P6411Complete response to large-field external beam radiation therapy forsevere, extensive dermatitis

Terence Sio, MD, MS, Mayo Clinic, Department of Radiation Oncology, Rochester,MN, United States; James Martenson, MD, Mayo Clinic, Department of RadiationOncology, Rochester, MN, United States; Marjorie Nagle, PA, Mayo Clinic,Department of Radiation Oncology, Rochester, MN, United States; MarkPittelkow, MD, Mayo Clinic, Department of Dermatology, Rochester, MN,United States

Background: External beam radiotherapy (RT) experience for chronic, recalcitrantdermatitis has generally been limited to superficial radiographs and Grenz raytherapies. We report the first case of using intensity modulated radiation therapy(IMRT), along with megavoltage RTwith 3 dimensional (3-D) planning, for a patientwith severe refractory dermatitis.

Case report: A 72-year-old man with no prior dermatologic history developedpersistent, discrete, multiple, large erythematous patches and plaques involvingthe trunk and medial thighs. His lesions were intensely pruritic. Multiple skinbiopsies confirmed subacute spongiotic to chronic dermatitis with plasma cells.Patch testing was negative. Multiple treatments including topical and systemicsteroids, wet dressings, antibiotics, and mycophenolate mofetil failed to providesustained benefit. He was referred for consideration of RT. CT scan-basedplanning was performed. Radioopaque wires were used to mark the lesions.Because the patient had large lesions along curved surfaces, they were notamenable to electron therapy or low energy photons. Accordingly, using 6 and 10megavolt photons, IMRT was used to treat the trunk, while 3-D therapy was usedfor the medial thighs. All areas were treated to a prescription dose of 3 Gy perfraction weekly, for 6 weeks (total 18 Gy). Tissue-equivalent bolus material wasused to overcome the skin-sparing nature of the high energy photon beams. Thevolume of tissue that received the prescription dose was 2612 cc for the trunkand 500 cc for the medial thighs. Results Severe pruritus resolved midwaythrough the RT course. After 5 treatments, he stated that the skin lesions ‘‘healedcompletely.’’ There were no adverse effects, and the patient was extraordinarilysatisfied with the outcome. Dermatologic examination confirmed completeresolution of his dermatitis, erythema, and scaling over the trunk and thighs.Only mild hyperpigmentation was observed. There has been no recurrence atthree months follow-up.

Conclusion: Large-field radiation therapy, using IMRT and 3-D treatments, wassuccessful in producing a complete objective and symptomatic response in thisseverely symptomatic patient with extensive dermatitis refractory to other thera-peutic measures. The treatment appears safe andwell-tolerated, with good cosmeticoutcome. The long-term durability of this therapy awaits further follow-up.

APRIL 20

cial support: None identified.

Commer

P6064Cutaneous metal reaction from titanium plate: A case report

Alice Kikko, MD, Associac~ao Pele Saud�avel, S~ao Paulo, Brazil; Analuiza Rezende,MD, Associac~ao Pele Saud�avel, S~ao Paulo, Brazil; Cam�elia Golfan, MD, Associac~aoPele Saud�avel, S~ao Paulo, Brazil; Cec�ılia Nakama, MD, Associac~ao Pele Saud�avel,S~ao Paulo, Brazil; Heloisa Cunali, MD, Associac~ao Pele Saud�avel, S~ao Paulo, Brazil;Rafael Soares, MD, Associac~ao Pele Saud�avel, S~ao Paulo, Brazil

A.G.O.P, a 29-year-old man, came to our dermatology service a few months after asevere orthopedic injury to his left leg on a car accident. An osteosynthesis wasmade and titanium plate and screws were placed to guarantee normal function ofhis leg afterwards. He gradually developed itching, erythema, and peelingresulting on an exudative area around the operatory scar. He was first treatedfor infection and bad circulation before his orthoepedic surgery on anotherservice with antibiotics and he not only did not get better but his symptoms goteven worse, which caused the total area affected to go from approximately 8 to13 cm. When we saw the pacient for the first time, he presented an erythem-atous, brown infiltrative plaque with exudative yellow secretion and parts ofshiny and smooth surface that extended to his circunference circle of the left leg,almost from his knee to his ankle. A biopsy was immediately made and hishistologic findings were compatible to cutaneous metal sensitivy and he startedtaking prednisone 0.8 mg/kg/day with a 15 days treatment of cefalexine 500 mg4 times a day with important healing of the lesion. All his medication wassuspended and 2 months later he returned with similar clinic. He was once againtreated with prednisone, same dose as before with another good healing. Thistime he was sent right away to the orthoepedic service for a new surgery and apossible change of his titanium plate. After the plate removal, his eczema clearedand he no longer had itching symptoms. Nickel and mercury are very wellrecognized causes of contact dermatitis with very consistent support on theliterature while contact allergic reactions to titanium have been rarely reported.Some authors use patch tests in addiction to biopsy with both positive andnegative findings. The suggestive biopsy with a clinical of eczema months after anorthopedic surgery supports our diagnosis.

cial support: None identified.

