Contact dermatitis is a very common and probably underreported disease. It can range from cases of irritation with an underarm anti-perspirant to Poison Ivy exposure. Allergic Patch testing may be helpful in determining potential allergens.
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EPIDEMIOLOGY CHARACTERIZATION INCIDENCE/
- Occupational contact dermatitis: etiology, prevalence, and resultant impairment/disability.
Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas 66160-7319, USA.
J Am Acad Dermatol. 2005 Aug;53(2):303-13. Abstract quote
Cutaneous irritant and allergic responses account for the vast majority of cases of occupational contact dermatitis (OCD). Although the pathophysiologic responses to these two different exposures are distinct, the clinical differentiation between chronic cumulative irritant contact dermatitis and allergic contact dermatitis can be difficult and frequently requires patch testing.
This article reviews the recommended algorithms that clinicians should utilize to assess whether a worker suffers from OCD. The prevalence of OCD, its predisposing factors (both endogenous and exogenous), and prognosis are discussed in depth.
Finally, issues surrounding the assessment of impairment and disability resulting from OCD are summarized.
- Prevalence and relevance of contact dermatitis allergens: a meta-analysis of 15 years of published T.R.U.E. test data.
Krob HA, Fleischer AB Jr, D'Agostino R Jr, Haverstock CL, Feldman S.
Department of Dermatology,Wake Forest University School of Medicine, Winston-Salem, NC 27157-1071, USA.
J Am Acad Dermatol. 2004 Sep;51(3):349-53. Abstract quote
BACKGROUND: The patch test procedure is frequently employed to help determine or confirm the cause of allergic contact dermatitis (ACD). The T.R.U.E. Test has become a global standard and is the commercially available patch test system currently used within the United States. Although many studies report T.R.U.E. Test data, none has measured the overall prevalence and relevance of reactions to the allergens tested by the T.R.U.E. Test. Our objective is to describe the prevalence and relevance of contact dermatitis allergens as tested by the T.R.U.E. Test.
METHODS: We conducted a search of the MEDLINE database from 1966 to June 2000 for all publications on the use of the T.R.U.E. Test in the clinical evaluation of ACD in human subjects. Inclusion and exclusion criteria were applied. For each study, we identified and recorded the number of subjects tested, the number of patients with positive reactions, and the number with relevant reactions. Data were analyzed using the SAS system (Cary, NC).
RESULTS: Ours is the first study to compile the entire corpus of published T.R.U.E. Test data and to examine these data using meta-analytic techniques. The meta-analysis shows that nickel (14.7% of tested patients), thimerosal (5.0%), cobalt (4.8%), fragrance mix (3.4%), and balsam of Peru (3.0%) are the most prevalent allergens. The 5 least prevalent allergens are paraben mix (0.5%), black rubber mix (0.6%), quaternium-15 (0.6%), quinoline mix (0.7%), and caine mix (0.7%). By contrast, North American Contact Dermatitis Data Group (NACDG) data show that the 5 most prevalent allergens are nickel (14.3%), fragrance mix (14%), neomycin (11.6%), balsam of Peru (10.4%), and thimerosal (10.4%). NACDG data indicate that the prevalence of allergy to cobalt is 9.2%. In order to assess the clinical importance of T.R.U.E. Test allergens, we employ the Significance-Prevalence Index Number (SPIN). Based on SPIN, the most clinically important allergens tested by the T.R.U.E. Test are nickel (SPIN=894), cobalt (266), fragrance mix (158), colophony (141), and thiuram mix (138).
CONCLUSIONS: Our results identify the prevalence of common contact dermatitis allergens as tested by the T.R.U.E. Test and are in general agreement with previously published reports using other patch test methods. Over 3700 allergens have been identified as causing ACD, of which the T.R.U.E. Test tests only 23. Thus, the T.R.U.E. Test is a screening test at best. Comparison with NACDG data suggests that clinically important allergens may be missed by the T.R.U.E. Test.
Occupational dermatitis in a 10-year material.
Section of Occupational Dermatology, University Hospital, Lund, Sweden.
Contact Dermatitis 1975;1(2):96-107 Abstract quote
This study included 1,752 patients considered to have occupational dermatoses. The most common diagnosis was contact dermatitis. The dermatitis was of an allergic type in three-quarters of men and in half of women. One-fifth of the women with irritant contact dermatitis had an atopic history. Contact dermatitis was localized on the hands in 94% of women and in 84% of men.
The most common allergens in men were chromium, rubber and plastic, and in women nickel, rubber and chromium. Chromium allergy occurred in four-fifths of the men in the building, metal and tanning industries. In one-fifth of the women, nickel allergy developed in cleaning work. Rubber allergy developed in the rubber industry in one-fifth of the cases. Half of the women with contact dermatitis were engaged in either nursing or cleaning work.
A follow-up 2-3 years after treatment of 555 patients with contact dermatitis was completed by means of questionnaires. The eczema was healed in one-quarter of the patients, one-half had periodic symptoms, and one-quarter had permanent symptoms. The prognosis was the same for those who changed their work or stopped working as it was for those who continued their eczema-inducing work.
Occupational allergic contact dermatitis is more prevalent than irritant contact dermatitis: A 5-year study.
Kucenic MJ, Belsito DV.
University of Kansas Medical Center, Kansas City, Kansas.
