EAACI/ESCD Skin Allergy Meeting 2017 (SAM 2017)

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Background: Children with very severe, persistent eczema have limited treatment options, and often require systemic immunosuppression. Effective new treatments are urgently required. We aimed to evaluate the effect of the temperature-controlled laminar airflow (TLA) device in children/adolescents with severe atopic eczema and allergic multisystem disease.

Methods:
In an open-label study, we recruited 15 children aged 2-16 years (median 10, interquartile range [IQR] 7.5-12) with longstanding severe eczema (median duration 116.5 [82-145.5] months), sensitization to ≥ 1 perennial allergen, and multiple atopic comorbidities (15/15 rhino-conjunctivitis, 14/15 food allergy, 11/15 asthma). Run-in period of 6-10 weeks (3 visits, median 7.14 weeks) was followed by a six-month treatment period using overnight TLA (Airsonett ® , Sweden). Main outcome measures were SCORAD-Index and Investigator Global Assessment (0-5 scale, IGA), and secondary outcomes included child/family dermatology quality of life (CDQLI, FDQLI), POEM, medication requirements, and healthcare contacts (during the 6 months before/after TLA-start). Analysis using Wilcoxon rank signed test, with reported 2-sided significance level at p < 0.1. Results: There were no significant changes during the run-in period for any of the outcome measures. We observed a significant improvement in SCORAD after the 6-month TLA-treatment period, from 34.9 [28.75-45.15] to 24. 1 [18.75-37.55], p = 0.026. IGA improved from a median of 4 [3][4] to 3 [1.5-3.5], p = 0.09. Similarly, there was a significant improvement in FDQLI (16.0 [12.0-19.0] to 11 [6.5-14.5], p = 0.054). We observed no significant changes in CDQLI or POEM. Clinical improvement in eczema severity during the treatment period was accompanied by a significant reduction in the requirement for potent topical corticosteroids (p = 0.033) and number of hospital-contacts for eczema (p = 0.082). Conclusions: TLA treatment leads to a significant clinical improvement in children with severe atopic eczema, with accompanying reduction in medication usage and healthcare utilization. A randomized controlled trial is urgently required. Background: Patients/parents usually report skin symptoms in suspected drug hypersensitivity reactions in children. The aim of our study was to analyse the incidence and clinical pattern of skin symptoms in suspected drug hypersensitivity reactions in children who were tested for drug allergy.
Methods: 41 children were tested for drug allergy in Vilnius University Hospital from 2014 to 2016: 24 (58.54%) girls and 17 (41.46%) boys. The mean age of children was 7.42 ± 5.18 (3 months-17 years) years old. Results: 60 drug hypersensitivity reactions were reported in our study. Four drug hypersensitivity reactions were reported in one child, three reactions -in 4 children, two reactions -in 6 children. 18 (30.0%) reactions were immediate type. Skin symptoms were reported in 55 (91.67%) suspected drug hypersensitivity reactions. Maculopapular rash was the most frequently reported (25 (41.67%) cases), followed by macular rash (14 (23.33%) cases), urticaria 16 (26.67%) cases) and angioedema (12 (20.0%) cases). Respiratory (5 (8.33%)), cardiovascular (5 (8.33%)) and gastrointestinal symptoms (3 (5.0%)) were reported less frequently. Antibiotics were the main suspected drugs (44 (73.33% reactions), followed by local anesthetics (9 (15.0%) reactions) and NSAIDs (5 (8.33%) reactions). Amoxicillin was the most frequently reported culprit drug (21 (35.0%) reactions). Four (9.76%) children were confirmed as being allergic, one patient to cefuroxime and cefotaxime, two patients to amoxicillin and one patient to ibuprofen. All these patients experienced skin symptoms in drug hypersensitivity reactions. Conclusions: Maculopapular and macular rash were the most frequently reported in suspected drug hypersensitivity reactions. Antibiotics were the main suspected culprit drugs. Drug allergy was confirmed in only one tenth of children with skin symptoms in our study. Only complete allergological diagnostic work-up can confirm drug allergy. Background: Hydrolyzed wheat proteins (HWP) are used in a variety of products ranging from cosmetics to foods. Recently, severe type I allergic reactions to HWP in foods have been reported. The aim of this study was to characterize and evaluate patients with a case-history of anaphylaxis related to a food product containing HWP and, further, to describe patients with other phenotypes of wheat allergy co-sensitized to HWP. Methods: We investigated 56 patients (age 1.1-78.6 years) with a sensitization to HWP either by specific-IgE (sIgE), basophil histamine release (BaHR) and/or Skin Prick Test (SPT). Based on case-history the population was divided into three groups, 1: anaphylaxis elicited by ingestion of HWP product (n = 9), 2: wheat-induced anaphylaxis (WIA) (n = 19) and 3: wheat-dependent, exercise-induced anaphylaxis (WDEIA) (n = 28). All patients were examined with detailed casehistory, SPT, sIgE and BaHR followed by an open food challenge (WDEIA ± exercise). Results: In total the positive rate of sIgE to HWP was 83.9% (47/56), SPT 83.3% (35/42) and BaHR 52.3% (22/42). Group 1: Nine patients, all wheat tolerant and mono-sensitized to HWP with sIgE (median 5.3 kU/L, [2.12;21.9]), SPT (median 6.0 mm, [5.5;16.5]) and BaHR (median threshold level 0.003 µg/mL, [0;0.1]) significantly higher than group 2 and 3 (p < 0.05). Group 2: The positive rate of sIgE to wheat was 100% (19/19) and to HWP 84.2% (16/19) (median 2.1 kU/L, [0.02;56.6]). Group 3: The positive rate of sIgE to omega-5-gliadin was 82.1% (23/28) and to HWP 78.6% (22/28) (median 1.2 kU/L, [0.0;19.2]). A complete negative pattern of IgE sensitization compared to the other phenotypes of wheat allergy was found in group 1 including , omega-5 gliadin (f416), gliadin (f98), High Molecular Weight (Tri a 26) and α-amylase trypsin inhibitor (Tri a 30). Conclusions: Reactivity to HWP seems to be confined to patients sensitized to this heterogeneous group of products without concomitant allergy to unmodified wheat. Irrelevant co-sensitization is also seen in classical wheat allergy. A striking finding was an ultrahigh reactivity in BaHR in patients with allergy to HWP. Background: Multiple drug hypersensitivity (MDH) is a syndrome that develops as a consequence of massive T cell stimulations and is characterized by long lasting drug hypersensitivity reactions (DHRs) to different drugs. Initial symptoms are mostly severe exanthems or drug rash with eosinophilia and systemic symptoms (DRESS). Subsequent symptoms due to another drug often appear in the following weeks or months to years and frequently differ in clinical presentation. The eliciting drugs can be identified by positive skin or in vitro tests. Clin Transl Allergy 2017, 7(Suppl 4):47

