Arieh Ingber

Nickel, chromium and cobalt in consumer products: revisiting safe levels in the new millennium.

The transition metals nickel (Ni), chromium (Cr) and cobalt (Co) are common causes of allergic contact dermatitis (ACD). Given the high frequency with which these allergens can be associated with hand eczema in those responsible for domestic work, it has been suggested that contamination of household consumer products with these metals may be of relevance to the causation/chronicity of hand dermatitis. Dose–response studies using 48u2003h occlusive patch test conditions in sensitized individuals show that ≥90% of sensitized patients fail to react below 1u2003p.p.m., even on irritated skin. Assessment under more realistic exposure conditions has shown that in the presence of irritants and/or following repeated exposures, such individuals rarely react to levels below 10u2003p.p.m. On the basis of this information, it was recommended a decade ago that household (and other consumer) products should not contain more than 5u2003p.p.m. of each of Ni, Cr or Co and that, for an even greater degree of protection, the ultimate target level should be 1u2003p.p.m. The data generated since the original recommendations were made serve to reinforce the validity of these recommendations. Indeed, it is our view that typically the level of each of these transition metals should not normally exceed 1u2003p.p.m. Then, where consumer products meet this guideline fully, modern quantitative risk assessment shows clearly that elicitation of ACD is highly improbable, and the chance of the induction of sensitization is even lower.

Investigation of the threshold for allergic reactivity to chromium

Allergy to chromium is relatively common, often in association with exposure to cement or in leather manufacture. However, in certain locations, there appears to be a relatively large cohort of chromium‐sensitive individuals whose allergy cannot be explained by these common sources. In particular, this group include Israeli housewives with persistent hand eczema and concomitant patch test positivity to chromium. The causation of their allergy has been linked with relatively high levels of chromium contamination in household products. To provide further information in respect of the definition of safe levels for such products, we examined 17 chromium‐allergic individuals to determine their threshold for reaction under closed patch test and repeated open application test (ROAT) conditions. The data derived indicated that, on normal skin, the patch test threshold was 10 ppm chromium; in the presence of an irritant (sodium lauryl sulfate) the threshold was closer to 1 ppm, 2/17 subjects giving 1+ reactions at this concentration. In the more realistic exposure conditions of the ROAT, 8/14 individuals failed to react to 50 ppm, whilst 3/15 reacted to 5 ppm. Interestingly, there was very poor correlation between patch test sensitivity and ROAT sensitivity. To ensure the large majority of chromium‐allergic individuals do not suffer elicitation of their allergy, as well as to limit the development of new chromium‐sensitive subjects, it is recommended that household products adhere to a previously published standard of a maximum limit of 5 ppm, with an ultimate target of 1 ppm contamination by chromium.

Low-dose low-molecular-weight heparin (enoxaparin) is beneficial in lichen planus: a preliminary report

BACKGROUNDnLow-dose heparin devoid of anticoagulant activity inhibits T-lymphocyte heparanase activity, which is crucial in T-cell migration to target tissues.nnnOBJECTIVEnThe purpose of this study was to assess the efficacy of low-dose enoxaparin (Clexane), a low-molecular-weight heparin, as monotherapy in lichen planus.nnnMETHODSnIncluded in the study were 10 patients with widespread histopathologically proven lichen planus (LP) associated with intense pruritus of several months duration. Patients were given 3 mg enoxaparin, subcutaneously once weekly; three patients received four injections, and seven patients received six injections.nnnRESULTSnIn nine patients the itch disappeared within 2 weeks. Within 4 to 10 weeks in eight of these patients, there was complete regression of the eruption with residual postinflammatory hyperpigmentation; in one patient, there was marked improvement. In one patient, no effect was observed. Of the four patients who also had oral LP, only one showed improvement. No side effects were observed in any of the patients.nnnCONCLUSIONnThese findings indicate that enoxaparin may be a simple, effective treatment for cutaneous LP.

