Shedding a light on the importance of photopatch testing: A 12-year experience in a dermatology unit.

BACKGROUND: Photopatch testing has been standardized for diagnosing photoallergic contact dermatitis but is still infrequently used. OBJECTIVES: To characterize photopatch test (PPT) results and their clinical relevance. METHODS: We collected retrospective data from patients photopatch tested in our Dermatology Unit (2010-2021), using the European PPT 'baseline' series, other allergens, and patient's own products, when appropriate. RESULTS: Out of 223 patients, 75 patients (33.6%) were reactive with 124 positive PPT reactions, considered relevant in 56/223 patients (25.1%) and in 72/124 reactions (58.1%). Most reactions were caused by topical drugs (n = 33; 45.8%), such as ketoprofen or promethazine, and 7 (9.8%) by systemic drugs, such as hydrochlorothiazide and fenofibrate. 'Classical' ultraviolet filters were responsible for six positive PPT reactions whereas there was only three relevant PPT to the 'newer' UV filters. Patients' sunscreens/cosmetics or plant extracts caused 10 positive PPT each. Additional patch test reactions were observed, mostly to Tinosorb® M. CONCLUSION: Contrary to the trend in ACD, most positive PPT reactions were caused by topical drugs, outweighing ultraviolet filters and cosmetics. We stress the low reactivity to the 'newer' UV filters included in the PPT series. PPT was occasionally positive in systemic drug photosensitivity, but overall PPT reactivity was low.

Allergic contact dermatitis to Compositae: An Australian case series.

BACKGROUND: Allergic contact dermatitis (ACD) to Compositae is caused by sensitisation to sesquiterpene lactones (SQLs) and subsequent exposure can occur from direct handling or from airborne transmission. Plants from the Compositae family are ubiquitous globally and their plant extracts are also used in various products. OBJECTIVES: Investigation of contact allergy (CA) and allergic contact dermatitis (ACD) to Compositae at a single dermatology centre. METHODS: A retrospective case review was performed on patients undergoing patch testing to Compositae between January 2011 and December 2020 in Melbourne, Australia. RESULTS: Of 3679 patients, 44 (1.2%) patch tested positive to Compositae and 19 (43.2%) reactions were deemed relevant. Thirteen cases (68.4%) were from direct contact with Compositae plants, mostly in gardeners. Six cases (31.6%) were from personal products and all these patients were female. Involvement of the face was significant (p = 0.007). Simultaneous allergic reactions included SQL mix in eight (42.1%), fragrance mix in seven (36.8%), potassium dichromate in three (15.8%) and colophonium in two (10.5%) cases. CONCLUSION: Contact with Compositae from gardening contributed most cases of ACD; however, personal products accounted almost one-third of cases. Treatment options remain limited and avoidance is the most important aspect of management.

Spreading Allergic Contact Dermatitis to Tea Tree Oil in an Over-the-Counter Product Applied on a Wart.

Tea tree oil is an essential oil obtained by distillation from the leaves and terminal branchlets of Melaleuca alternifolia and is now present in numerous products for body care and self-medication. We report a case of allergic contact dermatitis to tea tree oil in a young man who was applying a lotion containing tea tree oil on a wart localized on the plantar aspect of the right big toe, which had previously been treated with cryotherapy. He developed a severe eczematous eruption on the right foot and the right leg, with subsequent id reactions affecting the right thigh, the contralateral lower limb, the trunk and the upper limbs. The lotion was discontinued, and the dermatitis resolved after topical corticosteroid therapy. Patch testing with the aforementioned lotion 10% pet. and oxidized tea tree oil 5% pet. identified tea tree oil as the culprit agent of the dermatitis. This case report confirms that products made of natural ingredients, often perceived to be harmless, can cause allergic reactions.

Shoe Allergens: A Retrospective Analysis of Cross-sectional Data From the North American Contact Dermatitis Group, 2005-2018.

BACKGROUND: Shoe contact allergy can be difficult to diagnose and manage. OBJECTIVE: The aim of the study was to characterize demographics, clinical characteristics, patch test results, and occupational data for the North American Contact Dermatitis Group patients with shoe contact allergy. METHODS: This is a retrospective study of 33,661 patients, patch tested from 2005 to 2018, with a shoe source, foot as 1 of 3 sites of dermatitis, and final primary diagnosis of allergic contact dermatitis. RESULTS: Three hundred fifty-two patients met the inclusion criteria. They were more likely to be male (odds ratio = 3.36, confidence interval = 2.71-4.17) and less likely to be older than 40 years (odds ratio = 0.49, confidence interval = 0.40-0.61) compared with others with positive patch test reactions. The most common relevant North American Contact Dermatitis Group screening allergens were potassium dichromate (29.8%), p-tert-butylphenol formaldehyde resin (20.1%), thiuram mix (13.3%), mixed dialkyl thioureas (12.6%), and carba mix (12%). A total of 29.8% (105/352) had positive patch test reactions to supplemental allergens, and 12.2% (43/352) only had reactions to supplemental allergens. CONCLUSIONS: Shoe contact allergy was more common in younger and male patients. Potassium dichromate and p-tert-butylphenol formaldehyde resin were the top shoe allergens. Testing supplemental allergens, personal care products, and shoe components should be part of a comprehensive evaluation of suspected shoe contact allergy.