Multiple drug hypersensitivity is not infrequent in combination therapy
Methods: We performed a retrospective analysis > 2000 LTT analyzed over 6 years (2005)(2006)(2007)(2008)(2009)(2010) for the frequency of single and double sensitizations within drug allergic patients involving 4 commonly used drug combination therapies (amoxicillin/clavulanic acid, trimethoprim/sulfamethoxazole, piperacillin/tazobactam, sulfasalazine metabolites). Results: LTT results of patients who had DHR to a combination therapy are shown in Table 1. For amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole severe exanthems were the main presenting symptom, whereas initial reactions to piperacillin/tazobactam and sulfasalazine metabolites where mainly DRESS. Patients with DRESS to the above mentioned combination therapy were positive in 65-85% of LTT. Conclusions: The drugs involved in starting MDH are the same as for DRESS and are usually given in rather high doses. Fixed drug combination therapies are frequently involved in MDH and 30-40% of patients with severe DHR to combination therapy show T cell reactions to both components. As this is substantially higher than the reaction to the less immunogenic compound. Either the immunogenic drug or the high dose of combination therapy enhances T cell reactivity to the less immunogenic drug of the combination therapy as well.
Poster discussion session. Background: Omalizumab (anti-IgE) is a new 2nd line therapy for chronic spontaneous urticaria (CSU) non-responsive to H 1 -antihistamines. It is well tolerated and no regular monitoring is required. Previously, oral corticosteroids (OCS) and immunosuppressants such as ciclosporin, mycophenolate mofetil and methotrexate were used as 2nd/3rd line treatment. They carry risks of adverse reactions. Hence, regular blood monitoring is needed, which is costly and time consuming. Methods: A retrospective case review of all patients treated with 300 mg omalizumab every 4 weeks was undertaken to assess if it allowed for immunosuppressant and/or OCS withdrawal. Urticaria activity score 7 (UAS7) was used to monitor response, which was defined as a reduction (UAS7 < 16) or complete resolution of symptoms (UAS7 = 0). Results: 91 patients (60 female; mean age of 44) were treated with omalizumab between November 2015 to October 2016. 93.4% (85/91) patients responded by the 5th injection, with 68.2% (58/85) responding to the 1st injection. In the responder group, at the time of initiation of omalizumab, 28 patients were on prednisolone, 5 on immunosuppressant (3 ciclosporin, 1 methotrexate, 1 mycophenolate mofetil) and 6 on both prednisolone and immunosuppressant (3 ciclosporin, 2 methotrexate, 1 mycophenolate mofetil). In these 39 patients, mean pre-omalizumab UAS7 was 36 despite treatment. 88.2% (30/34) of patients on prednisolone successfully stopped it and 11.8% (4/34) were able to taper the dose but not fully withdraw due to underlying steroid-induced adrenal insufficiency. 90.9% (10/11) patients on immunosuppressant successfully discontinued them and 9.1% (1/11) remained on it for non-CSU reason (atopic dermatitis). Interestingly, all but 2 of these 39 patients had a negative basophil histamine release assay (BHRA) with a poor response to immunosuppressant before starting omalizumab. Moreover, in the group of 85 responders, 14 more patients had been on prednisolone and 39 more had failed to respond to one or more immunosuppressants at some point before the initiation of omalizumab. Conclusions: Omalizumab facilitates cessation of immunosuppressant in CSU patients. It has a good safety profile and maintains its efficacy during repeated courses. It is a reliable treatment option, which obviates the need for long-term OCS or immunosuppressant in most patients. Moreover, these results support our previous finding that a positive BHRA is a marker for immunosuppressant-responsive CSU. Background: Ca. 35-50% of patients with chronic urticaria (CU) have functional IgG autoantibodies (autoAbs) against the α-subunit of the high affinity IgE receptor (anti-FcεRIα) and/or against mast cell and basophil surface bound IgE (anti-IgE). These presumably autoimmune forms of CU can be identified by functional tests like autologous serum skin tests (ASST) or by CU-basophil activation tests (CU-BAT), which, however, are both cumbersome and not always reliable. We aim to improve and complement the CU-BAT on a blood donor free basis. Thus, we investigate the characteristics of anti-FcεRIα and anti-IgE autoAbs in CU measuring their quantity as well as their affinity and compare it to the CU-BAT. Methods: We established a chaotropic ELISA measuring autoAb titer combined with antibody affinity. In a first step, autoAbs of CU-patients and control sera were quantified using a human anti-FcεRIα ELISA and human anti-IgE ELISA. In a second step, autoAb quantified serum samples were normalized to a titer in the standard range. Diluted serum samples were incubated in presence and absence of the chaotropic agent ammonium thiocyanate, which is able to disturb intermolecular forces such as antibody-antigen binding sites. Antibody affinity was determined as the percentage of still bound autoAbs quantity after ammonium thiocyanate addition. Results: Anti-FcεRIα as well as anti-IgE autoAbs, which are found in CU-patient sera, differ greatly in their quantity and quality. Hence, based on autoAbs quantity and quality CU-patients can be divided in different subgroups: anti-FcεRIα respectively anti-IgE low affinity/low quantity, high affinity/low quantity, low affinity/high quantity, and high affinity/high quantity. Conclusions: Subdivision in affinity/quantity groups showed a better correlation to CU-BAT patient data compared to quantity analysis alone. Determination of quantity and affinity may be helpful in determining functionally relevant autoAbs and thus substitute CU-BAT and ASST as diagnostic tests. However, the value of affinity determination still needs to be analyzed in larger patient cohorts and to be correlated to the severity of CU. As a simple ELISA test the presented CU-serum tests are promising to follow the highly variable course of CU and to monitor the response and persistence of therapeutic interventions such as anti-IgE therapy. Background: The Urticaria Control Test (UCT) is a globally used and universal patient-reported outcome measure for measuring disease control in chronic urticaria patients. As of yet, its responsiveness has not been established. The aim of this study was to investigate the UCT's ability to detect changes over time, including the minimal important difference (MID) and the smallest detectable change (SDC). Methods: Sixty-five antihistamine-refractory CSU patients used the UCT to document their disease control as well as several anchor instruments for disease activity, disease control, health-related quality of life, and treatment response before and 4 weeks after the initiation of omalizumab therapy. The UCT's sensitivity to change was assessed by correlating its score changes with changes in the applied anchors. In addition, the MID and SDC were calculated by using distribution-criterion and anchor-based approaches. Results: After the initiation of omalizumab, UCT scores markedly improved as compared to pretreatment levels. The UCT score changes correlated strongly with changes of disease activity and health-related quality of life. In addition, UCT results and their changes were well in accordance with the patient's assessment of their treatment efficacy, their disease control, and with the patient's response to treatment. The MID and SDC of the UCT were found to be 3 and 4 points, respectively (Table 1).

