Halvor Möller

High frequency of contact allergy to gold sodium thiosulfate : an indication of gold allergy ?

When gold sodium thiosulfate was added to the patch test standard series, positive reactions were obtained in 8.6% of 823 consecutive patients with suspect contact allergy. The test reactions were clinically of an allergic type and, in several cases, long‐lasting. There was no correlation with other allergens in the standard series. In a special study on 38 patients with contact allergy to gold sodium thiosulfate, the following principal findings were obtained: positive patch tests to the compound itself in dilute concentration; positive patch tests to potassium dicyanoaurate; negative patch tests to gold sodium thiomalate, sodium thiosulfate, and metallic gold; positive intradermal tests to gold sodium thiomalate. Our findings make gold sodium thiosulfate the 2nd most common contact allergen after nickel sulfate. It is suggested that a positive skin test to gold sodium thiosulfate represents gold allergy.

Nickel allergy and hand eczema

A clinical study was performed in 66 female patients with hand eczema and contact allergy to nickel. They were drawn from a basic material of 165 patients with nickel allergy in which hand eczema occurred in 86 cases (52 %). The hand eczema started at an average age of 32 years and ii had been preceded by a metal hypersensitivity for an average of 6 years. The eczema was found to the chronic with a mean duration up to the time of examination of 8 years. It was associated with secondary eruptions in half of the cases. The hand eczema showed a low degree of relevance with regard to dependance of occupation or vacation, as well as to exacerbation of the dermatitis after a direct contact with nickel‐coated objects. The clinical examination disclosed in 77 % a pompholyx, i.e. a symmetric vesicular eruption mainly located on the palms and volar aspects of fingers, and sides of fingers. The eczema often showed a periodic activity, with about 15 annual eruptions in the pompholyx cases. It is concluded that simple external contact with the metal can hardly explain the most common clinical pattern of the hand eczema in nickel allergy.

Clinical relevance of contact allergy to gold sodium thiosulfate

BACKGROUND In our routinely patch tested patients with dermatitis gold was shown to be the second most common sensitizer. In most patients it was difficult to explain the source of sensitization to gold and to see any clinical relevance. OBJECTIVE Our purpose was to elucidate the clinical relevance of contact allergy to gold sodium thiosulfate. METHODS A questionnaire on gold exposure and gold sensitivity was answered by 156 consecutive patients with dermatitis. In another group of 1056 routinely tested patients data were collected and analyzed regarding factors such as profession, atopy, localization of the dermatitis, and presence of contact allergies. RESULTS Gold allergy was overrepresented in those having dental gold. In persons with contact allergy to gold a dermatitis on the ears, fingers, or eye area was most frequent. CONCLUSION Exposure to gold jewelry and to dental gold may be important in the sensitization and elicitation of dermatitis.

The development and course of test reactions to gold sodium thiosulfate

In our department, gold sodium thiosulfate has become the 2nd most common allergen in routinely patch tested dermatitis patients, with a rate around 10%. Test reactions to this compound often appear late, sometimes so late that active sensitization may be suspected. This study was performed to study the time course of the allergic reaction to gold sodium thiosulfate and to elucidate whether late test reactions mean active sensitization. 10 patients with contact allergy to gold sodium thiosulfate (0.5% pet.) were retested epicutaneously (e.c.) and intracutaneously (i.c.) with dilution series. The clinical course was followed for 2 months with initially short intervals, later more extended. During the entire study, 26 positive e.c, reactions were diagnosed. Within the 1st week, 17 (65%) were recorded, 12 reactions (46% of 26) were noted at the ordinary reading, 3 days after lest application. After 10 days, another 9 reactions (35%) appeared. The patients with the latter reactions also had positive test reactions within the 1st week. After 2 months, 9 reactions remained. Out of 30 i.e. tests applied, 25 became positive within 1 week 19 (76%) of these reactions changed in morphology Prom thin infiltrates to deep nodules. Another 4 nodules appeared in patients with previous negative i.c. tests. All 23 nodules remained after 2 months. E.c. and i.c. test reactions to gold sodium thiosulfate are long‐lasting. Positive patch test reactions emerging after 10 days do not automatically imply active sensitization. To diagnose contact allergy to gold sodium thiosulfate, the ordinary reading at day 3 is insufficient; even reading at 1 week is insufficient and must he supplemented by a reading at 3 weeks. All the i.c. test reactions, however, appeared within 1 week and, in sacral, a dermal nodule was formed.

Contact Allergy to Gold is Correlated to Dental Gold

Questionnaire studies have indicated that patients with dental gold will more frequently have contact allergy to gold. This study aimed at investigating the relationship between contact allergy to gold and the presence and amount of dental gold alloys. A total of 102 patients were referred for patch testing because of suspicion of contact allergy. Patch tests were performed with gold sodium thiosulphate 2% and 5%. The patients underwent an oral clinical and radiological examination. Contact allergy to gold was recorded in 30.4% of the patients, and of these 74.2% had dental gold (p=0.009). A significant correlation was found between the amount of gold surfaces and contact allergy to gold (p=0.008), but there was no statistical relationship to oral lesions. It is concluded that there is a positive relationship between contact allergy to gold and presence and amount of dental gold alloys.