Patch testing to plants: sensitisation associated with exposure to plants, essential oils and botanicals in cosmetics.

BACKGROUND: Contact allergy to plants, particularly Compositae, presents with dermatitis and is diagnosed with skin patch testing. Sesquiterpene lactone mix is a common screening allergen for plant allergy. The rate of plant allergen sensitisation in New Zealand, which is affected by local horticultural factors, has not previously been documented. AIMS: To investigate the rate of plant allergen sensitisation in New Zealand's regional population, characterise common allergens and reassess appropriate allergens for patch testing. METHODS: Retrospective analysis of patient demographics and patch-test results over an eight-year period (2012 to 2020) was performed at a tertiary patch-test clinic in Auckland, New Zealand. RESULTS: 820 patients completed patch testing. There was a 12.9% sensitivity rate (a positive reaction on patch testing) to at least one plant allergen and a 6.2% plant allergy rate (positive reaction of current relevance). The most frequent positive reactions were Myroxylon pereirae (n=38), colophonium (n=35) and sesquiterpene lactone mix (n=14). Of patients with a plant allergy (n=51), the allergy source was a botanical in a cosmetic product in 27 cases (52.9%), a plant in ten (19.6%) and an essential oil in two (3.9%). CONCLUSIONS: Reactions to plant allergens were related to botanicals in cosmetics and creams, plants and essential oils. Rates of plant sensitisation in our cohort are comparable with international data.

Diagnosis and Management of Dermatitis, Including Atopic, Contact, and Hand Eczemas.

This is a comprehensive and current guide for the diagnosis, differential diagnosis, treatment, and management of eczematous dermatitis, with a focus on atopic dermatitis, irritant and allergic contact dermatitis, hand dermatitis including recurrent vesicular and hyperkeratotic types, asteatotic dermatitis, and nummular or discoid dermatitis. Diagnostic options highlighted are clinical history, physical examination, and patch testing. Therapeutic options highlighted are moisturizers, topical corticosteroids, topical calcineurin inhibitors, crisaborole, phototherapy, and systemic medications including biologics.

Expanding Patch Testing Beyond the Baseline Series: Usefulness of Customized Antimicrobials, Vehicles, and Cosmetics Series.

BACKGROUND: Testing cosmetics and their ingredients is essential to avoid missing relevant allergens and to monitor fluctuating incidence of hypersensitivity. OBJECTIVE: The aim of this study was to review the usefulness of patch testing with a customized antimicrobials, vehicles, and cosmetics (AVC) series over 15 years at a single Canadian site. METHODS: Between January 1, 2005, and December 31, 2019, patients suspected of having cosmetics allergy were patch tested with a 40-allergen AVC series in addition to the North American Contact Dermatitis Group standard screening series. We reviewed the patch test results of 2868 patients. RESULTS: We consecutively patch tested with the baseline series 6103 patients, of which 2868 (47%) were also tested with the AVC series. Of 53 different allergens that were tested at some point, 26 remained in the series throughout the 15-year span. The most common positive allergens were thimerosal (4.52%), polyvidone-iodine (2.25%), propolis (2.06%), sodium metabisulfite (1.94%), dodecyl gallate (1.53%), carmine (1.10%), lauryl glucoside (1.01%), sandalwood oil (0.7%), and tert-butylhydroquinone (0.7%). CONCLUSIONS: Although the expansion of the North American Contact Dermatitis Group standard screening series has decreased the yield from the AVC series from 21.1% to 13.9%, it still remains a useful adjunct for patients suspected of having cosmetics or disinfectants allergy.

Increase in concentration of patch test allergen reduces patch test occlusion time to 12 hours without affecting patch test reactivity in patients with parthenium dermatitis.

BACKGROUND: Patch testing is the standard method to diagnose contact allergy. Patches are applied for 48 hours, which is inconvenient to patients in tropical weather. Therefore, we evaluated different patch test occlusion times with increased concentrations of an allergen to determine if occlusion time can be reduced without compromising patch test reactivity. METHODS: Patch test positive patients with parthenium dermatitis were enrolled and patch tested using five different concentrations (10%, 4%, 2%, 1%, and 0.5%) of parthenium extract. The patches were applied in triplicate. The first set was removed after 12 hours, whereas the second and third sets were removed after 24 and 48 hours, respectively. Readings were performed at 24, 48, and 96 hours. RESULTS: Fifty patients with parthenium dermatitis were included. The positive patch test reaction rates were comparable in all three sets at 24- and 48-hour readings irrespective of the occlusion time. All were positive, with 10%, 4%, and 2% concentrations at 96-hour reading with an occlusion time of 12 hours. CONCLUSION: An occlusion time of 12 hours seems adequate to elicit positive patch test reaction at a 96-hour reading if the concentration of patch test allergen can be increased, that is, from 1% to 2% in these patients.