J Am Acad Dermatol 2002 May;46(5 Pt 1):695-9 Abstract quote
BACKGROUND: Irritant contact dermatitis is thought to be the leading cause of occupational skin disease in the United States. Recent reports suggest otherwise.
OBJECTIVES: The purposes of this study were to determine the prevalence of allergic and irritant forms of occupational contact dermatitis in the population seen at a Midwestern dermatologic referral clinic, report professions commonly affected by occupational skin disease, and indicate which substances are frequent allergens.
METHODS: A retrospective analysis of patch test data collected at the University of Kansas between 1994 and 1999 was performed.
RESULTS: Of 537 patients who underwent patch testing, 135 (25%) had occupational skin disease. Allergic contact dermatitis affected 81 (60%) patients, and irritant contact dermatitis was found in 46 (34%). Health care professionals, machinists, and construction workers accounted for nearly half of all patients with occupational skin disease. Nickel sulfate, glutaraldehyde, and thiuram mix were the most common allergens.
CONCLUSION: Patch tests with a wider array of allergens than those currently available in the United States are needed to prevent misdiagnosis of occupational contact dermatitis.
PATHOGENESIS CHARACTERIZATION BACKGROUND
Early inflammatory markers in elicitation of allergic contact dermatitis.
Martin AP, Gallino N, Gagliardi J, Ortiz S, Ruiz Lascano A, Diller A, Daraio MC, Kahn A, Mariani AL, Serra HM.
BMC Dermatol 2002 Aug 7;2(1):9 Abstract quote
Background: Allergic Contact Dermatitis (ACD) is regarded as a T-cell-mediated delayed-type hypersensitivity reaction. We studied the kinetics of the expression of CS-1 fibronectin, thymus and activation-regulated chemokine (CCL17/ TARC) and different chemokine receptors (CR) in skin biopsies from individuals challenged in their back with the antigen responsible of their contact dermatitis and an irrelevant antigen.
Methods: Samples were taken at 2, 10, and 48 hours for histological and immunohistochemical studies using monoclonal antibodies against human CS-1 fibronectin, CCL17, CD3, CD68, CD49d, CXCR3, CCR5,and CCR3.
Results: At positive antigen stimulated sites there was an early expression of CS-1 fibronectin (2 hours), followed by CCL17 and a later accumulation of alplha4/beta1+ (CD49d), CD3+, CD68+, CXCR3+ and CCR5+ mononuclear cells. At 48 hours, approximately 59 % of infiltrating cells were CXCR3+, 42% CCR5+, and only 14 % CCR3+.
Conclusions: These results showed for the first time a very early expression of CS-1 fibronectin which preceded production of CCL17 in blood endothelial cells (BCEs) from patients' skin with ACD. The role of these molecules in recruitment of monocytes and effector T cells in ACD is discussed.
CD1a-positive dendritic cells transport the antigen DNCB intracellularly from the skin to the regional lymph nodes in the induction phase of allergic contact dermatitis.
Hunger RE, Yawalkar N, Braathen LR, Brand CU.
Dermatological Clinic, University of Berne, Switzerland.
Arch Dermatol Res 2001 Aug;293(8):420-6 Abstract quote
Dendritic cells are potent stimulators of T cell-mediated immune responses. In contact hypersensitivity reactions in animals dendritic cells have been reported to transport antigens to the regional lymph nodes.
In this study we investigated whether skin-derived dendritic cells transport contact antigens via the afferent lymph in humans. By means of a microsurgical technique lymph cells were collected after painting a defined skin region with a 2% concentration of the sensitizing agent 2,4-dinitrochlorobenzene on the leg of 14 volunteers. There was no significant change in flow, output or composition of cells after antigen painting. Using flow cytometric analysis we were able to detect the antigen in CD1a+ dendritic cells of the afferent lymph 15-25 h after antigen application. The antigen could only be detected after permeabilizing the dendritic cells, indicating that the main part of the antigen is transported intracellularly and not on the surface of these cells. Further analysis of cell surface antigens such as CD80, CD86, HLA-DR, CD11a, CD14, CD23, CD25 and CD54 revealed that in the course of cutaneous sensitization the phenotype of the dendritic cells was not altered in the afferent lymph.
These results provide direct evidence that during the induction phase of allergic contact dermatitis in humans antigen-bearing dendritic cells internalize the antigen and migrate from the skin via the afferent lymph vessels to the lymph nodes.
Vascular endothelium express CS-1 fibronectin in allergic contact dermatitis.
Martin AP, Ortiz S, Cabalier ME, Frede S, Burgos E, Hliba E, Serra H.
Inmunologia, Hospital Nacional de Clinicas, Universidad Nacional de Cordoba, Cordoba, Argentina Patologia, Facultad Cs. Quimicas, Hospital Nacional de Clinicas, Universidad Nacional de Cordoba, Cordoba, Argentina Cat. Dermatologia, Hospital Nacional de Clinicas, Universidad Nacional de Cordoba, Cordoba, Argentina.
J Cutan Pathol 2002 Jul;29(6):347-353 Abstract quote
Background: Allergic contact dermatitis (ACD) is a common human dermatosis in which not all the mechanisms involved in its pathogenesis have been elucidated. Objective: To study the expression of CS-1 fibronectin, TARC and Th1-associated chemokine receptors in biopsies from allergic patch test reactions.
