Multiple cases of sensitization to an antiseptic containing chlorhexidine digluconate/benzalkonium chloride/benzyl alcohol with different profiles of sensitization in adults and children.

BACKGROUND: An aqueous antiseptic containing "chlorhexidine digluconate/benzalkonium chloride/benzyl alcohol" (CBB) is widely used in France. The only previous documented study dealing with allergic contact dermatitis (ACD) to this antiseptic is one small case series in children. The French Vigilance Network for Dermatology and Allergy (REVIDAL-GERDA) has collected many cases in the last few years. OBJECTIVES: To evaluate the clinical and sensitization profiles of patients diagnosed with ACD to CBB. METHODS: We performed a retrospective study of patients with contact dermatitis to CBB and positive tests to CBB and/or at least one of its components. All patients had to be tested with all components of CBB. RESULTS: A total of 102 patients (71 adults and 31 children) were included. The lesions were extensive in 63% of patients and 55% had delayed time to diagnosis. CBB patch tests were positive in 93.8% of cases. The allergen was identified in 97% of patients, mainly benzyl alcohol in adults (81.7%) and chlorhexidine digluconate in children (54.8%). About 32.4% of the patients were sensitized to several components. CONCLUSION: CBB is a cause of ACD at all ages. The components of the antiseptic should be tested. The sensitization profile seems to be different between adults and children.

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.

The European Standard Series and its additions: are they of any use in 2013?

This study has two purposes:--to know whether the European standard series is still the key reference when it comes to contact dermatitis, i.e., are its components still the most frequently involved allergens in contact dermatitis nowadays?--to assess the results of the European standard series among French and Belgian dermatologists/allergists as, so far, most of them have failed to provide statistical data within the European community of allergists/dermatologists. 18 participants from 2 dermatology and allergy centres in Belgium and 11 centres in France collected their results from 3,073 patients tested in 2011. They assessed the relevance of some tests as well as that of the standard series and additional series to establish an etiological diagnosis of contact dermatitis. These results, together with the history of the European standard series, have shown that some allergens are obsolete and that others should be included in a new standard series for which we are making a few suggestions.

Cosmetovigilance: definition, regulation and use "in practice".

Cosmetovigilance is a recent concept. The term itself has just been indexed. It is a form of health public surveillance with a public health objective; it therefore differs from the surveillance carried out by industrialists, who aim at the safety of the product for commercial purposes, and differs from peer surveillance (Revidal-Gerda), whose purpose is medical. Cosmetovigilance concerns cosmetic products. The 2006 European resolution has laid the ground work for a cosmetovigilance system based on case notifications. As of 2013, the new European regulation requires that serious undesirable effects reported to the competent authority should be transmitted to the competent authorities of the other Member States and to the person responsible for the cosmetic product. Two problems are yet to be solved: causality assessment and reporting categories. Cosmetovigilance systems are genuine means of obtaining information on the safety of cosmetic products and their ingredients. They can be used by Europe to check that new directives ensure a high level of safety. Cosmetovigilance makes it possible to rule out or control potentially hazardous ingredients and can thus set our minds at ease about the products placed on the market.

Self-testing for contact sensitization to hair dyes--scientific considerations and clinical concerns of an industry-led screening programme.

The cosmetic industry producing hair dyes has, for many years, recommended that their consumers perform 'a hair dye allergy self-test' or similar prior to hair dyeing, to identify individuals who are likely to react upon subsequent hair dyeing. This review offers important information on the requirements for correct validation of screening tests, and concludes that, in its present form, the hair dye self-test has severe limitations: (i) it is not a screening test but a diagnostic test; (ii) it has not been validated according to basic criteria defined by scientists; (iii) it has been evaluated in the wrong population group; (iv) skin reactions have been read by dermatologists and not by the targeted group (consumers and hairdressers); (v) hair dyes contain strong and extreme sensitizers that are left on the skin in high concentrations, potentially resulting in active sensitization; and (vi) recommendations and instructions on how to perform the hair dye self-test vary greatly even among products from the same company, again suggesting that the basis for safe use of the test has not been determined. If the use of a hair dye self-test to predict contact sensitization becomes widespread, there is severe risk that a tool has been marketed that may cause morbidity in European consumers.

Patch test concentrations (doses in mg/cm2 ) for the 12 non-mix fragrance substances regulated by European legislation.

