Excited Skin Syndrome (Angry Back), What Do We Know About It? A Review of the Literature

In 1975, Mitchell brought up a theory that false positive reactions can be due to skin hyperirritability, called it "angry back syndrome" (ABS). The phenomenon is observed in patch testing of patients with several positive patch tests, mostly along with one or more strong reactions. Later, Maibach rephrased ABS to "excited skin syndrome" (ESS) because of generalized involvement of the skin, not only the back.

In this paper, we tried to analyze the possible ESS-related mechanisms and provide crucial information on how to deal with a suspected patient.

On July 2024, we made a wide systematic computer-assisted search of PubMed and Google Scholar (Embase, Scopus) data base, using "excited skin syndrome" and "angry back syndrome" keywords. We scanned 350 studies. After removing duplicate studies, 31 studies concerning ESS/ABS were included in our review.

Patch test results with more than a positive reaction can be due to EES development, particularly when the reactions are non-relevant to the patient. Several factors can alter the chance of ESS including: positioning of the allergens during the patch testing procedure, poly-sensitization, eczema/dermatitis.

We can consider the following points to manage ESS and minimize its occurrence chance: ESS should be suspected when multiple positive reactions are seen. In suspected cases of ESS, re-examining and re-taking history for any relevance of positive reactions is recommended. Retesting should be performed if positive reactions are clinically irrelevant. It is preferred to perform patch testing when no sign of dermatitis is present.