Conclusions:
The UCT score is sensitive to change. Accordingly, the UCT is a valuable tool to assess levels but also changes of disease control in patients with chronic urticaria over time, e.g. before and after treatment adjustment. Background: In adult patients with chronic urticaria (CU), causal relationship between food and disease exacerbation is relatively weak compared to childhood patients. However, there are many patients who report food-related aggravation of CU, and some of them may have histamine intolerance. The aim of this study was to evaluate the role of ingested histamine and to investigate the effect of histaminefree diet in adult patients with CU. port food-related aggravation of CU, and some of them may have histamine intolerance. Methods: Twenty-two adult patients with CU were enrolled. Foods with high amounts of histamine were prohibited to all patients for 4 weeks. Department of nutrition supplied the reference menu with histamine-free diet and consulted the patients. Severity degree of urticaria using Urticaria Severity Score (USS) and Urticaria Activity Score (UAS) were evaluated. Plasma histamine levels and diamine oxidase (DAO) activity were determined and compared between baseline and after the histamine-free diet. Results: Twenty-two adult patients were recruited and completed the 4 weeks of histamine-free diet. There was a significant difference in plasma histamine level between baseline and after the histamine free-diet (p = 0.014). DAO activity did not change after the histaminefree diet (p = 0.165). Likewise, both USS and UAS score significantly decreased after the histamine-free diet (p = 0.010, p = 0.006).

P04
Conclusions: Ingested histamine might be related with CU severity and histamine-free diet is helpful for adult patients with CU. Baseline and after the histamine free-diet (p = 0.014). DAO activity did not change after the histamine-free diet (p = 0.165). Likewise, both USS and UAS score significantly decreased after the histamine-free diet (p = 0.010, p = 0.006). Conclusions: The sex and mean age of the patients studied were similar to those described in literature. The most prevalent urticaria were CSU and symptomatic dermographism. Most of the patients were controlled with lifestyle modification and AH therapy. CSU was associated with a number of comorbidities. These need to be considered in the diagnosis and management of patients with CSU because conditions like anxiety/depression may have further impact on quality of life. On neck US multiple enlarged matting nodes without hilum in cervical and submandibular region. The neck-chest-abdomen CT scan confirmed a generalized lymphadenopathy and the node biopsy was suggestive for chronic lymphocytic leukemia. After the discharge, the patient showed a reactivation of herpes labialis associated with swelling of the lower lip till the submandibular right region that, due to the WS diagnosis, can be considered like an abnormal eosinophilic response to an infectious agent rather than a manifestation of acquired angioedema. In fact it solved with an adequate antiviral therapy. Results: In case of WS, due to the possible association with severe diseases like lymphoproliferative disorders, a thorough clinical evaluation becomes mandatory. Some authors believe that skin lesions may be a local hypersensitivity reaction triggered by a number of causative agents like viral infections or insect bites. In case of hematologic malignancy herpes viruses can reactivate with severe complications rather than abnormal local edema. The treatment is the one of the underlying disease.

Conclusions:
The correlation between clinical and histopathologic findings permitted to achieve the diagnosis of WS associated to a lymphoproliferative disorders. WS, due to the polymorphic clinical presentation and relative rarity, is a diagnostic challenge for the clinician.
Consent to publish Written informed consent was obtained from the patient involved in this study. Background: The prevalence of CSU in the population ranges from 0.5 to 1% and the duration of the disease is generally 1-5 years, but is likely to be longer in more severe cases (1). While the pathogenesis of CSU has been extensively investigated, no theory has been conclusively proven, and a combination of mechanisms may play a role. Vasoactive mediators released from mast cells and basophils play a key role in the pathogenesis of CSU. Histamine acts on H1 receptors (85%) and H2 receptors (15%) in the skin (2). Methods: We compared treatment outcomes of twenty randomly selected adult patients with СSU in Russia and in the UK. Treatment was done according to the local guidelines. Treatment with licensed doses of non-sedating H 1 -antihistamines relieves symptoms effectively in < 50% of patients. Although guideline-recommended updosing up to fourfold increases symptom control in many patients, a substantial number of patients have only little benefit from H 1 -antihistamines (1). Results: In Russia Levocetirizine was used and only 25% of patients showed significant improvement with a dose of 5 mg. In the remaining group of the patients the dose was increased, but unfortunately 40% of patients achieved insufficient control of their symptoms. In the UK on the licensed dose of Rupatadine 10 mg full control was achieved in 30% of cases, but 15% of patients after up-dosing and addition of Montelukast 10 mg in line with NICE guidelines had UAS7 of more than 28, and were enrolled on anti-IgE treatment.

