QUIZ: Module 4: Making an initial diagnosis, allergen Series and deciding what to test

SCENARIO 1: Teresa Williams is a 21-year-old student with a part time job working in a fishmonger, presenting to the occupational dermatology clinic with 3-year history of a rash affecting her hands and occasionally affecting her wrists and forearms. She describes it a burning, stinging and pruritic. She reports improvement when away from work.

She has worked at the fishmongers for 3 years working part-time – usually 2 days a week but occasionally more if there is a public holiday. Her duties include cutting fish, cleaning display cabinets, floors and dishes. Teresa usually uses vinyl gloves when handling fish and occasionally uses cotton gloves underneath. She usually has to wash her hand a minimum of 25 x day due to her duties and sometimes will use a hand sanitiser but finds this stings.

At home she uses and uses gloves at home when washing or cleaning. She uses QV wash, Palmolive liquid soap. She uses sorbolene moisturiser and novasone cream with some improvement. 

Past medical history of atopy – eczema, asthma and hayfever

She reports previously reacting to some cosmetics, washing powder and deep heat in the past.

Patch test results – all negative

Questions

SCENARIO 1: Which allergen series would you test with (tick all that apply)

SCENARIO 1: What additional test would you use? (Tick all that apply)

SCENARIO 1: What are the risk factors for developing CD in this patient?

SCENARIO 1: Additional RAST/Ige tests are positive for latex. What are the likely diagnosis (tick 3)

SCENARIO 2: Anna Fitzpatrick is a 25-year-old hairdressing apprentice presenting to the occupational dermatology clinic with a 2-year history of rash initially affecting her right hand but then spreading to her forearms. During the covid lockdown ¬ 12 weeks her skin condition completely cleared, but on returning to work flared up again. She notices with 2 days off the rash improves but does not completely clear. Additionally she reports sneezing and congestion when in the salon.
She has worked as a hairdressing apprentice for the past 3 years working full time Tuesday to Saturday. Her duties include drying hair, mixing and applying colour to the hair and occasionally cleans the salon. When she began, she did not use gloves but now uses a nitrile glove – but the salon reuses these gloves.
At home she was using Dermaveen wash. She uses Diprosone OV ointment on her hands once a day but no other moisturisers. She has had 2 courses of oral steroids. Occasionally she would apply band aid plasters to her hands if splitting was present and uses gloves at home when washing or cleaning.
Past medical history of atopy – eczema and hayfever
Family history – asthma
Patch test results
Paraphenylenediamine (PPD) ++ – in hair dyes used at the salon
Toluene-2,5-diamine ++
Toluene-2,5-diamine sulphate ++
Ammonium sulphate ++ – in hairdressing bleach
Textile dye mix +
Latex RAST – negative

SCENARIO 2: Which allergen series would you test with (tick all that apply)

SCENARIO 2: What are the workplace exposures for this patient?  Tick all that apply

SCENARIO 2: Can bleach cause airborne allergy?

SCENARIO 2: This presentation is not work related?

SCENARIO 2: What is the likely diagnosis (tick 2)

SCENARIO 2: Would single use disposable nitrile gloves prevent ACD?

SCENARIO 2: What workplace interventions would be suggested (Tick all that apply)

SCENARIO 2: This patient is eligible to apply for workcover?

SCENARIO 3: Tessa Pringle, a 43-year-old female presented to the occupational dermatology clinic with a 10 year history of hand dermatitis – particularly the palms. Works as a nurse in intensive care unit – for 19 years doing ¬ 60 hours in a fortnight. Improved in 2019 when working in a non-clinical role. At work she uses Cutan hand foam, Skinman handrub and microshield hand wash + rub. She had a small craft business on the side

At home she was using QV gentle wash, Dermaveen shower and bath oil and various lotions. She is not keen on using topical steroids on her hands. Occasionally she would apply dressings to her hands but with little improvement. Does not use gloves at home when washing/cleaning or doing crafts

Past medical history of atopy – eczema, hayfever and asthma

Family history – asthma

Previous investigations

Patch testing 2007 – relevant reaction to formaldehyde present in antimicrobial hand gel and hand wash 

Patch test results

Fragrance mix ++ ; Cinnamyl alcohol + ; Cinnamaldehyde + – found in 2 of her cosmetics

Quaternium 15 + – found in the microshield handwash

Benzalkonium chloride + found in the skinman handrub

Basic red 46 ++ unknown relevance

Latex RAST – negative

SCENARIO 3: Background of atopy is a risk factor for developing CD in this patient?

SCENARIO 3: What are the workplace exposures for this patient?  Tick all that apply

SCENARIO 3: Which allergen series would you test with (tick all that apply)

SCENARIO 3: What is the likely diagnosis (tick 3)

SCENARIO 3: What workplace interventions would be suggested (Tick all that apply)

SCENARIO 4: Ahmed Borka, a 42-year-old male presented to the occupational dermatology clinic with a 2-year history of hand dermatitis – which started on the dorsal aspect of the fingers, but also describes involvement of the abdomen and calves. He works as a self-employed bricklayer which he has been doing for ¬ 18 years, where he handles bricks, and mixes lime, sand, plasticizer and cement. His rash improved over the Christmas time but not completely. At work he washes his hands ¬ 5 x day with water. He regularly uses QV intensive moisturising cream,  but reports aggravation when under occlusion of gloves. He also uses 2 x daily topical steroids. He uses a nylon glove with a nitrile coated palm which can last between 2-3days. Whilst at home he does not use gloves when washing or cleaning.  

