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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