The Added Value of Patch Testing Beyond the Baseline Tray

Background: The patch test is the standard for diagnosing allergic contact dermatitis. Standardized trays allow the examination of the most prevalent allergens, whereas customized trays are more appropriate for addressing specific allergens and require expertise. They are therefore usually performed in specialized clinics.

Methods: We assessed the results of 4355 patch tests performed between 2012 and 2020 in a contact dermatitis clinic located in a large tertiary medical center. All patients were tested using the European baseline series and additional trays as clinically indicated. We assessed the frequency of relevant positive reactions outside the European baseline series. We then examined the added value and number of tests (NNTs) that need to be performed to elicit one relevant positive reaction per tray and common allergens.

Results: Nine hundred fifty-four patients (21.9%) had 1 or more positive relevant reactions; 43.3% tested positive for an allergen outside the European baseline series (OEBS). The acrylate and fragrance trays were highly represented among the positive and relevant reactions OEBS with NNTs of 4.4 and 6.8, respectively. 2-Hydroxyethyl methacrylate is the most prevalent allergen OEBS and is considered a marker for acrylate sensitivity with a high rate of cross-reactions and concordance rate of 85%, justifying its addition to the EBS in 2018. Other highly represented allergens include chloramphenicol, 2-hydroxyethyl acrylate, and Amerchol L-101, a lanolin derivative. The cosmetics and textile trays, although often tested, have relatively low added values of 3.7% and 2.3%, respectively. Surprisingly, the cutaneous adverse drug reaction series tray (CAD-1000) yielded no positive reactions, whereas testing the patients' medication yielded positive results in 10.9% of the cases.

Conclusions: Expanded patch testing is crucial to accurately diagnose allergic contact dermatitis and almost doubles the number of patients with relevant positive reactions. Acrylate sensitivity is an emerging epidemic with a high positive reaction rate and low NNT, as is sensitivity to the allergens in the fragrance tray. 2-Hydroxyethyl methacrylate is a reliable marker for acrylate sensitivity with a concordance rate of 85%. Chloramphenicol is a common culprit and should be added to the standard tray in countries with a high usage rate. A low NNT was also observed when testing the patients' own cosmetics and medications; this should, therefore, be encouraged. The textile tray yielded a relatively high NNT; however, it should be performed when clinically indicated in the absence of a reliable marker in the EBS.