Past medical history – nil. Previous reaction to deodorant (contained fragrance) ¬ 10 years ago

Smoker

Patch test results

Thiuram mix ++

Tetramethylthiuram monosulfide ++

Potassium dichromate 5% +

Potassium dichromate 2.5% +

Fragrance chemicals – anise alcohol + oakmoss ++ tree moss +

Latex RAST – negative

SCENARIO 4: What are the workplace exposures for this patient?  Tick all that apply

SCENARIO 4: Which allergen series would you test with (tick all that apply)

SCENARIO 4: What is the likely diagnosis (tick 3)

SCENARIO 5: John Smith is a 38-year-old male presenting to the contact dermatitis clinic with 20-year history of a rash affecting face, eyelids and flexures. He has been undergoing NB-UVB therapy with some improvement.

He works as a teacher and enjoys gardening in his spare time. He also participates in cleaning and washing up for which he wear disposable PVC gloves. He uses eleuphrat ointment for the rash on his body, tacrolimus ointment for the face as well as dermaveen soap free wash and QV intensive cream as a moisturiser.

Past medical history of atopy – eczema, hayfever

Patch test results – all negative

SCENARIO 5: Which allergen series would you test with (tick all that apply)

SCENARIO 5: What additional test would you use? (Tick all that apply)

SCENARIO 5: Additional RAST – positive for pollen. IgE is raised. What are the likely diagnosis (tick 2)

SCENARIO 6: Josie Thompson is a 57-year-old female presenting to the contact dermatitis clinic with 5-year history of a rash affecting face particularly the eyelid. She reports this is intensely pruritic and can flare up up to 2x month. When it is active it is irritated by sweat, tears and different moisturisers. The rash responds well to advantan ointment.  She also noticed a flare of her dermatitis when she was painting her house.

She currently is a carer for her child. She uses water to wash her face and eczema cream from the pharmacist. She uses herbal essence shampoo (https://www.woolworths.com.au/shop/productdetails/852183?googleshop=true&store_code=woolworths_supermarkets_3163&utm_source=google&utm_medium=cpc&utm_campaign=Shopping_LIA_Beauty_HV_WW-0001&utm_content=SEM&utm_term=BAU&cmpid=smsm:ds:GOOGLE:Woolies_8458_BAU_Shopping_LIA_Beauty%20HV_WW-0001:PRODUCT_GROUP&gclid=CjwKCAiA9tyQBhAIEiwA6tdCrMd06RjzxiP2sUu-GGd_Fe3bRTcmyp7z1MNTqkeiIhxf8Tw6YjPXoxoC8y8QAvD_BwE&gclsrc=aw.ds)

And sunscreen

(https://www.adorebeauty.com.au/la-roche-posay/la-roche-posay-anthelios-invisible-fluid-facial-sunscreen-spf-50.html?istCompanyId=6e5a22db-9648-4be9-b321-72cfbea93443&istFeedId=686e45b5-4634-450f-baaf-c93acecca972&istItemId=imltixxtm&istBid=tztx&gclid=CjwKCAiA9tyQBhAIEiwA6tdCrHyHuRU-Dm5Ciq_IjpWhqKLA5V3X60qgiIMGVJjF0Jo95GiJLRMMgBoChegQAvD_BwE)

Past medical history nil

Patch test results

Methylisothiazolinone ++ – found in her herbal essence shampoo

Dodecyl gallate +

SCENARIO 6: Which allergen series would you test with (tick all that apply)?

SCENARIO 7: Jane Marks is a 46-year-old female presenting to the contact dermatitis clinic with 4-year history of a rash affecting face particularly the eyelids. She works as a school teacher. She enjoys gardening in her spare time.

She reports previous problems with cheap jewellery as well as acrylic nails and has avoided these products as a result. She has also reported one episode of reacting to hair dye 2 years ago. She does not use this brand anymore but continues to dye her hair.

Past medical history nil Medications Over the counter vitamin c and zinc

Patch test results

PPD + – L’oreal hair dye

2-hydroxyethyl methacrylate ++

Ethyl cyanoacrylate +

Nickel sulphate ++

SCENARIO 7: Which allergen series would you test with (tick all that apply)?

SCENARIO 7: The patient can continue to use traditional hair dyes used at salons and in hair coloring kits?

SCENARIO 8: Rachel Sullivan is a 21-year-old female presenting to the contact dermatitis clinic with 1-year history of a rash affecting the perioral area reported as burning, stinging and pruritic. She reports aggravation with makeup and has stopped using all cosmetics. She has been using elidel cream with no improvement.  She has previously had eyelash extensions, acrylic nails and dyes her hair with no issues. She works in retail and is currently studying massage therapy.

Past medical history atopy – hayfever, eczema 

Current smoker

Patch test results

Linalool + found in face primer

Elidel cream +

SCENARIO 8: Which allergen series would you test with (tick all that apply)?

SCENARIO 8: The patient should be prescribed another treatment for her perioral rash?

SCENARIO 9: Marlin Anemone is a 39 year old nurse presenting to the occupational contact dermatitis clinic with 10 year history of hand dermatitis. He works as a nurse at the Skin Health Institute, and reports no improvement with time away from work. He has experienced severe flares that have required time off work as well as course of prednisolone or antibiotics. He reports using a liquid skin glue to help treat some of the cracks in the skin, but noticed it made his skin incredibly itchy after application.

Additionally when using Dettol hand soap this aggravated his rash, as did washing his new born twins.

At work he used nitrile gloves, and Microshield handwash, occasionally chlorhexidine cleanser and Debug hand rub. At home he occasionally uses latex gloves.

At night time he would use dermeze ointment together with eleuphrat ointment, then cotton gloves and nitrile gloves overnight.

PMH – eczema and asthma, mild hayfever, acne

Nil regular medications

SCENARIO 9: Which allergen series would you test with (tick all that apply)

SCENARIO 9: What additional test would you use? (Tick all that apply)

SCENARIO 9: What are the risk factors for developing CD in this patient?