Allergic contact dermatitis to phenol-formaldehyde resin at a single tertiary dermatology centre.

BACKGROUND: Phenol-formaldehyde resin 2 (PFR2) has been shown to be a useful marker of contact allergy (CA) to various phenol-formaldehyde resins. These compounds are used in several industries as solids, powders, or semisolid resins, and are known to be sensitizing agents. OBJECTIVES: The aims were to investigate contact allergy to PFR2 in a single tertiary dermatology centre, to examine associated simultaneous allergic reactions, and to identify cases of allergic contact dermatitis (ACD) to PFR2. METHODS: A retrospective study was performed of patients patch tested to PFR2 between 1 January 2003 and 17 June 2020. RESULTS: In all, 337 of 7922 patients were tested to PFR2 and 16 (4.7%) reacted. Of those 16 individuals, six (37.5%) had a relevant reaction (1.8% of total). Simultaneous allergic reactions were noted to colophonium in eight (50.0%) patients, Myroxylon pereirae in five (31.3%), and fragrance mix I (FMI) of three cases (18.8%). CONCLUSION: Contact allergy to PFR2, even in a selected population of patients, is uncommon. However, patients exposed to plastics and glues, or who work with wood products should be routinely patch tested to a plastics and glues series containing PFR2. We recommend that all centres include PFR2 in their plastics and glues series.

Allergic Contact Dermatitis to Dermabond Prineo After Elective Orthopedic Surgery.

The Dermabond Prineo skin closure system (Ethicon, Somerville, New Jersey) is a wound closure device that combines a 2-octyl cyanoacrylate liquid adhesive and a self-adhesive polyester mesh. Although cyanoacrylates traditionally have been associated with low rates of sensitization, allergic contact dermatitis (ACD) to Dermabond products is being increasingly reported after orthopedic surgery. The authors describe the first case series of ACD to Dermabond Prineo where patch testing confirmed the diagnosis in all patients. Six patients who had suspected Dermabond Prineo ACD after lower limb orthopedic surgery were assessed. Of these patients, 5 had itching within 4 days of surgery and rash within 5 days. All 5 of these patients reported previous exposure to Dermabond products. All patients had removal of the adhesive and mesh earlier than planned and were treated with corticosteroids. In addition, 4 patients received systemic antibiotics; however, only 1 had a microbiologically confirmed superficial skin infection. In all patients, the dermatitis resolved within 2 weeks of dressing removal, with no adverse effect on the orthopedic outcome. Patch testing showed positive reactions to Dermabond Prineo glue for all patients. Orthopedic surgeons should be aware of the potential for ACD to Dermabond Prineo, especially among patients with previous exposure to Dermabond products. The authors discuss the risk factors for ACD to Dermabond Prineo in the orthopedic cohort and provide recommendations for prevention and management. [Orthopedics. 2020;43(6):e515-e522.].

Contact allergy and allergic contact dermatitis caused by lavender: A retrospective study from an Australian clinic.

BACKGROUND: Lavender is commonly used in aromatherapy and in a broad range of personal and household products. It has been identified as a contact sensitizer, and has been reported to cause allergic contact dermatitis (ACD). OBJECTIVES: To report our experience with contact allergy and ACD caused by lavender, and to raise awareness of lavender as a potential contact allergen. METHOD: A retrospective database review was performed of patients attending patch testing clinics at the Skin and Cancer Foundation, Victoria, Australia, from January 1, 1993 to December 31, 2017. RESULTS: Among the 2178 patients patch tested with lavender over this period, a total of 58 positive reactions were recorded in 49 individuals, giving a positive patch test prevalence for patients tested with lavender of 2.2%. Twenty-seven patients were diagnosed with ACD. The most common sources of exposure to lavender were personal care products and essential oils. Of the patients with ACD, 74% were tested with lavender absolute, with positive results in 90% of cases. CONCLUSION: Lavender is an uncommon cause of ACD but is important to consider, given the potential for exposure through the use of personal care items and essential oils.

An update of the pathogenesis of frontal fibrosing alopecia: What does the current evidence tell us?

