Andrew Scheman

Contact Allergy: alternatives for the 2007 North American contact dermatitis group (NACDG) Standard Screening Tray.

ost primary care physicians see a large number of patients each year ith eczematous skin diseases. Although many of these patients have topic eczema, another extremely common cause of eczema is contact llergy. This subgroup of eczema patients is notably resistant to treatment nless the causative allergens can be identified and eliminated. It is stimated that allergic contact dermatitis (ACD) to topical products alone ccurs in 1% to 3% of the general population. Unlike respiratory and ood allergies, ACD is not histamine-mediated but is instead a T-cellediated delayed-type hypersensitivity reaction. The basic pathophysilogic process behind ACD is primary skin contact with an allergenic hemical which triggers an immune cascade and results in an eczematous eaction at the site of contact. On first exposure to low molecular weight chemical substances (haptens 500 Da), there is generally no skin reaction. During this first phase, hese haptens enter the epidermis and are recognized by antigen presentng cells, which in turn create signals that transform naive T cells into emory T cells, a process which typically takes 5 to 25 days. ubsequent reactions due to “challenge” with the same chemical subtance generally occur between 24 and 48 hours after exposure; however, eports of reactions occurring as early as 8 hours after exposure and as ong as 1 week after exposure are not uncommon.

Formaldehyde-related textile allergy: an update

Part I of this study explores whether clothing today contains formaldehyde levels likely to cause contact allergy in formaldehyde‐allergic patients. Part II of this study examines whether current reactions to textiles may be due to allergy to textile resins and whether individuals with formaldehyde‐related textile allergy will react to the newer low formaldehyde resins used in the textile industry. Part I: free formaldehyde was measured in 16 fabric specimens produced in the US and overseas. Additionally, since the textile industry has moved to the use of newer methods for measuring fabric formaldehyde content, the newer methodology was compared with the older methods used in the medical literature. Part II: 10 subjects with known textile contact allergy were patch tested to available Chemotechnique textile resins and 6 new low‐formaldehyde resins used by the textile industry. Part I: 8 fabric specimens yielded no detectable formaldehyde and 7 specimens yielded <200 ppm free formaldehyde, using Schiffs reagent and Merck testing methods. 1 specimen showed approximately 2000 ppm formaldehyde, as measured by the Merck test, but only 24 ppm free formaldehyde when retested by the method described in Japanese Law #112. Part II: all subjects reacted strongly to formaldehyde and DMDHEU (the predominant resin currently used in textiles). 6 subjects reacted to EUMF. 2 subjects had mild reactions to the newer low‐formaldehyde resins and 1 to the non‐formaldehyde Fixapret NF. Our results suggest that most clothing today yields free formaldehyde levels unlikely to cause contact allergy in formaldehyde‐allergic individuals. Japanese method #112 is the recommended methodology to measure free formaldehyde in future studies. DMDHEU may now represent the main cause of textile allergy and may be a better screen than EUMF for this problem. Newer resins yielding fabrics with <75 ppm free formaldehyde may cause occasional reactions, but are more likely to be tolerated by individuals with textile contact allergy. Treatment of these individuals should be directed at identification of reliable sources of garments utilizing these newer resins.

Systemic contact dermatitis to hydroxyzine

Systemic contact dermatitis is an underreported type of delayed hypersensitivity caused by a systemically administered substance. When interpreting patch test reactions, it is important to obtain a history of all current related oral medications. Many oral medications can cross-react with structurally similar topical antigens and induce systemic contact dermatitis. Identification and elimination of the inciting agent can lead to resolution of otherwise chronic, unresponsive eczema. We report a case of systemic contact dermatitis to hydroxyzine in a patient who was patch tested positive to ethylenediamine. Repeated oral provocation with hydroxyzine reproduced her eczema on several occasions. We conclude that systemic contact dermatitis to hydroxyzine, a common medication used to treat pruritus, must be considered as a potential cause for unresponsive eczema.

