring more than 1 hour after the initial drug administration), and the reaction severity. Regarding the allergy workup, the main novelty of this document is the fact that in some low‐risk nonimmediate reactions ST are not mandatory, especially in children. For DPT, further studies are necessary to provide data supporting the standardization of protocols, especially of those regarding nonimmediate reactions, for which there is currently no consensus.
Scabies is a human ectoparasitosis caused by Sarcoptes scabei var. hominis. World-wide around 300 million patients are affected. Infants and children have the highest incidence rates. Poverty and ...overcrowding are social factors contributing to a higher risk of transmission and treatment failure. The leading symptom of the infestation is itch. Complications are bacterial infections that are responsible for mortality. Diagnosis is clinical. Non-invasive imaging technologies like dermoscopy can be used. Polymerase chain reaction (PCR) is less sensitive and specific than microscopy of skin scrapings. Treatment of choice is topical permethrin 5%. Ivermectin is the only oral drug FDA-approved for scabies. It should be used in cases non-responsive to topical therapy and in case of high number of infested patients in addition to topical therapy. Pseudo-resistance to treatment is not uncommon. New drugs are on the horizon.
What is Known:
• Pruritus is the leading symptom causing sleep disturbances and scratching with the risk of secondary bacterial infections.
• Treatment failure is related to inappropriate application of topical drugs and asymptomatic family members.
What is New:
• COVID-19 pandemic and migration are contributing to an increased incidence of scabies.
• New compounds to treat scabies are on the horizon.
Introduction
Hypersensitivity to nonsteroidal anti‐inflammatory drugs (NSAIDs) is of great concern because they are frequently encountered in daily clinical practice. Drug provocation tests (DPTs) ...are particularly needed for NSAIDs.
Methods
The aim of this retrospective study was to detect eliciting dose thresholds during NSAIDs DPT in order to suggest optimal step doses, using the survival analysis method. Our secondary objective was to describe subgroups at higher risk during DPT and evaluate the safety of our 30 minutes incremental 1‐day protocol. The study comprised all the patients attended the Allergy of the University Hospital of Montpellier (France), between 1997 and 2017 for a suspicion of drug hypersensitivity reaction to NSAIDs.
Results
Throughout the study period, 311 positive DPT were analyzed (accounting for 285 hypersensitive patients). We identified eliciting thresholds (dose and time), and we suggest the following steps for future DPT: for the rapid absorption group (acetylsalicylic acid, ibuprofen, ketoprofen, and tiaprofenic acid), every 30 minutes: 20%‐30%‐50% of daily therapeutic dose, for the moderate absorption group, every 30 minutes: for diclofenac 5%‐15%‐30%‐50%, and for celecoxib, 20%‐80%. For the slow absorption group, piroxicam, 25%‐75%, was separated by a 3‐hours interval. A surveillance period of 3 hours after the last dose is mandatory for patients.
Conclusion
Drug provocation test protocols for NSAID are empirical, driven by the knowledge on patterns of DHR, cross‐reactivity between NSAID and pharmacological effects of these all drugs. This is the second experience in improving DPT protocols, after BL (B‐lactam) antibiotics.
This retrospective study determines eliciting dose threshold during NSAIDs DPT in patients with positive DPT history. We suggest steps for DPT to NSAIDs, according to the absorption pattern of the NSAID. New DPT protocol for the slow absorption: 25%–75% of DTD; moderate absorption (Diclofenac and Celecoxib): 5–15–30–50% and 20–80%, respectively; rapid absorption: 20%–30%–50% of DTD. Abbreviations: DPT, drug provocation test; DTD: daily therapeutic dose; NSAIDs: non‐steroidal anti‐inflammatory drugs
Kerion Celsi is an inflammatory, deep fungal infection of the scalp. It is rare in neonates but gets more common in children about 3 years and older. It represents with swelling, boggy lesions, pain, ...alopecia and purulent secretions. Secondary bacterial infection is not unusual after maceration. Extracutaneous manifestations include regional lymphadenopathy, fever and very rare fungemia. Id‐reactions can occur. Diagnosis is based on clinical suspicion, clinical examination and medical history. Diagnosis should be confirmed by microscopy, fungal culture and molecular procedures. The most common isolated fungal species are anthropophilic Trichophyton (T.) tonsurans and zoophilic Microsporum (M.) canis, while geophilic species and moulds rarely cause Kerion Celsi. Treatment is medical with systemic and topical antifungals supplemented by systemic antibiotics when necessary, while surgery needs to be avoided. Early and sufficient treatment prevents scarring alopecia. The most important differential diagnosis is bacterial skin and soft tissue infections.
