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• W2783205391 abstract "To the Editor: Adverse drug reactions commonly involve the skin. Although medication rechallenge is the most reliable method for definitive diagnosis, there is inherent medical and legal risk with rechallenge. There is a paucity of other validated confirmatory tests. This research letter analyzes the published data on patch testing for nonimmediate cutaneous adverse drug reactions (NI-CADR). The methods used for the systematic literature search is presented in Fig 1. The results are organized on the basis of type of NI-CADR and presented in Table I.1Robinson J.K. Dellavalle R.P. Bigby M. Callen J.P. Systematic reviews: grading recommendations and evidence quality.Arch Dermatol. 2008; 144: 97-99Crossref PubMed Scopus (88) Google ScholarTable IPatch testing by type of drug reactionDrug reactionGrade of recommendation∗According to criteria by Robinson et al,1 1 indicates a strong recommendation with high-quality, patient-oriented evidence; 2A indicates a weak recommendation with limited quality, patient-oriented evidence; and 2B indicates a weak recommendation with low-quality evidence.Quality of evidence†B indicates a systemic review or meta-analysis of low-quality clinical trials or studies with limitations and inconsistent findings, low-quality clinical trials, cohort studies, and case-control studies.Summary of published studies‡Complete reference list available from authors.MPE2ABOverall, 10.8%-38.4% of patients with MPE test positively to the implicated medication on patch testing. Radio contrast media, antiepileptics, penicillins, clindamycin, pristinamycin, and metamizole are more likely to have positive results compared with macrolides and sulfonamides, which are usually negative on patch testing for MPE.FDE2ABPatch testing is most likely to confirm culprit medication when NSAIDs and sulfa-based antimicrobials are tested. Note: patch testing must be performed on previously affected skin in FDE, with appropriate vehicle (ie, patch testing of cotrimoxazole is usually negative in petrolatum vehicle and more likely positive in DMSO).AGEP2ABLimited data suggests patch testing is often positive in AGEP (approximately 58% of cases). Most common medications that illicit positive patch tests include pristinamycin, ß-lactams, antiepileptics, and diltiazem.SCD2BBLimited data suggests patch testing is diagnostic in 100% of cases of SCD with known prior sensitization, and 50% of cases without known prior sensitization.DRESS2ABPatch testing can confirm the culprit medication in 32%-64% of cases of DRESS. Patch testing is most helpful for DRESS caused by antibiotics (ß-lactams and vancomycin), proton-pump inhibitors, and antiepileptics. Patch testing can confirm cross-reactions with antiepileptics.EM and SJS/TEN2BBData on patch testing for EM is limited. Data on SJS/TEN is limited and suggests no utility of patch testing, except possibly for carbamazepine-induced SJS/TEN.AGEP, Acute generalized exanthematous pustulosis; DMSO, dimethyl sulfoxide; DRESS, drug rash with eosinophilia and systemic symptoms; EM, erythema multiforme; FDE, fixed drug eruption; MPE, maculopapular exanthem; NSAID, nonsteroidal antiinflammatory drug; SCD, systemic contact dermatitis; SJS/TEN, Stevens-Johnson syndrome/toxic epidermal necrolysis.∗ According to criteria by Robinson et al,1Robinson J.K. Dellavalle R.P. Bigby M. Callen J.P. Systematic reviews: grading recommendations and evidence quality.Arch Dermatol. 2008; 144: 97-99Crossref PubMed Scopus (88) Google Scholar 1 indicates a strong recommendation with high-quality, patient-oriented evidence; 2A indicates a weak recommendation with limited quality, patient-oriented evidence; and 2B indicates a weak recommendation with low-quality evidence.† B indicates a systemic review or meta-analysis of low-quality clinical trials or studies with limitations and inconsistent findings, low-quality clinical trials, cohort studies, and case-control studies.‡ Complete reference list available from authors. Open table in a new tab AGEP, Acute generalized exanthematous pustulosis; DMSO, dimethyl sulfoxide; DRESS, drug rash with eosinophilia and systemic symptoms; EM, erythema multiforme; FDE, fixed drug eruption; MPE, maculopapular exanthem; NSAID, nonsteroidal antiinflammatory drug; SCD, systemic contact dermatitis; SJS/TEN, Stevens-Johnson syndrome/toxic epidermal necrolysis. Current guidelines recommend patch testing between 6 weeks and 6 months after resolution of NI-CADR and at least 1 month after discontinuation of oral steroids. Patch testing results for NI-CADR are reproducible in 89% of patients after a mean interval of 6.0 years.2Pinho A. Marta A. Coutinho I. Goncalo M. Long-term reproducibility of positive patch test reactions in patients with non-immediate cutaneous adverse drug reactions to antibiotics.Contact Derm. 2017; 76: 204-209Crossref PubMed Scopus (22) Google Scholar European guidelines exist for testing of commercially available medications at 30% and 20% concentrations.3Barbaud A. Gonçalo M. Bruynzeel D. Bircher A. Guidelines for performing skin tests with drugs in the investigation of cutaneous adverse drug reactions.Contact Dermatitis. 2001; 45: 321-328Crossref PubMed Scopus (435) Google Scholar Exceptions to the guidelines exist. Location of patch testing is generally performed on the upper back, except for fixed drug eruptions, in which patch testing must be performed on previously affected skin. Results of patch tests are read according to the International Contact Dermatitis Research Group guidelines.4Wilkinson D.S. Fregert S. Magnusson B. et al.Terminology of contact dermatitis.Acta Derm Venereol. 1970; 50: 287-292PubMed Google Scholar Most articles included in this review evaluated individual medications with high imputability; however, patch testing can be useful even when multiple drugs are suspected.5Liippo J. Pummi K. Hohenthal U. Lammintausta K. Patch testing and sensitization to multiple drugs.Contact Derm. 2013; 69: 296-302Crossref PubMed Scopus (8) Google Scholar Clinically significant relapse with patch testing is rare. In a multicenter study analyzing safety of patch testing in 134 patients with severe NI-CADR, only 1 patient had a relapse requiring treatment with systemic steroids.6Barbaud A. Collet E. Milpied B. A multicenter study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions.Br J Dermatol. 2013; 18: 555-562Crossref Scopus (269) Google Scholar No other articles included in this review noted clinically significant relapse with patch testing. Physicians should be aware that patch testing appears to be safe and useful to confirm the culprit medication in many instances of NI-CADR. Likelihood of a positive patch test varies on the basis of the medication and type of cutaneous adverse reaction (Table I).1Robinson J.K. Dellavalle R.P. Bigby M. Callen J.P. Systematic reviews: grading recommendations and evidence quality.Arch Dermatol. 2008; 144: 97-99Crossref PubMed Scopus (88) Google Scholar If confirmation of the culprit medication is necessary and is not evident based on medical history alone, patch testing should be considered." @default.
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• W2783205391 date "2018-02-01" @default.
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• W2783205391 title "Patch testing for nonimmediate cutaneous adverse drug reactions" @default.
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• W2783205391 doi "https://doi.org/10.1016/j.jaad.2017.08.049" @default.
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