Hereditary mucoepithelial dysplasia: Case report and review of the literature

Hereditary mucoepithelial dysplasia, a dyshesive, dyskeratotic epithelial syndrome caused by an abnormality in desmosomes and gap junctions, involves the mucosae, skin, hair, eyes, and lungs. A 16-year-old patient had nontender, fire-red mucosae; keratosis pilaris; diffuse, nonscarring alopecia; cataracts; photophobia; corneal vascularization; and decreased visual acuity. Histologic examination of gingival sections showed a dyshesive epithelium with atrophy, dyskeratosis, lack of keratinization, and unusual cytoplasmic inclusions. Results of electron microscopic studies showed a reduced number of desmosomes, amorphous intercellular material, and cytoplasmic inclusions resembling tonofilaments and gap junction material. The patient described in this report represents an apparently sporadic case of hereditary mucoepithelial dysplasia. Other cases described previously in the literature are reviewed. We believe this disorder should be brought to the attention of dermatologists because patients with hereditary mucoepithelial dysplasia have numerous skin problems and are susceptible to recurrent infection and potentially fatal bullous lung disease. Also, misinterpreted abnormal results from cervical Pap smears could lead to hysterectomy being performed unnecessarily on these patients.

Food avoidance diets for systemic, lip, and oral contact allergy: an american contact alternatives group article.

BackgroundPatients with systemic, lip, and oral contact allergy will often improve with an elimination diet of related ingredients. Elimination diets for avoidance of many common preservatives, antioxidants, and other food additives have not been published. ObjectiveThis study aims to create rational elimination diets (including lists of acceptable alternative foods) for several common food ingredients (propylene glycol, sorbic acid/sorbates, aspartame, benzoic acid/benzoates, propionic acid and propionates, gallates, and benzoyl peroxide). MethodsData from www.foodfacts.com, a Web site listing ingredient information for more than 75,000 foods, were extracted and sorted into products types, and an elimination diet was created for each of these food-related substances. Easily obtainable alternatives were identified and listed. ConclusionsUse of food elimination diets may yield improvement in some patients who have not improved with external avoidance of allergens.

Nickel exposure from keys: alternatives for protection and prevention.

BackgroundKeys are an important exposure source of metal allergens to consumers and confer a significant problem for nickel-allergic individuals because of repeated daily use. ObjectivesThe aims of this study were to investigate the frequency of nickel and cobalt release in keys and to consider the effectiveness of coatings for preventing metallic allergen release from common metal allergen-releasing keys. MethodsKeys from a variety of common stores were nickel and cobalt spot tested. Nickel-releasing keys were coated with enamel sprays, subjected to a use test, and retested to assess for metal allergen release. ResultsOf 55 tested keys, 80% showed a strong positive result to the nickel spot test. None of the tested keys exhibited cobalt release. No keys initially released nickel after enamel coatings. Key coatings chipped at the portion inserted into a lock after 30 insertions, and keys were found to release nickel. The handle of the key was not found to release nickel after 60 insertions. ConclusionsNickel release from keys is very common; nickel-allergic consumers should consider purchasing keys that do not release nickel (eg, brass, anodized). Enamel coating may be useful in protecting nickel-sensitive individuals from their keys but cannot consistently prevent nickel-release from portions used frequently.

Pediatric Contact Dermatitis Registry Inaugural Case Data

BackgroundLittle is known about the epidemiology of allergic contact dermatitis (ACD) in US children. More widespread diagnostic confirmation through epicutaneous patch testing is needed. ObjectiveThe aim was to quantify patch test results from providers evaluating US children. MethodsThe study is a retrospective analysis of deidentified patch test results of children aged 18 years or younger, entered by participating providers in the Pediatric Contact Dermatitis Registry, during the first year of data collection (2015–2016). ResultsOne thousand one hundred forty-two cases from 34 US states, entered by 84 providers, were analyzed. Sixty-five percent of cases had one or more positive patch test (PPT), with 48% of cases having 1 or more relevant positive patch test (RPPT). The most common PPT allergens were nickel (22%), fragrance mix I (11%), cobalt (9.1%), balsam of Peru (8.4%), neomycin (7.2%), propylene glycol (6.8%), cocamidopropyl betaine (6.4%), bacitracin (6.2%), formaldehyde (5.7%), and gold (5.7%). ConclusionsThis US database provides multidisciplinary information on pediatric ACD, rates of PPT, and relevant RPPT reactions, validating the high rates of pediatric ACD previously reported in the literature. The registry database is the largest comprehensive collection of US-only pediatric patch test cases on which future research can be built. Continued collaboration between patients, health care providers, manufacturers, and policy makers is needed to decrease the most common allergens in pediatric consumer products.

