Contact Dermatitis • Contact Points

NEUTROPHILIC FIXED FOOD ERUPTION • WATON ET AL.

A new entity: the neutrophilic fixed food eruption

Julie Waton, Barthelemy Splingard and Annick Barbaud
Dermatology Department, University Hospital of Nancy, Batiment des specialites medicales, Brabois Hospital, CHU, 54500 Vandoeuvre les Nancy, France
doi:10.1111/j.1600-0536.2010.01845.x

Key words: contact dermatitis; fixed food eruption; food allergy; neutrophilic fixed drug eruption; neutrophilic fixed
food eruption; work-related dermatitis.

We describe the first case of work-related contact and sys-
temic fixed food eruption with a neutrophilic perivascular
infiltrate, which we propose to call neutrophilic fixed food
eruption.
Case Report
A 26-year-old male, a cook in a restaurant, was referred
for a recurrent, work-related, fixed eruption caused
by contact with or ingestion of freshwater fish and
Correspondence: Professor Annick Barbaud, Dermatology Department,
University Hospital of Nancy, Brabois Hospital, 6 rue du Morvan, 54500 Van-
doeuvre les Nancy, France. Tel: +33(0)383157145; Fax: +33(3)383157011.
E-mail: a.barbaud@chu-nancy.fr
Conflicts of interest: The authors have declared no conflicts.
seafood. He had developed several erythematous, well-
demarcated, bullous plaques on his forearms. His long-
term treatment had not been modified for more than
6 years. His professional activity was disrupted because of
these fixed eruption outbreaks. For the previous 4 years,
as soon as he handled or ate fish, bullous lesions (Fig. 1)
appeared on his forearms, recurring on the same five sites
and healing with residual scars.
Allergological Test
Patch tests were performed with Finn Chambers® on
Scanpor® (Epitest Ltd oy, Tuusula, Finland), both on the
scarred lesions of the forearm and also on the back,
with all of the drugs and suspected foods taken by
the patient, with commercial extracts (Allerbio®-ALK

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NEUTROPHILIC FIXED FOOD ERUPTION • WATON ET AL.

Fig. 1. Clinical features of the neutrophilic fixed food eruption. Fig. 2. Biopsy sample from a positive patch test with tuna at 24 hr,
showing a polymorphous neutrophil infiltrate.

Laboratory, Courbevoie, France, or Stallergènes® SA,
Antony, France), or with fresh food, and read at 20 min,
on D2 and D4.
Prick tests were performed on normal skin on the
forearm, with commercial extracts or fresh food (prick-to-
prick). The results were compared with those obtained
with negative (0.9% saline) and positive (histamine
10 mg/ml) controls. Readings were performed at 20 min,
1 hr, and 24 hr. The allergen-specific immunoglobulin E
(IgE) antibody test was performed with the ImmunoCap
250 (Pharmacia Diagnostics, Saint Quentin en Yvelines,
France) analytical system.
Results
All of the patch tests on the back gave negative results,
but there were positive results on the residual scars of
the forearms at 30 min for shrimp, pollock, freshwater
fish (carp, yellow perch, and pike), tuna, anchovy, and

Table 1. Results of skin tests, prick tests performed on normal skin, and patch tests performed on scars

Prick tests on Prick tests on forearms Patch tests on forearm scars

forearms (normal skin)
20 min 1 hr 24 hr 20 min D2/D4

Avocado (A) − P3 E6 E6 NT NT
Salmon (A) − P1 E10 E3 − −/−
Monkfish (PP) − P4 E6 E6 NT NT
Tuna (A) − − − Tuna canned + +/+
Tuna fresh + +/+ (bullous)
Anchovy (fresh) NT NT NT + +/+
Pollock (A) − − − + +/+
Herring (fresh) + +/+
Freshwater fish (S) − − − + +/+
Cod (A) − − − NT NT
Whiting (A) − − − NT NT
Sardine (A) − − − NT NT
Wet gauze dressing − −/−
Mackerel (fresh) NT NT NT − −/−
Mussel (A) − − −
Shrimp (A) − − − + +/+
Crab (A) − − − − −/−
Lobster (A) − − − NT NT
Scampi (A) − − − NT NT
Latex (A) − − − NT NT
Paracetamol (C) − − − − −/−

A, Allerbio-ALK® laboratory commercial extracts; C, Chemotechnique® laboratory commercial extracts; E, diameter (mm) of the erythema;
NT, not tested; P, diameter (mm) of the papules; PP, prick-to-prick; S, Stallergènes® laboratory commercial extracts.
Patch tests performed on the back all gave negative results. The extract ‘freshwater fish’ contains proteins from carp, yellow perch, and pike.