Material and methods: Thirteen patients already diagnosed with ACD were challenged on the back with the antigen responsible of the disease and macroscopic responses and biopsies taken after 48 h. Skin biopsies from negative control challenge sites, AD and ICD were also taken. Samples were fixed, embedded in paraffin wax and processed in order to perform histological and immunohistochemical studies.
Results: All subjects with ACD showed a positive clinical response and a perivascular mononuclear cell infiltration at 48 h, which was not seen in the negative controls. The majority of skin-infiltrating cells were CD4+ and CD8+ and up to 54% or 40% of them expressed CXCR3 or CCR5, respectively. We also showed expression of CS-1 fibronectin in inflamed endothelial cells not only in ACD but also in AC and ICD. In contrast TARC was only expressed in ACD and AC.
Conclusion: We showed for the first time that CS-1 fibronectin is expressed in dermal vessels from allergic patch tests positive reactions, as well as irritant and atopic skin lesions.
CHARACTERIZATION RADIOLOGIC LABORATORY MARKERS
Comparative study of Finn Chambers and T.R.U.E. test methodologies in detecting the relevant allergens inducing contact dermatitis
Tina Suneja, MD
Donald V. Belsito, MD
Kansas City, Kansas
J Am Acad Dermatol 2001;45:836-9 Abstract quote
T.R.U.E. Test is a ready-to-use patch test system, which contains 23 allergens and is the only Food and Drug Administration-approved source of allergens currently commercially available in the United States. Previously, allergens dispersed in either petrolatum or water and designed to be applied utilizing Finn Chambers were also commercially available in the United States.
During a 5-year study at the University of Kansas Medical Center, 167 patients were patch tested using both Finn Chamber and T.R.U.E. Test methodologies. Discordant positive reactions were examined for clinical relevance. The Finn Chamber methodology was superior in detecting clinically relevant allergies to fragrance mix, balsam of Peru, and thiuram mix. T.R.U.E. Test performed somewhat better than the Finn Chamber in detecting relevant allergic reactions to nickel, neomycin, and methylchloroisothiazolinone/methylisothiazolinone.
Neither T.R.U.E. Test nor Finn Chamber methodologies performed optimally in detecting relevant allergies to formaldehyde and carbamates.
Practitioners limited to only the T.R.U.E. Test methodology need to be aware that relevant reactions to fragrances, rubber accelerators/pesticides (carbamates and thiurams), and formaldehyde may be missed with this system.
Confocal histopathology of irritant contact dermatitis in vivo and the impact of skin color (black vs white).
Hicks SP, Swindells KJ, Middelkamp-Hup MA, Sifakis MA, Gonzalez E, Gonzalez S.
Wellman Laboratories of Photomedicine, Massachusetts General Hospital, Harvard Medical School, and Contact Dermatitis Unit, Department of Dermatology, Massachusetts General Hospital.
J Am Acad Dermatol 2003 May;48(5):727-34 Abstract quote
BACKGROUND: The pathogenesis of irritant contact dermatitis and its modulation according to skin color is not well understood. Reflectance confocal microscopy (RCM) enables high-resolution, real-time, in-vivo imaging of human skin.
OBJECTIVE: The goal of our study was to use RCM to determine whether susceptibility to irritant contact dermatitis differs between black and white skin.
METHODS: Participants were placed in groups on the basis of skin color and the volar aspects of their forearms exposed to 1% and 4% sodium lauryl sulfate using Finn Chambers (Allerderm Laboratories Inc, Petaluma, Calif). They were evaluated at 6, 24, and 48 hours by RCM, transepidermal water loss, laser Doppler velocimetry, and routine histology.
RESULTS: Participants with white skin had more severe clinical reactions than those with black skin. RCM revealed microscopic changes even without clinical evidence of irritation. Confocal features included parakeratosis, spongiosis, perivascular inflammatory infiltrate, and microvesicle formation, and these features were confirmed by routine histology. Also, participants with white skin had greater mean increases in transepidermal water loss after exposure to 4% sodium lauryl sulfate than did participants with black skin.
CONCLUSION: In-vivo RCM can track early pathophysiologic events revealing differences between black and white skin during the development of irritant contact dermatitis, and may support the theory that those with black skin are more resistant to irritants.
Electrical impedance as a potential tool to distinguish between allergic and irritant contact dermatitis.
Nyren M, Kuzmina N, Emtestam L.
Department of Medicine, Section of Dermatology and Venereology, Karolinska Institutet at Huddinge University Hospital, Sweden.
J Am Acad Dermatol 2003 Mar;48(3):394-400 Abstract quote
BACKGROUND AND OBJECTIVE: The allergic contact reaction is a model reaction for studying the cell-mediated immune system of the skin. In this study we use a noninvasive method, electrical impedance (IMP), to compare nickel (Ni) allergic contact reactions with an irritant contact reaction induced by sodium lauryl sulfate, which has already been carefully evaluated with this method. For this purpose, we included only Ni- and sodium lauryl sulfate-induced reactions of very similar appearance.
METHODS: Various concentrations of Ni sulfate in distilled water were applied on the volar aspect of the forearms of 33 adult women who were allergic to Ni. Assessments were made using visual scoring, a new IMP technique, and transepidermal water loss 3 and 7 days later.