P08
Conclusions: A 25% difference in the number of patients who achieved acceptable control of symptoms with H1 antihistamines in Russia vs UK might be explained by biases in the severity of cases referred to clinics, brand of antihistamine used as first line treatment based on local polices and possibly geographical factors.
Background: Netherton syndrome is rare autosomal recessive hereditary ichthyosiform disease. The classical triad of clinical features includes ichthyosis, hair shaft abnormalities and atopic diathesis.

Methods:
The authors present the case of a 14-years old girl with the Netherton syndrome (molecular genetic diagnosis SPINK5 c.1048C > T p.R350X and c.2098G > T p.G700X). She has ichthyosis, bamboo hair (trichorrhexis invaginata), atopy: multi-sensitized, allergic rhinitis, asthma and has had once anaphylaxis due to eating fish. She was born from the 3rd pregnancy/3rd delivery at 37w + 5d (3100 g, 50 cm). Her 4 years older brother is healthy but her sister had ichthyosiform erythrodermia and died in 1994 at two months of age due to sepsis. Our patient had in newborn period oedematous skin, erythrodermia, problems with thermoregulation, dehyratation, metabolic acidosis, bacterial infection and she was living in the couveuse with high temperature and humidity for the first weeks of life.
Results: She has growing slowly, her weight is 43 kg (3-10 percentile) and height 153 (3-10 percentile).She has been active, communicative and has had good results in the studies. Her skin disease has been more or less under control, she has severe allergy against fish, house dust mitmes and pollens. Her asthma is well controlled, her spirometry (FEV 1-119%) and FeNO  Background: Atopic dermatitis (AD) -is a common chronic inflammatory disease of the skin with multifactorial pathogenesis. It is considered that pathogenesis involves damage of the skin barrier which could be followed by an allergen sensitization via transepidermal penetration and lead to the enhanced Th2 response. Allergen specific immunotherapy (ASIT) is the only pathogenetically relevant treatment of IgE-mediated diseases. However, the use of ASIT in patients with atopic dermatitis remains controversial.

Methods:
A 22 year-old woman attended to our department in October 2016 with a severe flare-up of atopic dermatitis. Her skin was very dry, with an erythematous maculopapular rash, plaques and lichenification on her upper extremities, trunk, neck and face. SCORAD index was estimated of 74 score. This worsening of her skin condition was continuing for a 2 year period, even following treatment consisting of emollients, topical glucocorticosteroids and oral antihistamines. Her relevant history included symptoms of atopic dermatitis from her childhood accompanied by the allergy to egg white. At that point, her skin problems were controlled only with emollients and diet, sometimes including topical glucocorticosteroids. Later, atopic dermatitis was in remission from 4 until 20 years old. During this period allergic rhinitis was diagnosed at the age of 13 due to sensitization to house dust mites. She had mild episodic symptoms of watery rhinitis, which was treated with oral antihistamines. At the age of 20 pruritic skin rash appeared all over her body, mainly on the trunk, arms, neck and face. After 2 years of treatment without any good effect, she came to our clinic for a consultation. The workup showed a normal total serum immunoglobulin E concentration, skin prick test was positive to house dust mites. Because she was highly sensitized to house dust mites, a decision was made to use subcutaneous specific immunotherapy with house dust mite allergoids using standard scheme. Results: From the second month of ASIT, the patient reported an obvious improvement on her symptoms, reducing the necessity of topical corticosteroids and oral antihistamines. SCORAD index was estimated of 28 score.
Conclusions: This clinical case shows significant efficacy of allergen specific immunotherapy for the treatment of our patient with AD. The effectiveness of ASIT for severe atopic dermatitis is encouraging, especially in the cases when severe atopic dermatitis do not properly respond to conventional treatment.
Consent to publish Written informed consent was obtained from the patient involved in this study.
Background: Component resolved diagnosis (CRD), such as Immu-noCap ISAC technique, allow the determination of serum levels of IgE directed against specific allergen components and, as a result, a more detailed evaluation of IgE responses in complex cases of patients, who experience severe or atypical symptoms. The Correct interpretation of the results of CRD is essential for proper management of patients. The potential role of CRD in circumstances such as identification of culprit food allergens in case of polysensitization, as well as evaluation of the necessity of allergen immunotherapy, etc was assessed. Methods: Case presentation of severe refractory atopic dermatitis. Results: A 7 years old girl was admitted with a 5-years history of severe Atopic Dermatitis. She also suffered from rhinitis and recurrent wheezing associated with pollination season. Despite treatment severe refractory atopic dermatitis was presented. There was an episode of severe acute urticaria after salmon consumption. Due to many episodes of self-reported food allergy, patient was restricted in consumption of many products including milk, egg, fish, etc. Presence of pets at home from the first year of life was reported by patient's parents during the collection of information for medical history. In order Clin Transl Allergy 2017, 7(Suppl 4):47 to reveal the main allergens of possible poly-sensitization and crossreactivity for this particular case the ImmunoCAP ISAC component test was used.