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NEUTROPHILIC FIXED FOOD ERUPTION • WATON ET AL.

herring (Table 1). These reactions changed to papulo-
erythematous plaques on D2, with a central blister in
some sites.
Prick test results on normal skin on the forearms were
negative after 20 min, but became positive after 1 hr for
avocado, salmon, and monkfish (Table 1). These tests
were also positive at 24 hr (erythematous infiltrating
reactions). The allergen-specific IgE antibody tests gave
negative results for all foods tested.
A biopsy sample taken at 20 min from positive
patch tests with fresh tuna showed a dermal oedema
without any cell infiltrate. At 24 h, on another
positive site, there was necrosis of suprabasal ker-
atinocytes, with dermo-epidermal blistering and a
neutrophilic, polymorphonuclear, perivascular infiltrate
(Fig. 2) without vasculitis.
Discussion
A fixed drug eruption, described in 1894 (1), is charac-
terized by cutaneous or mucosal well-demarcated ery-
thematous plaques that recur on the same site each
time that the drug is administered. The biopsy sample
shows focal necrosis of the basal keratinocytes, with
melanin incontinence and a perivascular lymphocyte-
predominant inflammatory infiltrate. In 1992, Hatzis
et al. (2) reported the first case of fixed eruption caused
by ‘cheese crisps’, and in 1996 Kelso (3) introduced
the term fixed food eruption. Since then, other cases
have been published that involved asparagus (4), cashew
nuts (5), lactose (6), lentils (7), Japanese sand lance (8),
liquorice (9), quinine (10), and strawberries (3). Prick
tests were performed in only 2 cases (3, 4), and were
negative. In 2001, Agnew et al. (11) reported a bullous
fixed eruption, caused by amoxycillin–clavulanic acid,
with intraepidermal spongiosis, a marked perivascular
and interstitial mixed inflammatory infiltrate with a pre-
dominance of intact neutrophils. The authors proposed
calling this new entity neutrophilic fixed drug erup-
tion. Two other cases of this have been described with
naproxen (12, 13). We report a case of neutrophilic fixed
eruption that recurred following contact with or ingestion
of fish. Considering the histological findings, our case
cannot strictly be classified as a fixed food eruption. We
propose that the clinical and histological characteristics
of this new entity should be called neutrophilic fixed food
eruption. As observed in neutrophilic fixed drug eruption,
there was a neutrophilic polymorphonuclear perivascular
infiltrate without vasculitis. Are these histological find-
ings specific for this entity, or should it be considered as
a stage in the histopathological evolution of any fixed
eruption (14)?
The occurrence of the lesion through contact and the
rapid outbreak after contact with or ingestion of fish or
seafood, reproduced by the patch tests, which showed
positive reactions after 20 min, are uncommon in fixed
eruption. Chronologically, in our case the hypersensi-
tivity to ingested food seems to have been secondary to
previous professional skin contact sensitization to fish and
crustaceans. The pathophysiological mechanism respon-
sible for the induction of this reaction is unknown,
but it seems to be a combination of localized immedi-
ate and delayed hypersensitivity, as in protein contact
dermatitis. However, its clinical features and histologi-
cal findings are different from those of a protein contact
dermatitis.
This multisensitization could be attributable to hyper-
sensitivity to fish albumin (15), to a common crustacean
allergen, such as tropomyosin, arginine kinase, or myosin
light chain (16), or to an avocado allergen without cross-
reactivity with latex.

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ALLERGIC CONTACT DERMATITIS CAUSED BY ACRYLATES • GOULDING & FINCH

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© 2011 John Wiley & Sons A/S • Contact Dermatitis, 65, 43–58 47