Safety of solar phototherapy at the Dead Sea

BACKGROUNDnClimatotherapy at the Dead Sea is effective for patients with psoriasis, atopic dermatitis, vitiligo, and other diseases. Although impressive improvement has been reported for patients with psoriasis, with a clearance rate of more than 80% after a 4-week stay, questions regarding the safety of this treatment have arisen.nnnOBJECTIVE AND METHODSnWe compare the mean UVB radiation intensities absorbed by psoriatic patients undergoing a 4-week climatotherapy under supervision at the DMZ Rehabilitation Clinic of Ein-Bokek (The Dead Sea, Israel), with similar climatotherapy studies in Sweden and Switzerland. We also compare the climatotherapy radiation dosages with the UVB intensities absorbed by psoriatic patients in radiation cabins at seven university clinics.nnnRESULTSnAccording to our individually computerized DMZ protocol, a psoriasis patient with skin type IV is exposed during a 4-week climatotherapy to a mean 3.11 J/cm2 (148 MED) of UVB, similar to that in Sweden and Switzerland. The range of the in-clinic annual phototherapy in the seven medical centers studied varied from 1.17 to 37.80 J/cm2 (56 to 1800 MED).nnnCONCLUSIONnWhen all relevant factors are taken into account, the mean UVB exposure dose at the Dead Sea is one of the lowest reported for clearance of psoriatic plaques.

Effects of virtual reality immersion and audiovisual distraction techniques for patients with pruritus

BACKGROUNDnVirtual reality immersion (VRI), an advanced computer-generated technique, decreased subjective reports of pain in experimental and procedural medical therapies. Furthermore, VRI significantly reduced pain-related brain activity as measured by functional magnetic resonance imaging. Resemblance between anatomical and neuroendocrine pathways of pain and pruritus may prove VRI to be a suitable adjunct for basic and clinical studies of the complex aspects of pruritus.nnnOBJECTIVESnTo compare effects of VRI with audiovisual distraction (AVD) techniques for attenuation of pruritus in patients with atopic dermatitis and psoriasis vulgaris.nnnMETHODSnTwenty-four patients suffering from chronic pruritus - 16 due to atopic dermatitis and eight due to psoriasis vulgaris - were randomly assigned to play an interactive computer game using a special visor or a computer screen. Pruritus intensity was self-rated before, during and 10 min after exposure using a visual analogue scale ranging from 0 to 10. The interviewer rated observed scratching on a three-point scale during each distraction program.nnnRESULTSnStudents t tests were significant for reduction of pruritus intensity before and during VRI and AVD (P=0.0002 and P=0.01, respectively) and were significant only between ratings before and after VRI (P=0.017). Scratching was mostly absent or mild during both programs.nnnCONCLUSIONSnVRI and AVD techniques demonstrated the ability to diminish itching sensations temporarily. Further studies on the immediate and late effects of interactive computer distraction techniques to interrupt itching episodes will open potential paths for future pruritus research.

Hormonal evaluation and autoimmune background in pruritic urticarial papules and plaques of pregnancy

There is little insight into the pathogenesis of most of the dermatoses specifically associated with pregnancy. We evaluated the hormonal profile and the autoimmune background in 11 pregnant women with pruritic urticarial papules and plaques of pregnancy. No statistically significant difference was found between the serum levels of the beta-subunit of human chorionic gonadotropin, estradiol, cortisol, and urinary estriol of the patients and gestational age-matched control subjects. No autoantibodies were found in the patients group. We conclude that patients with pruritic urticarial papules and plaques of pregnancy have no hormonal alterations when compared with normal pregnant women and that no known major autoimmune background plays a part in the pathogenesis of the disease.

Increased prevalence of onychomycosis among psoriatic patients in Israel.

