[Management and choice of antibiotics for patients with an allergy to penicillin].
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Biomedical subjects
Publications and source records attributed to G Smeenk.
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The local antibiotics are an important addition to the treatment of moderately severe skin infections. Development of contact allergy and bacterial resistance, however, are some of the adverse reactions that may occur. Fusidic acid and tetracycline are the most suitable products for the treatment of superficial primary infections of the skin caused by Gram-positive cocci and secondary infected dermatoses. In case of insufficient effect mupirocin may be tried. Mupirocin is an effective antibiotic in the treatment of nasal carriage of Staphylococcus aureus in cases of increased risk of infection (haemodialysis, continuous peritoneal dialysis, after thoracic surgery). Besides it is an important local antibiotic in the treatment of meticillin-resistant staphylococci in the nose. In order to prevent development of bacterial resistance its further use has to be restricted. Silver sulfadiazine is a good option for the local treatment of infections by Pseudomonas aeruginosa and other Gram-negative bacteria. Erythromycin and clindamycin are useful local antibiotics for the treatment of mild acne vulgaris. Disinfectants are mainly suitable for the use on the intact skin.
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In six patients (4 women aged 80, 62, 43 and 52 years and 2 men aged 58 and 51 years), who used eyedrops containing beta-blockers for the treatment of glaucoma, allergic contact dermatitis of the eyelids was diagnosed. Three were allergic to metipranolol, 2 to levobunolol and 1 to timolol. In literature, less than 50 cases of hypersensitivity to beta-blockers in eye medication have been reported. There are, however, reasons to assume that sensitization is more frequent: (a) not all patients are referred by the ophthalmologist to the dermatologist; (b) false-negative reactions to patch tests with the commercial preparations and with beta-blockers are not infrequent; (c) they are not routinely tested because beta-blockers are difficult to obtain in pure form; (d) cross-reactions with other beta-blockers are infrequent, and changing to another preparation therefore usually solves the clinical problem. Nevertheless it is advisable to test a battery of beta-blockers (befunolol, levobunolol, metipranolol, timolol) in allergic patients. A test preparation of 2% in water or 3%-10% in petrolatum may be suitable. Control testing in non-exposed individuals is necessary to exclude irritation reactions.
From 15 May to 15 December 1994, 2943 patients suspected of having contact dermatitis (1955 women, 988 men) were patch tested with methyldibromoglutaronitrile 0.3%, 0.1% and 0.05% pet. 119 patients (4.0%; women 4.1%, men 3.8%) proved to be allergic. 71% of the reactions were considered to be relevant. In 2/3 of the patients, causative products were cosmetics, in 1/3 moistened toilet tissues. Testing with methyldibromoglutaronitrile at lower concentrations (0.05% and 0.1%) and with commercial allergens (Euxyl K 400 and methyldibromoglutaronitrile, both containing methyldibromoglutaronitrile 0.1%), resulted in a number of false-negative reactions. All preservatives in the European standard series had lower scores than the 4% positive reactions to methyldibromoglutaronitrile (formaldehyde 2.0%, MCI/MI (Kathon CG) 3.2%, parabens 1.0%, quaternium-15 1.3%). It is concluded that methyldibromoglutaronitrile (present in the commercial preservative Euxyl K 400) is an important contact allergen in the Netherlands in cosmetics and moistened toilet tissues. It should be added to cosmetics series and to proctological series. The optimal test concentration is unknow, but may be 0.3% pet. The concentration of 0.1% methyldibromoglutaronitrile in the currently available commercial allergens appears to be too low, resulting in a number of false-negative reactions.
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To estimate the frequency of false-negative reactions to the fragrance mix, the 8 constituents of the mix in concentrations of 5% (2% for cinnamic aldehyde) were added to the European standard series for routine testing. Patients with positive reactions to individual ingredients in the absence of a reaction to the mix were retested with serial dilutions. In a 4-month period, 677 patients were tested. 61 (9%) reacted to the mix and to 1 or more of the ingredients. 4 patients (0.6% of all patients tested and 6.2% of the patients allergic to fragrances) had false-negative reactions to the mix. They were allergic to cinnamic alcohol, geraniol, isoeugenol and oak moss (1 reaction each), in the absence of a reaction to the fragrance mix. It is concluded that the currently used concentration of the mix (8 x 1%) not infrequently results in false-negative reactions, and that further research should be done to overcome this problem.