RESULTS: In the 19 patients who completed the study, 3 of the 4 impedance indices were significantly lower at the sodium lauryl sulfate sites than at the Ni sites on day 3; ie, the mean magnitude (MIX) (P < or = .001), imaginary part (IMAX) (P < or = .001), and real part (RIX) indices (P < or = .01). Unlike the irritant reactions, no significant increases in transepidermal water loss occurred in the allergic contact reactions. This may be because, in reactions of the studied magnitude, an allergic contact reaction does not significantly affect the epidermis because the inflammatory process is located deeper in the dermis than an irritant reaction.
CONCLUSION: This study suggests that IMP, as used herein, is suitable for distinguishing between contact reactions of allergic and irritant nature. Although pathophysiologic events in the tissue studied significantly modify impedance patterns, little is known about how to interpret the structural and chemical changes underlying these patterns. Studies are needed to determine the relation between anatomic or pathophysiologic parameters, and the findings using IMP and other established methods, such as chemical extraction and histopathology.
The detection of clinically relevant contact allergens using a standard screening tray of twenty-three allergens.
Saripalli YV, Achen F, Belsito DV.
Division of Dermatology, University of Kansas Medical Center, Kansas City 66160-7319, USA.
J Am Acad Dermatol. 2003 Jul;49(1):65-9 Abstract quote
BACKGROUND: The current standard tool for diagnosing allergic contact dermatitis (ACD) in the United States is the T.R.U.E. test panels, which consist of 23 allergens. Previous studies have raised concern regarding the adequacy of these panels in fully assessing patients with possible ACD.
OBJECTIVE: We sought to examine the use of the T.R.U.E. test allergens as the primary diagnostic method for detecting ACD.
METHODS: A retrospective analysis of all patients with possible ACD who presented to the University of Kansas' Section on Occupational and Contact Dermatitis in Kansas City, Kansas, and subsequently underwent patch testing from January 1, 1995, to December 31, 2001. Patients with positive allergic reactions were stratified into 3 groups: (1) reactions only to allergens on the T.R.U.E. test; (2) reactions only to allergens not present on the T.R.U.E. test; and (3) reactions to allergens on the T.R.U.E. test and additional allergens. These 3 groups were further analyzed to assess clinical relevance.
RESULTS: Of the 898 patients who were patch tested, 616 (68.6%) had at least 1 positive allergic reaction. Among these 616 patients, 25.5% would have been fully evaluated using the T.R.U.E. test allergens only. Of the remaining patients, 22.4% would not have had any of their allergens detected and 52.1% would have only been partially evaluated had only the T.R.U.E. test allergens been used. Similar percentages were observed when only patients with clinically relevant reactions were included.
CONCLUSIONS: In our study, the current T.R.U.E. test series of 23 allergens would have completely identified all allergens in only 25.5% of patients and clinically relevant allergens in 28% of patients. Expanding the number of allergens used according to a patient's environment and history will lead to improved outcome in the treatment and prevention of ACD.
J Am Acad Dermatol. 2005 Nov;53(5):845. Abstract quote
BACKGROUND: Contact dermatitis (CD) is a common occupational disease. There have been no systematic reviews of CD treatment or prevention.
METHODS: Multiple databases were systematically searched. Using independent double review and published quality review criteria, articles were rated as good, fair, or poor. Treatment benefit data were tabulated and conclusions were based on the rated strength of published evidence.
RESULTS: In all, 49 studies met inclusion criteria. Barrier creams containing dimethicone or perfluoropolyethers, cotton liners, and softened fabrics prevent irritant CD. Lipid-rich moisturizers both prevent and treat irritant CD. Topical skin protectant and quaternium 18 bentonite (organoclay) prevent rhus dermatitis. Diethylenetriamine pentaacetic acid (chelator) cream prevents nickel, chrome, and copper dermatitis. Potent or moderately potent steroids effectively treat allergic CD. There were no macrolide immunomodulator trials that met inclusion criteria. This review did not include studies of children, animals, or non-English language publications.
CONCLUSIONS: A limited number of interventions effectively prevent or treat irritant and allergic CD, but well-controlled, outcome-blinded studies, particularly in the area of allergic CD prevention are needed.
VARIANTS ANGRY BACK SYNDROME
Angry back syndrome is often due to marginal irritants: a study of 17 cases seen over 4 years.
Cockayne SE, Gawkrodger DJ.
Department of Dermatology, Royal Hallamshire Hospital, Sheffield, UK.
Contact Dermatitis 2000 Nov;43(5):280-2 Abstract quote
17 patients with angry back syndrome were identified over a 4-year period (1994-97).
10 such patients were classified as multiple reactors and 7 as exacerbations of atopic eczema. The 10 multiple reactors reacted most commonly to medicaments, rubber chemicals, fragrances, methylchloroisothiazolinone/methylisothiazolinone, colophonium and nickel. A final diagnosis of relevant allergic contact dermatitis was made in 8 of the 10 patients with multiple reactions. Relevant contact allergens were rubber chemicals, plants, metals and preservatives, all of which can be marginal irritants. None of the reactions in the patients with exacerbation of dermatitis were thought to be relevant or helpful in the further management of the patient.
Reactions in the angry back syndrome appear to be due most commonly to marginal irritants. In multiple reactors, marginal irritants were also the most common allergens finally identified.
Allergic contact dermatitis in response to budesonide reactivated by inhalation of the allergen.