Published data on the prevalence of onychomycosis in psoriasis patients compared with healthy controls are controversial, We therefore conducted a prospective study of toenail onychomycosis, among 113 psoriatic and 106 healthy non-psoriatic subjects, selected from the normal population in the Jerusalem area in the period 2003-05. The results revealed a prevalence of 47.6% toenail onychomycosis among psoriatic patients, compared with 28.4% in normal controls (p=0.0054). Both gender and age affected the prevalence of onychomycosis in both psoriatic and healthy controls, with a higher prevalence in male and elderly subjects. The type and duration of psoriasis were also found to have an impact on the prevalence of onychomycosis. However, the body area involved did not affect the prevalence of onychomycosis in psoriatic patients. Approximately the same percentages of dermatophytes and yeasts were found in psoriatic patients as in healthy controls. However, a higher percentage of moulds was found in psoriatic patients.

Prevalence of Candida on the tongue and intertriginous areas of psoriatic and atopic dermatitis patients

Data in the literature regarding the prevalence of Candida in psoriatic and atopic dermatitis patients are controversial. We conducted a prospective study to determine the prevalence of Candida on the tongue, axillae and groin of psoriatic patients when compared with atopic dermatitis patients and normal controls. During the period 2003–2005, data were collected from 100 psoriatic patients, 100 patients with atopic dermatitis and 100 normal controls. Fungal test specimens for Candida were collected from the axillae, groin and tongue of each patient. There was no increase in the prevalence of Candida in intertriginous area of either psoriatic or atopic dermatitis patients. However, the prevalence of Candida on the tongue was significantly higher in psoriatic patients (32%) compared with atopic dermatitis (18%) (Pu2003=u20030.024) and higher, although not significantly, than in normal controls (21%) (Pu2003=u20030.08). Our study did not reveal higher prevalence of Candida in the axillae and groin of either psoriatic or atopic dermatitis patients. There was a higher prevalence of Candida on the tongue of psoriatic patients. The Candida of the tongue was asymptomatic and did not correlate with age, gender, type of psoriasis or severity of the disease, therefore we conclude that this is clinically irrelevant.

Climatotherapy at the Dead Sea: an effective treatment modality for atopic dermatitis with significant positive impact on quality of life.

BackgroundAtopic dermatitis (AD) has an appreciable effect on quality of life. Improving the quality of life of AD patients is a priority. ObjectiveThis study aimed to evaluate the impact of Dead Sea climatotherapy (DSC) as a treatment of AD and its influence on the quality of life of these patients. MethodsForty-nine adult patients with AD treated during the years 2009–2010 at the Deutsches Medizinisches Zentrum Medical Center participated in this prospective study. Climatotherapy was administered in accordance with a computer-designed protocol and included gradually increased sun exposure after a sea bath. Severity of AD was evaluated using the Scoring Atopic Dermatitis (SCORAD) index. Patient quality of life was evaluated using Skindex-29. Statistical analysis was performed using a paired t test and Wilcoxon and Mann-Whitney U tests. ResultsAfter treatment, the mean SCORAD value improved by 39 points (P < 0.001). The overall Skindex-29 score improved by a mean value of 33 points (P < 0.001). The pretreatment SCORAD, duration of AD, and maximal daily sun exposure predicted the posttreatment SCORAD values. Pretreatment Skindex-29 and patient age predicted the posttreatment Skindex-29 in a multiple linear regression model. ConclusionsDead Sea climatotherapy provides an effective treatment modality for AD by improving the patient’s skin condition and quality of life.

The validity of the Mathias criteria for establishing occupational causation and aggravation of contact dermatitis

Mathias proposed 7 criteria for establishing occupational causation and aggravation of contact dermatitis (Mathias, J Am Acad Dermatol 1989, 20, 842–848). 4 of the 7 criteria must be positive to conclude occupational dermatitis. In order to evaluate the validity of these criteria, we re‐examined 19 patients (17 male and 2 female) with contact dermatitis, who had given a positive answer to at least 4 of the criteria and had either exchanged their workplace or stopped working. We re‐evaluated them, 2–5 years later, for the presence of contact dermatitis. 14 of 19 patients (74%) reported that their dermatitis had cleared after they had left their previous workplace. Only 5 patients still suffered from dermatitis, 2–5 years later. 3 of these 5 patients could have been exposed to the causative allergens in their new workplace. We conclude that the Mathias criteria are useful to assess occupational contact dermatitis.