In Patient_2, bortezomib was discontinued in October 2017 since she had reached partial response with decrease of the monoclonal component. Nine months later, biochemical progression and new bone lesions, with 18% of plasma cells in the bone marrow aspirate, prompted her hematologists to consider starting another proteasome inhibitor. Although no previous reports on tolerance to alternative proteasome inhibitor in patients with a history of severe skin reactions to bortezomib had been published, we set out to try carfilzomib (KYPROLIS ® , Amgen Inc., Thousand Oaks, CA, USA), since its molecular structure was different enough to predict a low level of cross-reactivity. SPT (2 mg/mL) and IDT (0.2 mg/mL) to carfilzomib were negative both at immediate and delayed reading. A controlled intravenous challenge with carfilzomib (20 mg/m 2 ) was performed in a hospital setting in July 2018, with good tolerance. The patient received two more cycles without any side effects.Here, we present two new cases of confirmed delayed hypersensitivity to bortezomib with positive late-reading intradermal tests that suggest an underlying T-cell mechanism. To our knowledge, this is the first report of a desensitization schedule to bortezomib and the first evidence that carfilzomib is well tolerated and can be considered as a safe alternative in patients with delayed hypersensitivity to bortezomib. CONF LICTS OF INTERESTThe authors declare that they have no conflicts of interest.In our experience, negative cases occurred mainly in users, without fingertip affectation and with more facial and leg involvement. The final predominant diagnosis was irritant hand dermatitis whichshould be always reached after ruling out sensitization to acrylates.As conclusions, our study confirms a prehensile pattern in patients who apply the substance (professionals or "do it yourself" users) and a different clinical location of lesions in negative patch tested patients. We highlight the limitation in work ability created in our patients which in many cases required a definitive change of job, and the potential sensitization to acrylates in general population, specially when these substances are self-applied by the user. CONF LICTS OF INTERESTThe authors declare that they have no conflicts of interest.

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Chronic spontaneous urticaria (CSU) is a heterogeneous condition that can severely impact quality of life, which is why rapid disease control is essential. Symptomatic first-line treatment of CSU is the licensed dose of second-generation H1 antihistamines. For second-line treatment, this dose may be increased by up to four times. In patients who fail to respond to these higher doses of H1 antihistamines, treatment with omalizumab (up to 24 weeks) is recommended to achieve disease control. After this 24-week period, the patient response profile to omalizumab should be defined in order to identify refractory patients. The optimal management approach for refractory patients has not been established. In this context, the aim of the present expert consensus study involving a group of specialists (allergists and dermatologists) with specific expertise in treating urticaria was to define specific patient profiles based on their differing responses to omalizumab. Another objective was to develop a treatment algorithm based on the specific response profile. First, a comprehensive literature review was conducted. Then, a group meeting was held to discuss all issues related to the therapeutic management of these patients that had not been addressed in any previous studies. In all cases, the experts considered both the available evidence and their own clinical experience with omalizumab. We believe that implementation of this proposed algorithm will help to optimise the management of CSU patients who are refractory to antihistamine treatment, reduce disease-related costs, and improve QoL.

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