Comorbid Scenarios in Contact Dermatitis: Atopic Dermatitis, Irritant Dermatitis, and Extremes of Age.

Contact dermatitis (allergic and irritant) occurs when the skin encounters haptens that elicit a T cell-mediated hypersensitivity reaction (allergic) or a nonimmunologic, toxic reaction (irritant). Patch testing is the reference standard for diagnosing allergic contact dermatitis (ACD), although positive results are not always relevant. Therefore, the definitive diagnosis of ACD requires an astute clinician able to connect the results of patch testing appropriately with the clinical history and the cutaneous examination findings. Comorbid conditions such as atopic dermatitis can confound the accurate diagnosis of ACD because of the similarities in clinical presentation. Furthermore, both extremes of age can further challenge the diagnostic specificity of ACD owing to the maturing immune system and the space limitations present when the very young are patch tested. The goal of this Continuing Medical Education article is to discuss the challenges of diagnosing ACD in patients with unique comorbidities such as atopic dermatitis, given the morphologic similarities, and when to patch test these patients. Diagnosis of ACD will also be discussed in very young patients with a focus on patch test allergen selection despite the limited geographic space. The most common allergens reported in very young and old patients will also be discussed.

Diagnosing contact dermatitis using machine learning: A review.

BACKGROUND: Machine learning (ML) offers an opportunity in contact dermatitis (CD) research, where with full clinical picture, may support diagnosis and patch test accuracy. OBJECTIVE: This review aims to summarise the existing literature on how ML can be applied to CD in its entirety. METHODS: Embase, Medline, IEEE Xplore, and ACM Digital Library were searched from inception to February 7, 2024, for primary literature reporting on ML models in CD. RESULTS: 7834 articles were identified in the search, with 110 moving to full-text review, and six articles included. Two used ML to identify key biomarkers to help distinguish between allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD), three used image data to distinguish between ACD and ICD, and one used clinical and demographical data to predict the risk of positive patch tests. All studies used supervision in their ML model training with a total of 49 704 patients across all data sets. There was sparse reporting of the accuracy of these models. CONCLUSIONS: Although the available research is still limited, there is evidence to suggest that ML has potential to support diagnostic outcomes in a clinical setting. Further research on the use of ML in clinical practice is recommended.

Beyond Avoidance: Advanced Therapies for Contact Dermatitis.

Contact dermatitis (CD) is a common and burdensome condition divided into irritant contact dermatitis and allergic contact dermatitis. Treatment relies on accurate diagnosis and identification of the trigger, because definitive treatment is irritant or allergen avoidance. However, avoidance is not always possible, such as when the patient is reacting to a necessary medical device, when the trigger is integral to the patient's occupation, and when avoidance is practically untenable. In these cases, treatment is particularly challenging, especially because the literature on treatments in this clinical scenario is limited. In addition, CD has a complex pathophysiology that varies according to the trigger type, leading to variable treatment efficacy. This article reviews the current literature on treatments for CD with a focus on treatments when trigger avoidance is not feasible.

Differential diagnosis of contact dermatitis: A practical-approach review by the EADV Task Force on contact dermatitis.

The diagnosis of eczema ('dermatitis') is mostly clinical and depends on the clinical history and exploratory objective findings (primary lesions, patterns). Contact dermatitis remains as an important condition in the group of eczematous disorders, with important socioeconomic and occupational relevance. Although irritant and allergic contact dermatitis have a different pathogenesis, both are characterized by a rather typical morphology, are triggered by external factors and tend to occur primarily in the area of contact with the exogenous agent. In addition, allergic and irritant dermatitis may also co-exist. The importance of diagnosing contact dermatitis, especially when allergic in nature, is both due to the possibility of avoiding the trigger, and due to its role in aggravating other skin conditions. Nevertheless, the heterogeneity of clinical presentations in daily practice may pose an important challenge for the suspicion and correct diagnosis of contact dermatitis. Furthermore, other conditions, with different pathogenesis and treatment, may clinically simulate contact dermatitis. The Task Force aims to conduct a review of the unifying clinical features of contact dermatitis and characterize its main clinical phenotypes, and its simulators, in order to contribute to an early suspicion or recognition of contact dermatitis and enable a correct differential diagnosis.