BACKGROUND: According to EU legislation, 26 fragrance substance allergens must be labelled on cosmetic products. For 12 of them, the optimal patch test concentration/dose has not been evaluated. OBJECTIVES: To establish the optimal patch test doses in mg/cm2 for the 12 fragrance substances that are not included in fragrance mix I or II in the European baseline patch test series. MATERIALS AND METHODS: Patch testing with the 12 fragrance substances was performed in a stepwise manner encompassing up to five rounds in at least 100 dermatitis patients for each round. Before patch testing, an individual maximum concentration/dose was determined for each fragrance substance. RESULTS: The predetermined maximum patch test concentrations/doses could be tested for all 12 fragrance substances, with no observable adverse reactions being noted. CONCLUSIONS: For each fragrance substance investigated, it is recommended that half of the maximum patch test dose (mg/cm2) be used for aimed and screening patch testing.

The EU Nickel Directive revisited--future steps towards better protection against nickel allergy.

In July 2001, the EU Nickel Directive came into full force to protect European citizens against nickel allergy and dermatitis. Prior to this intervention, Northern European governments had already begun to regulate consumer nickel exposure. According to part 2 of the EU Nickel Directive and the Danish nickel regulation, consumer items intended to be in direct and prolonged contact with the skin were not allowed to release more than 0.5 µg nickel/cm2/week. It was considered unlikely that nickel allergy would disappear altogether as a proportion of individuals reacted below the level defined by the EU Nickel Directive. Despite this, the EU Nickel Directive part 2 was expected to work as an operational limit that would sufficiently protect European consumers against nickel allergy and dermatitis. This review presents the accumulation of epidemiological studies that evaluated the possible effect of this major public health intervention. Also, it evaluates recent exposure assessment studies that have been performed using the dimethyl glyoxime test. It is concluded that the EU Nickel Directive has started to change the epidemiology of nickel allergy in Europe but it should be revisited to better protect consumers and workers since nickel allergy and dermatitis remain very frequent.

Essential oils: renewal of interest and toxicity.

Essential oils are complex mixtures of substances from vegetable matter, the definition of which is based on their method of extraction. They are characterized by their ambivalence, their ambiguity and their disparity: plant families from which essential oils are extracted are numerous; the composition of each essential oil depends not only on the family but also on the part of the plant from which it is extracted, and sometimes on the soil where the plant grows, or even on the time of the harvest. Gas chromatography is therefore necessary to characterize an essential oil. Essential oils can be found in cosmetics, in drugs, and in food. They are natural substances, but natural is not synonymous with harmless. Evaluation of the toxicity of essential oils and European regulation are underway.

Octocrylene, an emerging photoallergen.

BACKGROUND: Octocrylene is a new emerging photoallergen. We report and discuss 50 cases of photoallergic contact dermatitis from octocrylene use and/or positive photopatch test reactions to this UV filter and draw attention to the unexpected association in adults with a history of photoallergic contact dermatitis from ketoprofen. OBSERVATIONS: Patients were divided in 3 groups: group A comprised 11 children; group B, 28 adults with a history of photoallergy from sunscreen products; and group C, 14 adults systematically tested with octocrylene because of a history of photoallergy from ketoprofen. All patients but 3 in group C had positive test reactions to octocrylene. Ten of 11 children in group A and 9 of 28 adults in group B had positive patch test reactions to octocrylene. One child in group A, the other 19 adults in group B, and 11 of 14 adults in group C had positive photopatch test reactions to octocrylene. All adults in group C and 24 of 28 adults in group B had a history of photoallergy from ketoprofen and positive patch test or photopatch test reactions to other allergens that are often positive in patients with photoallergy from ketoprofen, especially fragrance components. CONCLUSIONS: Octocrylene appears to be a strong allergen leading to contact dermatitis in children and mostly photoallergic contact dermatitis in adults with an often-associated history of photoallergy from ketoprofen. Patients with photoallergy from ketoprofen frequently have positive photopatch test reactions to octocrylene. These patients need to be informed of sunscreen products not containing octocrylene, benzophenone-3, or fragrances.

Fragrance allergy: assessing the safety of washed fabrics.