Pediatric Contact Dermatitis Registry Data on Contact Allergy in Children With Atopic Dermatitis

Importance Atopic dermatitis (AD) and allergic contact dermatitis (ACD) have a dynamic relationship not yet fully understood. Investigation has been limited thus far by a paucity of data on the overlap of these disorders in pediatric patients. Objective To use data from the Pediatric Contact Dermatitis Registry to elucidate the associations and sensitizations among patients with concomitant AD and ACD. Design, Setting, and Participants This retrospective case review examined 1142 patch test cases of children younger than 18 years, who were registered between January 1, 2015, and December 31, 2015, by 84 health care providers (physicians, nurse practitioners, physician assistants) from across the United States. Data were gathered electronically from multidisciplinary providers within outpatient clinics throughout the United States on pediatric patients (ages 0-18 years). Exposures All participants were patch-tested to assess sensitizations to various allergens; history of AD was noted by the patch-testing providers. Main Outcomes and Measures Primary outcomes were sensitization rates to various patch-tested allergens. Results A total of 1142 patients were evaluated: 189 boys (34.2%) and 363 girls (65.8%) in the AD group and 198 boys (36.1%) and 350 girls (63.9%) in the non-AD group (data on gender identification were missing for 17 patients). Compared with those without AD, patch-tested patients with AD were 1.3 years younger (10.5 vs 11.8 years; P < .001) and had longer history of dermatitis (3.5 vs 1.8 years; P < .001). Patch-tested patients designated as Asian or African American were more likely to have concurrent AD (odds ratio [OR], 1.92; 95% CI, 1.20-3.10; P = .008; and OR, 4.09; 95% CI, 2.70-6.20; P <.001, respectively). Patients with AD with generalized distribution were the most likely to be patch tested (OR, 4.68; 95% CI, 3.50-6.30; P < .001). Patients with AD had different reaction profiles than those without AD, with increased frequency of reactions to cocamidopropyl betaine, wool alcohol, lanolin, tixocortol pivalate, and parthenolide. Patients with AD were also noted to have lower frequency of reaction to methylisothiazolinone, cobalt, and potassium dichromate. Conclusions and Relevance Children with AD showed significant reaction patterns to allergens notable for their use in skin care preparations. This study adds to the current understanding of AD in ACD, and the continued need to investigate the interplay between these disease processes to optimize care for pediatric patients with these conditions.

To patch or not to patch: what is your threshold for patch testing?

Patch testing is as much art as it is science; we all are influenced by our clinical experience as well as by the literature. In an effort to assist those new to this often underutilized technique, we have solicited comments from five experienced clinicians about when to patch test and when not to patch test. Their responses should be a guide for us all.

Prevalence of Preservatives Across All Product Types in the Contact Allergen Management Program.

Background Preservatives are known causes of allergic contact dermatitis. Objective The aim of this study was to determine the prevalence of preservatives in each product category in the Contact Allergen Management Program and compare prevalence with reported rates of allergic contact dermatitis. Methods Contact Allergen Management Program product information was queried based on the 53 approved preservatives for cosmetic products by the European Union and Association of Southeast Asian Nations plus 5 additional preservatives used in US products. Results Phenoxyethanol and parabens were the most common preservatives with 23.9% of products containing phenoxyethanol and 20.75% of products containing parabens. Methylisothiazolinone (MI) was found in 12.9% of products, most commonly in hair care and household products. Preservatives like MI and methylchloroisothiazolinone (MCI) that are both common in products and have a high incidence of allergic contact dermatitis are of greatest concern as contact allergy hazards. Phenoxyethanol and parabens are common and have weak sensitizing power, making them preferred preservatives. Conclusions Evaluating the prevalence of preservatives provides important information on allergen exposures. Using current positive reaction rates, the risk of sensitization to a given preservative can be more accurately estimated and may affect the use of certain preservatives by industry in the future.