Gene profiling in active dermatitis lesions strengthens the diagnosis of allergic contact dermatitis.

BACKGROUND: Distinguishing between allergic and nonallergic forms of Contact Dermatitis (CD) is challenging and requires investigations based on patch-testing. Early detection of allergy biomarkers in active CD lesions could refine and simplify the management of CD patients. OBJECTIVE: To characterize the molecular signatures of active CD lesions. METHODS: We studied the expression of 12 allergy biomarkers by qRT-PCR in active lesions of 38 CD patients. Allergic CD (ACD) was diagnosed based on patch test (PT) results and exposure assessment. Molecular signatures of active lesions, as well as positive PT reactions, were compared with those of reference chemical allergens and irritants. RESULTS: Nineteen of the 38 CD patients reacted positively upon patch-testing and exposure assessment confirmed ACD diagnosis for 17 of them. Gene profiling of active CD lesions revealed 2 distinct molecular patterns: patients harboring signatures similar to reference allergens (n = 23) or irritants (n = 15). Among the 23 patients with an "allergy signature," we found the 17 patients with confirmed ACD, while no culprit allergen was identified for the 6 other patients. Interestingly, the 15 patients without biomarker induction had negative PT, suggesting that they developed nonallergic CD reactions. CONCLUSION: Molecular signatures from active skin lesions may help to stratify CD patients and predict those suffering from ACD.

Fibreglass dermatitis: diagnostic challenges and occupational interventions.

Fibreglass dermatitis is a common occupationally acquired irritant contact dermatitis, where small spicules of fibreglass lodging in the stratum corneum result in mechanical irritation. We present two patients, an air-conditioning ducting worker and an injection moulding machine operator, who both presented with generalized pruritus. In the first case, polarized microscopy of a skin biopsy specimen demonstrated rare small spicules, with a diameter of 1 µm, lodged in the stratum corneum. In the second case, skin tape stripping demonstrated fibreglass particles, not found on skin biopsy. Proper work practices, personal hygiene and use of impervious barrier materials were recommended. The first patient did not return for follow-up, and the second patient's dermatitis resolved after handling of fibreglass-containing material was eliminated from his job scope. In conclusion, we present two cases of fibreglass dermatitis to illustrate the challenges in diagnosis and highlight strategies for prevention.

Hazard identification and the prevalence of occupational skin disease in Indonesian Batik workers.

Batik, a resist-dyeing technique to decorate a special cotton fabric, has been practiced for centuries in Indonesia. Unfortunately, as an informal enterprise, batik industry activities lack work safety and health regulations. This study aimed to identify potential health hazards, including inventorying the chemicals to which the workers are exposed, the PPE profile, and investigating the prevalence of occupational skin diseases (OSD) in the batik industry. A cross-sectional study and an inventory of exposure to the chemicals were done in traditional batik workplaces in 5 districts in Yogyakarta province, Indonesia. The chemicals were classified as potential sensitizers/irritants, and the workers were examined and interviewed using the Nordic Occupational Skin Questionnaire-2002/LONG. Of 222 traditional batik workers, OSD were diagnosed in 61 (27.5%) workers, with occupational contact dermatitis was the most common OSD encountered (n = 23/61; 37.7%) (allergic contact dermatitis n = 7/23; irritant contact dermatitis n = 16/23). A smaller portion of other OSD was also encountered including callus, miliaria, and nail disorder (9%, 6.3%, and 5.9%, respectively). During each step of the traditional batik manufacturing process, the workers are exposed to substances that act as irritants and/or as potential contact allergens. However, only one-fourth of the workers used PPE regularly, particularly during the coloring process and wax removal (wet processes). Traditional batik manufacturing process exposes the worker to various physical and chemical hazards, resulting in a high prevalence of occupational skin diseases, especially contact dermatitis among the employees.

Patch tests and hand eczema: retrospective study in 173 patients and literature review.