Conclusions:
There are several conclusions based on the result of ImmunoCap ISAC. The results of the test revealed the hypersensitivity to Kiwi and Cod. High levels of sIgE to fish parvalbumin, a major fish allergen and a marker of cross-reactions between different species of fish, and anaphylactic reaction (acute urticaria) of patient to salmon suggest that in this case strict avoidance of fish is recommended. This patient should carry adrenaline auto-injector for prevention of anaphylactic complications. Very high levels of sIgE to rFel d 4 Lipocalin suggest, that the patient should avoid contact with furry animals (Table 1). Patient changed the house, with no presence of cat and other pets and her skin condition significantly improved. Dermatitis was relieved, quality of life improved. The consumption of dairy products was successfully started without complications. Due to clinical symptoms and high levels of sIgE to Ragweed and Timothy grass specific immunotherapy is recommended.
Consent to publish Written informed consent was obtained from the guardians of the patient involved in this study.
Poster discussion session. Results: Strong positive reactions (+++) were observed to nickel 5.0% pet. in all 3 cases. All 3 had worn metal belt buckles next to the umbilicus. All belts had been purchased in Sweden. All buckles were positive when tested to the dimethylglyoxime test. No relapse was seen after the patients ceased to use the culprit metallic objects.

Conclusions:
The release of nickel ions from metallic objects in close skin contact is regulated in the EU. If an object leaches nickel ions and an eczema develops at the skin site of exposure to this object, a systemic exposure from the absorption of nickel ions in the area of the dermatitis is possible and this is thought to explain the clinical picture. Avoidance of prolonged skin contact with the nickel-releasing alloys will then result in clearance of the systemic dermatitis as seen in these 3 cases.
Consent to publish Written informed consent was obtained from the patients involved in this study.  Background: Urticarial vasculitis is considered a rare clinical pathologic entity characterized by recurrent episodes of urticaria with the histopathological features of a leukocytoclastic vasculitis of the small vessels. The variability in the clinical presentation may be due to the presence or absence of hypocomplementemia. We describe a case of normocomplementemic urticarial vasculitis refractory to conventional therapies that was successfully treated with IL-1 receptor antagonist Anakinra. Case report: A 49-year-old male patient, known for intrinsic asthma under control with Montelukast and inhaled corticosteroids, showed up in our consultation presenting since 2 weeks purpuric urticarial plaques at the lower and upper limbs and angioedema of the face. General practitioner already treated him with systemic antihistamines and prednisone. We stopped systemic corticosteroids and performed a skin biopsy with direct immunofluorescence. Laboratory tests showed physiological values for complements C1, C3 and C4, negative autoantibodies (cryogobulins, ANA, ENA, ANCA) and an elevated serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A total body CT scan excluded neoplastic aetiology of urticaria. Waiting biopsy results we restarted and increased the dosage of systemic corticosteroids and antihistamines without any improvement. Histological results were suggestive for an urticarial vasculitis so started a systemic treatment with Dapsone 50 mg daily, rapidly stopped because of appearance of an haemolytic anaemia and increased CO-Haemoglobin. We tried a subcutaneous therapy with Omalizumab 300 mg every 4 weeks, but after 2 injections we didn't find any improvement. Finally we introduced Anakinra 100 mg daily, thanks to which we remarked a slowly improvement of skin lesions. After 6 weeks patient symptoms were in remission and he now benefits of this treatment since two years: he's still in remission and without any adverse effects. Conclusions: IL-1 receptor antagonist Anakinra represents an effective treatment option for normocomplementemic urticarial vasculitis refractory to the conventional therapies or to Omalizumab. Treatment is safe and well tolerated by the patient and leads to complete and sustained remission within 4 to 6 weeks without relapse in the most cases.
Consent to publish Written informed consent was obtained from the patient involved in this study. Background: Acutely occurring allergies are amongst the most severe side effects related to the ingredients of tattoo inks. Since tattoo associated allergens cannot be removed from dermal layers of the skin without invasive surgical methods, they may cause a severe threat to the respective patients. In the literature, allergic reactions to tattoos are by far most common with red color shades. However, the chemical origin of these colors is usually not reported and analytical evidence of the pigments in the skin or inks provided by the tattoo is not been given either. In former years, mostly inorganic pigments like iron oxides were used for red and yellow shades, thus bearing the risk of intradermal exposure to sensitizing elements such as Ni, Cd, Mn and Co. In the last decades, the use of highly light-fast and color brilliant organic pigments started to dominate the market.

P17 Identification of potent allergens in 104 skin biopsies from allergic tattoo reactions
Since the pigments themselves are insoluble in water, they are generally considered biologically inert. The allergen is suggested to be a hapten formed in the skin over time, possibly associated with pigment metabolites or other breakdown products. It is known that allergies might be induced by sunlight exposure or laser irradiation suggesting that a hapten might also derive from chemical decomposition of the pigment. Yet, no specific haptens have been identified so far. As a prerequisite for future regulation of tattoo pigments, harmful substances that bear the risk of allergy formation or other adverse reactions have to be identified. Methods: Here, we screened 104 skin biopsies of patients who have developed an allergy against their red to violet tattoo. Specimens were analyzed for potential sensitizing elements using inductivecoupled plasma mass spectrometry (ICP-MS). Organic pigments were identified by matrix-assisted laser desorption/ionization time-of flight (MALDI-ToF)-MS/MS. Results: About half of the samples contained Cr, Ni or both elements. Organic pigments in the samples belonged to the azo and quinacridone family and can be traced back to five predominantly occurring pigments. The pigments themselves, their known decomposition products and extracts from sunlight simulation will be tested by the direct-peptide reactivity assay (DPRA) to identify the potentially sensitizing compounds. Conclusions: As a long term goal, the reactive compounds should be patch-tested in patients to achieve an ultimate proof of the true kind of sensitizer(s). Results: Patients were referred to various medical specialties including general practice, immunology, infectious diseases, dermatology, and general surgery. All patient received differing treatment regimens, including topical steroids. These patients are being followed up in light of the risk of antiperspirant allergy.