Isaksson M, Bruze M.
Department of Occupational and Environmental Dermatology, Malmo University Hospital.
J Am Acad Dermatol 2002 Jun;46(6):880-5 Abstract quote
BACKGROUND: Up to 5% of patients with dermatitis who are consecutively patch tested are allergic to one or more corticosteroids. However, few reports of allergic mucosal and skin symptoms in patients with asthma and rhinitis caused by inhaled corticosteroids exist.
OBJECTIVE: Our purpose was to determine whether inhalation of budesonide would result in reactivation of patch test reactions caused by budesonide.
METHODS: The study, which was randomized, double-blind, and placebo-controlled, was ethically reviewed by the Medical Faculty, University of Lund, Sweden. Fifteen nonasthmatic patients who were initially given a diagnosis of budesonide hypersensitivity on patch testing from less than 1 up to 8 years before the study were provoked with budesonide or placebo by inhalation 6 weeks after they had been patch tested with budesonide, its R and S diastereomers, and potentially cross-reacting substances. Lung function was studied by using spirometry and repeated peak expiratory flow measurements.
RESULTS: In 4 of 7 patients who inhaled budesonide, reactivation of previously positive patch test reactions was noted within 24 hours, in contrast to 0 of 8 patients who inhaled placebo (P =.026). No adverse pulmonary responses could be detected.
CONCLUSION: This study shows that allergic skin reactions may occur in patients with contact allergy to budesonide when inhaled forms of the drug are used.
Copper allergy revisited
Stefan Wöhrl, MD, MS
Wolfgang Hemmer, PhD
Margarete Focke, PhD
Manfred Götz, MD
Reinhart Jarisch, MD
J Am Acad Dermatol 2001;45:863-70. Abstract quote
Background: Positive patch tests to copper sulfate are regularly observed, although copper is reported as a rare allergen with a low sensitizing potential. Usually they are claimed to be irritant and unspecific.
Objective: The aim of this study was to assess the relevance and the diagnostic value of positive reactions to copper. Methods: A total of 2660 routine patch tests were analyzed for positive reactions to copper and other metal allergens: copper, 3.53%; nickel, 21.02%; palladium, 5.90%; cobalt, 3.31%.
Results: Reactions to copper and nickel were highly significantly associated with each other. Twenty-six patients with a positive routine test to copper were retested. The reproducibility was modest (38%), but again significantly associated with nickel sensitization.
Conclusion: These clinical data support a copper-nickel cross-reactivity concept on T-cell level based on recently published molecular data. We conclude that positive patch tests to copper are mostly specific; however, they are usually of low clinical relevance.
Allergic contact dermatitis to detergents: A multicenter study to assess prevalence
Donald V. Belsito, MD
Anthony F. Fransway, MD
Joseph F. Fowler Jr, MD, etal.
Kansas City, Kansas; Fort Meyers, Florida; Louisville, Kentucky; Winston-Salem, North Carolina; San Francisco, California; Hershey, Pennsylvania; Cincinnati, Ohio; New Orleans, Louisiana; Portland, Oregon; and Baltimore, Maryland
J Am Acad Dermatol 2002;46:200-6 Abstract quote
Background: Allergic contact dermatitis (ACD) to optical brighteners and enzymes in laundry detergents was the focus of numerous reports in the early 1970s. Subsequently, there has been little published on the incidence of allergic reactions to chemicals in laundry detergents. Nonetheless, consumers and physicians continue to ascribe allergic contact reactions to laundry detergents.
Objective: This article reports the findings of a multicenter study on the prevalence of patch test reactions to a liquid and a granular laundry detergent provided by Procter & Gamble Company (Cincinnati, Ohio).
Methods: Patients referred to members of the North American Contact Dermatitis Group for evaluation of potential ACD were invited to participate in the study, which involved the placement of 2 patch tests (a 0.1% aqueous dilution of a granular laundry detergent and a 0.1% aqueous dilution of a liquid laundry detergent). Whether the patients had atopic dermatitis and whether they or their physicians felt that their dermatitis might be related to laundry detergents were noted. Reactions to the laundry detergents were correlated with allergic reactions to the following screening chemicals: fragrances, nickel, and potassium dichromate. Patients who experienced a reaction to at least one of the laundry detergents could enter phase II of the study, which involved testing to varying dilutions of the laundry detergents, to 0.1% sodium lauryl sulfate (as an irritant control), and to laundered patches of cotton. Patients positive in phase II could enter phase III, which involved wearing a garment laundered with the detergent. Phases II and III were double blinded.
Results: Of the 3120 patients seen by members of the North American Contact Dermatitis Group during the 2 years of this study, 738 patients volunteered to enroll. Enrollment was not statistically randomized. Of these 738, 5 (0.7%) had positive patch test reactions to granular laundry detergent (0.1%, aqueous); 3 of these 5 also had positive reactions to the liquid laundry detergent (0.1%, aqueous). In 4 of the 5 patients, the reaction to detergent was thought to have present relevance to their dermatitis; in 1 of the 5, the reaction was deemed to have past relevance. One of these 5 patients had allergy to fragrances. None of the patients was positive to nickel or chromate. Two of the 5 entered phases II and III. Of these 2 patients, 1 had essentially negative repeat dilutional patch testing and “use testing” suggesting that the earlier reaction patterns may have been irritant. The remaining patient had positive dilutional reactions to both the liquid and granular laundry detergent; however, she also had a positive reaction to sodium lauryl sulfate and to a swatch from a T-shirt laundered without detergent. Upon “use testing” in phase III, this latter patient experienced diffuse dermatitis under both the half of the T-shirt laundered with detergent and that laundered without detergent. Conclusion: Laundry detergents appear to be a rare cause of ACD. Among 738 patients with dermatitis, 5 (0.7%) reacted to a 0.1% aqueous dilution of a laundry detergent. Only 2 of these 5 patients could be evaluated in greater detail to differentiate allergic from irritant patch test reactions to detergents. Upon further testing in 2 patients, the reaction in 1 of 2 could not be reduplicated and the reaction in the other was invoked both by the detergents and the controls.