Natural ingredients in cosmetic products-A suggestion for a screening series for skin allergy.

BACKGROUND: Naturally derived cosmetic product ingredients of both plant and animal origin are being included increasingly in product formulations in order to cater to consumer preferences. They may be an overlooked cause of reactions to cosmetic products in some patients with dermatitis. OBJECTIVES: To identify naturally derived cosmetic product ingredients with allergenic potential (type I and type IV) and propose a cosmetic screening test series. METHODS: The study was conducted in two steps. The first step was a market survey using a nonprofit application helping consumers avoid problematic substances in cosmetic products. The application contained 10 067 cosmetic products that were label checked for naturally derived cosmetic product ingredients. The second step was a literature search to examine how frequently the naturally derived ingredients were described and related to allergic reactions in cosmetics or other topically administered products. RESULTS: We identified 121 different naturally derived cosmetic product ingredients that were included in at least 30 cosmetic products. In total, 22 ingredients were selected for a screening test series. CONCLUSIONS: We propose a supplemental patch test and a prick test screening series with naturally derived cosmetic product ingredients for patients with skin reactions to cosmetic products, aiming to identify a cause in more patients than is currently possible.

Fragrant and sticky allergens from the pinewood: Cohabiting and coreacting.

BACKGROUND: Tree moss (Pseudevernia furfuracea [L.] Zopf.), a lichen growing on conifers, is a frequent fragrance sensitizer. Previous studies have shown two subgroups of tree moss-allergic patients: a group sensitized to common allergens of tree and oak moss (Evernia prunastri), and another group sensitized to colophonium-derived allergens, which may contaminate tree moss extract. OBJECTIVES: To report the results of including tree moss extract in the baseline series and discuss the clinical implications. METHODS: Tree moss extract was included in the baseline series and sensitized patients were assessed for concomitant allergy to colophonium and oak moss, and the relevance of these reactions was analyzed. RESULTS: Altogether, 22 of 632 patients (3.5%) had positive reactions to tree moss. Eight patients were sensitized to tree moss only (among fragrance allergens) and 75% had relevant reactions to colophonium. Fourteen patients were sensitized to other fragrance allergens as well and 28.5% had relevant colophonium reactions. CONCLUSIONS: The prevalence of positive tree moss reactions is high enough to justify its inclusion in the baseline series. If tree moss is not included, patients with positive colophonium reactions should be informed of possible (false) cross-reactivity to tree moss to avoid this labeled fragrance allergen.

Contact sensitization to plants of the Compositae family: Data of the Information Network of Departments of Dermatology (IVDK) from 2007 to 2016.

BACKGROUND: The Compositae plant family includes many thousands of species, making it one of the most widespread group of plants worldwide. Sensitization to Compositae allergens may occur in private or in occupational settings. OBJECTIVES: To monitor the current spectrum of sensitization to Compositae allergens, especially in cooks and florists. METHODS: We retrospectively analysed patch test results obtained with two Compositae mixes (CMs) (CM I and CM II; switch in October 2011), their individual components, and sesquiterpene lactone (SL) mix in 1492 cooks, 851 florists, and a control group (118 358 other patients) registered in the IVDK, 2007 to 2016. RESULTS: Florists reacted significantly more frequently to CM I and II (CM I, 8.7%; CM II, 10.6%) than did cooks (CM I, 2.1%; CM II, 0.8%) and controls (CM I, 1.3%; CM II, 1.2%). Additional testing with SL mix detected 14.3% more sensitizations than CM I or CM II alone. CONCLUSIONS: Florists are at considerable risk of sensitization to Compositae allergens. Patch testing with both CM and SL mix is recommended.

Photo-patch and patch tests in patients with dermatitis over the photo-exposed areas: A study of 101 cases from a tertiary care centre in India.

