Managing the excited skin syndrome: patch testing hyperirritable skin

Abstract

Inflammation-modulating phenomena (IMPs), humoral and cellular, fluctuate during the course of irritant and allergic contact dermatitis influencing irritability of the skin. The patch test procedure is a biological assay, a titration of responses to IMPs which can produce hyporeactivity or hyperirritability of the skin of patients who have dermatitis (PDs) and a single patch test is a 'snapshot' of the tempo of an evolving process. The excited skin syndrome (ESS) refers to hyperirritability from clinical and patch test dermatitis creating false-positive patch test reactions which are not reproducible when dermatitis and IMPs have subsided. During ESS, the threshold for irritancy decreases and irritant reactions increase. Patch test concentrations should be determined and ESS investigated in PDs having enhanced IMPs, not in 'normal' individuals, and if a patch test result is important to a patient the test should be performed more than once. Variable reproducibility is inherent in the patch test method, but ESS can be managed by appropriate testing and retesting, and search for relevance.

Diagnostic Testing for Nickel Allergic Hypersensitivity: Patch Testing versus Lymphocyte Transformation Test

“…If the initial positive reaction is not reproducible on retesting, allergy may be excluded; reactivity may have subsided, or the initial reaction may have been a false-positive finding due to excited skin syndrome [41,42]. In repeating the patch test, a dose-response assessment (serial dilution) may lead to the appropriate assessment and also potentially to the definition of a threshold sensitivity.…”

“…A potential cause of false-positive, clinically nonrelevant reactions on patch testing is hyperreactive skin, also known as the excited skin syndrome or 'angry back' [41,42]. This condition can result from multiple inflammatory skin conditions or from strong positive patch-test reactions magnifying adjacent patch test responses [43].…”

Operational Definition of a Causative Contact Allergen – A Study with Six Fragrance Allergens

“…There is also the possibility that false-positive reactions appear due to the excited skin syndrome [Maibach, 1981;Mitchell and Maibach, 1997;Mitchell, 1975;Bruynzeel et al, 1983]. The likelihood of this occurring can be reduced by carrying out patch tests in a timephased manner so that the number of patches is minimized.…”

“…Over 40% of such positive patch reactions are lost on re-patching [Mitchell, 1975;Bruynzeel et al, 1983;Mitchell and Maibach, 1997]. Indeed, some studies have involved phased patch testing schedules to avoid false-positive results due to this syndrome.…”

“…False-positive reactions can also arise from phenomena such as the 'excited skin syndrome' that occurs after a number of patches result in positive test results which cannot be reproduced when the patient is re-tested [Maibach, 1981;Mitchell and Maibach, 1997]. Over 40% of such positive patch reactions are lost on re-patching [Mitchell, 1975;Bruynzeel et al, 1983;Mitchell and Maibach, 1997].…”