Frontal fibrosing alopecia (FFA) is a primary patterned cicatricial alopecia with a complicated pathogenesis yet to be fully understood. FFA appears to be increasing in incidence worldwide, especially in the last decade. In order to consider current treatment options, we reviewed current evidence for its pathogenesis comprising immune-mediated, genetic, hormonal and environmental factors. Th1-mediated inflammation with collapse of hair follicle immune privilege and bulge epithelial stem cell destruction, peroxisome proliferator-activated receptor gamma (PPAR-γ) depletion and epithelial-mesenchymal transition are key events leading to permanent hair follicle destruction in FFA. Although the vast majority of cases are sporadic, familial reports of FFA implicate genetic or epigenetic mechanisms in its pathogenesis. The frequent onset of FFA in post-menopausal women, similar patterning and co-existence with female pattern hair loss, together with a reportedly good response to 5α-reductase inhibitors suggest a role for sex steroid hormones. The reported increasing incidence invites speculation for, yet unproven, environmental triggers such as sun exposure and topical allergens. More robust research into this unique entity is required to help understand the complexity of the pathogenesis of FFA in order to find satisfactory therapeutic targets for this often distressing condition.

Does clinical testing support the current guidance definition of prolonged contact for nickel allergy?

BACKGROUND: The European Chemical Agency (ECHA) definition of prolonged contact was introduced in 2014 and has not been evaluated clinically. OBJECTIVES: To assess whether nickel-sensitized individuals react on patch testing with high nickel-releasing metal discs for short and repetitive periods. MATERIALS AND METHODS: We patch tested 45 nickel-sensitized individuals double-blind with 2 different types of high nickel-releasing discs for 10, 30 and 60 minutes on 3 occasions over a period of 2 weeks, and for 1 longer period. Discs were tested for nickel release. RESULTS: Nickel release from both discs significantly exceeded the 0.5 µg Ni/cm2 /week limit of the EU REACH nickel restriction. However, only 1 individual tested had a largely dose-dependent allergic reaction. CONCLUSIONS: The majority of nickel-allergic subjects did not react to nickel discs after 2 hours or after repetitive exposures of up to 30 minutes on 3 occasions over a period of 2 weeks. The length of time needed to cause nickel allergic contact dermatitis in most nickel-allergic individuals is longer than the ECHA guidance definition. Longer test times are needed to define the time required to cause dermatitis in most nickel-allergic individuals. As a limitation, the test conditions did not adequately assess real-life factors such as friction, which is relevant for some uses of nickel.

Occupational skin disease among Australian healthcare workers: a retrospective analysis from an occupational dermatology clinic, 1993-2014.

BACKGROUND: Healthcare workers (HCWs) are at risk of developing occupational skin disease (OSD). OBJECTIVES: To ascertain the causes of OSD in Australian HCWs in a tertiary referral clinic. METHODS: A retrospective review was performed of patients assessed at the Occupational Dermatology Clinic in Melbourne from 1993 to 2014. RESULTS: Of 685 HCWs assessed in the clinic over a period of 22 years, 555 (81.0%) were diagnosed with OSD. The most common diagnosis was irritant contact dermatitis (ICD) (79.1%), followed by allergic contact dermatitis (ACD) (49.7%). Natural rubber latex allergy was also relatively frequent (13.0%). The major substances causing ACD were rubber glove chemicals (thiuram mix and tetraethylthiuram disulfide), preservatives (formaldehyde, formaldehyde releasers, and isothiazolinones), excipients in hand cleansers, which are hard-to-avoid weak allergens, and antiseptics. ACD caused by commercial hand cleansers occurred more frequently than ACD caused by alcohol-based hand rubs (ABHRs). Occupational ICD was mostly caused by water/wet work and hand cleansers, and environmental irritants such as heat and sweating. CONCLUSIONS: Understanding the causes of OSD in HCWs is important in order to develop strategies for prevention. We suggest that skin care advice should be incorporated into hand hygiene education. The use of ABHRs should be encouraged, weak allergens in skin cleansers should be substituted, and accelerator-free gloves should be recommended for HCWs with OSD.