Conclusions:
Allergy contact dermatitis to aluminium is uncommon as a complication of routine immunisation but must be considered in the differential diagnosis of post vaccination local reactions. Background: Typical allergic contact dermatitis from textile dyes presents as acute or subacute dermatitis at sites of friction and in major skin folds. However, patients may present a varied clinical picture, including urticaria and diffuse pruritus. Here we present a case of an atypical contact dermatitis from azo disperse dyes. Case report: A 40-year-old female with no history of atopic dermatitis developed a pruritic eruption all over her body. During two years he was consulted by several dermatologists and their diagnoses were prurigo and dermatographic urticaria. Initial examination revealed Clin Transl Allergy 2017, 7(Suppl 4):47 infiltrated erythematous papules with pronounced scratching marks on both arms, legs and abdomen. Despite topical corticosteroid, the lesions worsened and spread. Skin biopsy showed normal epidermis with lymphocytic infiltration of the dermis consistent with urticarial reaction. When asked, the patient indicated that she had a contact dermatitis form hair dyes 7 years ago but still dyes her hair despite experiencing signs of scalp dermatitis. She is always dressed in black synthetic clothes. Patch testing was performed with the European baseline series and was positive to p-phenylenediamine, textile dye mix 6.6%, thiuram mix, cobalt chloride, nickel chloride (all 3 +) and neomycin sulphate (2 +). Of these reactions present clinical relevance was established only to p-phenylenediamine and textile dye mix. Avoidance of dark clothes made from synthetic fibers was recommended.

Conclusions:
The diagnosis of textile dye contact dermatitis is often delayed because of unusual clinical presentation, and it is usually after patch testing that clothing is identified as causative.
Background: Calcipotriol, a synthetic vitamin D analogue, is widely used for the topical treatment of psoriasis. It often causes irritation reactions, whereas allergic contact dermatitis is less common [1]. Six patients with allergic contact dermatitis from calcipotriol, of whom 2 men and 4 women, were seen in our tertiary patch test clinic between 1990 and 2016. Methods: Patch tests were performed with the commercial preparation used by the patients (LEO Pharmaceutical Products, Ballerup, Denmark) and/or its ingredients, including calcipotriol (2 or 10 µg/ml in isopropyl alcohol). IQ Ultra ® Chambers (Chemotechnique Diagnostics, Vellinge, Sweden) were used and readings were scored according to the ESCD patch-testing guideline [2]. Results: For all six patients, allergic contact dermatitis was confirmed by at least one positive patch-test reaction (Table 1). In all cases, the lesions improved following substitution of the therapy by topical corticosteroids and/or oral medication. Conclusions: When topical treatment with calcipotriol fails to improve or even worsens the existing lesions, calcipotriol contact allergy should be ruled out. In order to avoid irritant patch test reactions, a concentration of 2 µg/ml in isopropyl alcohol is the most suitable, and in unclear cases, a repeated open application test (ROAT) should be performed [3]. According to the literature, patients sensitized to calcipotriol may tolerate topical therapy with other vitamin D analogues, in particular tacalcitol [4].

Background:
The term 'angry back syndrome' (ABS) was coined by Mitchell in 1975. It was stated that a strong positive patch test reaction could create an 'angry back' which becomes hyper-reactive to other patch test challenges. Usually marginal irritants may become "positive". A 74-year-old atopic male had grommets inserted bilaterally 15 years prior to presentation and due to secretion through the tubes a chronic otitis externa developed with intermittent severe itching. His hearing aids made the problem even worse. He was referred to us because of suspicion of contact allergy to the hearing aid. Methods: Patch testing was carried out with the Swedish baseline series (based on the European baseline series but supplemented with other sensitizers), an extended baseline series, a corticosteroid series, the grommets "as is", and as ethanol and acetone extracts. Patch tests were removed after 48 hrs and readings were performed on day (D)4 and D7. Results: Positive reactions were noted to 18 different test preparations on D4, 7 of which were +++, and 5 ++. On D7 14 positive reactions were noted, none of which were +++ and 8 of which were ++. Additional positive tests were noted to 7 preparations, 5 of which were to corticosteroids, and one each to methylisothiazolinone and colophony. Hydrocortisone-17-butyrate was one of the positive tests (+).

Conclusions:
In the present case only the 18 separate tests were positive with completely normal-looking skin between, speaking against ABS. Former clinical relevance was noted to Myroxylon pereirae, tixocortol pivalate, hydrocortisone, Amerchol L 101, and disperse dye mix. Colophony, aluminum, and hydrocortisone-17-butyrate were considered to have present relevance. The patient used a solution for his ears intermittently containing hydrocortisone-17-butyrate, which was considered the only culprit allergen regarding the chronic otitis externa. No relevance was found for gold, nickel, para-phenylenediamine, formaldehyde, cain mix II, methyldibromo glutaronitrile, diphenylguanidine, propylene glycol, carba mix, methylchloroisothiazolinone/methylisothiazolinone, methylchloroisothiazolinone, methylisothiazolinone, linalool oxidized, limonene oxidized, alclometasone We present a patient with a confirmed IgE-mediated chlorhexidine allergy and highlight some of the diagnostic pitfalls in the work-up of suspected allergy to this substance. Methods: An 81-year-old female patient presented with an acute urticarial reaction in recovery following a colposuspension under general anaesthetic. She was covered in an intensely itchy rash concentrated on the lower abdomen and upper inner thighs. She was treated with IV hydrocortisone and chlorphenamine. The rash settled after 4 hours. Allergy to latex was initially suspected. The patient had contact with latex gloves and a latex catheter throughout the procedure. She had received bupivacaine as a local anaesthetic in addition to induction agents, a muscle relaxant, and antibiotics. The pelvic area had been prepared pre-operatively with a chlorhexidine containing skin wash. A chlorhexidine-based cream was inserted as a vaginal pack post-operatively. Results: A RAST to latex was negative but chlorhexidine was positive (0.53 kAU/litre). Skin prick tests to latex (standardized extract) and bupivacaine (0.25%) were negative and aqueous chlorhexidine (0.5%) was inconclusive. Intradermal testing to chlorhexidine at 1:2500 dilution resulted in an itchy 10 mm weal response.