BACKGROUND: Hand eczema (HE) is a highly prevalent, recurrent, and multifactorial disease. It encompasses a group of eczematous diseases that affect the hands, etiologically classified into irritant contact dermatitis (ICD), allergic contact dermatitis (ACD) and atopic dermatitis (AD). Few epidemiological studies in Latin America have investigated the characteristics of patients with this condition and the origin of the disease. OBJECTIVES: To analyze the profile of patients diagnosed with HE submitted to patch tests aiming to determine its etiology. METHODS: A retrospective descriptive study was carried out on epidemiological data and patch tests of patients with HE treated at a tertiary hospital in the city of São Paulo from January 2013 to December 2020. RESULTS: A total of 173 patients were studied, whose final diagnosis was 61.8% of ICD, 23.1% of ACD and 5.2% of AD, with diagnostic overlap in 42.8% of the cases. The main positive and relevant patch tests were: Kathon CG (42%), nickel sulfate (33%), and thiuram mix (18%). STUDY LIMITATIONS: The number of treated cases and socioeconomic profile was limited to a vulnerable population group. CONCLUSION: HE is a diagnosis in which overlapping etiologies are frequent, with the main sensitizers identified in ACD being Kathon CG, nickel sulfate and thiuram mix.

Irritant contact dermatitis caused by cosmetics containing excessive mercury.

BACKGROUND: Irritant contact dermatitis (ICD) is a localized, nonimmune-induced inflammatory skin reaction, characterized by multiform skin lesions, including erythema, scaling, edema, blisters, and erosion. Mercury and its related compounds are highly allergic agents that can induce allergic contact dermatitis. AIMS: This article aims to clarify the skin damage caused by irritant contact dermatitis caused by the addition of high doses of mercury to skin care products. PATIENTS: A 30-year-old female patient sought treatment at our Institute for contact dermatitis. RESULTS: Through the patch test of the patients and the component detection of the skin care products her use. A large amount of mercury was found in skin care products, and the patient had no apparent allergic reaction to mercury. CONCLUSIONS: We considered irritant contact dermatitis caused by excess mercury, and the patient's condition improved with treatment.

Bullous impetigo-like irritant contact dermatitis caused by perfume.

Contact dermatitis usually presents as erythematous macules, papules, and vesicles. Sometimes, unusual clinical presentations of contact dermatitis are reported, including pustular, lymphomatoid, lichenoid, and pigmented variants. We describe the first patient with bullous irritant contact dermatitis caused by perfume, mimicking impetigo lesions. We report this case to raise awareness concerning the possibility of serious cutaneous reactions, such as bullous impetigo-like irritant contact dermatitis due to perfumes which are ubiquitous, especially after direct contact with the solution. Perfume ingredients, such as fragrance, solvents, and preservatives all may cause or contribute to irritant contact dermatitis.

SKIN FEATURES IMPORTANT FOR THE OCCURRENCE OF CONTACT DERMATITIS IN HEALTHCARE WORKERS.

The occurrence of skin lesions in healthcare workers is associated with a negative impact on important skin functions, including protection from mechanical injuries, sunlight, dehydration, and penetration of chemical substances or pathogenic microorganisms. In healthcare professionals, the most common occupational skin disease is contact dermatitis (CD), either irritant (ICD) or allergic (ACD), and typically on the hands. ICD accounts for about 80% of occupational CD, making it the most frequent cause. According to the literature, CD frequency is higher among healthcare professionals than other occupations, with critical occupational risk factors including contact with irritants and allergens at the workplace. Furthermore, ICD is a multifactorial disorder influenced by many constituent and environmental factors. Constituent factors include age, gender, body location, atopy, and genetic factors, while environmental factors include temperature, airflow, humidity, and occlusion. Commonly encountered irritants are water, detergents and surfactants, solvents, oxidizing agents, acids, and alkalis; however, use of protective gloves or equipment, hand-washing habits, use of cleansers and creams, active inflammatory skin diseases, and daily activities are also important for ICD onset. Additionally, ICD is known to predispose to ACD. Important risk factors for ACD development include occupation, age, history of atopic dermatitis, genetics, female gender, and fair skin phototype. In summary, numerous skin features and other occupation-related factors contribute to CD among healthcare practitioners. Given the high level of exposure to contact irritants/allergens in the healthcare setting, implementation of preventive measures is crucial for a safer work environment.

The transcriptome of hand eczema assessed by tape stripping.