A study on expert reading of patch test reactions: inter-individual accordance

To diagnose allergic or irritant contact dermatitis, a clinically relevant contact allergy has to be demonstrated or ruled out, respectively. Although patch testing has been used for 100 years, it remains the method of choice for diagnosing contact allergy. A disadvantage of patch testing is that reading is subjective, based on inspection and palpation of the test area, implying that the assessment is subject to the readers knowledge and experience. This study was carried out to investigate the accordance in reading patch test reactions between 5 dermatologists. 4 groups, each with 10 patients, participated. Within each group, all 10 were allergic to one and the same sensitizer; nickel, epoxy resin, ethylenediamine, or Kathon CG. The sensitizers were tested in serial dilutions and applied randomly to the back. The tests were read independently by the dermatologists in a blinded fashion. A protocol was used where the dermatologists had to note the presence of the morphological features erythema, infiltration, papules, vesicles, and bullae. In this way, it was possible to allocate the various readings into 4 classification systems, 3 European and one American, although the definition of the various classifications might differ slightly. Based on the readings and classifications, it was possible to calculate the degree of accordance within the 4 systems used. It was also possible to analyze the degree of accordance for the various morphological features. Total accordance for the 5 reading dermatologists for positive and negative test reactions was noted in 36% and 46%, respectively. The 3 European systems require homogenous erythema and infiltration for a reaction to be classified as allergic, while the American system also requires the presence of papules. Therefore, a higher number of allergic reactions (9%) was obtained with the European systems. Between the 4 classification systems, there were statistically significant differences, with the highest number of deviations for the system in which papules had discriminatory significance. When looking at the various morphological features, papules were most difficult to assess, followed by vesicles. Preferably, a classification system should not depend on papules. In conclusion, there was good accordance among the dermatologists in reading patch test reactions, since the 5 dermatologists read 82% of all tests similarly.

The flare-up reactions after systemic provocation in contact allergy to nickel and gold.

In a controlled double‐blind experimental study, patients with contact allergy to nickel or gold were exposed systemically to their contact allergen. Nickel sulfate was given orally, gold sodium thiomalate intramuscularly, and placebo by both routes. Clinical reactions including body temperature were followed and 7 plasma cytokines and acute phase reactants were assayed before and 24 h after provocation. Clinical flare‐up, with reactivation of healing patch tests and/or toxicoderma‐like reactions, was observed in patients receiving their specific allergen. A transient fever was noted in patients allergic to gold when exposed to gold, not in others. There was a significant increase in plasma tumour necrosis factor‐α, soluble tumour necrosis factor receptor 1, inter leukin‐1 receptor antagonist, and neutrophil gelatinase associated lipocalin in patients allergic to gold when exposed to gold allergen. Furthermore, in patients allergic to nickel exposed to nickel allergen there was a highly significant increase in plasma soluble tumour necrosis factor receptor 1. Interferon‐gamma, interleukin‐4, and C‐reactive protein did not increase in any of the patient groups. Clinical reactions during flare‐up in contact allergy are accompanied by release in the blood of several cytokines. This release is not a consequence of a toxic effect or bound to a particular allergen. Instead, the cytokine release should be considered a general phenomenon characteristic of the flare‐up in contact allergy.

Metal sensitivity: positive history but negative test indicates atopy

Among patients with a history of metal sensitivity, 50 were patch‐test‐negative to nickel, cobalt and chromate. 20 of them were further examined epicutaneously and intracutaneously. They were also studied with a clinical diagnostic method for symptoms and signs of atopy. Most patients in this category were found to be atopic.

Dental gold alloys and contact allergy.

Contact allergy to gold as demonstrated by patch testing is very common among patients with eczematous disease and seems to be even more frequent among patients with complaints from the oral cavity. There is a positive correlation between gold allergy and the presence of dental gold. Gold allergy is often found in patients with non‐specific stomatitides as well as in those with lichenoid reactions or with only subjective symptoms from the oral cavity. The therapeutic effect of substituting other dental materials for gold alloys is conspicuous in casuistic reports but less impressive in larger patient materials. The amount of dental gold is correlated qualitatively and quantitatively to the blood level of gold and the effects if any of circulating blood gold are unknown. There is clearly a need for prospective studies in the field and gold sodium thiosulfate is considered an important item in the dental series for patch testing.

Trends and forecasts for standard allergens in a 12‐year patch test material

Results from 12 years of patch testing were statistically analysed to establish changes in the incidence of individual contact allergies. Significant trends were found for y allergens. A marked increase was evident for nickel and cobalt. The analysis made it possible to forecast the future development of separate contact allergies.