Thus, whether our study patients were truly allergic and, if so, what the allergenic material(s) in detergents might be, remains unknown. Therefore the reported incidence rate for detergent-induced allergy of 0.7% in dermatitic patients may be too high, possibly because of false-positive irritant reactions.
EMLA(R) cream-induced irritant contact dermatitis.
Dong H, Kerl H, Cerroni L.
Department of Dermatology, University of Graz, Austria, Department of Dermatology, The First Teaching Hospital, Medical University of Henan, Public Republic of China.
J Cutan Pathol 2002 Mar;29(3):190-2 Abstract quote
BACKGROUND: The Eutectic Mixture of Local Anesthetics (EMLA(R) cream) is a topical anesthetic used for providing pain relief in patients undergoing superficial surgical procedures. Cutaneous side-effects have been reported rarely.
CASE REPORT: We present a case of irritant contact dermatitis induced by EMLA(R) cream in a 6-year-old boy with Wiskott-Aldrich syndrome. Our patient showed clinically a well circumscribed patch corresponding to the site of application of the topical anesthetic. Histopathology showed confluent necrosis of keratinocytes in the upper epidermis, a mixed inflammatory infiltrate with priminent neutrophils in the upper dermis, and focal signs of interface changes including basal cell vacuolization and subepidermal cleft formation.
CONCLUSIONS: Graft-vs.-host-disease (GVHD), necrolytic migratory erythema, dermatitis enteropathica and pellagra should be considered in the histopathologic differential diagnosis of acute contact dermatitis caused by EMLA(R).
EPOXY RESIN IN IMMERSION OIL FOR LIGHT MICROSCOPY
Allergic contact dermatitis to epoxy resin in immersion oil for light microscopy.
El-Azhary RA, Yiannias JA.
Department of Dermatology, Mayo Clinic, Rochester; and the Department of Dermatology, Mayo Clinic, Scottsdale.
J Am Acad Dermatol 2002 Dec;47(6):954-5 Abstract quote
Allergic contact dermatitis caused by immersion oil used for microscopy is a recently recognized phenomenon.
We report a case with characteristic findings of periorbital erythema and edema in a cytogenetics technician. Positive patch test responses to epoxy resin, epoxy acrylate, and the immersion oil were noted.
This case represents yet another contact allergic reaction, possibly airborne, to epoxy resin present in immersion oil used for microscopy.
Eyelid dermatitis: Experience in 203 cases.
Dr Guin is Professor Emeritus of Dermatology, University of Arkansas for Medical Sciences.
J Am Acad Dermatol 2002 Nov;47(5):755-65 Abstract quote
Allergic contact dermatitis has been considered the most common of the many dermatologic conditions found with eyelid dermatitis.
This is a retrospective study of 203 patients who presented with persistent or recurrent eyelid dermatitis with or without dermatitis elsewhere. Almost all underwent patch testing and, when indicated, radioallergosorbent test, skin prick and intradermal tests, and in many cases, usage tests as part of the workup.
Relevant allergic contact dermatitis was found in 151 of 203 patients (74.%): 46 (23.%) had protein contact dermatitis, but only 7% had protein contact dermatitis without concurrent allergic contact dermatitis. Less than 1% had irritant dermatitis alone. Twenty-three patients had atopic eczema, of whom 16 also had allergic contact dermatitis, protein contact dermatitis, or both. Other conditions included seborrheic dermatitis (n = 11), psoriasis (n = 7), dry eyes (n = 9), and dermatomyositis or overlapping connective tissue disease (n = 7).
Important sources of contact sensitivity include cosmetics, metals, topical medications including corticosteroids, eye medications, dust mites, animal dander, and artificial nails; only 5 cases were caused by nail lacquer.
Eyelid dermatitis is a multifaceted clinical problem, but in this group of patients, allergic contact dermatitis was a common cause, even among those with atopic eczema.
Systemic allergic contact dermatitis to 8-methoxypsoralen (8-MOP)
Jane Ravenscroft, MBChB MRCP
Victoria Goulden, MBChB MRCP
Mark Wilkinson, MD MRCP
J Am Acad Dermatol 2001;45:S218-9. Abstract quote
Photochemotherapy with psoralens and UVA (PUVA) is widely used in the treatment of psoriasis and many other skin conditions. Cutaneous adverse reactions to 8-methoxypsoralen (8-MOP) appear to be rare and may be difficult to distinguish from phototoxicity or UV-induced polymorphic light eruption.
We describe a patient who had a systemic allergic contact dermatitis to 8-MOP develop during her second course of PUVA treatment for psoriasis.