BACKGROUND: No biomarkers have been identified that can classify subtypes of hand eczema (HE). Although skin biopsies represent the gold standard for investigations of the skin, the invasive technique is not favorable when investigating skin from sensitive areas. Recent advances in the use of skin-tape strips for molecular investigations enable noninvasive investigations of HE. OBJECTIVE: By using whole transcriptome sequencing (WTS), the molecular profile of HE according to different localizations on the hands, etiologies, and clinical/morphological subtypes was investigated. METHODS: Thirty adult, Danish HE patients, 12 with and 18 without concurrent atopic dermatitis (AD), as well as 16 controls were included. Tape strip samples were collected from lesional, nonlesional, and healthy skin. Total RNA was extracted and WTS was performed. RESULTS: The largest molecular difference of HE patients with and without AD was found in nonlesional skin areas and included a downregulation of CXCL8 for HE patients without AD. Differences between allergic and irritant contact dermatitis included epidermal biomarkers such as EPHA1. CONCLUSION: Skin tape strip samples could be used to assess the gene expression profile of HE on different localizations of the hands. The skin tape strip method identified new molecular markers that showed promising result for the identification of HE subtypes.

Occupational contact dermatitis: Retrospective analysis of North American Contact Dermatitis Group Data, 2001 to 2016.

BACKGROUND: Patch testing is an important diagnostic tool for suspected allergic contact dermatitis (ACD) in occupational settings. OBJECTIVE: Provide an overview of occupational skin disease (OSD) and an analysis of occupational ACD in North American patients undergoing patch testing between 2001and 2016. METHODS: Patients with OSD were analyzed for frequency of allergic reactions to a screening series of allergens, occupational relevance, location of skin disease, and exposure sources. Demographic, occupation, and industry information were recorded. RESULTS: Of 38,614 patients evaluated, 4471 (11.6%) had OSD, of whom 3150 (70.5%) had ACD. The most common occupationally related allergens included rubber accelerators, preservatives, and bisphenol A epoxy resin. Hands (75.8%), arms (30.0%), and face (15.9%) were common sites of dermatitis. The occupations most affected were service workers and machine operators. LIMITATIONS: Our cohort may not reflect the general working population. CONCLUSION: This study identified common occupational allergens, exposure sources, and occupations/industries at risk. This information may help the clinician evaluate and manage patients with occupational contact dermatitis.

The History of Surfactants and Review of Their Allergic and Irritant Properties.

Surfactants, many of which are used as detergents, can be found in many common household items, such as shampoos, conditioners, soaps, and cosmetics. One should recognize the multitude of surfactants that are used in today's products to identify any potential allergic contact dermatitis (ACD) or irritant contact dermatitis (ICD). Given their abundance in everyday products, it is understandable that many cases of occupational contact dermatitis that arise can be attributed to surfactants. The products most connected with ACD are cocamidopropyl betaine, oleamidopropyl dimethylamine, decyl glucoside, 3-dimethylaminopropylamine, amidoamine, and cocamide diethanolamine. Similarly, the most common surfactant-related causes of ICD are sodium lauryl sulfate and benzalkonium chloride. It is important for dermatologists to identify the causes and differentiate between the two, to adjust treatments and products accordingly. Here, the most frequently used surfactants, as well as their correlation between ACD and ICD, will be reviewed.

Occupational contact dermatitis: Return to work using a multidisciplinary clinic model.

BACKGROUND: Occupational contact dermatitis often results in work disruption. Return-to-work (RTW) is an important outcome. OBJECTIVE: The objective of this study was to determine RTW outcomes and factors associated with such outcomes using a multidisciplinary clinic model. METHODS: Chart abstraction was performed for 194 workers who received RTW assistance over a 6-year period. Elements abstracted included demographic and diagnostic information and information about the RTW program including principles, program components, barriers, and facilitators. RESULTS: Of the 902 workers seen for dermatologic assessment, 194 received RTW assistance. At initial assessment, 37% were not working because of their skin disease, and at follow-up, 7% were not working because of their skin disease. The RTW plan components included a graduated or trial of RTW, specific recommendations for avoiding exposure, personal protective equipment, skin management, and ongoing skin monitoring. Principles associated with successful RTW included good communication and the availability of modified work and a worker adherence to the plan. Barriers included lack of modified work, unresponsive employers, and ongoing skin problems. CONCLUSIONS: Specific approaches are important to identify if RTW is to be successful for workers with occupational contact dermatitis.