Name:____________________



Patient______________________________________________

Patch Testing

Date & Time Applied Date & Time Removed

| |Readings at 48 to 72 hours |Date |Initials |Date |Initials |

To Do # | |Antigen- Cosmetics | |Induration |Erythema |Score | |Induration |Erythema |Score | | |1 |Hydroquinone 1% | | | | | | | | | | |2 |Toluenesulphonamide Formaldehyde Resin

10% | | | | | | | | | | |3 |Abitol 10% | | | | | | | | | | |4 |Compositae Mix 6% | | | | | | | | | | |5 |Benzyl Salicylate 1% | | | | | | | | | | |6 |Vanillin 10% | | | | | | | | | | |7 |Lemon Grass Oil 2% | | | | | | | | | | |8 |Balsam of Tolu 20% | | | | | | | | | | |9 |Cocamidopropylbetaine (in water) 1% | | | | | | | | | | |10 |Abietic Acid 10% | | | | | | | | | | |11 |Sodium Benzoate 5% | | | | | | | | | | |12 |Benzyl Alcohol 1% | | | | | | | | | | |13 |Dexpanthenol 5% | | | | | | | | | |

Grading

1= Weak non-vesicular Reaction: erythema, infiltration, and possibly papules (+)

2=Strong edematous and vesicular Reaction: erythema, edema, papules, and vesicles (++)

3=Extreme spreading, bullous, ulcerative Reaction (+++)

4=Doubtful Reactions, macular erythema only (?)

5=Irritant reaction (IR)

6=Negative Reaction (-)

Adverse reactions:_______________________________________________

Handouts given on where to avoid

Avoid these areas: _______________________________________

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