The Role of the Skin Barrier in Occupational Skin Diseases.

Occupational skin diseases (OSDs) are the second most common occupational diseases worldwide. Occupational contact dermatitis (OCD) is the most frequent OSD, and comprises irritant contact dermatitis (ICD), allergic contact dermatitis (ACD), contact urticaria and protein contact dermatitis. There are many endogenous and exogenous factors which affect the development of OCD, including age, sex, ethnicity, atopic skin diathesis, certain occupations and environmental factors. One of the most important contributing causes is skin barrier dysfunction. The skin provides a first-line defense from environmental assaults and incorporates physical, chemical and biological protection. Skin barrier disturbance plays a crucial role in various skin diseases such as atopic dermatitis (AD), ichthyosis, ICD and ACD. Genetic factors, such as filaggrin gene (FLG) mutations, and external factors, such as skin irritants interfering with stratum corneum structure and composition, may lead to abnormalities in skin barrier function and increased vulnerability to skin diseases. FLG encodes the cornified envelope protein, filaggrin, which is involved in skin barrier function. FLG mutation is associated with the development of OCD. High-risk occupations for OCD include health care workers, hairdressers and construction workers. There are often multiple contributing causes to OCD, as workers are exposed to both irritants and allergens. AD is also associated with skin barrier disruption and plays an important role in OCD. ICD often precedes and facilitates the development of ACD, with impairment of the skin barrier contributing to the concurrence of ICD and ACD in many workers with OCD.

Occupational skin disease in Victoria, Australia.

OBJECTIVES: To describe the characteristics of patients with occupational skin disease (OSD) in a tertiary referral clinic in Victoria, Australia. METHODS: A retrospective review was conducted of records from patients seen at the Occupational Dermatology Clinic in Melbourne, Australia between 1 January 1993 and 31 December 2010. RESULTS: Of the 2894 people assessed in the clinic during the 18-year period, 44% were women and 56% were men. In all, 2177 (75%) were diagnosed with occupational skin disease (OSD). Of the patients with a work-related skin condition, 45% (n = 979) were considered to be atopic. The most common diagnosis in those with OSD was irritant contact dermatitis (ICD) (44%), followed by allergic contact dermatitis (33%) and endogenous eczema (11%). Women were significantly more likely to have soaps and detergents (P < 0.001) and water/wet work (P < 0.001) as causes of their ICD than men. Men were significantly more likely to have oils and coolants (P < 0.001) and solvent exposures (P < 0.001) as causes of their ICD. Occupational groups with the highest incidence of OSD were the hair and beauty professions (70 per 100 000), followed by machine and plant operators (38 per 100 000) and health-care workers (21 per 100 000). CONCLUSION: We confirm the importance of occupational contact dermatitis as the most common cause of OSD, with ICD being the most common diagnosis. There are differences in the causes of ICD between our group of male and female workers. For the first time in Australia, rates of OSD in certain industries have been calculated.

Tobacco smoking and hand eczema - is there an association?

BACKGROUND: Numerous risk factors have been suggested for hand eczema. This systematic review evaluates the association between tobacco smoking and hand eczema. OBJECTIVE: To review the literature systematically on the association between smoking and hand eczema. METHODS: The PubMed and EMBASE databases were searched up to 27 January 2015 for articles on the association between tobacco smoking and hand eczema, including human studies in English and German only. Experimental studies, studies on tobacco allergy, case reports, reviews and studies on second-hand smoking were excluded. RESULTS: Twenty articles were included. Among studies in occupational settings, three of seven found a statistically significant positive association between tobacco smoking and hand eczema prevalence rate, as did four of eight population-based studies. The association was stronger for studies in occupational settings than for population-based studies. No studies reported tobacco to be a clear protective factor for hand eczema. Two of five studies regarding severity found a positive association between smoking and hand eczema severity. CONCLUSION: Overall, the data indicate that smoking may cause an increased frequency of hand eczema, particularly in high-risk occupations. However, data from studies controlling for other risk factors are conflicting, and few prospective studies are available. Studies controlling for other risk factors are needed, and information regarding the diagnosis of subclasses of hand eczema, as well as severity, may be important.