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Jessner's lymphocytic infiltration of the skin is a well-known but poorly understood disorder. Some doubt still exists about whether it is a single entity or a heterogeneous group that can pass into polymorphous light eruption, discoid lupus erythematosus, or even malignant lymphoma. Therefore, a large number of patients with lymphocytic infiltration of the skin (N = 100; 46 male, 54 female) were examined to elucidate these questions. We conclude that lymphocytic infiltration of the skin is a single entity. Progression into polymorphous light eruption, discoid lupus erythematosus, or lymphoma was not observed. However, this study shows that lymphocytic infiltration of the skin and polymorphous light eruption cases occur simultaneously in 1 patient. In this study the cases of 10 patients with this combination are reported. An effective but harmless therapy is yet unknown. Intermittent use of topical steroids can be useful but is not effective in many patients.
We have investigated patients with a contact allergy to Hirudoid cream. The hypersensitivity reactions appeared to be due to an allergy to the cream base, but the separate ingredients did not give rise to positive patch test reactions. The hypersensitivity proved to be due to an allergy to a reaction product, and the simultaneous presence of the preservatives 1,3,5-trihydroxyethylhexahydrotriazine and thymol was found to be necessary for the occurrence of a positive patch test reaction. A new allergen was found to be formed by the reaction between thymol and the degradation products of the triazine derivative. This allergen was identified by nuclear magnetic resonance spectroscopy and infrared spectroscopy as 3-(hydroxyethyl)-5-methyl-8-(2-methylethyl)-3,4-dihydro-2H-1,3-benzoxazi ne.
We report two patients treated with etretinate (Tigason) who developed a nodular prurigo-like eruption. We consider this to be an unusual side-effect of the drug.
The influence of short-contact anthralin on the therapeutic effect of ultraviolet B irradiation (Sylvania UV-21 tubes) was investigated with the half-body comparison method in fifteen outpatients with plaque-type psoriasis. The lesions on the right or left half of the body were exposed to one of the topically applied compounds (either anthralin and 2% salicylic acid in petrolatum or 2% salicylic acid in petrolatum alone) for 10 to 30 minutes daily. Of the fifteen patients, five (Group I) were given 0.3% anthralin and five (Group II) received increasing concentrations of anthralin (0.3, 1, 3%); the other five (Group III) were patients who had failed to respond to ultraviolet B therapy alone, and for them a new clearing treatment was started with the addition of anthralin in increasing concentrations (0.3%, 1%, 3%). Only two patients in Group I, one patient in Group II, and one in Group III showed a moderately better clearance of psoriasis on the short-contact anthralin side. Irritation of nonaffected skin by anthralin was common only during the first week of the treatment. Staining of clothes and bedding occurred.
Functional asplenia is described in the case report of an 80-year-old woman who was admitted with Sézary syndrome. The spleen could not be visualized by a Tc-99m tin colloid (SnC) liver and spleen scan, but was visualized by a Tc-99m sulfur colloid (SC) scan, suggesting a different mechanism in accumulation of SnC and SC in the spleen. In-111 oxine labeled Sézary cells could be found in the spleen, bone marrow, and lymph nodes.
The effect of PUVA therapy on the cardiovascular system was studied in 2 groups of patients. The first group consisted of 9 otherwise healthy patients, who were treated without airconditioning. The second group was formed by 15 otherwise healthy psoriasis patients, who were treated with photochemotherapy, using airconditioning. In both groups the cabinet-skin and rectal temperature rose significantly. The most marked finding however was the rise in heart rate. By applying airconditioning, significantly smaller increases in the measured parameters occurred. In none of the patients changes in the electrocardiograms were observed. The effects on the cardiovascular system can evidently be limited by applying airconditioning and by keeping the time of light exposure as short as possible.
35 patients attending a hospital dialysis unit were questioned for the presence and severity of pruritus. Attention was given to skin anomalies and loss of hair. In all patients the serum vitamin A level was determined. Although all of them showed an increased serum vitamin A level, no correlation could be found between the vitamin A content and the presence of pruritus.
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