Commer

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P6817Diagnosis and prevalence of lanolin allergy: A prospective study

Rachel Miest, MD, Mayo Clinic, Rochester, MN, United States; James Yiannias,MD, Mayo Clinic, Scottsdale, AZ, United States; Nidhi Singh, RN, Mayo Clinic,Scottsdale, AZ, United States; Yu-Hui Chang, PhD, Mayo Clinic, Scottsdale, AZ,United States

Background: The role of lanolin in allergic contact dermatitis has been disputed foryears. Current evaluation of suspected allergic contact dermatitis includes patchtesting to lanolin alcohol 30% in petrolatum. Using this method, the prevalence oflanolin allergy is low (1.8-2.5%). We hypothesized that patch testing to a singlelanolin derivative may lead to under-diagnosis.

Objective: To patch test patients to a total of 12 lanolin derivatives to better definelanolin contact allergy reaction rates and optimal derivative(s) for patch testing.

Methods: We conducted a prospective study at Mayo Clinic Arizona from January 1,2009 to December 31, 2011 with patients referred for patch testing as part of theirdermatologic care. Patients were patch tested at a minimum to (1) the Mayo ClinicStandard series (MCS, lanolin alcohol 30 % in petrolatum); (2) Amerchol L101 50% inpetrolatum (currently in our Mayo Clinic Cosmetic series, MCC); and (3) asupplemental series of 10 lanolin derivatives (SS) in concentrations and vehiclesrecommended by current literature. Generalized estimating equations were appliedto examine the risk factors associated with lanolin allergy and to compare positivereaction rates between each series.

Results: Of 286 patch tested patients, the overall prevalence of positive lanolinreactions to at least 1 of 3 patch test series was 6.29%. The prevalence of lanolinallergy using MCS, Amerchol L101, and SS was 1.05%, 3.85%, and 3.85%,respectively. Females were more likely to have lanolin allergy compared to males(OR ¼ 4.98; P ¼ .0127). When controlling for gender, Amerchol L101 50%in petrolatum was associated with increased reaction rates compared to MCS(OR ¼ 3.81; P ¼ .0073) and SS (OR ¼ 8.85; P \ .0001), while no difference inreaction rates was observed between the MCS and SS (P ¼ 1.778).

Conclusion: Our results show that lanolin reaction rates increase when multiplelanolin derivatives are tested (6.29%). The SS produced a higher, although notsignificant, reaction rate compared to the MCS (11/286 vs 3/286). However,Amerchol L101 50% in petrolatum was more likely to demonstrate lanolin allergythan the SS and the current standard lanolin alcohol 30% in petrolatum.Cumulatively, our results indicate Amerchol L101 should be added to a Standardpatch testing series to adequately identify lanolin allergy.

cial support: None identified.

Commer

P6893Emerging role of water in the etiopathogenesis of SNAS: Comparativestudy between Rome and Baltimore

Antonella Tammaro, Sant’Andrea Hospital, Rome, Italy; Alessandra Narcisi,Sant’Andrea Hospital, Rome, Italy; Claudia Abruzzese, Sant’Andrea Hospital,Rome, Italy; Giorgia Cortesi, Sant’Andrea Hospital, Rome, Italy; SeverinoPersechino, Sant’Andrea Hospital, Rome, Italy

Background: Nickel sulphate is an ubiquitous element, contained in various objectsand food. A complete elimination of this element from the diet is very difficult andcan lead to severe nutritional consequences. Its presence in the water is still poorlyevaluated. We studied the presence of nickel in Rome’s tap water, evaluating itschemical composition, the types of pipes used and filtration systems, comparing thedata obtained with those resulted from the study of drinking water and hydraulicsystem in the city of Baltimore. The aim of our study was to evaluate if the increasedincidence of SNAS with prevalent gastrointestinal symptoms in our patient wasrelated or not to the presence of nickel in the water.

Methods: We examined so 50 white patients in Rome and 50 patients in Baltimore,affected by nickel allergy, of both sexes aged between twenty and sixty years of agewith a moderate (++) and intense (+++) positivity at the patch test for nickel. Weevaluated the presence of gastrointestinal symptoms in these patients.

Results: All the 50 white patients affected by SNAS, resident in Rome, of both sexesaged between 20 and 60 years of age with a moderate (++) and intense (+++)positivity at the patch test for nickel, presented symptoms of SNAS, with prevalenceof gastrointestinal symptoms, not decreased after the removal of nickel from thediet. In the second group of 50 patients with moderate and intense positive patchtest for nickel, enrolled at the clinic of allergologic dermatology of the University ofMaryland the patients there are not patients reporting gastrointestinal symptoms.

Conclusion: The water supply of Rome and the province is still mostly made up ofolder types of tubes containing easily oxidizable metals, both from the samewater inthem and for the particularly acidic pH of the soil. This condition means that frees acertain amount of nickel in drinking water. On the contrary, already from few yearsMaryland has switched to using pipes made of PVC (polyvinyl chloride) which areresistant to oxidation and corrosion so as to cancel the release of nickel in the water.So, we hypothesized that the contribution of nickel introduced with the dailyconsumed water could be the main responsible of the divergence of symptoms inboth group of patients.

cial support: None identified.

Commer

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