Psoriasis is a chronic inflammatory disease associated with immune system dysfunction that can affect nails, with a negative impact on patient life quality. Usually, nail psoriasis is associated with ...skin psoriasis and is therefore relatively simple to diagnose. However, up to 10% of nail psoriasis occurs isolated and may be difficult to diagnose by means of current methods (nail biopsy, dermoscopy, video dermoscopy, capillaroscopy, ultrasound of the nails, etc.). Since the nail is a complex biological tissue, mainly composes of hard α-keratins, the structural and morphological techniques can be used to analyze the human fingernails. The aim of this study was to corroborate the information obtained using Raman spectroscopy with those obtained by scanning electron microscopy (SEM) and X-ray diffractometry and to assess the potential of these techniques as non-invasive dermatologic diagnostic tools and an alternative to current methods.
Background
Serum total tryptase has been shown to increase during acute allergic reactions (acute tryptase, TA); however, few studies have investigated the values of TA or a combination of TA and ...baseline tryptase (TB) to discriminate positive from negative testing in perioperative hypersensitivity reaction (POH) allergy work‐up. The aim of this study was to determine the diagnostic performance of TA in order to differentiate positive from negative allergy testing suspected POH and analyse the diagnostic performance of serial tryptase levels using several formulas.
Methods
All patients from the University hospital of Montpellier and Strasbourg, France, who presented with suspected POH and underwent complete drug allergy work‐up between March 2011 and December 2019 with available TA and TB were included. Four formulas, including a change in TA > 11 (F1), or >2 + 1.2 × TB (F2), or >3 + TB (F3), or >120%TB (F4), were applied.
Results
One hundred and sixty‐two patients were included, and 131 of them (80.8%) had Grade III or IV reactions. Ninety patients had positive allergy testing. The optimal cut‐off value of TA to distinguish positive from negative allergy testing patients was 9.8 μg/L with an AUC of 0.817 (95% CI: 0.752–0.882, p < .001). The 93% PPV threshold for TA was 33 μg/L (95.8% specificity). Paired tryptase levels according to formulas F2 and F3 yielded the highest Youden index (0.54 and 0.53, respectively).
Conclusion
The optimal cut‐off point for TA for distinguishing positive from negative allergy testing suspected POH was 9.8 μg/L. TA value of 33 μg/L was required to achieve >90% PPV.
The optimal cut‐off point (calculated according to the Youden index) for TA was 9.8 μg/L, in order to distinguish positive from negative allergy testing suspected POH patients. TA value of 33 μg/L or higher was required to achieve a PPV >90%. When TA increased >90% PPV, but with negative allergy tests, the undertaking of investigations and collaboration among anesthetists, surgeons and allergists is essential to identify other potential hidden allergic causes of POH.
SCARS is an updated and comprehensive overview focused on the pathological scarring process. The chapters are written by international authors, researchers, and clinical practitioners with an ...interest in scars and united in a valuable study. The book aims at providing a guideline for the diagnosis and treatment of scars, as well as opening research paths for future developments.
Borreliosis, also known as Lyme disease, is a vector-borne disease caused by different species of the Borrelia burgdorferi complex. It is frequent in Europe and Northern America. The major vectors ...are ixodoid ticks. Paediatric borreliosis is common and peaks in children between five to nine years. In Europe, the leading symptom of early infection is erythema migrans, in contrast to Northern America where arthritis is the dominating clinical finding. In this review, we focus on Europe, where cutaneous borreliosis is mainly caused by infection with B. afzelii. The cutaneous symptoms include erythema migrans, lymphocytoma, chronic atrophic dermatitis and juxta-articular nodules. In children, lymphocytoma is very common but chronic atrophic dermatitis is rare. Clinical symptoms, diagnosis, peculiarities of childhood disease and treatment are also reviewed. It is important to note that after haematogeneic spread, signs of infection may be non-specific, and this is a challenge for diagnosis.
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