Allergic contact dermatitis to topical minoxidil solution: Etiology and treatment
Edward S. Friedman, BS
Paul M. Friedman, MD
David E. Cohen, MD MPH
Ken Washenik, MD, PhD
J Am Acad Dermatol 2002;46:309-12 Abstract quote
After more than a decade of use, topical minoxidil solution has proven to be a safe and effective treatment for androgenetic alopecia. However, some patients present with complaints of pruritus and scaling of the scalp. The most common causes of these symptoms include irritant contact dermatitis, allergic contact dermatitis, or an exacerbation of seborrheic dermatitis. Patients suffering from allergic contact dermatitis may benefit from patch testing to determine the causative allergen.
Among the patients we patch tested, propylene glycol was found to be the contactant in a majority of cases, not the minoxidil itself. Many of these patients may be candidates for treatment with alternative formulations using other solvents, such as butylene glycol, polysorbate, or glycerol.
Although predictive, patch testing results do not ensure that the compounded preparations will be tolerated. Unfortunately, patients found to be allergic to minoxidil are no longer candidates for topical treatment of their alopecia with any preparations of minoxidil.
Traumatic osmium tetroxide inoculation
Jeff J. Ligon, MD
Jerrold L. Abraham, MD
Alan S. Boyd, MD
Nashville, Tennessee, and Syracuse, New York
J Am Acad Dermatol 2001;45:949-52. Abstract quote
Osmium tetroxide is a highly oxidizing, corrosive compound commonly found in electron microscopy laboratories. Although osmium tetroxide is known to cause rapid damage to organic tissue, its cutaneous effects have not been well studied.
We report a case of traumatic inoculation from a broken vial of 4% osmium tetroxide. Electron microscopy and energy dispersive x-ray spectroscopy confirmed the presence of osmium in the tissue specimen. The lesion was treated by simple excision.
Photoallergic contact dermatitis is uncommon.
Darvay A, White IR, Rycroft RJ, Jones AB, Hawk JL, McFadden JP.
Department of Environmental Dermatology, St John's Institute of Dermatology, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, U.K.
Br J Dermatol 2001 Oct;145(4):597-601 Abstract quote
Despite the enormous increase in sunscreen use, allergic contact (AC) and photoallergic (PA) reactions to ultraviolet (UV) filters are considered rare.
To analyse the data from 2715 patients who underwent photopatch testing at St John's Institute of Dermatology during the period 1983-98.
A retrospective analysis of all positive photopatch test episodes was undertaken with the results retrieved from the environmental dermatology database and further verified with the original archived patch test documentation for each individual patient.
In 111 patients with positive reactions (4.1%), there were 155 AC or PA reactions to allergens in the photopatch test series. Eighty PA reactions were observed in 62 (2.3%) patients (32 men and 30 women, age range 28-75 years), with UV filters accounting for 52 positive reactions (65%), drugs 16 (20%), musk ambrette 11 (14%) and the antiseptic trichlorocarbanilide one (1%). The most common UV filter photoallergen was benzophenone-3 with 14 positive results, followed by benzophenone-10 (n = 9), isopropyl dibenzoylmethane (n = 6), p-aminobenzoic acid (PABA) (n = 5), octyl dimethyl PABA (n = 5), butyl methoxydibenzoylmethane (n = 4), isoamyl methoxycinnamate (n = 2), ethyl methoxycinnamate (n = 2), octyl methoxycinnamate (n = 2), amyl dimethyl PABA (n = 2) and phenylbenzimidazole sulphonic acid (n = 1). A similar number of AC reactions to UV filters was detected in this study. Thus 49 patients (1.8%) had a total of 75 reactions: 51 due to UV filters and 24 as a result of exposure to fragrances and therapeutic agents. Benzophenone-10 accounted for 13 AC reactions and benzophenone-3 for eight reactions. Twenty-two patients had a PA reaction alone, whereas 19 patients had chronic actinic dermatitis and 15 patients polymorphic light eruption (PLE) in addition. Thus, 34 of the 62 patients (55%) had a preceding underlying photodermatosis.
These results show a low yield of positive photopatch tests. Thus, despite the large increase in the use of UV filters over the last decade, the development of PA reactions remains rare. Furthermore, most of the common UV filter photoallergens identified in this study, including PABA, amyl dimethyl PABA and benzophenone-10, are now rarely used in sunscreen manufacture, while isopropyl dibenzoylmethane was voluntarily removed from the market in 1993. Currently, benzophenone-3 is the commonest contact photoallergen still in widespread use. In contrast, the UVB filter octyl methoxycinnamate, used in a number of sunscreens, produced only two positive PA reactions in 12 years of testing. Nevertheless, although these reactions are extremely rare, patients with photodermatoses such as PLE and chronic actinic dermatitis do represent a group of patients at increased risk of developing photoallergy. Further photopatch test series should be regularly reviewed and updated, as the relevance of individual photoallergens changes over time. Currently, there is no evidence that PA reactions represent a common clinical problem.
HISTOPATHOLOGY CHARACTERIZATION GENERAL
Evaluation of the histologic characteristics of patch test confirmed allergic contact dermatitis.
Wildemore JK, Junkins-Hopkins JM, James WD.
Department of Dermatology, University of Pennsylvania Medical Center, PA 19104, USA.
