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Dear Editor, Eczema herpeticum (EH) is a dermatological emergency, which often affects the paediatric population because of the higher prevalence of eczema in children. Prompt initiation of antiviral therapy is indicated when EH is suspected, with the patient information leaflet from the British Association of Dermatologists recommending commencement of systemic antivirals 'as early as possible'. 1 Clear dosing information is always helpful when initiating treatment. However, neither the Summary of Product Characteristics for aciclovir/valaciclovir 2,3 or the British National Formulary 4 specify a recommended antiviral dose for EH in adults or children, nor does the National Institute for Health and Care Excellence guideline relating to EH in children. 5 The decision on dosing is easier in patients on systemic immunosuppressive treatment. However, the fact remains that the majority of patients with eczema are treated with topical medications only, while all still have a compromised skin barrier that makes them highly susceptible to opportunistic skin infections. Can this patient cohort be classed as immunocompetent?It is clear that recommendations need to be clarified. Correct prescribing in EH, when prompt treatment is essential, would be greatly helped by the presence of dosing information specifically for EH in the relevant literature. The absence of these recommendations may delay early initiation and adversely affect outcomes.

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BackgroundAdverse drug reactions to iodinated contrast media (ICM) have risen due to their increasing use in x‐ray‐based imaging modalities. Delayed hypersensitivity reactions are mainly caused by nonionic monomeric compounds and represent an issue impacting the diagnostic–therapeutic pathways of cancer, cardiology and surgery patients.ObjectivesTo prospectively evaluate the usefulness of skin tests in delayed hypersensitivity reactions to ICM and to evaluate the tolerability of iobitridol, a monomeric nonionic low osmolality compound, as a possible safe alternative.MethodsPatients with delayed hypersensitivity reactions to ICM referred to us from 2020 to 2022 were prospectively enrolled in the study. All patients underwent patch test and, if negative, intradermal test with the culprit ICM and iobitridol as alternative.ResultsA total of 37 patients (females 24, 64.9%) were enrolled in the study. Iodixanol and iomeprol were the most frequently involved ICM (48.5% and 35.2%, respectively); 62.2% of patients presented maculopapular eruption, while 37.8% reported delayed urticaria‐like rash. Skin tests resulted positive to the culprit ICM in 19 patients (51.4%), 16 to patch test and 3 to intradermal test. Skin tests with iobitridol, tested as alternative, resulted positive in 3/19 patients (15.8%). All 16 patients with negative results to iobitridol were administered this ICM and tolerated it.ConclusionsIn at least half of patients, delayed‐type hypersensitivity was demonstrated by skin tests, particularly by patch test. This diagnostic approach resulted simple, cost‐effective and safe, not only to confirm the culprit ICM but also to identify iobitridol as feasible alternative.

To the Editor, We read with great interest the article "Caution against injudicious vaccine allergy skin tests: adverse reactions after intradermal COVID-19 vaccine testing" by Chiang et al, 1 who reported the case of a woman with general-

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