Magnus Bruze

European Society of Contact Dermatitis guideline for diagnostic patch testing – recommendations on best practice

The present guideline summarizes all aspects of patch testing for the diagnosis of contact allergy in patients suspected of suffering, or having been suffering, from allergic contact dermatitis or other delayed‐type hypersensitivity skin and mucosal conditions. Sections with brief descriptions and discussions of different pertinent topics are followed by a highlighted short practical recommendation. Topics comprise, after an introduction with important definitions, materials, technique, modifications of epicutaneous testing, individual factors influencing the patch test outcome or necessitating special considerations, children, patients with occupational contact dermatitis and drug eruptions as special groups, patch testing of materials brought in by the patient, adverse effects of patch testing, and the final evaluation and patient counselling based on this judgement. Finally, short reference is made to aspects of (continuing) medical education and to electronic collection of data for epidemiological surveillance.

Monitoring levels of preservative sensitivity in Europe - A 10-year overview (1991-2000)

A 10‐year multicentre analysis of the frequency of sensitivity to common preservatives collected in 16 centres in 11 countries has shown stable but persisting high levels of sensitivity to formaldehyde and 5‐chloro‐2‐methyl‐4‐isothiazolin‐3‐one + 2‐methyl‐4‐isothiazolin‐3‐one (MCI/MI). It has also revealed a significant increase in the level of reactivity to methyldibromoglutaronitrile (MDBGN) from 0.7% in 1991 to 3.5% in 2000. The current high level of sensitivity to MDBGN requires an urgent safety re‐evaluation and risk assessment update along with consideration of immediate lowering of use concentrations, especially in leave‐on products.

Thoughts on sensitizers in a standard patch test series

Patch testing is the predominant method of establishing contact allergy. The present patch test technique is the result of a continuous process of development and improvement since its first application in the late 19th century. The perfect patch test should give no false‐positive and no false‐negative reactions. The ideal patch test should also cause as few adverse reactions as possible, particularly no patch test sensitization. Even though the history and examination of a patient with suspected allergic contact dermatitis will give clues to possible sensitizers, it is not suffcient t to patch test only with initially suspected sensitizers; unsuspected sensitizers used for patch testing frequently turn out to be the real cause of the dermatitis. Fortunately, a small number of substances are considered to account for the majority of delayed hypersensitivity reactions. Therefore, generally 20–25 test preparations consisting of chemically dened compounds, mixes of allergens, and natural and synthetic compounds, are grouped into a standard test series. The requirements to be fullled by a sensitizer in a standard patch test series are discussed in this article. A procedure of investigations is proposed before a sensitizer is included in a standard series.

A toxicologic and dermatologic assessment of cyclic and non-cyclic terpene alcohols when used as fragrance ingredients ☆

University of Missouri (Kansas City), c/o American Dermatology Associates, LLC, 6333 Long Avenue, Third Floor, Shawnee, KS 66216, USA Columbia University Medical Center, Department of Dermatology, 161 Fort Washington Avenue, New York, NY 10032, USA Malmo University Hospital, Department of Occupational and Environmental Dermatology, Sodra Forstadsgatan 101, Entrance 47, Malmo SE-20502, Sweden d Institute for Miliovurdering, Environmental Assessment Institute, Linnesgade 18, 1st Floor, Copenhagen 1361K, Denmark e Technical University of Munich, Institute for Toxicology and Environmental Hygiene, Hohenbachernstrasse 15-17, Freising-Weihenstephan D-85354, Germany Oregon Health Sciences University, Department of Dermatology L468, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA Boston University School of Medicine, Department of Pathology and Laboratory Medicine, 715 Albany Street, L-804, Boston, MA 02118-2526, USA Hospital Cantonal Universitaire, Clinique et Policlinique de Dermatologie, 24, Rue Micheli-du-Crest, Geneve 14 1211, Switzerland Department of Pharmacology, University of Arizona, College of Medicine, 1501 North Campbell Avenue, P.O. Box 245050, Tucson, AZ 85724-5050, USA 3-27-1 Kaigamori, Aoba-ku, Sendai 981-0942, Japan

Selected oxidized fragrance terpenes are common contact allergens

Terpenes are widely used fragrance compounds in fine fragrances, but also in domestic and occupational products. Terpenes oxidize easily due to autoxidation on air exposure. Previous studies have shown that limonene, linalool and caryophyllene are not allergenic themselves but readily form allergenic products on air‐exposure. This study aimed to determine the frequency and characteristics of allergic reactions to selected oxidized fragrance terpenes other than limonene. In total 1511 consecutive dermatitis patients in 6 European dermatology centres were patch tested with oxidized fragrance terpenes and some oxidation fractions and compounds. Oxidized linalool and its hydroperoxide fraction were found to be common contact allergens. Of the patients tested, 1.3% showed a positive reaction to oxidized linalool and 1.1% to the hydroperoxide fraction. About 0.5% of the patients reacted to oxidized caryophyllene whereas 1 patient reacted to oxidized myrcene. Of the patients reacting to the oxidized terpenes, 58% had fragrance‐related contact allergy and/or a positive history for adverse reaction to fragrances. Autoxidation of fragrance terpenes contributes greatly to fragrance allergy, which emphasizes the need of testing with compounds that patients are actually exposed to and not only with the ingredients originally applied in commercial formulations.