Occupational allergic contact dermatitis to chromium from cement: Estimating the size of the problem in Australia.

BACKGROUND: Allergic contact dermatitis (ACD) caused by chromium in cement is a significant occupational hazard. However, legislation in Europe over the past two decades to reduce the concentration of chromium in cement to <2 ppm through the addition of ferrous sulphate to cement, has seen a significant decrease in the incidence of chromium allergy. No such legislation exists in Australia. METHODS: A retrospective analysis of results from the Patchcams database of patients attending the Occupational Dermatology Clinic at the Skin & Cancer Foundation, Melbourne, who were patch tested for chromium between 1 January 1993 to 31 December 2013, was conducted. RESULTS: Our review revealed that there has not been any significant change in the number of cases of ACD to chromium attributed to sensitisation through cement. Based on our data, we estimate that a minimum of 24 cases of chromium occupational ACD (OACD) from cement is found in Australia yearly, causing considerable morbidity, often associated with an inability to work, costly workers' compensation claims and sometimes the development of the disabling condition, persistent post-occupational dermatitis. CONCLUSION: These findings highlight the need for high-level discussions about adopting European legislation in Australia in order to reduce the likelihood of developing chromium OACD from cement.

Allergic contact dermatitis to indium in jewellery: diagnosis made possible through the use of the Contact Allergen Bank Australia.

We report a case of a 39-year-old woman from Adelaide who developed allergic contact dermatitis to the rare allergen indium in her ring. The allergen was sourced for patch testing using the Contact Allergen Bank Australia (CABA), based at the Skin and Cancer Foundation in Melbourne, and posted to Adelaide. This case illustrates the usefulness of CABA in facilitating patch testing throughout Australia, especially when rare allergens are involved.

Allergic contact stomatitis to dodecyl gallate? A review of the relevance of positive patch test results to gallates.

Gallic acid esters or gallates are antioxidants used as preservatives in food and cosmetics. Few cases of gallates causing allergic contact dermatitis (ACD) have been reported in the literature. We present a case report of a 42-year-old beauty therapist who presented with a swollen tongue. Patch testing was positive to dodecyl gallate, commonly reported as being present in edible oil and oily foods such as margarine. Our patient avoided foods presumed to contain gallates and at the 6-week review reported a substantial improvement in her tongue symptoms. We reviewed our database and found 16 (7%) definitely or possibly relevant reactions to dodecyl gallate, seven (15%) definitely or possibly relevant reactions to propyl gallate and six (3%) definitely or possibly relevant reactions to octyl gallate. Most reactions were attributed to margarine, moisturising cream and lipstick. These products are often mentioned in the literature as containing gallates; however, ingredient labelling and discussions with manufacturers made it difficult to establish whether they are currently present in foods. Ascertaining relevance for these reactions is not always possible.

Allergic contact dermatitis from methyldibromo glutaronitrile in a sanitary pad and review of Australian clinic data.

Methyldibromo glutaronitrile (MDBGN) has rarely been reported as an allergen in adhesives but is recognized as a common allergen in skin care products in Europe. It has been banned for use in leave-on products by the European Union. In this study, we present a case with an unusual source of this common allergen and review all cases of allergy to MDBGN from our clinics over a 12-year period. A 49-year-old nurse presented with dermatitis affecting the vulva caused by MDBGN present in her sanitary pad. All other cases of allergy to MDBGN in patients attending the occupational dermatology or contact dermatitis clinics at the Skin and Cancer Foundation, Victoria, between January 1993 and December 2004, were reviewed. Patch testing was positive to her sanitary pad, the adhesive and MDBGN, which were used as a biocide in the pad adhesive. Only 20 cases of allergy to MDBGN have been diagnosed in 2837 patients tested during this period (0.7%). To conclude, this study highlights the importance of considering allergic contact dermatitis in the differential diagnosis of vulval rashes and the emergence of MDBGN as an important sensitizer. However, our review suggests that MDBGN remains an infrequent cause of allergy in Australia.