Conclusions:
Chlorhexidine is an antiseptic that is commonly used to disinfect the skin ahead of invasive procedures. Allergy to chlorhexidine is rare. The spectrum of hypersensitivity reactions is wide and includes IgE-mediated anaphylaxis. Allergy to chlorhexidine is important to recognise as exposure is extensive and not only limited to the health care setting. Chlorhexidine is found in a number of personal care products including toothpaste, mouthwash, and even some cosmetics. Allergy testing to chlorhexidine can be a challenge. Skin testing remains an important diagnostic tool albeit when the appropriate concentrations are used for testing. In our case, intradermal testing was done using a dilution of chlorhexidine 0.5% which was initially difficult to source. Moreover, it appears that the IgE antibody response to chlorhexidine decreases with time and RAST becomes less sensitive leading to potential false negative results*. This report should remind all healthcare professionals of an important potential hazard of this widely used antiseptic.
Consent to publish Written informed consent was obtained from the patient involved in this study.
Background: A young lady suffering from common cold treated herself with a combination preparation of 500 mg acetylsalicylic acid (ASA) and 30 mg pseudoephedrine hydrochloride dissolved in a glass of water which leads to a quick amelioration of nasal congestion and cough. The following day, she developed a generalized itchy maculopapular rash. After discontinuation of the medication and application of topical steroids twice daily, the rush disappeared within 5 days. She was presented at our outpatient clinic for allergologic work-up. Methods: Skin Testing (prick-, intradermal-and patch-test) was performed with an ASA mono-preparation for i.v. use, the ASApseudoephedrine combination preparation and etilefrine mono-preparation for i.v. use. Results: Prick-and intradermal tests resulted negative for all tested medications. Patch testing revealed a similar strongly positive reaction to the combination preparation and etilefrine after 24 h whereas ASA mono-preparation test remained negative. Conclusions: Pseudoephedrine is a widely used vasoconstrictive sympathomimetic agent. It is used topically as a mydriatic drug in ophthalmology or as decongestant nose drops. As systemic medication t is used for the treatment of low blood pressure or paroxysmal atrial tachycardia and in combination with non-steroidal anti-inflammatory drugs for the treatment of common cold. Allergic reactions to pseudoephedrine are very rare except for allergic contact dermatitis upon external use in ophthalmology. There are few cases of a rash with joint swelling, a toxic shock syndrome and fixed drug eruptions due to pseudoephedrine described. Little is known about cross-reactivity between different sympathomimetics other than pseudoephedrine, and ephedrine which are structurally very similar. We could hereby demonstrate that there is a cross-sensitivity between pseudoephedrine and etilefrine as well.
Poster discussion session. Background: Microdialysis has been extensively used to sample small unbound molecules from various tissues including the skin. However, sampling of larger molecules such as cytokines is more complicated, why in vitro assessment of sampling feasibility is crucial for every molecule of interest. Relative recoveries, defined as the fraction of the periprobe concentration collected in the dialysate, have traditionally been estimated in vitro by sampling from a reference solution, yet this approach pose a problem for probes with high molecular weight cutoffs (MWCO), as the larger pores cause leakage into the surrounding fluid, which often lead to no fluid recovery at all. Furthermore, several molecules are known to bind extracellular matrix components leading to a decreased recovery, which is not detected in in vitro reference solution setups. To overcome this, we suggest a novel approach using inert intact human ex vivo skin to estimate relative recoveries with cutaneous microdialysis. Methods: Skin from three donors was obtained and frozen at − 20 °C prior to use. Microdialysis probes (3000 kDa MWCO) were inserted in thawed skin specimens (n = 3). IL-1α, IL-6, IL-17, and TNF-α in three concentrations, or a vehicle control (perfusate), were injected around three replicate probes in each donor (n = 12 probes per donor) mimicking a reservoir around the probes. Probes were perfused with a solution of 1% human albumin in Ringer-lactate at 0.8 µl/min and dialysates were collected for 2 hours. Background levels in ex vivo skin and relative recoveries were determined by quantifying dialysate concentrations using ELISA.

Results:
The ultrafiltration observed in previous in vitro setups was markedly reduced in the skin reservoir model, as inserted probes yielded 80-110% of the expected volume output. Average relative recoveries of cytokines were independent of periprobe concentrations and quantified as 15.2% (IL-1α), 9.3% (IL-6), 10.4% (IL-17), and 6.3% (TNF-α). The coefficient of variation was ~ 30% and independent of skin donor. IL-1α was the only cytokine with background levels above detection limits.