J Am Acad Dermatol. 2003 Aug;49(2):243-8. Abstract quote
BACKGROUND: Microscopic features of experimentally induced allergic contact dermatitis (ACD) have been reported; however, the histologic characteristics of environmentally induced ACD have not been definitively elucidated.
OBJECTIVE: This pilot study was conducted to describe the histologic features most useful in differentiating ACD from other forms of eczematous dermatitis.
METHODS: A retrospective chart review of patients who underwent evaluation for contact dermatitis was performed. The results of skin biopsy were reviewed in a blinded manner, and two subgroups were compared: gold standard ACD cases and control cases (eczematous dermatitis with negative results of patch testing).
RESULTS: Of 317 cases reviewed, 39 fulfilled the inclusion criteria. Many histologic similarities were noted: both subgroups had substantial acanthosis and lymphocytic infiltration. In addition, present to a moderate degree in both groups were hyperkeratosis, spongiosis, eosinophils, and dermal dendritic fibrohistiocytic (DFH) cells. However, compared with the control cases, eosinophilic spongiosis and multinucleate dermal DFH cells were found to a considerably greater degree in the standard ACD cases.
CONCLUSIONS: Eosinophilic spongiosis and multinucleate dermal DFH cells, in the presence of acanthosis, lymphocytic infiltrate, dermal eosinophils, and hyperkeratosis, are particularly suggestive of ACD. While such findings alone are not diagnostic of ACD, the presence of these combined histologic features supports the pursuit of patch testing in cases of chronic eczematous dermatitis.
VARIANTS ALLERGIC CONTACT GRANULOMA
Sarcoidal-type allergic contact granuloma: a rare complication of ear piercing.
Casper C, Groth W, Hunzelmann N.
Department of Dermatology, University of Cologne, Germany.
Am J Dermatopathol. 2004 Feb;26(1):59-62 Abstract quote.
As body piercing is increasingly en vogue, complications are on the rise as well. Biopsies of such lesions can impose special problems to the reviewing dermatopathologist.
We present two patients who developed papulonodular lesions at the sites of ear piercings. Unexpectedly, the findings included prominent sarcoidal granuloma formation with confluent areas of fibrinoid necrosis. An infectious etiology was excluded. However, patch testing revealed contact allergy to palladium, platinum, and nickel. Interestingly, histopathologic examination of the patch test sites also demonstrated granuloma formation. These findings suggest that the lesions represent allergic contact granulomas.
When confronted with this special type of tissue reaction in skin biopsies of piercing sites, the reviewing dermatopathologist should consider the possibility of an allergic reaction. Careful history and thorough diagnostic procedures, including biopsy of the patch test site can establish the diagnosis of contact allergic granuloma.
PROGNOSIS AND TREATMENT CHARACTERIZATION PROGNOSTIC FACTORS
Quality of life in patients with allergic contact dermatitis.
Kadyk DL, McCarter K, Achen F, Belsito DV.
Division of Dermatology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160-1719, USA.
J Am Acad Dermatol. 2003 Dec;49(6):1037-48. Abstract quote
BACKGROUND: Allergic contact dermatitis (ACD), a common dermatological disorder, often results in ongoing disease and disability. However, relatively little has been published quantifying the quality of life (QoL) of patients with ACD. OBJECTIVES: This study was conducted to investigate the impact of ACD on QoL and explore prognostic factors that influence outcomes.
METHODS: A total of 428 subjects with ACD were, at varying times after diagnosis, mailed a QoL questionnaire modified from Skindex-16 to include an additional 5 items pertaining to occupational impact. The QoL scores were correlated with subject demographics, disease characteristics, and management techniques to ascertain factors that impact QoL in subjects with ACD.
RESULTS: The response rate was 35%, with 149 subjects returning the postal survey. Responders reported being bothered most by itching, skin irritation, and persistence of the condition. Of the four scales included in the QoL questionnaire, the emotions scale had the worst composite QoL score, followed by symptoms, functioning, and occupational impact. Patients with ACD of the face were significantly more bothered by the appearance of their skin. Hand involvement and occupationally related ACD were associated with worse QoL scores within the occupational impact and functioning scales. Subjects that had changed jobs because of ACD had more severe QoL impairment than any other group analyzed, with significantly worse scores on 17 of the 21 QoL items. A history of atopic eczema seemed to impart improved outcomes on patients with ACD, and these subjects were less worried about being fired from their jobs. Subjects diagnosed by patch testing more than 36 months after disease onset seemed to have worse QoL scores than those diagnosed earlier in the natural history of the disease. Patients diagnosed by patch testing within the last 6 months had the worst QoL scores, while the best outcomes were reported in subjects patch tested 6 to 12 months ago. A slight decline in QoL was observed 12 months after patch testing, but scores did not diminish back to the level seen immediately after diagnosis.
CONCLUSIONS: ACD has an appreciable effect on QoL, especially when it affects the hands, the face, or is occupationally related. Of the four scales included in our study, the emotions scale suffered the greatest effect. Emotional impact is therefore an important measure of QoL in ACD patients. Outcomes in patients with ACD were improved by early diagnosis and subjects enjoyed their best QoL at 6 to 12 months after patch testing. However, individuals who elected to change jobs because of their skin condition reported significantly worse QoL than those who retained their current positions.
TREATMENT Removal of offending allergen
Topical or systemic steroid treatment
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