The Use of Photos from Patch Test Reactions on Day 7 in Professional Ice Hockey Players in Sweden

Background: A survey was undertaken in all ice hockey players in 26 professional teams in Sweden representing the 2 highest divisions. All players answered a questionnaire and the players from 6 teams, 3 from each one of the 2 divisions, were patch tested with 72 test preparations in a baseline series supplemented with a series representing the work environment of the players. For practical reasons, the patch testing and test reading on day 3 (D3) took place in the arenas of the teams. As a traditional dermatologist reading on D7 was impossible to perform in all but one team, the players and coaches were asked to use their mobile phones to take photos of the tested backs of the players on D7 and send to the investigative team. In one team a dermatologist reading took place on D7 independent of the mobile photos.


Introduction
To trace contact allergy, the International Contact Dermatitis Research Group (ICDRG) recommended patch test reading on day 3 or 4 (D3/4) [1].However, a substantial number of contact allergies is missed unless an additional reading is performed on D7 [2,3].A second patch test reading on D7 is mandatory at the Malmö department since 1992 [4].A test reading on D7 is also mandatory according to the recent recommendations by the European Society of Contact Dermatitis [5].
In a study on occupational dermatoses in professional ice hockey players in Sweden, patch testing was performed with a baseline series and a series representing the work environment [6].A second patch test reading on D7 was virtually impossible.The aim of this study was therefore to investigate if photos from mobile phones taken on D7 by the subjects themselves or someone helping them could add positive reactions to those noted from traditional test readings on D3 when the images of tested backs were sent to the investigators for evaluation.

General Information
The

Ethics
The study was approved by the Central Ethical Review Board in Lund, Sweden.The subjects were informed in writing and they gave their written informed consent.

Results
Four subjects out of 107 patch tested were excluded due to too short application time of the tests.In a way, it is again demonstrated that a reading after one week should be mandatory [4].A reading after one week is also recommended in the guidelines of the European Contact Dermatitis Society [5].However, do we know that these reactions absent on D3 but appearing on the photos from D7 really represent contact allergic reactions?Actually, we do not know as the ordinary D6 reading of the players in one

Conclusion
We found 14% (7/50) additional contact allergies on D7 in mobile photos of patch tested backs of the ice hockey players.Our results showed high compliance to send digital photos and benefit from a simplified two partite method as a late test reading, when an ICDRG reading could not be done.
Improvements in mobile photo hard ware and image analyzing techniques in a future test reading situation can be of importance.Further investigations are needed.

Vol- 1
photos of the tested backs of the players on D7 (+/-1 day) in a well-illuminated room with neutral background such as a dressing room.Cameras with 3.15 Megapixel or less were used and images from all players in the 6 teams were sent digitally to the investigators.

(
+,++,+++ = allergic patch test reactions; D = day) D6 were not registered as positive when viewing the photos without knowledge of the D3 readings.The allergic reactions on the dermatologist reading on D6 were registered as positive at the photo evaluation.DiscussionThe patch test reading after one week based on mobile photos resulted in the detection of 7 additional contact allergic reactions.The contact allergies concerned 7 different test preparations and most likely 6 sensitizers as mercaptobenzothiazole giving a contact allergic reaction also is present in mercapto mix.The first test reading on D3 by dermatologists resulted in 50 allergic reactions[6].The additional reading thus gave 14% more contact allergic reactions diagnosed.Of all contact allergic reactions detected in the players (57 reactions), the allergies detected after one week constitute 12.3% which is a figure similar to the one for routinely patch tested dermatitis patients at our department (unpublished results).

Vol- 1
photos are taken according to written advice.It is unlikely that a negative reaction on the photo does not represent a negative reaction.The problem arises when there is a reaction and it might be difficult to conclude whether it is a doubtful or allergic reaction.Occasionally, it might not matter as the tested individual is not exposed to the tested substance/product anymore or it is easy to avoid the substance/product.In this situation it might not be necessary for the individual to come to the clinic for evaluation of the test area.On the other hand, if there is a reaction on the photo where the decision on whether it is an allergic reaction or not is very important, we think that the tested person must come to the clinic for evaluation.Such examples are a possible formaldehyde reaction in any individual as chemical analyses may be required and a possible epoxy reaction in a worker exposed to epoxy professionally, as it may affect compensation and rehabilitation matters.

Table 1 .
Additional contact allergies noted in the late test reading from mobile photos in 95 players in 6 Swedish professional ice hockey teams.