BACKGROUND: Many patients with dermatitis over photo-exposed body areas are positive to many contact allergens and have a pre-existing allergic contact dermatitis. METHODS: This study included patients who presented to a tertiary centre in India with dermatitis on photo-exposed body areas suspected of chronic actinic dermatitis. Their detailed histories were recorded and cutaneous and systemic examinations were performed. Patch testing was done in all the patients and photo-patch testing was carried out in 86 patients. RESULTS: Altogether 101 patients were included (69 males, 32 females). The most common presentation was lichenified hyperpigmented plaques on the photo-exposed sites. Photosensitivity was recorded in 64 (63%) patients and summer exacerbation in 52 (52%). Exposure to the Parthenium hysterophorus weed was recorded in 70 (69%) patients, 27 (26.7%) had a history of hair dye application and 20 (20%) had a history of atopy. Photo-patch test was positive in 11 (12.8%) patients and patch testing was positive in 71 (70%). Parthenium hysterophorus was the most common allergen implicated and was positive in three (4%) photo-patch and 52 (52%) patch tests. Other positive photo-patch test allergens were perfume mix, balsam of Peru, thiuram mix, Compositae mix and promethazine hydrochloride. Other common patch test allergens were parthenolide, colophony, fragrance mix and p-phenylenediamine (PPD) base. CONCLUSION: In the Indian population parthenium and perfume mix are the most common photoallergens in patients with dermatitis over photo-exposed areas, while parthenium, colophony, fragrance mix and PPD are the common positive allergens.

Allergenic sesquiterpene lactones from cushion bush (Leucophyta brownii Cass.): new and old sensitizers in a shrub-turned-a-pot plant.

BACKGROUND: The Australian cushion bush (Leucophyta brownii) of the Compositae family of plants has become a popular pot and container plant. The plant produces the sesquiterpene lactone allergen calocephalin. OBJECTIVES: To assess the sensitizing potential of sesquiterpene lactones from cushion bush. PATIENTS/MATERIALS/METHODS: Eleven Compositae-sensitive patients were patch tested with seven sesquiterpene lactones isolated from cushion bush. RESULTS: Six of seven sesquiterpene lactones elicited positive reactions in 4 of 11 patients. CONCLUSIONS: The well-known sesquiterpene lactone pseudoivalin and its derivative pseudoivalin acetate, as well as calocephalin and tomentosin, were confirmed to be sensitizers, whereas leucophytalin A and 4α-hydroxy-5αH,10αH-1,11(13)-guaidien-8ß,12-olide were shown to be allergenic for the first time. The patch test reaction patterns seem to follow the chemical patterns, which may eventually make it possible to trace primary sensitizers and advise patients more precisely.

[Hypersensitivity reactions to implantable cardiac pacemakers and defibrillators]. / Unverträglichkeitsreaktionen auf implantierbare Herzschrittmacher und Defibrillatoren.

Nowadays, for modern electrotherapy of cardiac arrhythmias different pacemaker systems are used. Antibradycardia pacing systems (e. g. single-chamber, two-chamber, three-chamber systems, frequency-adapted pacemaker) can be distinguished from antitachycardia pacing systems like implantable or portable cardioverter defibrillators and combined antibradycardia/antitachycardia systems. Cutaneous reactions overlying a pacemaker or defibrillator are often termed "pacemaker dermatitis". In terms of the differential diagnostic workup, these cutaneous reactions can have various causes. After exclusion of infection by analyzing clinical and laboratory-chemical results, "pressure dermatitis" or the often clinically asymptomatic "reticular telangiectatic erythema" (synonym "postimplantation erythema") must be considered. Histological examination of the affected skin can contribute to the diagnosis. In case of suspected contact hypersensitivity to implant material, allergological exploration should be realized. In addition to patch testing with commercially available contact allergens, product-related material metal alloy discs are often available from the pacemaker manufacturer for epicutaneous testing. Due to the lack of additional benefit compared to standardized patch testing, a clear recommendation for such metal alloy discs cannot be given. In selected cases of suspected hypersensitivity reaction, sensitization can eventually be analyzed by the lymphocyte transformation test. Positive reactions must always be critically interpreted taking into consideration the corresponding clinical signs. Depending on the cause, cutaneous reactions are occasionally self-limiting. In many cases, however, removal of the pacemaker is inevitable.

[Diagnostic workup of fragrance allergy]. / Diagnostik der Duftstoffallergie.

The diagnostic workup of contact allergy to fragrances must not be limited to patch testing with the two well-established fragrance mixes. False-positive reactions to these mixes occur in up to 50 % of the patch tested patients. For the diagnostic work-up of positive reactions, and in cases of suspected fragrance allergy, patch testing with the single mix components and additional fragrances is mandatory. Frequently sensitizing fragrance materials are the 14 components of the two fragrance mixes and tree moss (Evernia furfuracea), ylang ylang oil (I + II; Cananga odorata), lemongrass oil (Cymbopogon schoenanthus), sandalwood oil (Santalum album), jasmine absolute (Jasminum spp.), and, less frequently, clove oil (Eugenia caryophyllus), cedarwood oil (Cedrus atlantica/deodara, Juniperus virginiana), Neroli oil (Citrus aurantium amara flower oil), salicylaldehyde, narcissus absolute (Narcissus spp.), and patchouli oil (Pogostemon cablin).