Hand eczema severity and quality of life: a cross-sectional, multicentre study of hand eczema patients

Background and Objectives:  Hand eczema is a chronic disease with negative impact on quality of life (QoL). In this study, QoL in hand eczema patients is assessed and related to age, sex, severity, and diagnostic subgroups.

Further important sensitizers in patients sensitive to fragrances - II. Reactivity to essential oils

The aim of this study was to determine the frequency of responses to selected fragrance materials in consecutive patients patch tested in 6 dermatological centres in Europe. 1855 patients were evaluated with the 8% fragrance mix (FM) and 14 other frequently used well‐defined fragrance chemicals (series I). Each patient was classified regarding a history of adverse reactions to fragrances: certain, probable, questionable, none. Reactions to FM occurred in 11.3% of the subjects. The 6 substances with the highest reactivity following FM were Lyral® (2.7%), citral (1.1%), farnesol P (0.5%), citronellol (0.4%), hexyl cinnamic aldehyde (0.3%), and coumarin (0.3%). 41 (2.2%) of the patients reacted only to materials of series I and not to FM. 6.6% of 1855 patients gave a history of adverse reactions to fragrances which was classified as certain. This group reacted to FM only in 41.1%, to series I and FM in 12.0% and to series I only in 7.2%. 74.3% of the 39 patients reacting to both FM and 1 of the materials of series I had any type of positive fragrance history, which was significantly higher in comparison to those with isolated reactions to series I (53.6% of 41), p = 0.04. The study identified further sensitizers relevant for patch testing of patients with contact dermatitis, of which Lyral® is the most important single chemical.

Deodorants on the European market: quantitative chemical analysis of 21 fragrances

Deodorants are one of the most frequently used types of cosmetics and side‐effects from them are common. Recent studies relate perfume allergy to this type of product. 73 deodorants were analyzed by gas chromatography ‐ mass spectrometry for the determination of the contents of 7 well‐known fragrance allergens from the fragrance mix and 14 other commonly used fragrance materials. The deodorants were purchased at retail outlets in 5 European countries. It was found that in general, fragrance mix ingredients were more frequently present in vapo‐ and aerosol sprays than in roll‐on products. The levels of the fragrance mix substances ranged from 0.0001–0.2355%. The products investigated contained cinnamic aldehyde and isoeugenol less frequently (17% and 29% respectively), and eugenol and geraniol most frequently (57% and 76% respectively). The 14 other fragrance materials were found in 40–97% of the deodorants, with hedione and benzyl acetate the most frequently found substances. The concentration of these 14 substances ranged from 0.0001–2.7%. It is concluded that the levels of cinnamic aldehyde and isoeugenol found in the deodorants could prove to be relevant for elicitation of contact dermatitis. No conclusions could be drawn about the other fragrance mix constituents, as threshold levels in sensitized individuals have not been investigated. Furthermore, all of the fragrance materials investigated were frequently found in deodorants and, apart from the fragrance mix ingredients, the extent of problems with sensitization to these fragrance materials is largely unknown.

Hand eczema classification: a cross-sectional, multicentre study of the aetiology and morphology of hand eczema.

Background  Hand eczema is a long‐lasting disease with a high prevalence in the background population. The disease has severe, negative effects on quality of life and sometimes on social status. Epidemiological studies have identified risk factors for onset and prognosis, but treatment of the disease is rarely evidence based, and a classification system for different subdiagnoses of hand eczema is not agreed upon. Randomized controlled trials investigating the treatment of hand eczema are called for. For this, as well as for clinical purposes, a generally accepted classification system for hand eczema is needed.

Individual variation in nickel patch test reactivity

BACKGROUND AND OBJECTIVE Various factors such as hormones, drugs, and ultraviolet (UV) radiation may influence patch test reactions. The aim was to study the individual variation in nickel reactivity, also in relation to the menstrual cycle. METHODS Thirty women allergic to nickel were studied for 7 months with patch tests with a serial dilution of nickel sulfate in water on four different test occasions. The patients belonged to two different eczema groups, one with nickel allergy, atopy, and pompholyx (12 patients); and the other with nickel allergy, but without both atopy and hand eczema. RESULTS None of the patients showed the same patch test reactivity on all four occasions, and the highest individual difference noticed was 250 times for the four test occasions. Furthermore, two of the patients had completely negative test reactions on at least one test occasion. CONCLUSION The variation in nickel reactivity as shown in this article is of great importance and should be kept in mind when a patient has a positive history of allergic contact dermatitis but negative patch test results to nickel.