Conclusions:
The skin reservoir model is a novel approach to estimate relative recoveries of large unbound molecules by cutaneous microdialysis. This setup diminished problems with probe leakage seen in previous in vitro approaches. Furthermore, this model closer resembles an in vivo cutaneous environment, why we believe the relative recoveries obtained more accurately represents potential in vivo recoveries. Clin Transl Allergy 2017, 7(Suppl 4):47 Background: Post-burn pruritus is a common distressing sequela of burn wounds. Empirical antipruritic treatment often fails to have a satisfactory outcome because the mechanism has not been fully elucidated. Transient receptor potential (TRP) channels are considered to be related to pathway of pruritus. Methods: Sixty-five burn patients with (n = 40) or without (n = 25) pruritus were investigated, including skin biopsies. Keratinocytes and fibroblasts from those samples were separated. Immunohistochemical staining for TRPV3 and TRPA1; and immunofluorescence staining for TSLP, TSLPR, loricrin, involucrin, -SMA, and TGF-, were performed on samples of burn scars and normal skin. Real-time PCR and western blotting of TRPV3, TRPA1, PAR2 NK1R, TSLP, and TSLPR were done. We also measured intracellular Ca 2+ levels in keratinocytes from scars with or without pruritus, following TRPV3 activation and blocking, and measured the effects of PAR2 agonist on TRPV3 function. Expressions of TSLP after TRPV3 activation in keratinocytes were measured by western blotting and real-time PCR. Results: In immunohistochemical and immunofluorescence staining, TRPV3, TSLP, and TSLPR stained more intensely the epidermis of the burn scars of post-burn-pruritus patients, than that of non-pruriticburn patients. Real time-PCR showed that mRNA of TRPV3 and TSLP were significantly more abundant in keratinocytes from pruritic burn scars than in keratinocytes from non-pruritic burn scars. In addition, mRNA and protein levels of PAR2, NK1R, TSLP, and TSLPR were also significantly increased in pruritic burn scars. With TRPV 3 activation, intracellular Ca 2+ concentrations were more significantly increased in keratinocytes from pruritic burn scars than in those from non-pruritic ones. In keratinocytes from pruritic burn scars, PAR2 activation markedly potentiated opening of TRPV3 channels. TRPV3 activation itself resulted in little increase of Ca 2+ influx with PAR2 inhibition in keratinocytes. In keratinocytes from all samples, PLC-β, PKA, PKCs, and PKD inhibitor markedly reduced intracellular Ca 2+ level by TRPV3 activation, as well as by PAR2 activation. TRPV3 activation also increased mRNA and protein expression of TSLP in keratinocytes.

Conclusions:
We confirmed that TRPV3 of keratinocytes and PAR2, NK1R, TSLP, and TSLPR were highly expressed in pruritic burn scars. In addition, it seemed that PAR2 sensitized TRPV3 channels with PKA, PKC, PKD signaling pathways. It also seemed that TRPV3 activation induced TSLP expression. Background: A 19 week old infant (five weeks corrected) presented to the emergency department of our hospital with an orofacial and perineal rash of one week duration. He had a background of extreme prematurity, (25 weeks and 5 days gestation) and suspected necrotising enterocolitis. He had no history of parenteral nutrition, and no family history of zinc deficiency or cystic fibrosis. He was exclusively breastfed since birth. One week prior to presentation he developed fleshcoloured and inflamed papules on his chin associated with scale. They spread over days to involve his cheeks, peinasal area, and suprapinnar fissures. The lesions then became red and crusted over. Simultaneously, he had developed a symmetrical erosive dermatitis in his napkin area. There was associated 'peeling paint' desquamation and scrotal oedema. There was a sharp demarcation to the abnormal areas of the skin, with the neck, trunk, and limbs markedly spared. The nails were normal and there was no loss of hair. He had a history of loose, light green stools since meconium had been passed in early life. He was otherwise healthy, feeding well, and apyrexial. Methods: Treatment was initiated by the general paediatric team with intravenous antibiotic and antiviral therapy, with no improvement. Of note, a topical barrier ointment containing zinc oxide was used on the napkin area but not the face, and was associated with a significant improvement in that area. Following consultation with the dermatology team, a zinc level and skin biopsy were performed. Zinc supplementation at 1 mg/kg twice daily was empirically initiated. A dramatic and rapid improvement was noted within 48 hours.

Maternal serum and breastmilk zinc -awaited
Conclusions: Zinc is a cofactor for many enzymes and is transferred via the placenta during the third trimester of pregnancy. Risk factors for zinc deficiency include premature birth, male gender, vegan/vegetarian Mother, and low albumin. Sign of zinc deficiency in infancy include periorofacial and acral dermatitis, diarrhea, behavioural change, and neurological disturbance. Our patient was a premature, breastfed, male infant with diarrhoea and orofacial and napkin dermatitis who had a remarkable recovery post zinc supplementation.
Consent to publish Written informed consent was obtained from the guardians of the patient involved in this study. Background: Mast cells are known to contain large amounts of mediators and proteases that are released upon activation during infections or allergy. It is however not know to what degree these mediators affects the metabolic rate of drugs in the skin. In order to investigate if mediators from activated mast cells contribute to the metabolism of subcutaneous (sc) administered drugs, intact ex vivo human skin was activated with/without codeine, and metabolism of a peptide drug, known to undergo rapid degradation after sc administration in a previous phase I study, was investigated. Metabolism was estimated over 21 hours by cutaneous microdialysis, which can be applied to investigate immunological reactions in the skin by sampling low and high molecular weight biomarkers as well as pre-clinical drugs from the extracellular compartment. Methods: Healthy abdominal ex vivo skin was obtained after cosmetic surgery with full ethical consent. Microdialysis probes with a molecular cut-off of 300 kDa were inserted 2 cm intradermally into the skin, which was injected with a mast cell degranulator (codeine), or a buffer control. The peptide drug was subsequent administrated sc, and dialysates were collected over a period of 21 hours and analyzed by liquid chromatography with tandem mass spectrometry detection after desalting of the samples. Skin was incubated on Transwell membranes with a skin optimized medium and kept at 37 °C in a cell incubator until point of sampling.

Results:
The results demonstrate a rapid degradation of the peptide drug in the skin forming a known metabolite. Degradation of the metabolite was followed during 21 hours and found to be slower than that of the parent peptide drug. However, no difference between metabolism in skin sites injected with codeine and sites injected with the buffer control could be detected. The rate of metabolism in the ex vivo skin was on par with the previous clinical observations.

Conclusions:
The experiments demonstrated that while ex vivo skin did metabolize the peptide drug candidate, activation of in situ mast cells with subsequent release of proteases did not appear to increase the metabolic rate of this particular drug. However, the ex vivo skin metabolism model has proven to be a very useful model for the study of drug metabolism and ought to be considered for investigation of metabolism of other drugs or even the fate of sc administered allergens for allergy testing.