BACKGROUND: Previously, a quantitative risk assessment suggested there was no risk of induction of fragrance allergy from minor residues of fragrance chemicals on washed fabrics. OBJECTIVE: To investigate whether there was any risk of the elicitation of contact allergy from fragrance chemical residues on fabric in individuals who were already sensitized. METHODS: Thirty-six subjects with a positive patch test to isoeugenol (n = 19) or hydroxyisohexyl 3-cyclohexene carboxaldehyde (n = 17) were recruited. Dose-response and fabric patch tests were performed, respectively, with filter paper and a cotton sample loaded with fragrance in ethanol-diethylphthalate (DEP) and applied in a Finn Chamber or a Hill Top Chamber. RESULTS: Only two subjects reacted to an isoeugenol patch test concentration of 0.01% (>20x the estimated likely skin exposure level), none reacted to lower concentrations. Of 36 subjects, 18 reacted to the fabric patch treated with ethanol-DEP vehicle alone and 20 to the fragrance-chemical-treated fabric patch. These were only minor non-specific skin reactions. They were also quite evenly distributed between the two fragrance chemical allergic groups. CONCLUSIONS: On the basis of the examples studied, fragrance chemical residues present on fabric do not appear to present a risk of the elicitation of immediate or delayed allergic skin reactions on individuals already sensitized.

Active sensitization and contact allergy to methyl 2-octynoate.

BACKGROUND: Methyl 2-octynoate is a synthetic fragrance which was first described to have sensitizing properties in 1935. It is one of the 26 fragrances to be labelled on the ingredient list according to current European cosmetics regulation. OBJECTIVES: To report the experience with patch testing with methyl 2-octynoate 1% and 2% in pet. METHODS: 230 eczema patients were consecutively patch tested with 1% methyl 2-octynoate at department of Dermato-allergology Gentofte Hospital, Denmark and 120 eczema patients were consecutively patch tested with 2% M2O in Finn Chambers at the Départment de Dermatologie, CHU Saint Jacques, France. RESULTS: Three cases of active sensitization were observed. 2 (0.87%) of the 230 Danish subjects tested with 1% in pet. and of the 120 French subjects patch tested with 2% in pet. 1 (0.83%). There was no statistical difference in active sensitization between the two groups (P = 0.72). Allergic contact dermatitis was observed in two patients (1.67%) in the French group and none in the Danish group. CONCLUSION: Contact allergy to methyl 2-octynoate was frequently seen when patch testing with 2% in pet. However, active sensitization was also observed, when patch testing with concentrations of 1% and 2% methyl 2-octynoate. The patch test concentration should be below 1% in pet., but a safe concentration remains to be defined.

Hydrolysed wheat proteins present in cosmetics can induce immediate hypersensitivities.

Cosmetics containing hydrolysed wheat proteins (HWP) can induce rare but severe allergic reactions. 9 patients, all females without common wheat allergy, but with contact urticaria to such cosmetics, were studied. 6 of them also experienced generalized urticaria or anaphylaxis to foods containing HWP. All patients had low to moderate levels of immunoglobulin (Ig)E specific of wheat flour (f4) or gluten (f79). Their sensitivity to HWP and their tolerance to unmodified wheat proteins extracted from grains were confirmed using skin tests. Immunoblotting analyses showed that IgE from all patients reacted with almost all HWP tested. Reactions generally occurred with large random peptide aggregates. IgE reacted also with unmodified grain proteins, which contrasted with skin tests results. They reacted always with salt soluble proteins but variably with gluten proteins. No reaction occurred with gliadins in patients without associated immediate hypersensitivity to food containing HWP. These results show the role of hydrolysis on the allergenicity of wheat proteins, both through skin or digestive routes. At least part of the epitopes involved is pre-existing in unmodified wheat proteins. The aggregation of peptide bearing these epitopes and others created by hydrolysis, along with the increased solubility and the route of exposure, are possible factors of the allergenicity of HWP.

Allergic contact dermatitis from shellac in mascara.

We report 6 cases of allergic contact dermatitis of the eyelids due to mascara. Allergy occurred in women aged 17-34 years, between September 1999 and June 2001. The main ingredient responsible for allergy was shellac, which gave positive patch test reactions in 5/5 patients. This resinous substance is mainly used in cosmetics, food and industry. The exact nature of the hapten remains unknown, and its presence and level in shellac can vary with the source and the treatments applied to it. One patient was also sensitized to quaternium-22, a quaternary ammonium compound in the cosmetic. These reports underline the rôle of networks, such as REVIDAL-GERDA, in monitoring the emergence of contact allergens and disseminating such information among the medical community.